Effectiveness of a PENG catheter and the implications and a complication of tunnelling.

Pericapsular nerve group (PENG) block is a recently developed technique for analgesia for hip surgeries. We chose to use a PENG catheter for effective analgesia perioperatively. In this case report, we performed PENG catheter for a patient posted for hip hemiarthroplasty. During the process of tunnelling after securing the catheter, we accidentally sheared the catheter and had to redo the procedure. The patient was comfortable during their stay with minimal pain. This case report emphasises the importance of securing a catheter in providing prolonged analgesia and also the importance of dealing with complications due to the procedure itself.

Erosion of urethra by malleable penile prosthesis in a spinal cord injury patient with diabetes mellitus and repeated misplacement of Foley balloon in the urethra: lessons we learn: a case report.

INTRODUCTION: Spinal cord injury patients with indwelling urethral catheters are at high risk for erosion of urethra by penile prosthesis. Repeated misplacement of a Foley catheter with the balloon inflated in the urethra produces additional compression, thus predisposing to erosion of urethra by the prosthesis. CASE PRESENTATION: A 22-year male sustained tetraplegia in 1980. He underwent implantation of bladder stimulator, urethral sphincterotomy twice, transurethral resection of bladder neck and then, prostate. In 1991, malleable penile prostheses were implanted to facilitate maintenance of a penile sheath. He required urethral catheter drainage since 1996. The balloon of Foley catheter was misplaced in membranous/bulbar urethra during catheterisations since 2018. In 2020, he developed recurrent penile cellulitis and periurethral abscess resulting in perineal urethro-cutaneous fistula. Cystoscopy showed erosion of urethra at the verumontanum by both prostheses. The prostheses were removed; suprapubic cystostomy was performed. CONCLUSION: Inflation of Foley balloon in the urethra for prolonged periods, aggravated by recurrent cellulitis of penis and diabetes mellitus resulted in urethral erosion by the prostheses. Urethral catheterisations in spinal injury patients, who have undergone sphincterotomy, resection of bladder neck/prostate, should be performed by experienced clinicians to prevent complications of catheterisation. Suprapubic cystostomy, performed earlier, could have averted these adverse events.

In Vitro Inactivation of Human Coronavirus by Titania Nanoparticle Coatings and UVC Radiation: Throwing Light on SARS-CoV-2

The newly identified pathogenic human coronavirus, SARS-CoV-2, led to an atypical pneumonia-like severe acute respiratory syndrome (SARS) outbreak called coronavirus disease 2019 (COVID-19). Currently, nearly 23 million cases have been confirmed worldwide with the highest COVID-19 cases been confirmed in the United States. As there is no vaccine or any effective interventions, massive efforts to create a postential vaccine to combat COVID-19 is underway. In the meantime, safety precautions and effective disease control strategies appear to be vital for preventing the virus spread in the public places. Due to the longevity of the virus on smooth surfaces, photocatalytic properties of self-disinfecting/cleaning surfaces appear to be a promising tool to help guide disinfection policies to control infectious SAR-CoV-2 spread in high-traffic areas such as hospitals, grocery stores, airports, schools, and stadiums. Here, we explored the photocatalytic properties of nanosized TiO2 (TNPs) as induced by the UV radiation, towards virus deactivation. Our preliminary results using close genetic relative of SAR-CoV-2, HCoV-NL63, showed the virucidal efficacy of photoactive TNPs deposited on glass coverslips, as examined by quantitative RT-PCR and virus culture assays. Efforts to extrapolate the underlying concepts described in this study to SARS-CoV-2 are currently underway.

Generalised muscle weakness after bladder wall injection of Abobotulinum Toxin A: experience of a woman with tetraplegia who required increased caregiver support: importance of doctor-patient communication: duty of candour for spinal cord physician and responsibilities of a patient.

