Do spinal cord injury patients always get the best treatment for neuropathic bladder after discharge from regional spinal injuries centre?

OBJECTIVE: To draw attention to inadequate care received by some spinal cord injury patients after discharge from the regional spinal injury center. SETTING: Regional Spinal Injuries Centre, Southport, UK. METHODS: Presence of the urethral stricture was not recognised in a 69-year-old male with T-3 paraplegia, who attended a health-care facility with a urinary infection. A Foley catheter was inserted into the urethra only half-way and the catheter balloon was then inflated in the urethra distal to the stricture. In a 68-year-old male with T-8 paraplegia, a long-term indwelling catheter was eroding the urethra and he developed a severe degree of hypospadias while being managed in the community. A 49-year-old male with C-4 tetraplegia developed recurrent urine infections. He received several courses of antibiotics, which were prescribed by community health professionals. But he continued to be unwell. Subsequently, the patient was admitted to a district general hospital, where he was diagnosed to have mild chest infection and was about to be sent home. However, his wife was not happy, and then ultrasound of abdomen was taken, which revealed pyonephrosis. He was then transferred to a spinal unit. RESULTS: : These patients were not seen promptly in a regional spinal injury centre when they developed medical problems. The complications, which ensued, might have been prevented if expert medical treatment had been provided without delay. CONCLUSION: In order to meet the needs of a growing population of persons living in the community with spinal cord injury, more beds are required in spinal units. Provision of day surgery wards within spinal units, out-reach clinics and home visits by spinal cord clinicians may reduce the demand for admission in a spinal unit. Education of community health professionals on delayed complications of spinal cord injury, and good communication between spinal cord clinicians, patients, carers, and community health professionals by telephone, e-mail or conventional postal system are likely to improve the care of spinal cord injury patients after discharge from spinal injury centres. Spinal cord clinicians should adopt a patient-centred care instead of the traditional, paternalistic, doctor-centred care.

Community-care waiting list for persons with spinal cord injury.

OBJECTIVES: To disseminate the concept of community care waiting lists for spinal cord injury (SCI) patients with particular reference to carer support for management of neuropathic bladder by a regime of intermittent catheterisation. METHODOLOGY: The surgical waiting list focuses only on operative procedures, and ignores the wider requirements for ensuring satisfactory rehabilitation of people with spinal cord injury in the community. A community-care waiting list for individuals with spinal cord injury should include the following aspects of community care: (1) Home adaptation; (2) Provision of appropriate mobility needs (including wheelchair and cushion); (3) Equipment for comfortable living (including provision of hoist, pressure relieving mattress); (4) Psychological support for spinal cord injury patients and their partners; (5) Nursing home or residential care placement where appropriate; (6) Carer support for global management of complex needs associated with spinal cord injury (eg neuropathic bladder and bowel). RESULTS: Whereas full physical adaptation of the home can wait for some time after discharge, carer support for intermittent catheterisation is required from the first day after discharge from a spinal unit. Lack of such support means that some SCI patients are discharged with long-term indwelling urinary catheters, even though clean intermittent catheterisation is known to be the safest regime for managing the neuropathic bladder. Therefore, the absence of a community care waiting list means that best practice cannot be achieved for some tetraplegic subjects. CONCLUSION: We believe that a community care waiting list for bladder management will help to provide optimum care for neuropathic bladder and, hopefully, reduce the complications related to long-term indwelling catheters in spinal cord injury patients.

Blunt trauma to scrotum in men with spinal cord injury after they had completed rehabilitation in a spinal unit.

