Current and future international patterns of care of neurogenic bladder after spinal cord injury.

PURPOSE: We aim to summarize the literature on international patterns of care for patients with neurogenic bladder (NGB) from spinal cord injury (SCI). METHODS: We performed a PubMed database search, hand review of references, communication with professional societies, and registry evaluations for pertinent data. RESULTS: Established patterns of care, including SCI registries and specialty centers, are available in high-resource countries such as the US and UK. As such, mortality rates from complications of NGB/SCI are lower. Access to intermittent catheterization supplies, among other resources, may be inadequate in many low-income regions. Cultural and religious beliefs may also hinder integration of proper bladder management in SCI patients. While guidelines exist in many parts of the world, it is unclear how rigorously they are disseminated or followed. CONCLUSIONS: While there is a paucity of high-level evidence, the differences in patterns of care are closely related to socioeconomic status and resources of the geographic area. Future research efforts should focus on improving access to diagnostic modalities, supplies, and specialists in these areas.

Semen parameters are unaffected by statin use in men evaluated for infertility.

The effects of statin use on conventional semen parameters in humans are largely unknown and have not been previously studied in subfertile men. We retrospectively reviewed data from 10,140 patients seen at our fertility clinic between 2002 and 2013 to assess the effects of statin use on semen parameters. Men who used any statins for >3 months before semen sample collection were included as cases. Data were gathered on patient age, medication use and conventional semen parameters. A total of 118 patients (126 samples) used statins for at least 3 months before semen sample collection. Data from 7698 patients (8,760 samples), who were not using any medications, were used as controls. In age-adjusted regression models, statin use was not associated with statistically significant changes in semen parameters. When used in combination with other nonspermatotoxic medications, it was associated with 0.3 ml decrease in semen volume (95% confidence interval: 0.02 to 0.58 ml, p-value = .04). In conclusion, statin use was not adversely associated with semen parameters other than semen volume in subfertile patients. These findings from our large-scale retrospective study suggest that there are no clinically relevant deleterious effects from statin use on conventional semen parameters.

Multi-institutional Outcomes and Associations After Excision and Primary Anastomosis for Radiotherapy-associated Bulbomembranous Urethral Stenoses Following Prostate Cancer Treatment.

OBJECTIVE: To evaluate the outcomes of excision and primary anastomosis (EPA) for radiation-associated bulbomembranous stenoses using a multi-institutional analysis. The treatment of radiation-associated urethral stenosis is typically complex owing to the adverse impact of radiation on adjacent tissue. METHODS: An IRB-approved multi-institutional retrospective review was performed on patients who underwent EPA for bulbomembranous urethral stenosis following prostate radiotherapy. Preoperative patient demographics, operative technique, and postoperative outcomes were abstracted from 1/2007-6/2018. Success was defined as voiding per urethra without the need for endoscopic treatment and a minimum follow-up of 12 months. RESULTS: One hundred and thirty-seven patients from 10 centers met study criteria with a mean age of 69.3 years (50-86), stenosis length of 2.3 cm (1-5) and an 86.9% (119/137) success rate at a mean follow-up 32.3 months (12-118). Univariate Cox regression analysis identified increasing patient age (P = .02), stricture length (P <.0001) and combined modality radiotherapy (P = .004) as factors associated with stricture recurrence while body mass index (P = .79), diabetes (P = .93), smoking (P = .62), failed endoscopic treatment (P = .08) and gracilis muscle use (P = .25) were not. On multivariate analysis, increasing patient age (H.R.1.09, 95%CI 1.01-1.16; P = .02) and stenosis length (H.R.2.62, 95%CI 1.49-4.60; P = .001) remained associated with recurrence. Subsequent artificial urinary sphincter was performed in 30 men (21.9%), of which 25 required a transcorporal cuff and 5 developed cuff erosion. CONCLUSIONS: EPA for radiation-associated urethral stenosis effectively provides unobstructed instrumentation-free voiding. However, increasing stenosis length and age are independently associated with surgical failure. Patients should be counseled that further surgery for incontinence may be necessary.

[Osteocartilaginous exostoses (osteochondromas)].