INTRODUCTION: Generalised muscle weakness can occur after bladder wall injection of Abobotulinum toxin and the patient may require additional caregiver support. CASE PRESENTATION: A woman with C-8 AIS A tetraplegia received bladder wall injection of Abobotulinum toxin A 1000 units for detrusor over-activity. After 2.5 weeks, she developed weakness of arms; could not lift herself for pressure relief; could not transfer using sliding board; she regained the original muscle strength in 6 weeks. After 13 months, Abobotulinum toxin A 1000 units were injected into detrusor. Ten days after the second Abobotulinum toxin A injection, she developed generalised muscle weakness. She had not regained full function in her arms and hands 8 months later.Prior to bladder wall injection of Abobotulinum toxin A, this patient was not aware that she could develop muscle weakness albeit very rarely. Therefore, the patient made no association of the muscle weakness, which occurred after the first injection, to Abobotulinum toxin A. For this reason, she did not inform the clinicians that she developed weakness of upper limbs following Abobotulinum toxin A injection. As she was not informed of this side effect before the second bladder wall injection of Abobotulinum toxin A, she consented to undergo the repeat procedure and developed generalised muscle weakness. DISCUSSION: Patients should inform doctors the adverse effects of medical therapy so that future treatment is amended to ensure patient safety. Professional duty of candour states that doctors should discuss risks which occur often, those that are serious even if very unlikely, and those that are important to the patient.

Persistent urine leakage around a suprapubic catheter: the experience of a person with chronic tetraplegia.

INTRODUCTION: Persistent urine leakage after suprapubic cystostomy in tetraplegic subjects occurs due to shrinkage of the urinary bladder and bladder spasms. The patient's social life is adversely affected as clothes become wet, smelly, and require frequent changing, thus increasing the workload of carers. CASE PRESENTATION: A 48-year-old male sustained C-4 complete (AIS:A) tetraplegia while swimming in 2007. Suprapubic cystostomy was performed in 2009. From 2012, this patient had urine leakage around the suprapubic catheter, which became progressively more frequent. Propiverine, then oxybutynin tablets instead of propiverine, oxybutynin transdermal patches, and mirabegron in addition to oxybutynin were tried. An indwelling urethral catheter was used in addition to the suprapubic catheter to alleviate urine leakage when the bladder was undergoing spasms. This patient continued to have leakage around the suprapubic catheter. Leakage of urine was occasionally accompanied by autonomic dysreflexia. Leakage of urine caused huge amounts of extra work for carers, and family. Furthermore, leakage of urine had a significant impact on quality of life, and going out with friends and family. Bladder wall injection of Botox was performed in 2015 and in 2016, which reduced urine leakage. DISCUSSION: Bladder wall injection of Botox to treat persistent urine leakage around the suprapubic catheter in spinal cord injury patients with suprapubic cystostomy has not been mentioned in NICE guidelines or publications indexed in PubMed. While recommending suprapubic cystostomy to subjects with tetraplegia, leakage of urine around the suprapubic catheter, which may occur sometime after suprapubic cystostomy, should be included in the conversation so that patients and carers become aware of this potential complication.

Fatal cerebral hemorrhage in a tetraplegic patient due to autonomic dysreflexia triggered by delay in emptying urinary bladder after unsuccessful intermittent catheterization by carer: lessons learned.

INTRODUCTION: Over-distension of urinary bladder in a high spinal cord injury patient is a triggering factor for autonomic dysreflexia. Removing triggering factors is vital to prevent autonomic dysreflexia. CASE PRESENTATION: A 36-year-old tetraplegic patient, who was managed by intermittent catheterizations performed by caregivers, developed recurrent autonomic dysreflexia during a week due to: 1) carers not performing intermittent catheterizations every night; 2) infrequent catheterizations during the day, leading to distension of urinary bladder. A day before his demise, carer attempted routine catheterization; but was unable to insert the catheter; blood pressure rose to 192/109 mmHg. Nifedipine 10 mg was administered. Thirty minutes later, blood pressure was 181/113 mmHg; second dose of Nifedipine was not given. Forty minutes elapsed before a senior carer came and catheterized successfully. Meanwhile, patient developed pounding headache; became drowsy; was talking incoherently. Four and half hours after unsuccessful catheterization, carers contacted emergency services and the patient was taken to Accident and Emergency; CT of head revealed very large acute intracranial hemorrhage in the right frontal and parietal lobes. The patient expired a day later. The Coroner's verdict: "Patient died of massive intracranial hemorrhage caused by autonomic dysreflexia, a known complication of high spinal cord injury. Emergency protocols to manage autonomic dysreflexia were not followed in the days leading up to his death." CONCLUSION: Failed urethral catheterization is a potentially life-threatening emergency; every patient should have a care plan explicitly describing what should be done when catheterization is not successful. Preventive measures rather than episodic treatment of autonomic dysreflexia should be the guiding principle.

