International spinal cord injury pulmonary function basic data set.

OBJECTIVES: To develop the International Spinal Cord Injury (SCI) Pulmonary Function Basic Data Set within the framework of the International SCI Data Sets in order to facilitate consistent collection and reporting of basic bronchopulmonary findings in the SCI population. SETTING: International. METHODS: The SCI Pulmonary Function Data Set was developed by an international working group. The initial data set document was revised on the basis of suggestions from members of the Executive Committee of the International SCI Standards and Data Sets, the International Spinal Cord Society (ISCoS) Executive and Scientific Committees, American Spinal Injury Association (ASIA) Board, other interested organizations and societies and individual reviewers. In addition, the data set was posted for 2 months on ISCoS and ASIA websites for comments. RESULTS: The final International SCI Pulmonary Function Data Set contains questions on the pulmonary conditions diagnosed before spinal cord lesion,if available, to be obtained only once; smoking history; pulmonary complications and conditions after the spinal cord lesion, which may be collected at any time. These data include information on pneumonia, asthma, chronic obstructive pulmonary disease and sleep apnea. Current utilization of ventilator assistance including mechanical ventilation, diaphragmatic pacing, phrenic nerve stimulation and Bi-level positive airway pressure can be reported, as well as results from pulmonary function testing includes: forced vital capacity, forced expiratory volume in one second and peak expiratory flow. The complete instructions for data collection and the data sheet itself are freely available on the website of ISCoS (http://www.iscos.org.uk).

International bowel function extended spinal cord injury data set.

STUDY DESIGN: International expert working group. OBJECTIVE: To develop an International Bowel Function Extended Spinal Cord Injury (SCI) Data Set presenting a standardized format for the collection and reporting of an extended amount of information on bowel function. SETTING: Working group consisting of members appointed by the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS). METHODS: A draft prepared by the working group was reviewed by Executive Committee of the International SCI Standards and Data Sets and later by the ISCoS Scientific Committee and the ASIA Board. Relevant and interested scientific and professional organizations and societies (around 40) were also invited to review the data set and it was posted on the ISCoS and ASIA websites for 3 months to allow comments and suggestions. The ISCoS Scientific Committee, ISCoS Council and ASIA Board received the data set for final review and approval. RESULTS: The International Bowel Function Basic SCI Data Set includes 26 items providing a thorough description of bowel-related symptoms as well as clinical assessment of anal sphincter function and description of total gastrointestinal or segmental colorectal transit times. CONCLUSION: An International Bowel Function Extended SCI Data Set has been developed. This Data Set is mainly for research purposes and it should be used in combination with the information obtained from the International SCI Core Data Set and the International Bowel Function Basic SCI Data Set.

International bowel function basic spinal cord injury data set.

STUDY DESIGN: International expert working group. OBJECTIVE: To develop an International Bowel Function Basic Spinal Cord Injury (SCI) Data Set presenting a standardized format for the collection and reporting of a minimal amount of information on bowel function in daily practice or in research. SETTING: Working group consisting of members appointed by the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS). METHODS: A draft prepared by the working group was reviewed by Executive Committee of the International SCI Standards and Data Sets, and later by ISCoS Scientific Committee and the ASIA Board. Relevant and interested scientific and professional (international) organizations and societies (approximately 40) were also invited to review the data set and it was posted on the ISCoS and ASIA websites for 3 months to allow comments and suggestions. The ISCoS Scientific Committee, Council and ASIA Board received the data set for final review and approval. RESULTS: The International Bowel Function Basic SCI Data Set includes the following 12 items: date of data collection, gastrointestinal or anal sphincter dysfunction unrelated to SCI, surgical procedures on the gastrointestinal tract, awareness of the need to defecate, defecation method and bowel care procedures, average time required for defecation, frequency of defecation, frequency of fecal incontinence, need to wear pad or plug, medication affecting bowel function/constipating agents, oral laxatives and perianal problems. CONCLUSION: An International Bowel Function Basic SCI Data Set has been developed.

International standards to document remaining autonomic function after spinal cord injury.