Osteochondroma is the most common true bone neoplasm formed by a cartilage capped bony projection arising on the external surface of a bone containing a marrow cavity that is continuous with that of the underlying bone. Osteochondromas generally arise in the bones preformed by cartilage. Osteochondromas may be solitary and multiple. Most reported cases have been in the first 3 decades with no known sex predilection. The lesion has three layers - perichondrium, cartilage and bone. The cartilage cap is usually less than 2.0 cm thick, superficial chondrocytes are clustered, the ones close to the transition to the bone resemble a growth plate, they are organized into chords and undergo enchondrial ossification. Loss of the architecture of cartilage, wide fibrous bands, myxoid change, increased chondrocyte cellularity, mitotic activity, significant chondrocyte atypia and necrosis are all features that may indicate secondary malignant transformation.

Neuromuscular and biomechanical characteristic changes in high school athletes: a plyometric versus basic resistance program.

BACKGROUND: In order to improve neuromuscular and biomechanical characteristic deficits in female athletes, numerous injury prevention programs have been developed and have successfully reduced the number of knee ligament injuries. However, few have investigated the neuromuscular and biomechanical changes following these training programs. It is also largely unknown what type of program is better for improving the landing mechanics of female athletes. OBJECTIVES: To investigate the effects of an 8 week plyometric and basic resistance training program on neuromuscular and biomechanical characteristics in female athletes. METHODS: Twenty seven high school female athletes participated either in a plyometric or a basic resistance training program. Knee and hip strength, landing mechanics, and muscle activity were recorded before and after the intervention programs. In the jump-landing task, subjects jumped as high as they could and landed on both feet. Electromyography (EMG) peak activation time and integrated EMG of thigh and hip muscles were recorded prior to (preactive) and subsequent to (reactive) foot contact. RESULTS: Both groups improved knee extensor isokinetic strength and increased initial and peak knee and hip flexion, and time to peak knee flexion during the task. The peak preactive EMG of the gluteus medius and integrated EMG for the gluteus medius during the preactive and reactive time periods were significantly greater for both groups. CONCLUSIONS: Basic training alone induced favourable neuromuscular and biomechanical changes in high school female athletes. The plyometric program may further be utilised to improve muscular activation patterns.

The safety and efficacy of clomiphene citrate in hypoandrogenic and subfertile men.

Our objective was to evaluate the safety and efficacy of clomiphene citrate (CC) in infertile and hypoandrogenic men through a retrospective study between September 2013 and May 2014. We identified 47 men between 18 and 55 years placed on 50 mg CC every other day. We evaluated the effect of CC on testosterone after 2 weeks, rates of adverse effects and predictors of CC response. Mean baseline testosterone, bioavailable testosterone and estradiol were 246.8 ng dl(-1), 125.5 ng dl(-1) and 20.8 pg dl(-1), respectively. At 2 weeks, mean testosterone, bioavailable testosterone and estradiol increased to 527.6 ng dl(-1), 281.8 ng dl(-1) and 32.0 pg dl(-1) (all P<0.001). Two patients at 2 weeks and one patient at 3 months had a paradoxical decrease in testosterone. Mean total motile count (TMC) and concentration increased from 59.7 million (s.e.m.: 16.5) and 50.7 millions ml(-1) (s.e.m.: 11.1) at baseline to 90.9 million (s.e.m.: 25.9) and 72.5 millions ml(-1) (s.e.m.: 17.5), respectively, at 3 months, although this was nonsignificant (P=0.09, 0.09). No patient on CC experienced a paradoxical decrease in TMC or sperm concentration. On age-adjusted regression analysis, age, BMI, longitudinal testis axis, baseline follicle-stimulating hormone, LH and estradiol did not correlate with improvement in bioavailable testosterone at 2 weeks. CC improves testosterone and may improve semen parameters, although a small percentage of men may not demonstrate improvement in testosterone.

Effect of renal transplantation on pituitary gonadal function.

