Bladder cancer risk in patients with spinal cord injury.

Bladder cancer (BC) is the fourth most common cancer in men. It is associated with several risk factors (RF), of which only a few have been evaluated in previous studies. Models incorporating only one or a severely restricted number of RFs did not predict BC well. We employed 19 a priori RFs and 12 interactions in a multivariate logistic regression analysis for the prediction of BC in a sample of subjects with spinal cord injury (SCI), of whom 149 were outpatients (7 with BC) and 4 were inpatients with BC. We also replicated dichotomous predictions for 10 of the 19 RFs that have been most frequently associated with a higher BC risk in the literature. The overall test for 31 predictors was significant (p = 0.0038). A dichotomized predictor correctly identified 9 of 11 BC cases and all 142 but one of the cases without BC. A more parsimonious subset of 21 predictors satisfied a Scheffé-type multiple comparison criterion. Although duration of SCI satisfied a Bonferroni criterion for statistical significance, it did not satisfy a Scheffé criterion. In the replication studies, only dichotomized duration of indwelling catheterization for at least 10 years significantly replicated the previous findings. Results of this study suggest that using multiple risk factors and interactions in a comprehensive statistical model may provide useful screening of patients with SCI for BC risk. Since early identification of BC substantially improves prognosis, such a model may identify patients at highest risk who are most likely to benefit from bladder biopsy.

Polyethylene glycol versus vegetable oil based bisacodyl suppositories to initiate side-lying bowel care: a clinical trial in persons with spinal cord injury.

INTRODUCTION: Neurogenic bowel dysfunction resulting from spinal cord injury (SCI) frequently requires bowel care (BC) with stimulant suppositories for initiation of effective defecation. The excessive time required for BC and bowel complications have limited quality of life after SCI. OBJECTIVE: To test the hypothesis that: the time required for bowel care with bisacodyl suppositories can be reduced by substituting a polyethylene glycol base (PGB) for the traditional hydrogenated vegetable oil base (HVB) in the suppository. SETTING: Inpatient SCI medicine unit. SUBJECTS: Fourteen persons with SCI with chronic stable paralysis from upper motor neuron SCI for greater than one year with a stable HVB bisacodyl suppository initiated BC. DESIGN: Crossover Controlled. METHOD: Subjects received HVB bisacodyl suppositories for six sequential BC sessions and then were crossed over to PGB bisacodyl suppositories for six more BCs. OUTCOME MEASURES: BC event times were utilized to derive BC intervals: suppository insertion to first flatus= Time to flatus, first flatus until the beginning of stool flow = Flatus to stool flow, begin stool flow until end stool flow = Defecation period, end stool flow until end of clean up = Clean up, and suppository insertion until end clean up = Total bowel care time. RESULTS: The data included two groups of BC sessions: HVB (n = 84) and PGB (n = 81). Mean times in minutes and P values from t tests for paired samples yielded: Time to flatus: (HVB 31, PGB 12.8 P < 0.002), Defecation period: (HVB 58, PGB 32, P < 0.0005), Clean up: (HVB 1.9, PGB 3.2 P = 0.165), Total bowel care time: (HVB 102, PGB 51.2 P < 0.0005). CONCLUSION: This analysis suggests that PGB based bisacodyl suppositories may stimulate reflex defecation sooner and shorten the Total BC Time as compared with HVB bisacodyl suppositories.

Paradigm for SCI nurse competency on adult-geriatric SCI rehabilitation unit.

This article is based upon an SCI Model Project, funded by the American Association of Spinal Cord Injury Nurses (AASCIN). The purpose of this project was to develop a model to validate theoretical and practical knowledge of Registered Nurses and Licensed Practical Nurses/Licensed Vocational Nurses in an SCI rehabilitation setting. The investigators were direct care providers in a 68 bed SCI rehabilitation service at the James A. Haley Veterans Hospital in Tampa, Florida. The theoretical framework was based upon three aspects: Competency Validation, Theoretical Knowledge, and Practical Knowledge. Competency Validation was directed towards incorporating the elements of assessment, maintenance, demonstration, and improvement of competencies on an ongoing basis. Theoretical knowledge encompassed the cognitive and psychomotor aspects of SCI nursing, and Practical Knowledge highlighted the application of principles of caregiving. Two instruments were developed to harmonize theoretical and practical dimensions for competency validation: SCI Knowledge/Skill Appraisal (SKA) and Expertise in SCI Nursing Practice (ESNP). The purpose of this project was to design a model for validating theoretical and practical knowledge of Registered Nurses (RN's) and Licensed Practical Nurses/Licensed Vocational Nurses (LPN/LVN's) in an SCI rehabilitation setting. The investigators were direct care Licensed Practical Nurses/Licensed Vocational Nurses (LPN/LVN's) in an SCI rehabilitation setting. The investigators were direct care providers in a 68 bed spinal cord injury (SCI) rehabilitation service at the James A. Haley Veterans Hospital in Tampa, Florida.

Intermittent catheterization the right way! (Volume vs. time-directed).

Intermittent catheterization (ICP) is a well-proven effective means of urologic management for spinal cord diseased (SCD) persons who meet the following criteria: adequate low pressure bladder capacity (350-400 cc minimum), adequate hand function, unobstructed urethra and compliant, understanding, continent, cooperative patients. Time-directed (Q4 H-Q6 H), ICP-obtained volumes on twenty-one patients revealed a majority of early, unnecessary as well as some late over-distended bladder catheterizations. The PCI 5000 or "Bladder Manager", a miniaturized ultrasonic bladder volume measuring device developed by Diagnostic Ultrasound of Seattle, was evaluated. It allowed the patients to perform volume-directed ICP which results in less frequent catheterizations and prevents bladder overdistension.