Fatal collapse due to autonomic dysreflexia during manual self-evacuation of bowel in a tetraplegic patient living alone: lessons to learn.

BACKGROUND: To identify areas for improvement, the National Health Service in England mandates the review of case reports of patients who have died, which should be translated into improved care for other patients. CASE REPORT: A 49-year-old Caucasian man sustained C-7 tetraplegia in a motorcycle accident in 1992. In 2009, he developed seizures and collapsed in the lavatory on a number of occasions during manual self-evacuation of his bowel. A 24-hour electrocardiogram recording at that time showed sinus rhythm with a maximum heart rate of 97 and a minimum of 39 beats per minute; there were no significant arrhythmias that could have contributed to his episodes of collapse. In 2015, the patient again collapsed while performing manual evacuation of his bowel; on this occasion, he did not suffer a seizure. He was found unresponsive in the bathroom by his daughter, who contacted the emergency services. He recovered consciousness on arrival at the Accident and Emergency Department. A noncontrast computed tomography scan of his head revealed no acute intracranial pathology. In 2016, he suffered a fatal collapse in the lavatory, again while performing manual bowel evacuation. At autopsy, no other significant disease was found that might have caused death, and given the clinical history, the cause of death was recorded as autonomic dysreflexia. CONCLUSION: There were delays in 1) recognizing that his episodes of collapse in the lavatory were due to autonomic dysreflexia induced by manual bowel evacuation; 2) recommending the prior application of topical 2% lidocaine jelly to prevent or limit autonomic dysreflexia occurring during manual bowel evacuation; and 3) considering alternative bowel management such as stimulant laxatives, transanal irrigation, or colostomy, which could have prevented the occurrence of autonomic dysreflexia caused by manual evacuation.

Severe, Protracted Spasm of Urinary Bladder and Autonomic Dysreflexia Caused by Changing the Suprapubic Catheter in a Cervical Spinal Cord Injury Patient: Treatment by a Bolus Dose and Increased Total Daily Dose of Intrathecal Baclofen.

BACKGROUND: Intrathecal administration of baclofen by implanted pump reduces rigidity and muscle spasms. Its use specifically to control bladder spasms has not been reported. CASE REPORT: A tetraplegic patient developed severe, protracted, bladder spasms, abdominal muscles spasms, and high blood pressure after change of suprapubic catheter; nifedipine, diazepam, and paracetamol did not control spasms; bolus dose of baclofen intrathecally produced prompt relief via baclofen pump. CONCLUSION: Severe, protracted bladder spasms, abdominal muscles spasms, and autonomic dysreflexia, induced by change of suprapubic catheter in a spinal cord injury patient, were treated successfully by a bolus dose and increased total daily dose of intrathecal baclofen.

Large subcapsular hematoma following ureteroscopic laser lithotripsy of renal calculi in a spina bifida patient: lessons we learn.