STUDY DESIGN: Experts opinions consensus. OBJECTIVE: To develop a common strategy to document remaining autonomic neurologic function following spinal cord injury (SCI). BACKGROUND AND RATIONALE: The impact of a specific SCI on a person's neurologic function is generally described through use of the International Standards for the Neurological Classification of SCI. These standards document the remaining motor and sensory function that a person may have; however, they do not provide information about the status of a person's autonomic function. METHODS: Based on this deficiency, the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS) commissioned a group of international experts to develop a common strategy to document the remaining autonomic neurologic function. RESULTS: Four subgroups were commissioned: bladder, bowel, sexual function and general autonomic function. On-line communication was followed by numerous face to face meetings. The information was then presented in a summary format at a course on Measurement in Spinal Cord Injury, held on June 24, 2006. Subsequent to this it was revised online by the committee members, posted on the websites of both ASIA and ISCoS for comment and re-revised through webcasts. Topics include an overview of autonomic anatomy, classification of cardiovascular, respiratory, sudomotor and thermoregulatory function, bladder, bowel and sexual function. CONCLUSION: This document describes a new system to document the impact of SCI on autonomic function. Based upon current knowledge of the neuroanatomy of autonomic function this paper provides a framework with which to communicate the effects of specific spinal cord injuries on cardiovascular, broncho-pulmonary, sudomotor, bladder, bowel and sexual function.

Homocysteine and hypertension in persons with spinal cord injury.

STUDY DESIGN: Cross-sectional analysis of a convenience sample of locally recruited participants, including both patients and volunteers. OBJECTIVES: To determine whether there is an association between plasma homocysteine and hypertension in persons with spinal cord injury (SCI). SETTING: Spinal Cord Injury Service of the Veterans Affairs Palo Alto Medical Center (California, United States of America). METHODS: The incidence of hypertension, dyslipidemia, insulin resistance, and the presence of metabolic syndrome were determined in 168 individuals with SCI (mean age 50.2 +/- 12.8 years). Fasting lipids, insulin, glucose, plasma homocysteine, and anthropometric data was gathered for each subject. RESULTS: Blood pressure values (P < 0.001) and mean arterial pressure (P < 0.05) increased with higher plasma homocysteine levels. Homocysteine values were also significantly greater among individuals with hypertension compared with those who were normotensive or prehypertensive (P < 0.0001). There was an inverse relationship between plasma homocysteine levels and glomerular filtration rate and effective renal plasma flow (P < 0.05). CONCLUSIONS: Plasma homocysteine levels are elevated in persons with SCI who have hypertension and inversely related to renal function, which suggests that renal dysfunction may be a link between homocysteine and hypertension in persons with SCI. SPONSORSHIP: Funded by the VA Rehabilitation Research and Development Service, Merit Review Grant #B2549R.

Functional magnetic stimulation facilitates colonic transit in rats.

OBJECTIVE: To investigate the effect of functional magnetic stimulation (FMS) on colonic transit in rats. DESIGN: Experimental. SETTING: Functional magnetic stimulation laboratory in a Veterans Administration health care system. ANIMALS: Twenty-four female Wistar rats, divided into an experimental group and a control group. INTERVENTIONS: All rats had technetium 99m (Tc 99m) infused through a cecal catheter to assess colonic transit times. FMS was performed over the cervical region; a figure of 8 magnetic coil was used in the experimental group. The colon was removed and sectioned into 10 segments, and a stool sample was taken in both groups. MAIN OUTCOME MEASURES: Distribution of radioactivity within the large intestine and stool were measured. RESULTS: Geometric center calculations showed significant differences (p <.001) between the control group and the experimental group when the distribution of radioactivity along the colon was measured. The percentage of Tc 99m recovered from the stool in the experimental group was significantly higher than the percentage recovered from the control group. CONCLUSION: FMS facilitates colonic transit in a rat model.

Functional magnetic stimulation for conditioning of expiratory muscles in patients with spinal cord injury.

OBJECTIVE: To evaluate the effectiveness of functional magnetic stimulation (FMS) in conditioning expiratory muscles patients with spinal cord injury (SCI). DESIGN: A prospective before-after trial. SETTING: The Functional Magnetic Stimulation Laboratory of the SCI Health Care Group, VA Long Beach Health Care System, and the Spinal Cord Injury Services, Department of Veterans Affairs, Palo Alto Health Care System. PARTICIPANTS: Eight men with tetraplegia. INTERVENTION: Expiratory muscle training was achieved by placing a magnetic stimulator with a round magnetic coil along subjects' lower thoracic spine. MAIN OUTCOME MEASURES: Measures taken were the maximal expired pressure at total lung capacity (MEP-TLC) and at functional residual capacity (MEP-FRC), expiratory reserve volume (ERV), and the forced expiratory flow rate at TLC (FEF-TLC) and at FRC (FEF-FRC) by subjects' voluntary maximal efforts. RESULTS: After 4 weeks of conditioning, the mean +/- standard error of the mean values were: MEP-TLC, 55.3 +/- 8.6cmH(2)O; MEP-FRC, 29.6 +/- 5.6cmH(2)O; ERV,.57 +/-.08L; FEF-TLC, 4.3 +/- 0.5L/s; and FEF-FRC, 1.9 +/- 0.2L/s. These values correspond to, respectively, 129%, 137%, 162%, 109%, and 127% of pre-FMS conditioning values. When FMS was discontinued for 2 weeks, the MEP-TLC returned to its pre-FMS training value. CONCLUSION: A 4-week protocol of FMS of the expiratory muscles improves voluntary expiratory muscle strength significantly, indicating that FMS can be a noninvasive therapeutic technology in respiratory muscle training for persons with tetraplegia.

