Short-Term Changes in Hypsarrhythmia Assessed by Spectral Analysis: Group and Individual Assessments.

Objectives: To perform spectral analysis on previously recorded electroencephalograms (EEGs) containing hypsarrhythmia in an initial recording and to assess changes in spectral power (µV2) in a follow-up recording after a period of 10-25 days. Methods: Fifty participants, aged 2-39 months, with hypsarrhythmia in an initial recording (R1), were compared with regard to their spectral findings in a later recording (R2). Typically, anticonvulsant therapy was initiated or modified after R1. Average delta, theta, alpha, and beta power was derived from approximately 3 min of artifact-free EEG data recorded from 19 electrode derivations. Group and individual changes in delta power between R1 and R2 formed the main analyses. Results: Delta accounted for 84% of the total power. In group comparisons, median delta power decreased statistically significantly between R1 and R2 in all 19 derivations, for example, from 3940 µV2 in R1 to 1722 µV2 in R2, Cz derivation. When assessing individual participants, delta power decreases in R2 were >50% in 60% of the participants, but <25% in 24% of the participants. Conclusion: Spectral analysis may be used as an additional tool for providing a potential biomarker in the assessment of short-term changes in hypsarrhythmia, including the effects of treatment.

The Role of Clonal Evolution on Progression, Blood Parameters, and Response to Therapy in Multiple Myeloma.

Introduction: A variety of biomarkers are considered for diagnosis (e.g., ß2-microgobulin, albumin, or LDH) and prognosis [e.g., cytogenetic aberrations detected by fluorescence in situ hybridization (FISH)] of multiple myeloma (MM). More recently, clonal evolution has been established as key. Little is known on the clinical implications of clonal evolution. Methods: We performed in-depth analyses of 25 patients with newly diagnosed MM with respect to detailed clinical information analyzing blood samples collected at several time points during follow-up (median follow-up: 3.26 years since first diagnosis). We split our cohort into two subgroups: with and without new FISH clones developing in the course of disease. Results: Each subgroup showed a characteristic chromosomal profile. Forty-three percent of patients had evidence of appearing new clones. The patients with new clones showed an increased number of translocations affecting chromosomes 14 (78% vs. 33%; p = 0.0805) and 11, and alterations in chromosome 4 (amplifications and translocations). New clones, on the contrary, were characterized by alterations affecting chromosome 17. Subsequent to the development of the new clone, 6 out of 9 patients experienced disease progression compared to 3 out of 12 for patients without new clones. Duration of the therapy applied for the longest time was significantly shorter within the group of patients developing new clones (median: 273 vs. 406.5 days; p = 0.0465). Discussion: We demonstrated that the development of new clones, carrying large-scale alterations, was associated with inferior disease course and shorter response to therapy, possibly affecting progression-free survival and overall survival as well. Further studies evaluating larger cohorts are necessary for the validation of our results.

Functional outcome of supratrigonal cystectomy and augmentation ileocystoplasty in adult patients with refractory neurogenic lower urinary tract dysfunction.

AIMS: To investigate the functional outcome after supratrigonal cystectomy and augmentation ileocystoplasty in adult patients with refractory neurogenic lower urinary tract dysfunction (NLUTD). METHODS: Retrospective follow-up investigation in a single spinal cord injury rehabilitation center. In 29 patients, urodynamic data before and after supratrigonal cystectomy and augmentation ileocystoplasty, clinical outcome and post-operative complications were evaluated. RESULTS: The median age of the 29 patients at the time of surgery was 31 years, a median 14 years after NLUTD had occurred. At the last follow-up visit (median 2.4, range 0.4-9.0 years post-operatively), 20/29 patients (69%) were continent compared to 2/29 pre-operatively (P = 0.001). Furthermore, 16 patients required no or less detrusor relaxation therapy after augmentation ileocystoplasty. Augmentation cystoplasty resulted in a significant (P = 0.001) increase in the median bladder capacity (from 240 ml to 500 ml) and compliance (from 13 ml/cm H2 O to 50 ml/cm H2 O). The median maximum detrusor pressure had decreased significantly (P = 0.001) from 38 cm H2 O to 15 cm H2 O. Significantly (P = 0.001) fewer patients presented with a risk for renal damage (1 vs. 15 with maximum detrusor pressure >40 cm H2 O and 1 vs. 12 with detrusor compliance <20 ml/cm H2 O) at the last follow-up. The following complications were observed in 11/29 (38%) patients: paralytic and obstructive ileus, impaired bowel function, bladder stones, dehiscence, metabolic acidosis and autonomic dysreflexia. CONCLUSIONS: Protection of renal function, adequate bladder capacity and low detrusor pressure can be achieved using supratrigonal cystectomy and augmentation ileocystoplasty in patients suffering from refractory NLUTD.