Magnetic resonance imaging examinations of gluteal decubitus ulcers in spinal cord injury patients.

The purpose of our study was to use magnetic resonance imaging (MRI) to determine deep changes in soft tissues and bones underlying decubitus ulcers which occur in spinal cord injury (SCI) patients. By diagnosing these deep changes adjacent to decubitus ulcers, MRI can facilitate proper clinical management and prevent contraindicated surgery. MRI evaluation was performed on 37 male SCI patients for a total of 44 diagnostic studies. The studies were evaluated by the following criteria: 1) the presence of an adjacent fluid collection, 2) bone involvement raising the possibility of osteomyelitis and 3) heterotopic bone formation. Results demonstrated 11 patients (29.7 percent) with fluid collection in the deep soft tissues underlying the decubitus ulcer and eight patients (21.6 percent) with abnormal adjacent bone marrow signal. Four patients (10.8 percent) had heterotopic bone formation near the ulcer. We conclude that MRI is helpful in determining the depth and extent of soft tissue involvement underlying decubitus ulcers including underlying fluid collections, heterotopic bone formation and evidence of adjacent bone marrow edema. This is beneficial in planning proper therapy.

Selective permeability of [3H]-D-mannitol and [14C]-carboxyl-inulin across the blood-brain barrier and blood-spinal cord barrier in the rabbit.

Selective permeability across the blood-brain and blood-spinal cord barriers was studied in a rabbit experimental model. To maintain steady state levels of the tracers in the circulation, 50muCi each of [3H]-D-mannitol and [14C]-carboxyl-inulin were administered as a bolus and by slow intravenous infusion for 60, 90 and 120 minutes; 90 min proved to be the optimal equilibration time for uptake of radioactive tracers into central nervous system (CNS) regions. Kinetic transfer of [3H]-D-mannitol and [14C]-carboxyl-inulin from blood into CNS was computed as apparent transfer constant (KD). The KD for [3H]-D-mannitol in regions of brain (cerebrum, cerebellum, mid-brain, pons and brain stem), and spinal cord (cervical, thoracic and lumbar) were 0.033 to 0.054 microliter/min/g-1 and 0.053 to 0.065 microliter/min/g-1, respectively. The KD for [14C]-carboxyl-inulin into brain and spinal cord regions were 0.016 to 0.033 and 0.037 to 0.054 microliter/min/g-1, respectively. Of the regions of spinal cord and brain examined, lumbar cord appears to be the most permeable. The KD values pooled for samples of the spinal cord show a significant increase in uptake of [3H]-D-mannitol (p = 0.0043) and [14C]-carboxyl-inulin (p = 0.0001) compared to samples of brain. The blood-spinal cord barrier was more permeable to these substances than the blood-brain barrier.

Randomized comparison of balloon dilation and transurethral incision for treatment of symptomatic benign prostatic hyperplasia.

The concept of relieving the symptoms of benign prostatic hyperplasia (BPH) by dilating the urethral has existed for centuries. Thirty patients with a clinically estimated prostate gland size of 25 g or less were randomized to either balloon dilation (BDP) or transurethral incision of the prostate (TUIP). The mean pretreatment Madsen-Iverson symptom scores in the two groups were 15.0 +/- 4.9 (SD) and 15.4 +/- 4.4, respectively. The early response rates were 87% fo BDP and 86% for TUIP, with the mean symptom scores declining to 3.4 +/- 2.8 after dilation and 4.2 +/- 6.6 after incision. Among the 14 patients who initially responded to BDP, 2 have been lost to follow-up, 1 died of unrelated causes at 17 months with no urinary symptoms, 2 remain in response at 32 and 38 months, and the other 9 (75% of those available for evaluation) have developed recurrences. Among the 12 patents who responded to TUIP, 2 have been lost to follow-up, 8 remain in response at 14 to 48 months, and 2 (20%) developed recurrences by 44 months of follow-up. In the short term, both BDP and TUIP are effective for treating bladder outlet obstruction in men with relatively small prostates. However, the effect of dilation appears to be less durable than that of incision.

Balloon dilation of the prostate. Critical evaluation.

We describe the results of prostatic balloon dilation in 7 patients with a follow-up of 9 months. Symptom scores dramatically fell in 5 patients (success rate 71%), which is confirmed by a significant improvement in peak flow in 4 of them. Two patients failed to improve and needed a subsequent intervention which revealed a stage A2 prostatic carcinoma in one. During subsequent open prostatectomy, a condition analogous to dilation with the Deisting dilator was seen. We conclude that the indications and results obtained with the balloon dilator are similar to those with the Deisting dilator.

Balloon dilatation of the external urethral sphincter: a case study.

A new and simple endoscopic treatment procedure of external urethral sphincters is described. The external urethral sphincter was dilated with a balloon catheter 25mm in diameter in a multiple sclerosis patient; the sphincter spasticity made intermittent catheterization impossible. Post dilatation, the resistance to catheterization completely disappeared and the urethral pressure profile showed a dramatic fall in sphincteric pressure. This fall in sphincteric pressure has remained at a normal post dilatation level at the time of submission of this article (7 months).

Transurethral sphincteric stimulation.

Electrical stimulation of the external urethral sphincter is a valuable aid in teaching sphincterotomies and transurethral procedures. It helps accurately locate the external urethral sphincter which should be transected totally during a sphincterotomy and left intact in a transurethral procedure.