Functional magnetic stimulation of the colon in persons with spinal cord injury.

OBJECTIVE: To evaluate the usefulness of functional magnetic stimulation (FMS) as a noninvasive method to stimulate the colon in individuals with spinal cord injury (SCI). DESIGN: A prospective before-after trial consisting of 2 protocols. SETTING: FMS laboratories of 2 SCI centers. PARTICIPANTS: Two able-bodied men and 13 men with SCI levels ranging from C3 to L1. Protocol 1 consisted of 9 subjects, 2 of whom were excluded from the analysis. Protocol 2 consisted of 4 subjects. INTERVENTION: Commercially available magnetic stimulators with round magnetic coils (MCs) were used. Protocol 1 measured the effects of FMS on rectal pressure by placing the MC on the transabdominal and lumbosacral regions. Protocol 2 consisted of a 5-week stimulation period to investigate the effects of FMS on total and segmental colonic transit times (CTTs). MAIN OUTCOME MEASURE: An increase in rectal pressure and a decrease in CTT by magnetic stimulation. RESULTS: Data were averaged and the standard error of the mean was calculated. Statistically significant changes in rectal pressure and CTT were also measured. Rectal pressures increased from 26.7 +/- 7.44cmH(2)O to 48.0 +/- 9.91cmH(2)O, p =.0037, with lumbosacral stimulation, and from 30.0 +/- 6.35cmH(2)O to 42.7 +/- 7.95cmH(2)O, p =.0015, with transabdominal stimulation. With FMS, the mean CTT decreased from 105.2 to 89.4 hours, p =.02. CONCLUSION: FMS is able to stimulate the colon and reduce CTT. FMS is a noninvasive, technological advancement for managing neurogenic bowel in patients with SCI.

Progressive decrease in bone density over 10 years of androgen deprivation therapy in patients with prostate cancer.

OBJECTIVES: Several reports suggest an increased incidence of osteoporosis and concomitant fractures in men receiving androgen deprivation therapy (ADT) for prostate cancer. We sought to estimate the longitudinal effects of ADT on loss of bone density in this cross-sectional study. METHODS: Hip and spine bone mineral density (BMD) studies were performed by dual-energy x-ray absorptiometry on 36 patients with prostate cancer. The year 0 cohort (n = 8) consisted of patients who had not yet begun planned ADT. These men were compared to patients receiving ADT who underwent BMD evaluation at year 2 (n = 6), year 4 (n = 7), year 6 (n = 5), year 8 (n = 5), and year 10 (n = 5) of therapy. All BMD values for the patients with prostate cancer were compared to age-matched control subjects. RESULTS: Hip BMD was significantly lower in patients on ADT (mean BMD 0.802 g/cm(2)) compared with those not on ADT (mean BMD 0.935 g/cm(2)). Patients at year 0 had hip and spine BMD similar to age-matched control subjects. There was a significant trend for decreased hip BMD with increasing years of ADT (r = 0.46, P = 0.00008). This relationship was more dramatic when hip BMD at each time point was compared to age-matched control subjects (r = 0.55, P = 0.5 x 10(-16)). This bone loss was evident even up to year 10. BMD loss was more dramatic in patients who had undergone surgical castration than those receiving medical ADT (P = 0.08). Patients on intermittent ADT had similar BMD loss as patients on continuous ADT at year 2 and year 4 but demonstrated less bone loss at year 6 (P = 0.07) despite equivalently low testosterone levels. CONCLUSIONS: There is diminished BMD with increasing duration of ADT. Continuous ADT and surgical castration may be more deleterious than medical therapy, particularly when the medical therapy is given in an intermittent fashion.