STUDY DESIGN: A report of three men with spinal cord injury (SCI) who sustained blunt trauma to scrotum after they had completed rehabilitation in the spinal unit. OBJECTIVES: To raise awareness amongst health professionals regarding: (1) mechanism of scrotal trauma in men with SCI (2) need for prompt assessment of scrotal injury (3) measures to be taken by men with SCI and their carers to prevent injury to the scrotum. SETTING: Regional Spinal Injuries Centre, Southport, England. CASE REPORTS: (1) A 31-year-old with C-6 tetraplegia sustained traumatic haematocele as he squashed his right testis while he jumped on to a toilet seat in a hurry for bowel movement. (2) A 28-year-old male with T-7 paraplegia sat on his left testis while transferring on to a car seat. (3) A boxer dog jumped on to the scrotum of a 40-year-old male with T-8 paraplegia, while he was lying on his bed. CONCLUSIONS: Men with SCI are at high risk of sustaining trauma to scrotum during transfers. The scrotum may be squashed by the weight of the body during transfers, or the scrotum may be trapped between the thighs or under the torso. Men with SCI or their carers should check after each transfer that the scrotum is not trapped between the thighs or under the torso. The health professionals should encourage men with SCI to update their transfer skills at regular intervals in order to prevent trauma to the scrotum during transfers. Blunt trauma to scrotum requires prompt evaluation by ultrasonography so that appropriate treatment can be instituted without delay.

Relationship of glycosaminoglycan and matrix changes to vascular smooth muscle cell phenotype modulation in rabbit arteries after acute injury.

PURPOSE: The phenotype of vascular smooth muscle cells (SMCs) is altered in several arterial pathologies, including the neointima formed after acute arterial injury. This study examined the time course of this phenotypic change in relation to changes in the amount and distribution of matrix glycosaminoglycans. METHODS: The immunochemical staining of heparan sulphates (HS) and chondroitin sulphates (CS) in the extracellular matrix of the arterial wall was examined at early points after balloon catheter injury of the rabbit carotid artery. SMC phenotype was assessed by means of ultrastructural morphometry of the cytoplasmic volume fraction of myofilaments. The proportions of cell and matrix components in the media were analyzed with similar morphometric techniques. RESULTS: HS and CS were shown in close association with SMCs of the uninjured arterial media as well as being more widespread within the matrix. Within 6 hours after arterial injury, there was loss of the regular pericellular distribution of both HS and CS, which was associated with a significant expansion in the extracellular space. This preceded the change in ultrastructural phenotype of the SMCs. The glycosaminoglycan loss was most exaggerated at 4 days, after which time the HS and CS reappeared around the medial SMCs. SMCs of the recovering media were able to rapidly replace their glycosaminoglycans, whereas SMCs of the developing neointima failed to produce HS as readily as they produced CS. CONCLUSIONS: These studies indicate that changes in glycosaminoglycans of the extracellular matrix precede changes in SMC phenotype after acute arterial injury. In the recovering arterial media, SMCs replace their matrix glycosaminoglycans rapidly, whereas the newly established neointima fails to produce similar amounts of heparan sulphates.

Doctor-patient communication: do people with spinal cord injury wish to receive written information about their medical condition from the physicians after an outpatient visit or after a readmission in the spinal unit?

STUDY DESIGN: A survey of spinal cord injury patients attending a follow-up clinic in a Regional Spinal Injuries Centre. OBJECTIVES: To investigate whether spinal cord injury patients wish to receive written information about any changes in their medical condition after an outpatient visit or, following readmission in a spinal unit. SETTING: Regional Spinal Injuries Centre, Southport, United Kingdom. METHODS: A questionnaire was developed to assess the following: (1) Whether spinal cord injury patients wished to receive written information about changes in their medical condition after an outpatient visit or following readmission in a spinal unit; and (2) Whether provision of such written information would cause needless anxiety to patients and/or their relatives/carers. RESULTS: A total of 128 adults with spinal cord injury filled in this questionnaire. One hundred and six persons (83%) wished to receive written information about any changes in their medical condition after an outpatient visit, whereas eight (6%) felt that provision of such written information was not required. 115 individuals with spinal cord injury (90%) preferred to receive a copy of the MRI scan report, with interpretation of the findings, while 11 (9%) would be happy not to receive such information. 115 persons with spinal cord injury (90%) felt that written information about their medical condition would be valuable for showing to a locum General Practitioner (GP), if necessary, who may not be acquainted with their medical status. Only eight (6%) did not perceive a need for written information to appraise a locum GP. One hundred and twenty-two persons with spinal cord injury (95%) did not feel that provision of written information would cause needless anxiety to them; only four (3%) felt the other way. One hundred and nineteen (93%) individuals with spinal cord injury wished to receive written information about changes in their medical condition after a readmission to the spinal unit, while six (5%) did not wish to receive such information. CONCLUSION: Although the vast majority of people with spinal cord injury reported they wished to receive written information, a small proportion of patients did not wish to receive such information. Acceptance of written information is not universal and clinicians must ensure that provision of written information to people with spinal cord injury should be tailored to the needs of individual patients.

