Nocturnal bladder emptying and Quality of Life in patients with spinal cord injury.

BACKGROUND: Little is known about the relationship between sleep disruption due to nocturnal bladder emptying and Quality of Life in patients with spinal cord injury. AIM: The aim of this study was to evaluate the possible influence of number of nocturnal bladder emptying, bladder emptying method and nocturnal incontinence on the Quality of Life of patients with spinal cord injury. DESIGN: The design of this paper is a cross-sectional descriptive study. SETTING: The setting is in- and outpatient. POPULATION: Seventy-nine patients aged between 18 and 77 years with SCI in a first rehabilitation period or follow-up. METHODS: Patients were asked to complete Short Form-36 and Incontinence Quality of Life questionnaires and a medical information form. Independent samples t-tests and ANOVA were used to compare scores between groups. RESULTS: The response rate was 71 out of 79 (89%; 51 males and 20 females). 16 paraplegic and 4 tetraplegic patients were chronic, 29 paraplegic and 22 tetraplegic patients were in rehabilitation therapy or had finished this treatment recently. The paraplegic group had a significantly better Short Form-36 total score and emotional function score, while the tetraplegic group had a significantly better Incontinence Quality of Life total score and avoidance and limiting behavior score. The paraplegic patients with 0-1 nocturnal bladder emptying had better Short Form-36-derived Quality of Life than those with ≥2 emptying. Quality of Life score was not associated with gender, leg oedema, incontinence, or acute/chronic group. Incontinence Quality of Life score was significantly better for patients with incomplete spinal cord injury. Fully completed questionnaires were returned by 36 patients; at least 1 item was missing for 35 participants. CONCLUSIONS: General Short Form-36-derived Quality of Life was better for the paraplegic population. Incontinence-related Quality of Life was better in tetraplegic patients, most of whom used suprapubic catheterization. Paraplegic patients had compromised sleep and Quality of Life when the patient had to wake up two or more times at night to empty the bladder by voiding or intermittent catheterization. The high number of incomplete responders indicates the shortcomings of Quality-of-Life questionnaires for wheelchair-bound patients with spinal cord injury. CLINICAL REHABILITATION IMPACT: The use of suprapubic catheterization should be considered to improve Quality of Life for tetraplegic patients. For paraplegic patients, we must focus urological policy on aiming to reduce the number of nighttime bladder emptying to one or none.

Assessment of Intermittent Self-Catheterization Procedures in Patients with Neurogenic Lower Urinary Tract Dysfunction: Dutch Translation and Validation of the Intermittent Catheterization Satisfaction Questionnaire, Intermittent Catheterization Acceptance Test, Intermittent Self Catheterization Questionnaire and Intermittent Catheterization Difficulty Questionnaire.

BACKGROUND: Intermittent self-catheterization (ISC) is by far the most appealing therapy to achieve a complete bladder emptying in patients with neurogenic lower urinary tract dysfunction (NLUTD). Four questionnaires have been developed in French in order to assess patient's satisfaction, difficulties and acceptance of this technique. OBJECTIVES: The aim of this study was to translate, culturally adapt and validate Dutch versions of the Intermittent Catheterization Satisfaction Questionnaire (InCaSaQ), the Intermittent Catheterization Acceptance Test (ICAT), the Intermittent Self Catheterization Questionnaire (ISCQ) and the Intermittent Catheterization Difficulty Questionnaire (ICDQ). METHODS: (1) Translation and cross-cultural adaptation of the questionnaires were performed according to the standardized guidelines. (2) The test of the pre-final version was performed by a group of bilingual lay people by comparing the original version of the questionnaires and the back translated one, assessing the comparability of language and comparability of interpretation. (3) Problematic issues were reviewed for correction. (4) Reliability was examined by intra-class correlation coefficients (ICC) statistics and Cronbach alpha analysis. RESULTS: Pre-test by 45 raters who are fluent in the source language led to an adapted and improved version of the translated questionnaires. Fifty native Dutch-speaking patients performing ISC (>6 months) due to an NLUTD were prospectively included. InCaSaQ, ICAT, ISCQ and ICDQ showed good internal consistency (α respectively (test and re-test): 0.79-0.88, 0.88-0.92, 0.85-0.88, and 0.88-0.86) and reproducibility (ICC respectively 0.77, 0.84, 0.84, and 0.87). CONCLUSION: The translated versions of InCaSaQ, ICAT, ISCQ and ICDQ are reliable and valid, allowing self-reported assessment of satisfaction, acceptance, difficulties and quality of life related to ISC in Dutch-speaking patients with NLUTD.

