A case of metastasizing pleomorphic adenoma.

The pleomorphic adenoma is the most common benign salivary neoplasm. A case is presented in which a palatal pleomorphic adenoma seeded a metastasis in the medullary cavity of the anterior maxilla, apparently by hematogenous spread after surgical manipulation.

Urinary catheter blockage depends on urine pH, calcium and rate of flow.

Urinary catheters tend to block when biofilm from urease-producing organisms build up on the catheter surface. This is a locally-occurring process that influences and influenced by the composition of the urine. In this work we relate urine pH and calcium to catheter blockage and suggest how to reduce the rate of encrustation. Sixty patients with indwelling urinary catheters were studied, 26 of them being troubled by frequent blockage of their catheters, 34 of them not. A series of small urine samples were collected during a 24 h period. Urinary pH and calcium concentration were combined into discriminant functions designed to separate Blockers from Non-blockers and achieved a 95% correct classification. The results indicate that a high and uniform rate of fluid intake is mandatory for the patient with a tendency for catheter blockage. Excessive total fluid intake may be avoided by attention to uniformity. Other avoidable risk factors include: excess dietary calcium from certain protein supplements and antacids; excess dietary magnesium from certain beverages and antacids; alkali from effervescent tablets; excess dietary citrate from some fruit juices and cordials; intermittent dehydration from alcohol ingestion. Less tractable risk factors include infection of the urinary tract with urease-positive organisms, hypercalciuria of immobilisation, hyperhydrosis and postural oliguria. The processes involved in catheter encrustation and blockage provide a model for the formation of calculi in spinal cord injured patients. Therefore the above considerations may also be relevant to the management of stone disease in paraplegic and tetraplegic patients.

The reduced urinary output after spinal cord injury: a review.

Oliguria in patients following spinal cord injury was first mentioned in 1649, but has since been referred to only occasionally. The work detailed here was completed 30 years ago but is reported because of the lack of any comparable study and because suitable patients are not now readily available. A total of 27 water load tests were carried out on 20 patients. The test included measurement of serum osmolality to confirm absorption of ingested water. Impaired response to the water load was obtained in 17 tests: 12/13 between 1 and 5 days after onset of the cord lesion and 5/14 more than 2 weeks after injury. The possibilities that oliguria was due to dehydration, failure to absorb ingested water, hypotension or renal failure are discounted. In the first few days after injury, oliguria may be due to release of antidiuretic hormone as part of the metabolic response to trauma. The impaired response seen later is discussed in relation to possible neural and hormonal mechanisms. There is a need for further study of factors influencing water excretion in tetraplegic and paraplegic patients.

The blocking urinary catheter: the role of variation in urine flow.

OBJECTIVES: To relate blockage of the urinary catheter to urine chemistry. PATIENTS AND METHODS: Of 44 patients (age range 19-72 years) with an indwelling urinary catheter, 21 were troubled by frequent blockage and 23 experienced no blockage. Variation in urinary pH and calcium concentration were determined during a 24 h period and related to the occurrence of blockage using discriminant analysis. RESULTS: The maximum pH and calcium concentrations observed, or the maximum discriminant factors calculated, correctly discriminated 91% of patients (95% CI, 78-97%). CONCLUSION: Attention to volume and variability of fluid intake by the patient should have a major impact on the incidence of blockage of the indwelling urinary catheter.

Creatinine, calcium, citrate and acid-base in spinal cord injured patients.

The aim of this work was to recognise factors responsible for reduced citrate excretion, previously reported in patients with spinal cord lesions and possibly related to the occurrence of urinary tract stone or catheter blockage. Inter alia, a reference range for creatinine in plasma (34-88 mumol/l) was also obtained. Two groups of subjects were studied. The first group consisted of 64 male inpatients with spinal cord lesions and 20 male control subjects. The second group were 342 spinal patients who attended an outpatient clinic and 31 control subjects. Plasma calcium was within the normal range but higher in patients within 1 year of onset of the cord lesion than it was later or than was found in control subjects. Plasma pH and bicarbonate were within the normal range but higher in the patients than in the control subjects. When patients with urea-splitting infection were omitted the patients had a higher urinary pH and a lower urinary ammonium than the controls. Urinary and plasma citrate were lower in the patients than in the controls. Urinary citrate was related to urinary potassium and creatinine clearance. Fractional renal tubular reabsorption of citrate did not differ between patients with normal renal function and control subjects. Patients with normal glomerular filtration had lower filtered load of citrate than the controls. The coincidence of relative alkalosis and reduced citrate excretion may be relevant to the understanding of catheter blockage and urinary stone formation in spinal cord injured patients.