Late complications of tissue glues in aortic surgery.

BACKGROUND: Tissue glues are used in cardiothoracic surgery as an adjunct to operative procedures where tissues are frail, as in aortic dissection, or where added hemostasis is required. This study was undertaken to review the use of tissue glue in our institution over a 5.5-year period. The aim of the study was to identify any potentially glue-related complications. METHODS: A review of tissue glue use for the period from January 1993 to September 1998 was performed and pre-, intra-, and postoperative parameters were collected. After some unusual surgical findings, of special interest was a range of pathology found at late reoperation. RESULTS: A total of 67 cases of tissue glue use were identified, with the majority of operations for type A dissection (76%). There were two intraoperative deaths. Twenty-seven of 65 patients (41%) required 29 further open chest operations; of these, 17 were for acute problems of bleeding or tamponade. Twelve patients (18%) underwent late reoperations months to years later. Nine of these patients, concentrated in two operative groups (7 patients with aortic valve resuspension and 2 patients who had undergone "switch" operations for transposition of great vessels), displayed complications related to the application of gelatin-resorcinol-formaldehyde (GRF) tissue glue. CONCLUSIONS: Indications for tissue glues in cardiothoracic surgery must be carefully considered. We have reviewed our use of some tissue glues in acute type A aortic dissections and in pediatric cardiac patients and have discontinued the use of GRF glues because of unsatisfactory long-term complications.

Up regulation of AT4 receptor levels in carotid arteries following balloon injury.

Angiotensin IV, (V-Y-I-H-P-F), binds to AT4 receptors in blood vessels to induce vasodilatation and proliferation of cultured bovine endothelial cells. This latter effect may be important not only in developing tissues but also in injured vessels undergoing remodelling. In the present study, using normal rabbit carotid arteries, we detected AT4 receptors in vascular smooth muscle cells and in the vasa vasorum of the adventitia. Very low receptor levels were observed in the endothelial cells. In keeping with the described binding specificity of AT4 receptors, unlabelled angiotensin IV competed for [125I]angiotensin IV binding in the arteries, with an IC50 of 1.4 nM, whereas angiotensin II and angiotensin III were weaker competitors. Within the first week following endothelial denudation of the carotid artery by balloon catheter, AT4 receptor binding in the media increased to approximately 150% of control tissue. AT4 receptor binding further increased in the media, large neointima and re-endothelialized cell layer to 223% at 20 weeks after injury. In view of the known trophic effects of angiotensin IV, the elevated expression of AT4 receptors, in both the neointima and media of arteries, following balloon injury to the endothelium, suggests a role for the peptide in the adaptive response and remodelling of the vascular wall following damage.

Pathophysiology of autonomic dysreflexia: long-term treatment with terazosin in adult and paediatric spinal cord injury patients manifesting recurrent dysreflexic episodes.

