Bacillary angiomatosis of the conjunctiva.

A 70-year-old man had unilateral congestion of the right upper eyelid, which contained a nodular mass. A biopsy was performed, and histologic, immunocytochemical, and ultrastructural studies disclosed a pseudoneoplastic proliferation of endothelial cells and pericytes in a region containing clumps of bacteria. This combination of histologic features is characteristic of bacillary angiomatosis, which has been described in the skin, particularly in association with immunodeficient states, especially acquired immunodeficiency syndrome, but not in the conjunctiva. A second biopsy contained a diffuse polyclonal lymphocytic infiltrate in which large lymphocytes with irregular nuclei and mitotic figures were prominent. Systemic examination disclosed mild splenomegaly and a benign paraproteinemia. Treatment with topical gentamicin and systemic erythromycin brought about a complete resolution of the symptoms and signs within eight weeks, and there has been no sign of recurrence for the past two years.

Review of urinary tract abnormalities in 100 patients with spinal cord paralysis.

The importance of long term follow up of neurological status of patients with spinal cord injuries is well recognised. Although there is a general agreement about continued radiological surveillance of these patients, there is lack of uniformity of approach and guidelines as to how frequently such screening should be undertaken and for how long it should be continued. The present study, following analysis of clinical and radiological data of 100 sequential patients, indicates that morphological complications of urinary tract are common (63% in patients studied) and that a significant number (70-75%) develop complications within the first year following onset of spinal cord dysfunction. The development of these changes appears to be related to more than 8 weeks of presence of continuous indwelling catheter during patients' initial bladder management. The study further suggests that the risk of developing demonstratable abnormalities after 10 years of normal radiology is very small (approximately 1%). It is, therefore, suggested that patients with spinal cord paralysis should have surveillance of urinary tract annually for 10 years and that the follow up beyond 10 years should be determined by clinical necessity rather than a fixed protocol.

Rehabilitation of spinal cord injured patients on long term ventilation.

Recent advances in roadside management and resuscitation techniques have resulted in an increased survival rate of people with high cervical cord injury. A few become partially or permanently ventilator dependent. Not only are these people dependent on assisted ventilation, but their speech is also compromised, along with loss of voluntary control and many other bodily functions, as they are tetraplegic. By using recent technological advancements, such as portable ventilators, phrenic nerve stimulation, environmental controls and specialised wheelchairs it has been possible to manage such patients at home. Furthermore, patients on ventilators are unable to have verbal communication. There is therefore a need for them to develop either augmentative communication or the use of alternative communication aids. Recent published reports indicate the factors other than the clinical state that may prevent such patients from taking advantage of modern advances; the main issues appear to be cost factors, community care provision and ethical considerations.

N-nitrosamine generation by urinary tract infections in spine injured patients.

Urine was collected from 33 patients resident at the Welsh Spinal Injuries Unit and analysed for volatile N-nitrosamines by gas chromatography. N-nitrosodime-thylamine, N-nitrosopiperidine or N-nitrosopyrrolidine was detected in 32 of the samples. Thirty-one of the samples were infected by one or more microbial species. Nitrate and N-nitrosamines were not found in the sterile urines of a group of 10 control individuals exposed to the same dietary and environmental influences as the spinal patients. Although N-nitrosamines were found in some of the catheter drainage system products, they did not elute into urine on 24-h exposure. In addition, 6 of the nitrosamine-containing urines had no contact with drainage systems as they were collected from spinal patients who were capable of independent voiding. It was concluded that the nitrosamines detected in the urines arose from the bacterial nitrosation of urinary amines. These results support the hypothesis that chronic urinary tract infection may have a role in the aetiology of bladder cancer in spine injured patients.

Increased urinary nitrosamine excretion in paraplegic patients.