Bacterial persistence in the prostate after antibiotic treatment of chronic bacterial prostatitis in men with spinal cord injury.

OBJECTIVE: To investigate the microbiologic outcome after antibiotic treatment of bacterial prostatitis in men with spinal cord injury (SCI). METHODS: A retrospective investigation was done in an SCI rehabilitation center. The microbiologic culture results of urine and ejaculate or prostatic fluid samples were collected from 34 men with SCI presenting with recurrent urinary tract infections and bacterial prostatitis. Furthermore, patient characteristics, bladder diary details, and the administered antibiotic treatment were collected. RESULTS: The median age of the 34 investigated men was 42.5 years (lower quartile, 31.8; upper quartile, 46.1 years), and they had sustained SCI a median of 15.2 years (lower quartile, 4.7; upper quartile, 22.9 years) ago. The majority (24 of 34 patients; 71%) evacuated their bladder with intermittent catheterization. The most commonly used antibiotics to treat bacterial prostatitis were fluoroquinolones (n = 41) followed by trimethoprim-sulfamethoxazole (n = 8) and second-generation cephalosporins (n = 7). In merely 2 men, antibiotic treatment resulted in bacterial eradication from the prostate. A shift in the bacteria species identified in the ejaculate or prostatic fluid cultures was observed during the follow-up. Most men (28 of 34; 82%) presented with mostly the same bacteria (55 of 62, 89%) in the urine as in the ejaculate or prostate samples. CONCLUSION: Antibiotic treatment did not result in the eradication of bacteria from the prostate of men with SCI. The antibiotic treatment of bacterial prostatitis in men with SCI should aim at eradicating symptoms and not bacteria.

Chronic bacterial prostatitis in men with spinal cord injury.

PURPOSE: Recurrent urinary tract infections (UTI) are a major problem affecting spinal cord injury (SCI) patients and may stem from chronic bacterial prostatitis. We have therefore investigated the presence of chronic bacterial prostatitis and its role in the development of recurrent symptomatic UTI in SCI men. METHODS: This study is a prospective cross-sectional investigation of bacterial prostatitis in SCI men in a single SCI rehabilitation center. In 50 men with chronic SCI presenting for a routine urologic examination, urine samples before and after prostate massage were taken for microbiologic investigation and white blood cell counting. Furthermore, patient characteristics, bladder diary details, and the annual rate of symptomatic UTI were collected retrospectively. RESULTS: No participant reported current symptoms of UTI or prostatitis. In most men (39/50, 78 %), the microbiologic analysis of the post-massage urine sample revealed growth of pathogenic bacteria. The majority of these men (32/39, 82 %) also presented with mostly (27/39, 69 %) the same pathogenic bacteria in the pre-massage sample. There was no significant (p = 0.48) difference in the number of symptomatic UTI in men with a positive post-massage culture compared with those with a negative culture. No significant (p = 0.67) difference in the frequency distribution of positive versus negative post-massage cultures was detected between men with recurrent and sporadic UTI. CONCLUSIONS: Most SCI men are affected by asymptomatic bacterial prostatitis; however, bacterial prostatitis does not play a major role in the development of recurrent UTI. The indication for antibiotic treatment of chronic bacterial prostatitis in asymptomatic SCI men with recurrent UTI is questionable.

Dissociative mental states are canonically associated with decreased temporal theta activity on spectral analysis of EEG.