INTRODUCTION: Spinal cord injury (SCI) results in disruption of synaptic influences on the sympathetic preganglionic neurones. Remodelling of spinal cord circuits takes place in spinal neurones caudal to cord injury. There is an increased vascular alpha-adrenoceptor responsiveness, and peripheral afferent (bladder) stimulation in SCI subjects induces a marked noradrenaline spillover below the level of spinal lesion. These neurophysiological changes possibly contribute to the development of autonomic dysreflexia, a condition of sympathetic hyper-excitability that develops after cervical, or upper dorsal cord injury with resultant paroxysmal rise in arterial pressure, and provide the scientific basis for the use of terazosin, a once-a-day, selective alpha-one adrenergic blocking drug. OBJECTIVES: The use of terazosin, a long-acting, alpha 1-selective blocking agent was investigated in SCI patients who developed recurrent symptoms of autonomic dysreflexia, eg headache, sweating flushing of the face together with an increase in the arterial pressure. DESIGN: An open, prospective study of the efficacy of terazosin in controlling recurrent autonomic dysreflexia in traumatic tetraplegic/paraplegic patients manifesting clinical features of dysreflexia in the absence of an acute precipitating cause such as a blocked catheter. SETTING: The initial assessment and treatment were carried out in the Spinal Injuries Centre. Subsequently, the patients were followed-up in the community. They were monitored by telephonic interviews, follow-up visits by the patients to the hospital, and home-visits by the staff of the spinal unit. SUBJECTS: Eighteen adults with tetraplegia (female: 1; male: 17), three children with ventilator-dependent tetraplegia and three adult male patients with paraplegia who exhibited recurrent features of autonomic dysreflexia in the absence of an acute predisposing factor for dysreflexia eg performance of an invasive procedure such as cystoscopy, digital evacuation of bowels, or acute urinary retention, were enrolled in this study. INTERVENTION: After discussion with the patients and their carers, terazosin was prescribed with a starting dose of 1 mg in an adult and 0.5 mg in a child administered nocte. The patients were observed for (1) drug-induced hypotension; (2) clinical symptoms due to side effects of terazosin; and (3) continued occurrence of dysreflexic symptoms. Step-wise increments of the dose of terazosin (1 mg in case of adults, and 0.5 mg in a child) was carried out at intervals of 3-4 days, if a patient continued to develop dysreflexia but did not manifest any serious side effect. OUTCOME MEASURES: Complete subsidence of dysreflexic symptoms, or development of an adverse event necessitating termination of the terazosin therapy was the clinical end point. RESULTS: The dysreflexic symptoms subsided completely with the terazosin therapy in all the patients. The twenty-one adult patients required a dose varying from 1-10 mg, whereas the paediatric patients required only 1-2 mg of terazosin. The side effects of postural hypotension and drowsiness were transient, and mild. One tetraplegic patient developed persistent dizziness and therefore, the drug therapy was discontinued. CONCLUSION: In 21 adult and three paediatric spinal cord injury patients manifesting recurrent episodes of autonomic dysreflexia in the absence of an acute predisposing cause, the use of terazosin, a once-a-day, specific alpha-one blocker resulted in complete subsidence of the dysreflexic symptoms. However, one tetraplegic patient required termination of terazosin therapy because of persistent dizziness.

Arterial heparan sulfate proteoglycans inhibit vascular smooth muscle cell proliferation and phenotype change in vitro and neointimal formation in vivo.

PURPOSE: The aim of this study was to determine whether heparan sulfate proteoglycans (HSPGs) from the normal arterial wall inhibit neointimal formation after injury in vivo and smooth muscle cell (SMC) phenotype change and proliferation in vitro. METHODS: Arterial HSPGs were extracted from rabbit aortae and separated by anion-exchange chromatography. The effect of HSPGs, applied in a periadventitial gel, on neointimal formation was assessed 14 days after balloon catheter injury of rabbit carotid arteries. Their effect on SMC phenotype and proliferation was measured by point-counting morphometry of the cytoplasmic volume fraction of myofilaments (Vvmyo) and 3H-thymidine incorporation in SMCs in culture. RESULTS: Arterial HSPGs (680 microg) reduced neointimal formation by 35% at 14 days after injury (P=.029), whereas 2000 microg of the low-molecular-weight heparin Enoxaparin was ineffective. HSPGs at 34 microg/mL maintained subconfluent primary cultured SMCs with the same high Vvmyo (52.1%+/-13.8%) after 5 days in culture as did cells freshly isolated from the arterial wall (52.1%+/-15.1%). In contrast, 100 microg/mL Enoxaparin was ineffective in preventing phenotypic change over this time period (Vvmyo 38.9%+/-14.6%, controls 35.9%+/-12.8%). HSPGs also inhibited 3H-thymidine incorporation into primary cultured SMCs with an ID50 value of 0.4 microg/mL compared with a value of 14 microg/mL for Enoxaparin (P< .01). CONCLUSION: When used periadventitially in the rabbit arterial injury model, natural arterial HSPGs are effective inhibitors of neointimal formation. In vitro, the HSPGs maintain SMCs in a quiescent state by inhibiting phenotypic change and DNA synthesis. This study suggests that HSPGs may be a natural agent for the treatment of clinical restenosis.