An increased risk of bladder cancer is a recognized complication in spine-injured patients undergoing long-term urethral catheterization to preserve renal function. Aerobic cultures from 28 of 30 paraplegic patients showed complex bacterial flora containing nitrate-reducing organisms (Escherichia coli, Proteus and Klebsiella spp.). Urine samples from 29 paraplegic patients were also found to contain volatile nitrosamines. Mean N-nitrosamine excretion levels were 0.65 +/- 0.69 micrograms/day N-nitrosodimethylamine, 0.25 +/- 0.44 micrograms/day N-nitrosopiperidine and 0.39 +/- 0.50 micrograms/day N-nitrosopyrrolidine. A mean urinary nitrite excretion of 10.4 +/- 13.2 mg/day was found in 24 out of 30 paraplegic patients. In the sterile urine of control volunteers (medical staff attending the paraplegic patients and in-patients from other wards of the hospital), no urinary excretion of volatile N-nitrosamines and nitrite was found. The results clearly demonstrate a bacterially mediated in vivo formation of N-nitroso compounds in the urinary tracts of paraplegic patients which may be an important etiological risk factor for bladder cancer in this patient group.

An appraisal of antibiotic policies for urinary tract infections in patients with spinal cord injuries undergoing long-term intermittent catheterisation.

The antibiotic policies that have been recommended in the literature for the prevention and treatment of urinary tract infections in patients with spinal cord injuries undergoing long-term intermittent catheterisation are reviewed. Current practices in spinal units in England and Wales are reported and the rational bases of these policies are considered.

Pseudomonas aeruginosa and long-term indwelling bladder catheters.

The ability of urinary isolates of nine species of bacteria to bind to urinary catheters has been assessed using a bioluminescence technique. The experiments revealed the particularly adherent properties of Pseudomonas aeruginosa. This organism has also been shown to be most frequently isolated from the urines of the patients undergoing indwelling catheterization. It is suggested that P. aeruginosa commonly grows on the surface of catheters in situ, and that at this site it can survive antibiotic therapy and cause apparent recurrence of infection by reinoculation of the urine once therapy has been completed.

Assessment of antiseptic bladder washout procedures using a physical model of the catheterised bladder.

A simple physical model of the catheterised bladder has been used to assess the activities of antiseptic agents that have been recommended as bladder instillations in the treatment of urinary tract infections in patients with indwelling catheters. The activities of povidone-iodine, phenoxyethanol, chlorhexidine, chlorhexidine supplemented with EDTA + Tris, noxythiolin and neomycin were examined against selected species of uropathogens. Except for phenoxyethanol against Pv. stuartii and possibly Ps. aeruginosa, single applications of these antibacterials for 30 min were not effective in sterilising urine in the artificial bladder. However, a second application 1 h later of phenoxyethanol but not chlorhexidine or povidone-iodine did eradicate Ps. aeruginosa. It is suggested that bacteria growing as a film on the bladder wall are particularly resistant to antimicrobials.

The resistance of urinary tract pathogens to chlorhexidine bladder washouts.

Isolates of Providencia stuartii, Pseudomonas aeruginosa, Proteus mirabilis, Klebsiella pneumoniae and Streptococcus faecalis from urinary-tract infections in spinally-injured patients together with Escherichia coli 10418 were challenged with chlorhexidine (200 mg l-1) in a model of a catheterized bladder under conditions which simulate the bladder washout technique. All species survived the antiseptic. Organisms growing on the wall of the bladder model appeared to be particularly resistant and electron microscopy showed that these cells were embedded in a protective glycocalyx. The effect of chlorhexidine bladder washouts on the bacterial flora in the urine of patients was also observed and shown to be minimal and temporary. Examination of urinary sediments from patients revealed the presence of micro-colonies of bacteria embedded in a polysaccharide matrix. We conclude that bladder washouts with chlorhexidine are not likely to eliminate established infections with organisms that occur in patients with indwelling bladder catheters.

A study of the skin flora of spinal cord injured patients.