Functional magnetic stimulation facilitates gastrointestinal transit of liquids in rats.

The purpose of this study was to investigate the effect of a relatively novel technology, functional magnetic stimulation (FMS), on gastrointestinal transit of liquids in rats. Orogastric gavage with technetium-99 solution was used to assess gastric emptying and gastrointestinal transit time in 92 rats. FMS was performed over the anterior cervical and/or dorsal thoracolumbar regions using a figure-8 coil. Stimulation protocols were 1, 2, or 4 h in length. FMS accelerated gastric emptying and decreased gastrointestinal transit time. The acceleration was dependent on the stimulation parameters used as well as on the duration of the protocol; high levels of FMS produced a quicker effect, whereas lower levels were effective at later times. This study provides evidence that FMS could be an alternative or adjunct therapy to treat disorders in gastrointestinal motility.

Bone mineral and geometric changes through the femur with immobilization due to spinal cord injury.

This cross-sectional study describes bone mineral and geometric properties of the midshaft and distal femur in a control population and examines effects of immobilization due to spinal cord injury (SCI) at these skeletal sites. The subject populations were comprised of 118 ambulatory adults (59 men and 59 women) and 246 individuals with SCI (239 men and 7 women); 30 of these were considered to have acute injury (SCI duration <1 year). Bone mineral density (BMD) was assessed at the femoral neck, and midshaft and distal femur by dual energy absorptiometry. Geometric properties, specifically cortical area, polar moment of inertia, and polar section modulus, were estimated at the midshaft from cortical dimensions obtained by concurrent radiography. Reduction in BMD was noted in all femoral regions (27%, 25%, and 43% for femoral neck, midshaft, and distal femur, respectively) compared with controls. In contrast, although endosteal diameter was enlarged, geometric properties were not significantly reduced in the midshaft attributable to the age-related increase in periosteal diameter. These results suggest that simultaneous assessment of bone mineral and geometric properties may improve clinically relevant evaluation of skeletal status.

Functional magnetic stimulation: a new modality for enhancing systemic fibrinolysis.

OBJECTIVE: To investigate whether functional magnetic stimulation (FMS) of the leg muscles could enhance systemic fibrinolysis. DESIGN: A within-subject analysis of systemic fibrinolysis before and after 60 minutes of FMS. SETTING: The Functional Magnetic Stimulation and Special Coagulation Laboratories in the Spinal Cord Injury Service at a Veterans Administration health care facility. PARTICIPANTS: Twenty healthy volunteers were recruited. The exclusion criteria were: (1) personal or family history of venous or arterial thrombosis, (2) personal or family history of cardiac arrythmias, (3) current use of medication, and (4) the presence of a cardiac pacemaker or other metallic implants. MAIN OUTCOME MEASURES: Whole blood clot lysis time (WBCLT) and tissue plasminogen activator (t-PA) antigen determined at baseline and 10 and 60 minutes after FMS. RESULTS: A significant decrease was observed in the mean WBCLT after FMS. The WBCLT decreased from 17+/-1.3 h before FMS to 12+/-1.0 h and 11+/-0.8 h at 10 and 60 minutes post-FMS, respectively. The mean t-PA antigen levels did not show a significant change (p = .6701) from pre-FMS (6.7+/-0.91 ng/mL) to 10 min post-FMS (6.8+/-0.91 ng/mL) and 60 min post-FMS (7.0+/-1.02 ng/mL). Several patterns of fibrinolytic response to FMS were observed. They differed in relation to the degree of enhancement, the period at which maximum enhancement occurred, and the corresponding t-PA antigen levels observed. CONCLUSIONS: The FMS-induced contractions of the leg muscles enhanced systemic fibrinolysis ex vivo. The improvement in fibrinolysis occurred immediately after FMS and was also observed at 60 minutes post-FMS. FMS appears to produce a sustained enhancement of systemic fibrinolysis that may prove useful in deep-vein thrombosis prophylaxis.

Methicillin-resistant Staphylococcus aureus in patients with spinal cord injury.

During the past decade, methicillin-resistant Staphylococcus aureus (MRSA) has become a major cause of nosocomial and community-acquired infections in the United States. A retrospective chart review of MRSA-positive cases from January 1990 to December 1994 was done to assess the extent of the problem, the factors associated with MRSA acquisition, and the effectiveness of a Center for Disease Control (CDC) protocol to treat MRSA infection in a population with spinal cord injury (SCI). Seventy-four percent of the patients acquired MRSA during their hospitalization. Urine was the most common site of colonization, and 73 percent of the patients with positive urine cultures managed their bladders with indwelling catheters. Implementation of the CDC protocol in 1991 was associated with a decrease in the MRSA incidence rate in subsequent years. Other simple methods of treatment, such as bladder irrigation, were also effective. To control the spread of MRSA, a continual concerted effort by hospital staff through education and implementation of the MRSA protocol is necessary.