INTRODUCTION: Paraplegic patients are at greater risk of developing complications following ureteroscopic lithotripsy because of urine infection associated with neuropathic bladder, difficulties in access due to altered anatomy of urinary bladder and urethra, spinal curvature, spasticity, and contractures. We report the occurrence of large subcapsular hematoma following ureteroscopy and discuss lessons we learn from this case. CASE REPORT: A 48-year-old male patient with spina bifida underwent ureteroscopy with laser lithotripsy and ureteric stenting for left ureteric stone and staghorn calculus with hydronephrosis; laser lithotripsy was repeated after 3 months; both procedures were performed by a senior urologist and did not result in any complications. Ureteroscopic laser lithotripsy was performed 5 months later by a urological trainee; it was difficult to negotiate the scope as vision became poor because of bleeding (as a result of the procedure). Postoperatively, hematuria persisted; temperature was 39°C. Cefuroxime was given intravenously followed by gentamicin for 5 days; hematuria subsided gradually; he was discharged home. Ten days later, this patient developed temperature, the urine culture grew Pseudomonas aeruginosa, and ciprofloxacin was given orally. Computed tomography (CT) of the urinary tract, performed 4 weeks after ureteroscopy, revealed a 9×7 cm subcapsular collection on the left kidney compressing underlying parenchyma. Percutaneous drainage was not feasible because of severe curvature of spine. Isotope renogram revealed deterioration in left renal function from 30% to 17%. Follow-up CT revealed reduction in the size of subcapsular hematoma, no hydronephrosis, and several residual calculi. CONCLUSION: Risk of subcapsular hematoma following ureteroscopic lithotripsy can be reduced by avoiding prolonged endoscopy and performing ureteroscopy under low pressure. When a paraplegic patient develops features of infection after ureteroscopy, renal imaging should be carried out promptly. Extended perioperative medical care is required for spinal cord injury patients because of their propensity to develop sepsis. Antibiotics should be prescribed on the basis of recent urine microbiology results. Spinal cord injury patients should be treated by senior, experienced doctors and cared for in a spinal injuries unit in order to minimize complications.

Acute Urinary Obstruction in a Tetraplegic Patient from Misplacement of Catheter in Urethra.

A male tetraplegic patient attended accident and emergency with a blocked catheter; on removing the catheter, he passed bloody urine. After three unsuccessful attempts were made to insert a catheter by nursing staff, a junior doctor inserted a three-way Foley catheter with a 30-mL balloon but inflated the balloon with 10 mL of water to commence the bladder irrigation. The creatinine level was mostly 19 µmol/L (range: 0-135 µmol/L) but increased to 46 µmol/L on day 7. Computerized tomography urogram revealed that the bilateral hydronephrosis with hydroureter was extended down to urinary bladder, the bladder was distended, prostatic urethra was dilated and filled with urine, and although the balloon of Foley catheter was not seen in the bladder, the tip of the catheter was seen lying in the urethra. Following the re-catheterization, the creatinine level decreased to 21 µmol/L. A follow-up ultrasound scan revealed no evidence of hydronephrosis in both kidneys. Flexible cystoscopy revealed inflamed bladder mucosa, catheter reaction, and tiny stones. There was no bladder tumor. This case report concludes that the cause of bilateral hydronephrosis, hydroureter, and distended bladder was inadequate drainage of urinary bladder as the Foley balloon that was under-filled slipped into the urethra resulting in an obstruction to urine flow. Urethral catheterization in tetraplegic patients should be performed by senior, experienced staff in order to avoid trauma and incorrect positioning. Tetraplegic subjects with decreased muscle mass have low creatinine level. Increase in creatinine level (>1.5 times the basal level) indicates acute kidney injury, although peak creatinine level may still be within laboratory reference range. While scanning the urinary tract of spinal cord injury patients with indwelling urinary catheter, if Foley balloon is not seen within the bladder, urethra should be scanned to locate the Foley balloon.

Urinary retention and acute kidney injury in a tetraplegic patient using condom catheter after partying: a preventable complication.

