Effect of autonomic hyperreflexia on plasma renin.

Four patients with paroxysmal hypertension related to spinal cord injury (autonomic hyperreflexia) were studied to determine if the plasma renin became elevated in relation to a sympathetic stimulus. Using bladder distention to produce the autonomic hyperreflexia, renin determinations were made during and after the hypertensive episode. None of the patients demonstrated elevation of the plasma renin after this event.

Adenocarcinoma of bladder.

Twenty-five patients with pure primary adenocarcinoma of the bladder were treated in a fifteen-year period. Practically all patients presented with some combination of gross hematuria, irritative lower urinary tract symptoms, or obstruction. Almost half the lesions were at the dome of the bladder. Most of the lesions were high grade and invasive. Transurethral resection is, at best, only diagnostic and palliative, and radiotherapy has been of little value. Radical cystectomy seems to produce five-year survival almost twice that of segmental resection. However, solitary lesions at the dome of the bladder, which usually represent neoplasia in a urachal remnant, seem to behave somewhat differently from lesions elsewhere in the bladder. Indeed, five-year survival of patients with lesions at the dome of the bladder who underwent segmental resection approximated that of those with similar lesions who underwent total cystectomy.

Carcinoma of the breast metastatic to the ureter presenting with flank pain and recurrent urinary tract infection.

Urinary tract infection in the female patient is not an uncommon finding. Flank pain associated with urinary tract infection is usually due to calculus disease or pyelonephritis. In patients with history of breast carcinoma, metastasis to the periureteral area with resulting obstruction should be considered. The incidence of metastatic breast carcinoma presenting in this fashion is as high as 7.8 per cent. This case shows a patient with metastatic lobular carcinoma of the breast with ureteral obstruction, causing flank pain and recurrent urinary tract infection. This report emphasizes the importance of long-term follow-up in patients with history of breast cancer, especially invasive lobular carcinoma, and the high degree of suspicion required to diagnose and institute proper therapy.

Autonomic pain: features and methods of assessment.

The distribution of pain originating in the sympathetic nervous system does not match the somatic segmental sensory distribution at the postganglionic level. The two types of distribution are separate and different. At the preganglionic level, fibers show typical segmental sensory distribution, which resembles but is not identical to somatic segmental sensory distribution. Instead, sympathetic pain has its own distribution along the vascular supply and some peripheral nerves. It cannot be called atypical in terms of somatic segmental sensory distribution. Several techniques are available to assess autonomic function in cases of chronic pain. Infrared thermography is superior to any other physiologic or pharmacologic method to assess sympathetic function. Overactivity of sympathetic function in the area of pain is the probable cause of temperature reduction in that area. Accordingly it would appear that in cases in which thermography demonstrates decreased temperature, sympathetic block or sympathectomy would provide relief from the pain.

Surgical management of wounds.

Surgical management of a wound whether elective or post-traumatic requires strict adherence to certain basic precepts if a successful outcome is to be expected: 1. The patient must be stabilized. 2. Blood supply to the tissues must be adequate in order for the wound to heal. 3. All necrotic tissue must be debrided as it provides an excellent medium for bacterial growth. 4. Wound irrigation is necessary to remove foreign matter, hematoma, and decrease contaminants, e.g., bacteria. 5. Deep structures may be repaired as appropriate to help restore function. 6. Antibiotics and tetanus prophylaxis protocol are administered as appropriate. 7. Wound closure is performed as indicated, i.e., primary closure, delay primary closure, secondary intention (granulation).

Physical medicine and rehabilitation-important advances in clinical medicine: mechanical prophylaxis of deep vein thrombosis.

The Scientific Board of the California Medical Association presents the following inventory of items of progress in physical medicine and rehabilitation. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, research workers or scholars to stay abreast of these items of progress in physical medicine and rehabilitation that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on Physical Medicine and Rehabilitation of the California Medical Association and the summaries were prepared under its direction.

Somatosensory evoked potentials in spinal cord injured patients.

Out of 25 patients with traumatic spinal cord injuries, ten patients with complete and 15 incomplete (five serially) were evaluated with somatosensory evoked potentials. Clinical correlations are presented and discussed.

Quantitative analysis of visual acuity through amber discolored lenses.

Discoloration of hydrogel contact lenses is frequently encountered in clinical practice and often precipitates lens replacement. This investigation sought to determine if lens discoloration was associated with a compromise in low or high contrast, high illumination visual acuity. This association would lead to a more scientific rationale for lens replacement. Amber lens discoloration was achieved using human-worn 55% water hydrophilic contact lenses (Methafilcon-A) heated in a 1% potassium sorbate, low pH saline solution. A spectrum of 6 discolored lenses was obtained with a peak absorbance at 320 nm. Fifteen subjects, between the ages of 22 and 38 years, were tested wearing each of the discolored lenses. None of the differences in high or low contrast acuity between our discolored and nondiscolored lenses were found to be statistically significant using a paired t-test at the 99% significance level.

Biomechanical review: Coe-alginate impression techniques.