Twelve adult male patients who had undergone successful renal transplantation were investigated. The gonadotropin responses to 100 microgram luteinizing hormone-releasing hormone (LRH) were studied, and basal serum testosterone and prolactin assayed. Significantly elevated mean basal levels of luteinizing hormone (LH) and follicle stimulating hormone (FSH) were found, associated with a correspondingly excessive LH and FSH response to LRH. Mean basal serum testosterone levels in the posttransplant patients were significantly lower than in normal controls, while the mean basal prolactin levels were similar in the two groups. The results were not influenced by the varying degrees of renal function found in the posttransplant patients.

A recurrent nonrandom translocation (3;7)(q27;p12) associated with BCL-6 gene rearrangement in B-cell diffuse large cell lymphoma.

Two cases of B-cell diffuse large cell lymphoma associated with the t(3;7)(q27;p12) and BCL-6 rearrangement are described. Cytogenetic studies revealed [case 1] 47,XY,t(3;7)(q27;p12),+12 and [case 2] 45,X,-Y,t(3;7)(q27;p12),del(6)(q21q25),+16,-21. The translocation of each case had a non-random chromosomal change involving a 3q27 locus associated with BCL-6 gene rearrangement identified by Southern blot analysis. Both cases involved multiple lymph nodes and extranodal regions, such as stomach and peritoneal cavity in case 1, extranodal retroperitoneal space, subcutis, probable liver, and colon in case 2. Chemotherapy provided only short survival after onset: 17 and 16 months, respectively. Altered expression of adhesion molecules CD44, CD54 (case 1) and CD11a and CD18 (case 2) may help to explain the poor outcome of these patients.

Reduced sodium chloride intake normalises blood pressure distribution.

The blood pressure distribution of 172 healthy normotensive subjects aged 3-77 years receiving diets containing different amounts of sodium are presented. On their usual intake of sodium (154 +/- 63 mmol Na+/day) and after two weeks on a high sodium intake (201 +/- 92 mmol Na+/day) supine systolic and supine diastolic blood pressure distribution were positively skewed to the right. After two weeks on a reduced sodium diet (77 +/- 37 mmol Na+/day) the blood pressure distribution was normal. An incremental effect of sodium on diastolic blood pressure occurred in 22% of the subjects. The fall in blood pressure on the reduced sodium diet in these 'sodium sensitive' subjects reduced the mean blood pressure level, which was associated with 'normalisation' of the blood pressure distribution.

Multiple myeloma involving the myocardium and coronary vessels.

We report a case of metastatic plasmacytoma to the myocardium and coronary vessels in a 57-year-old man with multiple myeloma. Originally, the patient had a large plasmacytoma in his left chest wall and lung. He received local radiation and chemotherapy. Subsequently, the patient presented with symptoms of congestive heart failure. He had no prior history of cardiac disease. The patient was treated medically and later died from respiratory failure. At autopsy, a metastatic plasmacytoma was identified within the myocardium and externally compressing the coronary arteries. The tumor infiltrated into the coronary sinus. It is difficult to speculate whether the patient's symptoms were due to cardiac involvement since the tumor burden in his chest was also considerable. To our knowledge, coronary vessel involvement with plasmacytoma has not been previously described.

'Sodium sensitivity' in man.

Increased cell membrane permeability to sodium is proposed as the initial event leading to high blood pressure in susceptible subjects when sodium intake is increased. All cells, including circulating cells, would be affected, but a key role for endothelial cells in the pathophysiology of the diastolic blood pressure elevation is proposed. Involvement of capillary endothelium could increase capillary permeability to proteins, and thereby would contribute to the altered fluid distribution on the high sodium diet which has been observed. If movement of fluid into the interstitium raised interstitial fluid pressure, venous capacitance would fall and right atrial pressure would rise. Several mechanisms would cause vascular smooth muscle tone to increase. Altered fluid distribution correlates with the rise in diastolic blood pressure from reduced sodium to high sodium diet, but arteriolar constriction would reduce capillary flow so altered fluid distribution occurs first. Arteriolar constriction could serve as a negative feedback to the raised atrial filling pressure by reducing raised capillary flow, which would decrease both altered fluid distribution and interstitial fluid pressure rise. Consequently, diastolic blood pressure would be chronically raised in 'sodium sensitive' subjects taking increased amounts of sodium in the diet. The relationship of the findings to "essential" hypertension and to premorbid cardiovascular sequelae, and the key role of capillary endothelium in the development of "essential" hypertension is discussed.