Conservative treatment for leg oedema and the effect on nocturnal polyuria in patients with spinal cord injury.

OBJECTIVES: To evaluate the possible influence of non-pharmacological interventions, such as compressive bandages and intermittent pneumatic compression (IPC), on leg oedema and nocturnal polyuria (NP), and the possible interrelation between both pathologies in patients with spinal cord injury (SCI), as patients with SCI often have leg oedema and during the night the oedema decreases as a result of natural drainage mechanisms that can cause NP. PATIENTS AND METHODS: Patients with SCI who followed their first rehabilitation after their SCI with bilateral leg oedema and/or with as much or a larger urine volume at night as during the day. The patients were all wheelchair users and followed the rehabilitation programme daily for 3 weeks. In all, 24 patients, aged between 21 and 63 years, were selected for participation in the 3-week rehabilitation programme. During the first week, baseline data were collected. During the second week, IPC was executed from the moment the patient went to lie down. During the third week, the patients wore multilayer compressive bandages. Leg circumference was measured in the morning before sitting up and at the moment they went to lie down in bed. During each study week, a daily frequency-volume chart (24 h) was completed. RESULTS: The leg volume of both legs was significantly different between the morning and evening (right leg F = 103.90, P < 0.001; left leg F = 100.77, P < 0.001) and between the three treatments (right F = 9.70, P < 0.001; left F = 9.66, P < 0.001). There was a significant difference between the compressive bandages and the baseline period (right and left leg, both P < 0.001) and between the compressive bandages and IPC (right leg P = 0.009 and left leg P = 0.015). There was no significant difference between IPC and the baseline. When no treatment or IPC was used, urine production was significantly higher during the bed-rest period. The urine production was significantly lower comparing the use of compressive bandages to baseline and IPC, during bed rest (P = 0.009) and during sleep (P < 0.001). There was a significant decrease in absolute voided volume at night with the compressive bandages as treatment (P < 0.001). There was a significant positive association between the leg volume change during the day and the urine-production ratio, 100 mL increase in leg volume was associated with 8% increase in the log-transformed urine-production ratio. CONCLUSION: There are alternative treatment options for patients with SCI who have oedema or NP. Oedema formation and urine production appear to be related to each other. Therefore, the use of compressive bandages was shown to be a valuable treatment option to improve both leg oedema and NP.

Evaluation of the occurrence and diagnose definitions for nocturnal polyuria in spinal cord injured patients during rehabilitation.

BACKGROUND: Little is known about the occurrence of nocturnal polyuria (NP) in spinal cord injured (SCI) patients and the definitions which are preferable in this population. AIM: To determine the occurrence of NP in SCI patients during in-patient rehabilitation in the Ghent University Hospital. To study the influence of different time periods (daytime, bed rest and sleep) on the accuracy of the existing diagnose definitions for NP specifically for this type of patients. DESIGN: Retrospective study using patient records. SETTING: SCI patients during hospital-based rehabilitation between 2011 and 2014. POPULATION: Seventy-four SCI patients were selected and their records of frequency-volume charts (FVC) were examined, after exclusion of unreliable data, forty-seven patients were retained for the current study. METHODS: Retrospective study using data from FVC of either two or three days from patients with SCI. Nocturnal urine production (NUP) and nocturnal polyuria index (NPi) were calculated. RESULTS: There was a significant increase in diuresis, calculated as urine production, between day time and bed rest (P=0.008) and between day time and sleep (P=0.001). All patients showed NP during a 12-hour night time period (including both bed rest and sleep) and 39 patients showed NP during the 8-hour period of sleep. There was no significant difference in mean urine production between bed rest and sleep. Prevalence of NP did not significantly differ between the complete or incomplete SCI patients or between patients with higher and lower SCI levels. CONCLUSIONS: This study showed that the occurrence of NP in patients with SCI is high and that it is important to consider which definitions of NP are used for diagnosis. Increase in diuresis is observed during bed rest and sleep and the diagnose is correctly estimated when nocturnal urine production definitions are used in both time periods. In accordance with what was expected, diagnose of NP was overestimated when NP index type definitions were used. CLINICAL REHABILITATION IMPACT: It is important to be aware of the frequent-occurrence of NP in SCI patients and the impact of their daily routine to the accuracy of the diagnosis of NP. More knowledge about this topic can help to avoid incontinence caused by nocturnal polyuria.