Effect of intermittent urethral catheterization and oxybutynin bladder instillation on urinary continence status and quality of life in a selected group of spinal cord injury patients with neuropathic bladder dysfunction.

OBJECTIVES: A comparative assessment of (i) urinary continence status, (ii) quality of life, and (iii) sexuality in spinal cord injury patients prior to, and during intermittent catheterization with adjunctive intravesical oxybutynin therapy (Cystin: manufactured by Leiras Oy. Helsinki, Finland). SETTING: A hospital, and community-based study of selected adult, male, spinal cord injury patients registered with the Regional Spinal Injuries Centre, Southport. PATIENTS: Seven patients (mean age: 44.3 years) suffering from neuropathic bladder due to suprasacral spinal cord lesion of traumatic aetiology, and well settled in the community in the north-west of England were the subjects of this study. Before commencing the intermittent catheterization regime, these patients were on penile sheath drainage. INTERVENTION: Intermittent urethral catheterization was performed with sterile, single-use Nelaton catheters 5-6 times a day with intravesical instillation of oxybutynin 5 mg in 30 ml. 1-3 times a day for periods ranging from 14 to 30 months. OUTCOME MEASURES: Assessment of urinary continence, sexuality, and quality of life was made (i) at the outset before any intervention, (ii) during intermittent catheterization regime, and (iii) when the patients were using the oxybutynin bladder instillation along with intermittent catheterization. RESULTS: Initially all the seven patients were constantly wearing penile sheaths and leg bags. When these patients performed intermittent catheterization 5-6 times in 24 h, they attempted to discard the penile sheath during the day but they were experiencing mild to moderate urine leak between catheterization. They were compelled to wear penile sheaths during night. Subsequently, five patients took oxybutynin by mouth, but developed an unacceptable degree of side-effects necessitating discontinuation of the medication. Following commencement of intravesical oxybutynin therapy, all of them were able to discard the penile sheaths and leg bags during the day as well as during the night. However, on waking-up after a full night's sleep, three patients found dampness of their undergarments 1-2 times per week. None of the patients experienced side-effects attributable either to the intermittent catheterization procedure, or to the intravesical oxybutynin therapy. The number of episodes of urinary infection requiring antibiotic therapy was 0.08/patient/month. All the seven patients noticed a remarkable improvement in the quality of life because they had achieved a high degree of continence. All the seven patients commented on the improved sense of their own sexuality which was attributed to (i) absence of incontinence episodes, (ii) improved self-image, and (iii) not wearing penile sheaths and leg bags. CONCLUSION: These seven spinal cord injury patients achieved socially acceptable continence with improved quality of life, and enhanced sexuality with the intermittent urethral catheterization regime and intravesical oxybutynin therapy.

A review of the readmissions of patients with tetraplegia to the Regional Spinal Injuries Centre, Southport, United Kingdom, between January 1994 and December 1995.