Biochemical response to change in the environment and the nature of "essential" hypertension.

The abnormality of Na+, K+-cotransport detected in erythrocytes of patients with "essential" hypertension, appears to be an inherited biochemical disorder characteristic of the disease. This explains several features of "essential" hypertension. However, characteristics of the kinetics of this Na+ transport system are similar to characteristics of enzymes in halophilic organisms, which live in a high saline environment. Cell Na+ is increased in patients with "essential" hypertension and in halophilic organisms. This suggests that the enzyme characteristics are response mechanisms to maintain extracellular Na+ concentration within an optimal range. Based on this view two assumptions of biochemical response have been put forward which form the biochemical basis of a general biological theory. The implications of this for understanding the nature of "essential" hypertension are discussed. To explain the nature of the inheritance of the Na+, K+-cotransport defect in erythrocytes of patients with "essential" hypertension, a theory of acquired genetic transmission called "improvisation" theory is proposed. Improvisation may be the mechanism whereby new gene formation occurs, and be the mechanism for evolution of species if successful reproduction of offspring is allowed to continue.

Syncope and atypical chest pain in an intercollegiate wrestler: a case report.

OBJECTIVE: To present the case of a 20-year-old collegiate wrestler who suffered from atypical chest pains and syncope after rigorous exercise, dehydration, and ingestion of a metabolic stimulant. BACKGROUND: As a result of pressure to obtain a lower body weight for competition, wrestlers often pursue practices to lose a substantial amount of weight in a short period of time. These practices include rigorous exercise, starvation, dehydration, laxatives, diuretics, and over-the-counter stimulants. Our case involves an athlete who ingested a metabolic stimulant containing ma huang (ephedrine) and suffered from syncope and atypical chest pains during a bout of rigorous exercise and dehydration to lose weight for competition. DIFFERENTIAL DIAGNOSIS: Hypertrophic cardiomyopathy, electrolyte imbalance, drug overdose, traumatic head injury, myocardial infarction, syncope. TREATMENT: The emergency medical services transported the athlete to the emergency room, and he was hospitalized for 2 days. After discharge, the team physician counseled the athlete in the dangers of metabolic stimulants and excessive weight-loss techniques. UNIQUENESS: This case is unique because it presents an athlete who ingested an over-the-counter stimulant to lose weight and suffered from syncope and atypical chest pains during a bout of rigorous exercise and dehydration. CONCLUSIONS: Athletic trainers must understand not only the dangers of excessive weight loss, but also the dangers of using unregulated ephedrine-containing stimulants to aid in weight loss.

Proprioception and neuromuscular control of the shoulder after muscle fatigue.

OBJECTIVE: To examine the effects of fatigue on proprioception and neuromuscular control of the shoulder. DESIGN AND SETTING: Subjects were randomly assigned to either an experimental group or control group. Subjects were tested using either the active angle-reproduction or the single- arm dynamic stability test. The subjects were then fatigued using a dynamometer performing continuous, concentric rotation exercises of the shoulder. Once fatigued, the subjects were posttested using the same test. One week later, the subjects returned and were pretested, fatigued, and posttested using the other test. SUBJECTS: Thirty-two college-age (18 to 25 years) subjects (16 males, 16 females) with no history of glenohumeral instability or upper extremity injury volunteered for this study. MEASUREMENTS: Absolute angular error was measured using an electrogoniometer present within the isokinetic dynamometer, while sway velocity was measured using a force-plate system. RESULTS: Repeated-measures analysis of variance revealed a significant difference between the pretest and posttest values for absolute angular error in the experimental group, whereas no significant difference was revealed between pretest and posttest sway velocity for either the control or experimental group. CONCLUSIONS: Fatigue of the internal and external rotators of the shoulder decreased proprioception of the shoulder, while having no significant effect on neuromuscular control.