The relationship of heterotopic ossification to passive movements in paraplegic patients.

Heterotopic ossification (HO) occurs in 4-49% of patients with spinal cord injury, but the cause of the complication has not been established. The aim of this study was to investigate clinical factors related to the occurrence of HO. The incidence of HO was determined in 91 consecutive patients with traumatic lesions of the spinal cord who had been admitted to the National Spinal Injuries Centre for management and rehabilitation. Clinical data were analysed. Clinically apparent HO occurred only in 10 of 56 patients in whom the start of passive movements to their paralysed limbs was delayed until 7 days or more from time of injury. The findings of this study are consistent with the view that HO occurs as a result of trauma induced by passive movements carried out on joints where contractures have started to develop.

Haemoglobin and albumin as predictors of length of stay of spinal injured patients in a rehabilitation centre.

The aim of this work was to identify factors related to the length of stay of patients admitted to this centre for rehabilitation. The study involved 200 patients admitted within one year of onset of a spinal cord lesion. Clinical and laboratory data were recorded. Length of stay was related to the level of the spinal cord lesion and whether it was complete or incomplete. The length of stay was increased in patients in whom anaemia or hypoalbuminaemia occurred; the cause of these conditions was not always evident. We conclude that attention directed towards recognising and treating the cause of anaemia or hypoalbuminaemia may be expected to shorten the time required for rehabilitation in this centre.

Associations between mood and specific health composites during U.S. Navy Persian Gulf operations.

Previously conducted field studies using shipboard U.S. Navy personnel during at-sea operations in the Persian Gulf have shown that crew members experience mood changes and degradations in general physical health. The objectives of this study were to: (a) examine the relationship between mood and health complaints among personnel deployed in the Persian Gulf; and (b) extend previous research using specific health composites rather than a general measure of health. Mood was assessed for 104 shipboard volunteers using the Profile of Mood States Tension/Anxiety and Fatigue subscales. Health symptoms were measures using the Environmental Symptoms Questionnaire. Results of multiple regression analyses showed that each of 11 distinct health composites was significantly associated with one or both mood variables. Further, the two mood factors were differentially associated with 9 of the 11 health composites. This study underscores the usefulness of employing multiple specific health measures rather than global measures.

Blockage of indwelling urinary catheters: the roles of urinary composition, the catheter, medication and diet.

The aim of this work was to study factors related to the blockage of indwelling urinary catheters. There were 40 patients with indwelling catheters, 20 of whom had catheters that blocked frequently. The other 20 were trouble free at the time of our study. The type and gauge of catheter and frequency of events were recorded. Urine samples for biochemical analysis comprised 24-hour collections, morning specimens on up to 10 different days and 5-8 samples at different times during the same day. Chemical analysis of debris removed from blocked catheters showed it to consist of mixed phosphates of calcium and magnesium, thus being similar to urinary stones that may be seen in spinal cord injury patients. Patients with frequent catheter blockage had significantly elevated urinary pH and ammonium and calcium concentrations. Discriminant analysis gave 78-94% separation of catheter blocking patients from nonblockers depending on the type of sample. We conclude that bacterial urease activity and urinary calcium concentration are the most important factors in catheter blockage. Elevation of urinary pH following ingestion of effervescent preparations, drug- or diet-induced increases in urinary calcium or magnesium excretion and inadequate or erratic fluid intake may be avoidable contributing factors.

Citrate excretion in spinal cord patients.

Low urinary citrate is a risk factor in calcium renal stone disease. The aim of this work was to identify the factors responsible for the low excretion of citrate frequently observed in patients with spinal cord lesions. Thirty male patients with spinal cord lesions were studied by blood and urine biochemistry. The most important single factor related to urinary citrate was urinary potassium. The presence or absence of urinary stone disease and variations in urinary volume also contributed significantly to variations in citrate excretion. Determination of plasma and urinary citrate, urinary sodium and bacteriological culture of urine permitted complete discrimination of the 7 stone formers from the other patients.