Diastematomyelia and late onset presentation: a case report of a 72-year-old woman.

BACKGROUND: We would like to present the case of a 72-year-old woman, in whom diastematomyelia was surprisingly discovered when looking for an explanation for her neurological and urological complaints. Diastematomyelia is a rare disease in the group of "spinal dysraphisms," mostly discovered at birth and very rare at advanced age. The clinical pattern could be seen in the general presentation of 'tethered cord' and there are 2 types of presentation with a different treatment. CASE REPORT: In our case report the two dominant complaints were pain in the right foot and sphincter problems. Further investigations ultimately revealed diastematomyelia. Surgical resection of the septum was one of the possibilities, but because of the limited clinical impact, a conservative treatment was followed. CLINICAL REHABILITATION IMPACT: In conclusion this case shows that even at advanced age diastematomyelia can be first discovered, so attention to this rare disease stays important.

OnabotulinumtoxinA injections in detrusor facilitate self-catheterisation in a patient with paraplegia and bladder outlet dyssynergia.

This case report describes the case of improvement of clean intermittent catheterisation procedures after each intradetrusor administration of onabotulinumtoxinA in a 45-year-old man with L1 paraplegia with neurogenic detrusor overactivity and bladder outlet dyssynergia.On three occasions, improvement on clean intermittent catheterisation procedures appeared 10 to 14 days after intradetrusor injections of onabotulinumtoxinA and lasted for 9 months. We hypothesise a possible influence of intravesical injections of onabotulinumtoxinA on the storage reflex. We also discuss the possibility of a dispersion of onabotulinumtoxinA towards contiguous structures such as the urethral sphincter.

Circadian Rhythms in Water and Solute Handling in Adults with a Spinal Cord Injury.

PURPOSE: We evaluated nocturnal urine production and circadian rhythms of renal function (glomerular filtration, and water and solute diuresis) in adults with spinal cord injury compared to controls. MATERIALS AND METHODS: This prospective observational study was done at Ghent University Hospital, Belgium. Participants were asked to perform a 24-hour urine collection. A blood sample was taken to calculate the diuresis rate and the renal clearance of creatinine, free water, solutes, sodium and urea. RESULTS: A total of 119 patients were divided into 32 with spinal cord injury, and 68 controls with and 19 without nocturnal polyuria. Spinal cord injured patients showed no circadian rhythms in the diuresis rate or in the renal clearance of creatinine, free water, solutes, sodium or urea. Controls without nocturnal polyuria reported a lower nighttime diuresis rate and lower nighttime clearance of creatinine, solutes, sodium and urea compared to daytime levels. Controls with nocturnal polyuria had no circadian rhythms in the diuresis rate or creatinine clearance and a significant increase in nocturnal free water clearance compared to daytime levels. CONCLUSIONS: Comparing the mechanisms underlying nocturnal urine production between patients with spinal cord injury and controls revealed important differences. Spinal cord injured patients showed absent circadian rhythms in the renal clearance of creatinine (glomerular filtration), free water (water diuresis) and solutes such as sodium and urea (solute diuresis). Future research must be done to evaluate the role of patient stratification to find the most effective and safe treatment or combination of treatments for spinal cord injured patients with complaints or complications related to nocturnal polyuria.

Measuring participation when combining subjective and objective variables: the development of the Ghent Participation Scale (GPS).