BACKGROUND: Spinal cord injury patients, who manage their bladder using a condom catheter, are at risk of developing urine retention when they consume large volumes of alcoholic drinks within a short period of time. CASE PRESENTATION: A male tetraplegic patient had been managing satisfactorily penile sheath drainage for 8 years. He went out socializing during which he consumed large volumes of alcohol but did not take any recreational drugs. The following morning, he noticed distension of the lower abdomen and passed urine in dribbles. He then developed a temperature and became unwell. He was seen by district nurses and a doctor, who prescribed antibiotics. He continued to feel unwell. After 8 days, he referred himself to a spinal unit at Regional Spinal Injuries Centre, Southport. The blood test results showed the following: blood urea: 19.8 mmol/L; creatinine: 172 µmol/L; and C-reactive protein: 336.4 mg/L. Urethral catheterization led to immediate drainage of 1,400 mL of urine. A computed tomography scan revealed an enlarged, swollen left kidney, indicating acute bacterial nephritis. He was prescribed intravenous fluids and Meropenem. Creatinine decreased to 46 µmol/L. CONCLUSION: Spinal cord injury patients using condom catheters should be made aware of the risk of urine retention when they consume large amounts of alcoholic drinks in a short period of time. Patients and caregivers should be informed to consider intermittent catheterizations for 24-48 hours or insert indwelling urethral catheter when planning for an evening out.

Complications and salvage options after laser lithotripsy for a vesical calculus in a tetraplegic patient: a case report.

BACKGROUND: Laser lithotripsy of vesical calculi in tetraplegic subjects with long-term urinary catheters is fraught with complications because of bladder wall oedema, infection, fragile urothelium, bladder spasms, and autonomic dysreflexia. Severe haematuria should be anticipated; failure to institute measures to minimise bleeding and prevent clot retention can be catastrophic. We present an illustrative case. CASE PRESENTATION: A tetraplegic patient underwent laser lithotripsy of vesical stone under general anaesthesia. During lithotripsy, severe bladder spasms and consequent rise in blood pressure occurred. Bleeding continued post-operatively resulting in clot retention. CT revealed clots within distended but intact bladder. Clots were sucked out and continuous bladder irrigation was commenced. Bleeding persisted; patient developed repeated clot retention. Cystoscopy was performed to remove clots. Patient developed abdominal distension. Bladder rupture was suspected; bed-side ultrasound scan revealed diffuse small bowel dilatation with mild peritoneal effusion; under-filled bladder containing small clot. Patient developed massive abdominal distension and ileus. Two days later, CT with oral positive contrast revealed intra-peritoneal haematoma at the dome of bladder with perforation at the site of haematoma. Free fluid was noted within the peritoneal cavity. This patient was managed by gastric drainage and intravenous fluids. Patient's condition improved gradually with urethral catheter drainage. Follow-up CT revealed resolution of bladder rupture, perivesical haematoma, and intra-peritoneal free fluid. CONCLUSION: If bleeding occurs, bladder irrigation should be commenced immediately after surgery to prevent clot retention. When bladder rupture is suspected, CT of abdomen should be done instead of ultrasound scan, which may not reveal bladder perforation. It is debatable whether laparotomy and repair of bladder rupture is preferable to nonoperative management in tetraplegics. Anti-muscarinic drugs should be prescribed prior to lithotripsy to control bladder spasms; aspirin and ibuprofen should be omitted. If significant bleeding occurs during lithotripsy, procedure should be stopped and rescheduled. Percutaneous cystolithotripsy using a wide channel could be quicker to clear stones, as larger fragments could be retrieved; lesser stimulant for triggering autonomic dysreflexia, as it avoids urethral manipulation. But in patients with small, contracted bladder, and protuberant abdomen, percutaneous access to urinary bladder may be difficult and can result in injury to bowels.

Screening for proteinuria in 'at-risk' patients with spinal cord injuries: lessons learnt from failure.