Quantitative electroencephalographic (QEEG) changes relating to dissociative experiences have only rarely been demonstrated, and dissociative states were not quantified in those studies. The aim of this study was to explore concurrent associations between quantified dissociative states and QEEG spectral parameters, in particular theta activity, in psychiatric patients. Fifty psychiatric patients completed the State Scale of Dissociation (SSD) immediately after a 15-min EEG recording. The EEG was assessed by conventional clinical visual analysis as well as by quantitative (QEEG) spectral analysis. Canonical analysis was performed between the set of SSD subscale scores and the following QEEG parameters: alpha-theta magnitude ratios, and relative as well as absolute theta magnitude obtained from right and left mid- to posterior-temporal and parieto-occipital derivations. The SSD transferred well to the present data in terms of reliability and internal criterion-related validity. The SSD and Dissociative Experiences Scale (DES) correlated significantly (r = .73, p < .001). Conventional EEG analysis identified 29 EEGs (58%) as abnormal. The main abnormality in 23 EEGs was slowing, maximal temporally in half of these cases. Canonical analyses confirmed a statistically significant relationship between the dissociation variables (especially conversion and depersonalization symptoms) and the QEEG variables (especially relative theta magnitude in the temporal regions; R = .72, p = .03, for SSD-QEEG; and R = .66, p = .04, for DES-QEEG). Quantified dissociative mental states are positively canonically associated with decreased temporal theta activity and increased alpha-theta ratios on QEEG in psychiatric patients with a high tendency to dissociate. The potential implications of the dissociation-theta-alpha relationship for understanding normal attentional processes need to be studied further.

Prostate volume in male patients with spinal cord injury: a question of nerves?

OBJECTIVE: To assess the influence of standardized complete surgical deafferentation of the lower urinary tract by sacral deafferentation (SDAF) and sacral anterior root stimulation (SARS) on prostate volume in men with spinal cord injury (SCI). PATIENTS AND METHODS: In a prospective study, the prostate volume of men with SCI who underwent SDAF/SARS was measured using transrectal ultrasonography. The prostate volumes of these men were compared with those of men with complete SCI but who did not undergo SDAF/SARS, those of men with incomplete SCI, and those of a historical sample of able-bodied men. RESULTS: The median [25th;75th percentile] prostate volume of men who underwent SDAF/SARS (20.0 [14.0; 29.0]) and of men with complete SCI who did not undergo SDAF/SARS (20.0 [16.5; 29.0]) was significantly smaller than in the reference group (25.0 [5.0; 84.0]). The mean prostate volume was associated with age in the reference group (r = 0.185; P < 0.001) and in men with incomplete SCI (r = 0.284; P = 0.031), but not in men with complete SCI, irrespective of SDAF/SARS. CONCLUSIONS: The prostate volume of men with complete SCI was significantly smaller than that of able-bodied men. Our data imply that sustained central innervation of the prostate plays an important role in prostate growth.

Clinical usefulness of ultrasound assessment of detrusor wall thickness in patients with neurogenic lower urinary tract dysfunction due to spinal cord injury: urodynamics made easy?

PURPOSE: To evaluate the clinical usefulness of sonographic measurement of detrusor wall thickness (DWT) for the prediction of risk factors in patients with neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI). METHODS: In a prospective study, 60 consecutive patients with NLUTD due to SCI presenting for routine urodynamic assessment at a specialized SCI center underwent additional measurement of DWT at varying bladder volumes. Results of urodynamic testing were classified into favorable and unfavorable. DWT at maximum capacity was used to calculate a possible cutoff value for favorable urodynamic results. RESULTS: Urodynamic results were favorable in 48 patients and unfavorable in 12 patients. A DWT of 0.97 mm or less can safely (sensitivity 91.7 %, specificity 63.0 %) be used as a cutoff point for the absence of risk factors for renal damage. CONCLUSION: According to our results, DWT may be useful as an additional risk assessment for renal damage in patients with NLUTD due to SCI. However, as other parameters required for bladder management, especially detrusor overactivity, cannot be evaluated by this technique, it cannot replace urodynamic testing.