BACKGROUND: The ICF reflects a bio-psycho-social paradigm and is increasingly used in outpatients rehabilitation settings. The component of participation is in the ICF the manifestation of a bio-psycho-social reasoning. Different participation measures have already been developed and were operationalized through objective and/or a limited set of subjective variables, but keeping them as separate concepts. There is still need for a generic participation instrument including both objective and all relevant subjective variables resulting in one participation score. AIM: To develop a generic participation measure based on objective and subjective aspects and leading to one final score; the Ghent Participation Scale (GPS). Additionally it was the aim to explore whether the GPS has a good internal validity by means of factorial validity and homogeneity and whether the GPS is feasible and interpretable. DESIGN: Cross-sectional study. SETTING: Outpatient rehabilitation centre. POPULATION: One hundred thirty former rehabilitation outpatients with various conditions. METHODS: Item derivation for the GPS was based on qualitative research. The participants administered the GPS in the third week after discharge from the Ghent University Hospital. An exploratory factor analysis was performed to determine underlying dimensions. Statistical coherence was expressed in both item-total correlations and in Cronbach's α coefficient. RESULTS: An exploratory factor analysis showed 3 underlying dimensions within the GPS: 1) performing activities according to preferred choices and wishes; 2) social appreciation and acceptance by performing activities; and 3) the need to delegate activities explaining 55.8% of the total variance. The results show a good to strong homogeneity (item-total ranged from 0.58 to 0.80) and a strong internal consistency (Cronbach's α ranged from 0.76-0.92). CONCLUSIONS: The results of this preliminary validation study suggest that the GPS appears to be a valid measure to rate participation. CLINICAL REHABILITATION IMPACT: Further research and more and more powerful psychometric models such as Rash Analysis or Item Response models are needed to establish a psychometrically sound instrument.

Secondary Voice Restoration After Laryngotracheal Separation (LTS) for Dysphagia with Intractable Aspiration.

Intractable aspiration is a serious, often life-threatening condition due to its potential impact on pulmonary function. Aspiration requires therapeutic measures, starting with conservative management but often necessitating surgical treatment. The basic surgical principle is to separate the alimentary and respiratory tracts through a variety of procedures which, unfortunately, nearly all result in the loss of phonation, with the exception of total laryngectomy (TL) which includes the placement of an indwelling voice prosthesis. In this study, we present a modified laryngotracheal separation (LTS) technique that, we believe, offers multiple advantages compared to standard TL. After reviewing the medical records of 35 patients with intractable aspiration who have undergone LTS, we describe the surgical technique and present the postoperative result. In a second surgical procedure about two months following LTS, we aimed to achieve voice restoration by placement of an indwelling voice prosthesis. Intractable aspiration was successfully treated in all patients. Placement of an indwelling voice prosthesis during a second operation was successful in 15 patients, representing the largest reported cohort thus far. LTS is a reliable surgical technique to treat intractable aspiration, with restoration of oral intake, thereby improving the general condition and quality of life of these unfortunate patients. Furthermore, voice restoration can be achieved in selected patients, by placement of a voice prosthesis.

Urinary plasma protein patterns in acute prostatitis.

We evaluated the diagnostic utility of urinary alpha1-microglobulin, alpha2-macroglobulin and albumin in the diagnosis of acute prostatitis. We studied 133 men (43 +/- 17 years) with, and a reference population (n=36, 41 +/- 16 years) without, urinary tract infection. Prostatectomy samples were used to study the potential interference between prostatic proteins and protein analysis. Urinary alpha2-macroglobulin/albumin ratio was significantly lower in prostatitis compared to the reference population, cystitis or acute pyelonephritis (p < 0.0001). Low alpha2-macroglobulin concentrations in prostatitis are due to inhibition (p = 0.0001) of the immune reaction between alpha2-macroglobulin in presence of polyclonal rabbit antibodies (used for immunonephelometry) by soluble prostatic proteins (+/- 60 kDa) which appear in urine in acute prostatitis. The urinary alpha1-microglobulin/creatinine ratio diagnoses acute pyelonephritis (sensitivity 100% and specificity 87%) and the urinary alpha2-macroglobulin/albumin ratio diagnoses acute prostatitis (sensitivity 100% and specificity of 90%). Stepwise multinomial logistic regression analysis reveals that urinary alpha1-microglobulin, alpha2-macroglobulin, albumin and creatinine provide optimal differentiation between acute pyelonephritis and acute prostatitis (pseudo R2=0.83; Loglikelihood -30.55, p < 0.000001). In conclusion, the combination of hematuria and absence of urinary alpha-2-macroglobulin is diagnostic for acute prostatitis. Even without hematuria, alpha2-macroglobulin remains lower compared to patients without prostatitis.