UNLABELLED: Spinal cord injury patients may develop proteinuria as a result of glomerulosclerosis due to urosepsis, hydronephrosis, vesicoureteric reflux, and renal calculi. Proteinuria in turn contributes to progression of kidney disease. We report one paraplegic and two tetraplegic patients, who developed recurrent urine infections, urinary calculi, and hydronephrosis. These patients required several urological procedures (nephrostomy, cystoscopy and ureteric stenting, ureteroscopy and lithotripsy, extracorporeal shock wave lithotripsy). These patients had not received antimuscarinic drugs nor had they undergone video-urodynamics. Proteinuria was detected only at a late stage, as testing for proteinuria was not performed during follow-up visits. Urine electrophoresis showed no monoclonal bands in any; Serum glomerular basement membrane antibody screen was negative. Serum neutrophil cytoplasmic antibodies screen by fluorescence was negative. All patients were prescribed Ramipril 2.5 mg daily and there was no further deterioration of renal function. Spinal cord injury patients, who did not receive antimuscarinic drugs to reduce intravesical pressure, are at high risk for developing reflux nephropathy. When such patients develop glomerulosclerosis due to recurrent urosepsis, renal calculi, or hydronephrosis, risk of proteinuria is increased further. TAKE HOME MESSAGE: (1) Screening for proteinuria should be performed regularly in the 'at-risk' patients. (2) In the absence of other renal diseases causing proteinuria, spinal cord injury patients with significant proteinuria may be prescribed angiotensin-converting enzyme inhibitor or angiotensin-II receptor antagonist to slow progression of chronic renal disease and reduce the risk of cardiovascular mortality.

Substandard urological care of elderly patients with spinal cord injury: an unrecognized epidemic?

BACKGROUND: We report the anecdotal observation of substandard urological care of elderly paraplegic patients in the community suffering from long-term sequelae of spinal cord injuries. This article is designed to increase awareness of a problem that is likely underreported and may represent the 'tip of the iceberg' related to substandard care provided to the vulnerable population of elderly patients with chronic neurological impairment. FINDINGS: A registered Nurse changed the urethral catheter of an 80-year-old-male with paraplegia; patient developed profuse urethral bleeding and septicaemia. Ultrasound revealed balloon of Foley catheter located in membranous urethra. Flexible cystoscopy was performed and a catheter was inserted over a guide wire. Urethral bleeding recurred 12 days later. This patient was discharged after protracted stay in spinal unit. A nurse changed urethral catheter in an 82-year-old male with paraplegia. The catheter did not drain urine; patient developed pain in lower abdomen. The balloon of Foley catheter was visible behind the urethral meatus, which indicated that the balloon had been inflated in penile urethra. The catheter was removed and a 16 French Foley catheter was inserted per urethra. About 1300 ml of urine was drained. A 91-year-old lady with paraplegia underwent routine ultrasound examination of urinary tract by a Consultant Radiologist, who reported a 4 cm × 3 cm soft tissue mass in the urinary bladder. Cystoscopy was performed without anaesthesia in lithotomy position. Cystoscopy revealed normal bladder mucosa; no stones; no tumour. Following cystoscopy, the right knee became swollen and there was deformity of lower third of right thigh. X-ray revealed fracture of lower third of right femur. Femoral fracture was treated by immobilisation in full plaster cast. Follow-up ultrasound examination of urinary tract, performed by a senior Radiologist, revealed normal outline of urinary bladder with no tumour or calculus. CONCLUSION: The adverse outcomes can be averted if elderly spinal cord injury patients are treated by senior, experienced health professionals, who are familiar with changes in body systems due to old age, compounded further by spinal cord injury.

Missed signs of autonomic dysreflexia in a tetraplegic patient after incorrect placement of urethral Foley catheter: a case report.