Clinical usefulness of the transobturator sub-urethral tape in the treatment of stress urinary incontinence in female patients with spinal cord lesion.

OBJECTIVES: To evaluate the clinical usefulness of transobturator sub-urethral tapes for the treatment of stress urinary incontinence in women with spinal cord injury. METHOD AND SUBJECTS: Chart review for all female patients with spinal cord injury who underwent implantation of a transobturator sub-urethral tape for treatment of stress urinary incontinence at our institution. RESULTS: Nine women, median age 45.1 years, received a sub-urethral transobturator tape in the period November 2007 to September 2010. Four patients had paraplegia and five had tetraplegia. Seven women performed intermittent catheterization. At follow up, three of the nine patients were either cured or vastly improved. One major late complication (urethral erosion) occurred. Five of the six patients without treatment success underwent second-line treatment (artificial sphincter or urinary diversion). CONCLUSION: In our case series, implantation of transobturator sub-urethral tapes in women with stress urinary continence due to intrinsic sphincter deficiency and a low leak point pressure led to unfavorable results.

Outcome prediction for prostate cancer detection rate with artificial neural network (ANN) in daily routine.

BACKGROUND: We evaluated the use of the artificial neural network (ANN) program "ProstataClass" of the Department of Urology and the Institute of Medical Informatics at the Charité-Universitätsmedizin Berlin in daily routine to increase prostate cancer (CaP) detection rate and to reduce unnecessary biopsies. MATERIALS AND METHODS: From May 2005 to April 2007, a total of 204 patients were included in the study. The Beckman Access PSA assay was used, and pretreatment prostate specific antigen (PSA) was measured prior to digital rectal examination (DRE) and 12 core systematic transrectal ultrasound (TRUS) guided biopsies. The individual ANN predictions were generated with the use of the ANN application for the Beckman Access PSA and free PSA assays, which relies on age, PSA, percent free prostate specific antigen (%fPSA), prostate volume, and DRE. Diagnostic validity of total prostate specific antigen (tPSA), %fPSA, and the ANN was evaluated by ROC curve analysis. RESULTS: PSA and %fPSA ranged from 4.01 to 9.91 ng/ml (median: 6.65) and 5% to 48% (median: 15%), respectively. Of all men, 46 (22.5%) demonstrated suspicious DRE findings. Total prostate volume ranged from 7.1 to 119.2 cc (median: 35). Overall, 71 (34.8%) CaP were detected. Of men with suspicious DRE, 28 (60.9%) had CaP on initial biopsy. The ANN was 78% accurate in the original report. The AUC of ROC curve analysis was 0.51 for PSA, 0.66 for %PSA, and 0.72 for the ANN-Output, respectively. CONCLUSIONS: Our results in this independent cohort show that ANN is a very helpful parameter in daily routine to increase the CaP detection rate and reduce unnecessary biopsies.

Does a new ultrasound probe change the complication rates of transrectal ultrasound-guided needle biopsies of the prostate?

BACKGROUND: Transrectal ultrasound-guided prostate needle biopsies are performed to diagnose prostate cancer. This study prospectively evaluated the safety, morbidity and complication rates with two different ultrasound probes. PATIENTS AND METHODS: Three huntred and thirty-two patients were biopsied using a biplane 7.5 MHz probe (GE Medical Systems Kretz Ultrasound, Zipf, Austria) and 101 patients using a biplane 5-10 MHz probe (BK-Medical, Herlev, Denmark). Four weeks after the procedure the patients were asked to fill out a questionnaire. RESULTS: There were 3 major and 75 minor complications. The most common complication was haematuria in 8.1% of cases, followed by pain with urination in 5.3% of cases. After changing the ultrasound probe, the complication rates were slightly higher, but no statistical difference in any of the complication rates was found between the two groups. CONCLUSIONS: Changing the method within the same team has no influence on complication rates and on prostate cancer detection rates.

Evaluation of symptoms and patients' comfort for JJ-ureteral stents with and without antireflux-membrane valve.