Patients with chronic tetraplegia are prone to develop unique clinical problems which require readmission to specialised centres where the health professionals are trained specifically to diagnose, and treat the diseases afflicting this group of patients. An appraisal of the readmission pattern of tetraplegic patients will provide the necessary data for planning allocation of beds for treatment of chronic tetraplegic patients. Hospital records of patients with tetraplegia readmitted to the Regional Spinal Injuries Centre, Southport, UK between 1 January 1994 and 31 December 1995 were analyzed to find out the number of tetraplegic patients who required readmission, reasons for readmission, duration of hospital stay, and mortality among patients readmitted. During the 2-year period, 155 tetraplegic patients were readmitted and 44 of them (28.4%) required more than one readmission (total readmission episodes: 221); these patients occupied 4.5 beds which is equivalent to 11.5% of the total bed capacity of the spinal unit. Among the reasons for the readmissions, evaluation and care of urinary tract disorders topped the list with 96 readmission episodes (43.43%) involving 70 patients; the median hospital stay was 3 days, and 18 patients (26%) required more than one readmission during this period. One hospital bed was occupied by the tetraplegic patients requiring treatment/evaluation of urinary tract disorders. Assessment and treatment of cardio-respiratory diseases was the second most common reason for readmission with 51 readmission episodes pertaining to 27 patients having a median hospital stay of 6 days; 13 patients (48%) were readmitted more than once within this 2-year period. Treatment of cardio-respiratory diseases in chronic tetraplegic patients required 1.2 hospital beds yearly. Only five tetraplegic patients were readmitted for treatment of pressure sore(s); however they had a prolonged hospital stay (median duration: 101 days). Social reasons accounted for 13 readmission episodes concerning nine patients who stayed in the hospital for varying periods (median: 6.5 days; mean: 35 days). Four tetraplegic patients readmitted with acute chest infection expired. An 81 year-old tetraplegic died of myocardial infarction. Urinary sepsis, renal insufficiency, respiratory failure and intra-cerebral haemorrhage accounted for the demise of a 41 year-old tetraplegic patient following surgical removal of a large, impacted stone at the pelviureteric junction. A tetraplegic patient who was admitted with haematuria subsequently underwent cystectomy for squamous cell carcinoma of the urinary bladder; he developed secondaries and expired 5 months later. As more patients with high cervical spinal cord injury survive the initial period of trauma, and as the life expectancy of tetraplegic patients increases, it is likely that greater numbers of tetraplegic patients will be requiring readmission to spinal injuries centre. Although it may be possible to prevent some of the complications of spinal cord injury and hence the need for a readmission, progress in medicine and rehabilitation technology will create additional demands for readmissions of chronic tetraplegic patients in order to implement the newer therapeutic strategies. Thus a change in the pattern of readmission of chronic tetraplegic patients is likely to be the future trend and this should be taken into account while making plans for providing the optimum care to chronic tetraplegic patients.

Bowel management outcomes in individuals with long-term spinal cord injuries.

Outcomes of bowel management were evaluated in 1993 among 221 British long-term spinal cord injury survivors who were followed-up as part of a longitudinal study of aging with spinal cord injury. Representing a population-based sample followed up by two regional spinal cord injury treatment centres - Stoke Mandeville Hospital in Aylesbury and the District General Hospital in Southport, England - all had been injured at least 20 years when the study was begun in 1990; all underwent comprehensive assessments and extensive interviewing at their centres in 1990 and 1993. When assessed in 1993, 42% of the entire sample reported constipation, 35% reported gastrointestinal pain, and 27% complained of bowel accidents. Physician examiners diagnosed significantly more hemorrhoids among those using primarily suppositories and enemas to manage their bowels (P < 0.05) and more constipation among persons with paraplegia (P < 0.05) and those using digital stimulation, manual evacuation, or increased abdominal pressure in their bowel programs. Fecal incontinence and diarrhea was diagnosed three times more often in participants with tetraplegia as in other neurological groupings. These and other findings suggest future research needs and directions relative to long-term bowel management for spinal cord injury survivors.

Inhibition of phenotype modulation, growth, and migration of vascular smooth muscle cells by a guanosine-rich 30-mer phosphorothioate oligodeoxynucleotide.

The testing of a 30-mer dG-rich phosphorothioate oligodeoxynucleotide (LG4PS) for effects on the behaviour of vascular smooth muscle cells (VSMC) in vitro and in vivo is described. LG4PS at 0.3 microM inhibited significantly the phenotype modulation of freshly isolated rabbit VSMC, and cell outgrowth from pig aortic explants was inhibited approximately 80% by 5 microM LG4PS. The growth of proliferating rabbit and pig VSMC was inhibited approximately 70% by 0.3 microM and 5 microM LG4PS, respectively. Though less marked, the antiproliferative effects of LG4PS on human VSMC were comparable to those obtained with heparin. The cytotoxic effects of LG4PS on VSMC in vitro were low. Despite these promising results, adventitial application of 2-200 nmol LG4PS in pluronic gel failed to reduce vascular hyperplasia in balloon-injured rabbit carotid arteries, and the highest dose caused extensive mortality.

Southport experience with domiciliary ventilation.

Experience of the Southport Spinal Injuries Centre in reestablishing ventilator dependent patients back in their own homes has confirmed the view that such level of disability need not prevent people from returning to the community and start living again. Convincing the carers in the community and abolishing the traditional boundaries between hospital and community appear to be the fundamental prerequisites. Increased use of advanced assistive technology will enable these disabled people to have more acceptable control of their lives.