BACKGROUND: Autonomic dysreflexia is poorly recognised outside of spinal cord injury centres, and may result in adverse outcomes including mortality from delayed diagnosis and treatment. We present a spinal cord injury patient, who developed autonomic dysreflexia following incorrect placement of urethral Foley catheter. Health professionals failed to recognise signs and symptoms of autonomic dysreflexia as well as its significance in this tetraplegic patient. CASE PRESENTATION: A tetraplegic patient started sweating profusely following insertion of a Foley catheter per urethra. The catheter was draining urine; there was no bypassing, no bleeding per urethra, and no haematuria. Patient's wife, who had been looking after her tetraplegic husband for more than forty years, told the health professionals that the catheter might have been placed incorrectly but her concerns were ignored. Ultrasound scan of urinary tract revealed no urinary calculi, no hydronephrosis. The balloon of Foley catheter was not seen in urinary bladder but this finding was not recognised by radiologist and spinal cord physician. Patient continued to sweat profusely; therefore, CT of pelvis was performed, but there was a delay of ten days. CT revealed the balloon of Foley catheter in the over-stretched prostate-membranous urethra; the tip of catheter was not located within the urinary bladder but was lying distal to bladder neck. Flexible cystoscopy was performed and Foley catheter was inserted into the bladder over a guide wire. The intensity of sweating decreased; noxious stimuli arising from traumatised urethra might take a long while to settle. CONCLUSION: Inserting a catheter in a tetraplegic patient should be carried out by a senior health professional, who is familiar with spasm of bladder neck which occurs frequently in tetraplegic patients. Facilities for urgent CT scan should be available to check the position of Foley catheter in spinal cord injury patients when a patient manifests signs and symptoms of autonomic dysreflexia following insertion of a urethral catheter. When an isolated symptom such as flushing or sweating is noticed in a tetraplegic patient, doctors should seek out other signs/symptoms of autonomic dysreflexia.

Candida albicans Fungaemia following Traumatic Urethral Catheterisation in a Paraplegic Patient with Diabetes Mellitus and Candiduria Treated by Caspofungin.

A 58-year-old paraplegic male, with long-term indwelling urethral catheter, developed catheter block. The catheter was changed, but blood-stained urine was drained intermittently. A long segment of the catheter was seen lying outside his penis, which indicated that the balloon of Foley catheter had been inflated in urethra. The misplaced catheter was removed and a new catheter was inserted correctly. Gentamicin 160 mg was given intravenously; meropenem 1 gram every eight hours was prescribed; antifungals were not given. Twenty hours later, this patient developed distension of abdomen, tachycardia, and hypotension; he was not arousable. Computed tomography of abdomen revealed inflamed uroepithelium of right renal pelvis and ureter, 4 mm lower ureteric calculus with gas in right ureter proximally, and vesical calculus containing gas in its matrix. Urine and blood culture yielded Candida albicans. Identical sensitivity pattern of both isolates suggested that the source of the bloodstream infection was most likely urine. Both isolates formed consistently high levels of biofilm formation in vitro as assessed using a biofilm biomass stain, and high levels of resistance to voriconazole were observed. Both amphotericin B and caspofungin showed good activity against the biofilms. HbA1c was 111 mmol/mol. This patient was prescribed human soluble insulin and caspofungin 70 mg followed by 50 mg daily intravenously. He recovered fully from candidemia.

Failure of Urological Implants in Spinal Cord Injury Patients due to Infection, Malfunction, and Implants Becoming Obsolete due to Medical Progress and Age-Related Changes in Human Body Making Implant Futile: Report of Three Cases.

Any new clinical data, whether positive or negative, generated about a medical device should be published because health professionals should know which devices do not work, as well as those which do. We report three spinal cord injury patients in whom urological implants failed to work. In the first, paraplegic, patient, a sacral anterior root stimulator failed to produce erection, and a drug delivery system for intracavernosal administration of vasoactive drugs was therefore implanted; however, this implant never functioned (and, furthermore, such penile drug delivery systems to produce erection had effectively become obsolete following the advent of phosphodiesterase type 5 inhibitors). Subsequently, the sacral anterior root stimulator developed a malfunction and the patient therefore learned to perform self-catheterisation. In the second patient, also paraplegic, an artificial urinary sphincter was implanted but the patient developed a postoperative sacral pressure sore. Eight months later, a suprapubic cystostomy was performed as urethral catheterisation was very difficult. The pressure sore had not healed completely even after five years. In the third case, a sacral anterior root stimulator was implanted in a tetraplegic patient in whom, after five years, a penile sheath could not be fitted because of penile retraction. This patient was therefore established on urethral catheter drainage. Later, infection with Staphylococcus aureus around the receiver block necessitated its removal. In conclusion, spinal cord injury patients are at risk of developing pressure sores, wound infections, malfunction of implants, and the inability to use implants because of age-related changes, as well as running the risk of their implants becoming obsolete due to advances in medicine. Some surgical procedures such as dorsal rhizotomy are irreversible. Alternative treatments such as intermittent catheterisations may be less damaging than bladder stimulator in the long term.