The skin flora of 11 spinally-injured patients was compared to that of 11 healthy control subjects. The perinea, groins, penile shafts and urethras of the patients were heavily colonized by a range of multi-drug resistant Gram-negative bacilli. Observations on patients from admission for up to 25 days suggest that the Gram-negative bacilli start to colonize the skin 2-3 days after admission. Some species, e.g., Citrobacter diversus and Escherichia coli appear as transient organisms while others such as Enterobacter aerogenes, Serratia marcescens, and Klebsiella pneumoniae seem to become stable skin residents. The relationship of the skin flora to the organisms causing urinary tract infections in these patients was studied.

Providencia stuartii: a search for its natural habitat.

A selective differential medium has been used to search for Providencia stuartii in sewage, sewage contaminated natural waters and the faeces and skin of a small population of healthy non-hospitalized males. Colonization of 12 male patients with long-term indwelling bladder catheters and the general environment of the spinal injury unit was also examined. Providencia stuartii was not isolated from the non-hospital samples, but colonization of the urine (two patients) faeces (five patients) and skin (eight patients) was observed. Apart from equipment that had been in contact with patients urine or skin there was no general contamination of the ward environment suggesting that colonized patients were the main reservoir of this multiply antibiotic-resistant nosocomial pathogen.

Antiseptic and antibiotic resistance in gram-negative bacteria causing urinary tract infection in spinal cord injured patients.

Fifty-seven isolates of Gram-negative bacterial species from urinary tract infections in spinal cord injured patients were tested for their sensitivity to chlorhexidine, cetrimide, glutaraldehyde, phenyl mercuric nitrate (PMN), a phenolic disinfectant (Hycolin) and a proprietary antiseptic containing a mixture of picloxydine, octylphenoxypolyethoxyethanol and benzalkonium chloride (Resiguard). None of the isolates were resistant to glutaraldehyde, Hycolin or PMN but a substantial percentage were resistant to chlorhexidine (44 per cent), cetrimide (26 per cent) and Resiguard (42 per cent). The resistant organisms were members of the genera Proteus, Providencia and Pseudomonas and they were also generally resistant to five, six or seven antibiotics. Significant correlations were observed between multiplicity of antibiotic resistance and the minimum inhibitory concentrations of the three cationic antiseptics. It is suggested that an antiseptic policy for the bladder management of spinal cord injured patients that relies on the extensive use of cationic agents might lead to the selection of a flora of notoriously drug-resistant species.

Some observations on the activity of three antiseptics used as bladder irrigants in the treatment of urinary tract infection in patients with indwelling catheters.

A comparison has been made of the activity of three antiseptics that are used as bladder irrigants in the treatment of urinary tract infection in catheterised patients. At the concentrations and exposure times used for bladder irrigation, phenoxyethanol (2:4% v/v) proved to be highly bactericidal against urine-grown cells of all the common urinary pathogens tested. Chlorhexidine (200 microgram/ml) was active against Escherichia coli and produced significant reductions in the viability of Klebsiella pneumoniae, Proteus mirabilis and Pseudomonas aeruginosa but failed to eradicate Providencia stuartii. Exposure to noxythiolin (2.5% v/v) for 20 min had little effect in any of the bacteria, even though all strains tested had been recorded as noxythiolin-sensitive by conventional plate sensitivity tests. Contact with noxythiolin for periods of at least 1-2 hrs was necessary before extensive bactericidal activity was detected. These results provide an explanation of the poor clinical performance of noxythiolin that we have observed.

Electronic communications and environmental control systems for the severely disabled.

A wireless environmental controller is described. The controller can either be used by itself or with other systems. It is suggested that commercially available personal computers, for environmental control and communication, will enable the severely disabled to lead a more independent life and may provide useful mental recreation.

Techniques for improving the strength and fitness of spinal injured patients.

Physiological data on athletes and animals has been used to design this training programme and to suggest new perspectives for trainin the spinal cord injured. The training routines proposed are designed to improve endurance and strength and modern weight training equipment has been modified for this purpose.