OBJECTIVES: To evaluate safety and patients' comfort by using the ureteral stent symptom questionnaire. Ureteral stents are used to provide upper urinary-tract drainage. METHODS: A total of 133 JJ-ureteral stents with and without antireflux-membrane valve as consecutive referrals for therapy of hydronephrosis have been inserted. Four weeks after insertion of the ureteral stent, the patients were asked about pain while urination, flank pain due to reflux, and the comparison with former stents. Ultrasound of the kidney for hydronephrosis grade and creatinine value as follow-up have been documented. Statistical analysis included chi(2) test after Pearson correlation computed and performed by SPSS software. RESULTS: We found a high correlation between the JJ-ureteral stent used and the detection of a hydronephrosis (P = .004). More patients who had a JJ-ureteral stent without valve complained of flank pain (P <.0005) and pain in the bladder (P <.0005). Patients who had a ureteral stent before were asked to compare new stents with the former ones. No patients with a JJ-ureteral stent with valve found this one to be worse than what they had before. CONCLUSIONS: JJ-stent related symptoms are a major problem for these patients. New stent designs and materials will be developed in the future to reduce stent-related morbidity and improve patient comfort. JJ-ureteral stents with an antireflux-membrane valve have a lower complication rate and provide a higher patient comfort compared with stents without valve.

Complications and risk factors of transrectal ultrasound guided needle biopsies of the prostate evaluated by questionnaire.

BACKGROUND: Transrectal ultrasound guided prostate needle biopsies are routinely performed to diagnose and stage prostate cancer. We prospectively evaluated the safety, morbidity, and complication rate. MATERIALS AND METHODS: We studied 336 patients who underwent transrectal ultrasound guided prostate needle biopsy. A post-biopsy questionnaire was sent to the patients 4 weeks after biopsy concerning questions about minor complications. Information on major complications was obtained by telephone interview. RESULTS: There were 2 major and 48 minor complications. The most common complication was hematuria in 6.5% of cases, followed by pain while urinating in 6.0% of cases. There was no statistically significance difference between hematuria and aspirin/thrombolytic drug use (P = 0.170) and between positive microbiology in urine and elevated temperature (P = 0.665). CONCLUSIONS: Transrectal ultrasound guided prostate needle biopsy is safe for diagnosing prostate cancer with few major and minor complications. Aspirin/thrombolytic drug use in patients' history is no risk factor for hematuria. Positive microbiology in urine before biopsy is no risk factor for a higher infection rate.

Chemotherapy with gemcitabine, paclitaxel, and cisplatin in the treatment of patients with advanced transitional cell carcinoma of the urothelium.

Chemotherapeutic agents are active in advanced bladder cancer, and various combinations have shown promising results. The objective of this study was to evaluate the efficacy of combination chemotherapy with gemcitabine, paclitaxel, and cisplatin in patients with advanced urothelial carcinoma. Fifty-nine patients with metastatic or locally advanced transitional cell carcinoma of the urothelium were treated between 2000 and 2005. No patient had received any previous systemic chemotherapy. All patients received chemotherapy intravenously with gemcitabine at a dose of 1000 mg/m(2) on days 1 and 8, paclitaxel at a dose of 80 mg/m(2) on days 1 and 8, and cisplatin at a dose of 50 mg/m(2) on day 2. Treatment courses were repeated every 21 days. After completion of four to six courses in this regimen an intravenous application of gemcitabine was repeated every 28 days at a dose of 1000 mg/m(2). Fifty-nine patients were treated between 2000 and 2005. Nine patients (15%) had >or=1 visceral site of metastases, and no patient had received any previous systemic chemotherapy. Forty-eight patients (81%) achieved objective responses to treatment (56% complete responses). The median actuarial survival was 22 months, and the actuarial 1-year and 2-year survival rates were 68% and 39%, respectively. After a median follow-up of 17.5 months, 29 patients remained alive and 25 were free of disease progression. The median progression-free survival for the entire group was 10 months. The median survival time for patients with an Eastern Cooperative Oncology Group (ECOG) status of 0, 1, and 2 was 37.5, 17, and 12 months, respectively. Grade 3-4 neutropenia occurred in 39% of the patients. The combination of gemcitabine, paclitaxel, and cisplatin is a highly effective and tolerable regimen for patients with advanced urothelial carcinoma. This treatment should be considered as a suitable option that deserves further prospective evaluation. The ECOG performance status is an important predictive factor for survival.