Postoperative Complications Leading to Death after Coagulum Pyelolithotomy in a Tetraplegic Patient: Can We Prevent Prolonged Ileus, Recurrent Intestinal Obstruction due to Adhesions Requiring Laparotomies, Chest Infection Warranting Tracheostomy, and Mechanical Ventilation?

A 22-year-old male sustained C-6 tetraplegia in 1992. In 1993, intravenous pyelography revealed normal kidneys. Suprapubic cystostomy was performed. He underwent open cystolithotomy in 2004 and 2008. In 2009, computed tomography revealed bilateral renal calculi. Coagulum pyelolithotomy of left kidney was performed. Pleura and peritoneum were opened. Peritoneum could not be closed. Following surgery, he developed pulmonary atelectasis; he required tracheostomy and mechanical ventilation. He did not tolerate nasogastric feeding. CT of abdomen revealed bilateral renal calculi and features of proximal small bowel obstruction. Laparotomy revealed small bowel obstruction due to dense inflammatory adhesions involving multiple small bowel loops which protruded through the defect in sigmoid mesocolon and fixed posteriorly over the area of previous intervention. All adhesions were divided. The wide defect in mesocolon was not closed. In 2010, this patient again developed vomiting and distension of abdomen. Laparotomy revealed multiple adhesions. He developed chest infection and required ventilatory support again. He developed pressure sores and depression. Later abdominal symptoms recurred. This patient's general condition deteriorated and he expired in 2011. Conclusion. Risk of postoperative complications could have been reduced if minimally invasive surgery had been performed instead of open surgery to remove stones from left kidney. Suprapubic cystostomy predisposed to repeated occurrence of stones in urinary bladder and kidneys. Spinal cord physicians should try to establish intermittent catheterisation regime in tetraplegic patients.

Challenges in diagnosis and treatment of a cervical spinal cord injury patient with melanoma, adenocarcinoma, and hepatic and osteolytic metastases: need to implement strategies for prevention and early detection of cancer in spinal cord injury patients.

A male tetraplegic patient with, who had been taking warfarin, developed haematuria. Ultrasound scan revealed no masses, stones, or hydronephrosis. Urinary bladder had normal configuration with no evidence of masses or organised haematoma. Urine cytology revealed no malignant cells. Four months later, CT urography revealed an irregular mass at the base of urinary bladder. Cystoscopic biopsy revealed moderately differentiated adenocarcinoma, which contained goblet cells and pools of mucin showing strongly positive immunostaining for prostatic acid hosphatase and patchy staining for prostate specific antigen. Computed Tomography revealed multiple hypodense hepatic lesions and several osteolytic areas in femoral heads and iliac bone. With a presumptive diagnosis of prostatic carcinoma, leuprorelin acetate 3.75 mg was prescribed. This patient expired a month later. Conclusion. (i) Spinal cord injury patient, who passed blood in urine while taking warfarin, requires repeated investigations to look for urinary tract neoplasm. (ii) Anti-androgen therapy should be prescribed for 2 weeks prior to administration of gonadorelin analogue to prevent tumour flare causing bone pain, bladder outlet obstruction, uraemia, and cardiovascular risk due to hypercoagulability associated with a rapid increase in tumour burden. (iii) Spinal cord physicians should adopt a caring and compassionate approach while managing tetraplegic patients with several co-morbidities, as aggressive diagnostic tests and therapeutic procedures may lead to deterioration in the quality of life.