The authors have found Coe-alginate to have many uses in podiatric surgery. They describe the technique and believe that its reproduction quality is superior to that obtained by using other materials.

Parameter consistency in disposable lenses.

An evaluation of parameter consistency and edge defects as they might relate to premature lens fracture was undertaken for 2 disposable lens types, 50 Johnson & Johnson Acuvue lenses and 50 Wesley-Jessen FreshLook lenses. Diameter measurements varied from 13.97 to 14.48 mm (mean = 14.28 mm, SD = 0.138 mm) for Acuvue and 14.30 to 14.63 mm (mean = 14.41 mm, SD = 0.064 mm) for FreshLook. Based on previously reported information, these diameter variations for Acuvue may be sufficient to affect lens fitting characteristics. Calculated back surface sagittal depth varied from 3.27 to 3.38 mm (mean = 3.32, SD = 0.029 mm) for Acuvue and 3.68 to 3.87 mm (mean = 3.75 mm, SD = 0.039 mm) for FreshLook. Center thickness was generally consistent across the power range evaluated (-0.50 to -4.00 D) for the FreshLook lenses, and appeared to increase significantly for low minus powers for the Acuvue lenses. Twenty-one (44%) Acuvue lenses and 6 (12%) FreshLook lenses showed edge defects that might contribute to premature lens fracture.

Epidermoid cyst of the testis: a critical analysis.

Our experience with 163 patients (11 from our institution) with simple epidermoid cyst of the testis was analysed. The lesion is nearly as common as interstitial cell tumour of the testis. In its simple form it is a benign lesion that usually appears as a solitary, asymptomatic, testicular, 2-cm mass in non-black young men (usually 20 to 40 years of age). It has been suspected on circumstantial clinical evidence in a few patients (17.5%) who have been successfully treated by simple enucleation. In the majority, however, fear of looking for a zebra in a herd of horses or not thinking of zebras at all has led to radical orchiectomy. None of the 80 patients followed up for a maximum of 37 years has suffered any ill effects.

Lumbar fracture-dislocation related to range-of-motion exercises.

Range-of-motion exercises are an established and widely accepted therapeutic modality in the treatment of the person with spinal cord injury and are usually uneventful. Occasionally, however, accidents do occur; among them are fractures and dislocations of limbs. An unusual "slice" fracture of L4, related to range of motion exercises, occurred in a young man who was a quadriplegic and converted him from upper to lower motor neuron bowel, bladder and sexual function. This iatrogenic fracture, although extremely rare, can be prevented if symptoms are properly interpreted.

Secondary spinal lesions in spinal cord injury patients.

On hospital admission, 6 spinal cord injured patients were noted to have second noncontiguous levels of spinal injury that were previously unrecognized. These secondary levels of spinal injury were diagnosed as a result of routine admission total spine radiographic examinations. Two cases are described in detail, one with the secondary spinal lesion above and the other below the primary spinal cord injury. Careful total spine radiographic studies are recommended to prevent complications, in the event that such lesions are initially unrecognized.

Silent hydronephrosis, a hazard revisited.

Six patients with neurogenic bladder secondary to spinal cord injury were seen in our Centre for routine follow-up. All of these individuals had attained the catheter-free state by various means and were, by their standards, functioning very well. They had gone from 6 months to 2 1/2 years without genito-urinary re-evaluations. One individual had a normal urogram 1 year after catheter removal and then 2 years later was noted to have bilateral hydronephrosis. Development of silent hydronephrosis in the catheter-free state, its treatment, and a regimen for following patients are discussed.

Sequential changes in factor VIII and platelets preceding deep vein thrombosis in patients with spinal cord injury.

The relationships between factor VIII associated activities, platelet function, and venous thrombosis were studied in 18 patients with lower limb paralysis following acute spinal cord injury (SCI). Deep vein thrombosis (DVT) was detected in 13 patients (72%). Eight of the 13 thromboses were documented between 6 and 8 d following injury while the other five episodes were noted on days 11 (two), 13, 18 and 22. The detection of thrombosis was preceded by marked increases in VIIIR:Ag and VIII:RCoF whereas VIII:C was only marginally increased. The platelet aggregation response to collagen was hyperactive by the sixth day while the platelet aggregate ratio (PAR) did not become abnormal until after DVT was detected. These studies suggest a chronology in the series of events leading to DVT in patients with lower limb paralysis following SCI. Initial elevations in VIII:Ag and VIII:RCoF are followed in sequence by increased platelet responsiveness to collagen, the occurrence of DVT, and the appearance of circulating platelet aggregates. Conceivably, VIIIR:Ag elaborated by endothelial cells alters platelet reactivity and provides an important determinant for venous thrombosis.

An explanation for the persistence of residual urine after external sphincterotomy.

After external urethral sphincterotomy 7 patients were found to have residual urine in excess of 80 ml. By measurement of the urethral pressure and analysis of the cystometrogram it was found that these patients fail to sustain bladder contraction and, thereby, fail to empty the bladder completely.