Anesthetic technique (sufentanil versus ketamine plus midazolam) and quantitative electroencephalographic changes after cardiac surgery.

OBJECTIVES: Cardiac surgery involving cardiopulmonary bypass is associated with neurologic deterioration. Several interventions, including anesthetic techniques, have been designed to limit ischemic brain damage and have been evaluated in animals. Markers of neurologic injury may facilitate the assessment of these interventions in humans. DESIGN: A blinded randomized prospective study comparing 2 anesthetic techniques (one sufentanil-based, the other ketamine and midazolam-based) in patients undergoing cardiac surgery. Quantitative electroencephalography was used to detect postoperative neurologic injury. SETTING: Major teaching hospital. PARTICIPANTS: Forty-two patients aged 18 to 70 years undergoing cardiac surgery. INTERVENTIONS: Patients were anesthetized with either a sufentanil-based or a ketamine and midazolam-based technique for cardiac surgery with cardiopulmonary bypass. Quantitative electroencephalography was performed preoperatively as well as 5 to 6 days postoperatively. MEASUREMENTS AND MAIN RESULTS: Quantitative electroencephalography outcome did not differ (p > 0.05) between the 2 groups. It showed significant deterioration between preoperative and postoperative assessments with a decrease in faster and an increase in slower frequencies. In addition, the alpha attenuation index decreased. This may reflect a decrease in alertness. Both the intergroup comparisons and the assessment of individual changes failed to reveal significant differences between the anesthetic techniques. The adjuvant use of isoflurane correlated with less deterioration of quantitative electroencephalographic variables. CONCLUSIONS: The use of either sufentanil-based or ketamine and midazolam-based anesthetic techniques for cardiac surgery with cardiopulmonary bypass had no effects on a marker of postoperative neurologic injury (ie, quantitative electroencephalography).

Narcolepsy caused by acute disseminated encephalomyelitis.

BACKGROUND: Narcolepsy with cataplexy is caused by a selective loss of hypocretin-producing neurons, but narcolepsy can also result from hypothalamic and rostral brainstem lesions. PATIENT: We describe a 38-year-old woman with severe daytime sleepiness, internuclear ophthalmoplegia, and bilateral delayed visual evoked potentials. Her multiple sleep latency test results demonstrated short sleep latencies and 4 sleep-onset rapid eye movement sleep periods, and her cerebrospinal fluid contained a low concentration of hypocretin. Magnetic resonance imaging showed T2 and fluid-attenuated inversion recovery hyperintensity along the walls of the third ventricle and aqueduct, which are consistent with acute disseminated encephalomyelitis. RESULTS: After treatment with steroids, this patient's subjective sleepiness, hypersomnia, and hypocretin deficiency partially improved. CONCLUSIONS: Autoimmune diseases such as acute disseminated encephalomyelitis can produce narcolepsy. Most likely, this narcolepsy is a consequence of demyelination and dysfunction of hypocretin pathways, but direct injury to the hypocretin neurons may also occur.

Amygdala, affect and cognition: evidence from 10 patients with Urbach-Wiethe disease.

Patients with Urbach-Wiethe disease constitute a unique nature experiment as more than half have bilaterally symmetrical damage in the amygdaloid region. Ten such patients were studied neuropsychologically and, nine of them, neuroradiologically with static (CT) and functional imaging techniques [single-photon emission computed tomography (SPECT) and PET]. Their principal bilateral amygdala damage was confirmed. Neuropsychologically, the patients showed cognitively little deviation from normal subjects, while they differed emotionally. This was evident in their judgement of all emotions in facial expressions, in an odour-figure association test as well as in remembering negative and positive pictures. This suggests that the human amygdala influences both negative and positive emotional processing.