Use of contact laser crystal tip firing Nd:YAG to relieve urinary outflow obstruction in male neurogenic bladder patients.

BACKGROUND AND OBJECTIVE: Endoscopic urologic procedures for transurethral prostatectomy (TURP), external sphincterotomy (TURS), bladder neck incision, and incising strictures using diathermy have resulted in excessive bleeding and risk of hyponatremia. This presentation is a review of a methodology developed to evaluate the use of contact laser crystal firing Nd:YAG laser. Details of the technique are presented. RESULTS: A review of 129 patients following laser TURS with 34% of these patients also needing TURP and 29% of patients also requiring TUIP has been done. Following contact laser endoscopic surgery, the catheter was removed in 24 hours. There was minimal to nil haemorrhage perioperatively and secondary haemorrhage was absent. CONCLUSIONS: The technique employing contact laser crystal provides an easy TURP, TURS, and stricture ablation. Follow up indicates durable results.

Effect of alpha1 adrenoceptor antagonist on the urodynamics of the upper and lower urinary tract of the male rat.

In this investigation, we examined the impact of the alpha1 adrenoceptor (alpha1-ADR) antagonist prazosin on the urodynamic characteristics of upper urinary tract function and associated micturition characteristics of the adult male rat. The focus of the study was to evaluate the extent to which prazosin affects urine production and ureteral transport relative to its effect on micturition. Control micturition studies were first performed using 28 awake Sprague-Dawley rats that were placed in metabolic cages for characterization of the frequency and mean and total volume voided over a 4-hr period. Following the control studies, the effect of intraperitoneal prazosin, 30 microg/kg, was evaluated under identical conditions. Urodynamic studies were done to identify the bladder filling and voiding characteristics of anesthetized rats that were infused with saline at a rate of 0.22 ml/min. From the urodynamic studies the parameters of bladder pressure (Pves) and volume (V) during filling, urethral opening (Puo) measured at the moment of micturition, and maximum detrusor pressure during voiding (Pdetmax) were evaluated. External sphincter electromyography was also monitored and recorded together with bladder pressure during voiding. Renal pelvic pressure was measured via a nephrostomy catheter and recordings were made simultaneously with bladder filling and voiding. The upper urinary tract was visualized using microscopic video imaging of the ureter, contrasted by perfusing the renal pelvis with indigo carmine. Characterization of upper tract transport was made in terms of renal pelvic pressure, ureteral peristaltic rate, and bolus length and velocity. The results show that in the awake rat, 30 microg/kg of prazosin decreased the urine production rate from 4.8 +/- 0.074 to 1.6 +/- 0.23 ml (P < 0.001) and micturition frequency by a similar proportion from 1.99 +/- 0.44 to 0.53 +/- 0.08/hr. In the lower urinary tract, prazosin did not change the baseline pressure of the bladder but produced significant dose-dependent decreases in Pdetmax, Puo, and frequency of micturition. In the upper urinary tract, ureteral and pelvic frequencies decreased, whereas the length of bolus increased significantly corresponding to increased doses of prazosin. These results suggest that, although prazosin facilitates micturition by reducing urethral opening pressure, it also reduces the rate of urine production and modulates the function of urine transport in the upper urinary tract.

Functional magnetic stimulation for restoring cough in patients with tetraplegia.

OBJECTIVE: To evaluate the usefulness of functional magnetic stimulation (FMS) as a noninvasive method for assisting cough in patients with tetraplegia. DESIGN: A prospective before-after trial. SETTING: The functional magnetic stimulation laboratory of a spinal cord injury (SCI) service. PARTICIPANTS: Thirteen male SCI patients, with injury levels between C4 and C7. INTERVENTION: A commercially available magnetic stimulator with a round magnetic coil (MC) was used. Expiratory muscle activation was achieved by placing the MC along the lower thoracic spine. MAIN OUTCOME MEASURE: The planned major outcome measures were the maximal expired pressure (MEP), expiratory reserve volume (ERV), and forced expiratory flow rate (FEF) by FMS compared with voluntary maximal efforts. Another outcome was the optimal MC placement and stimulation intensity that would result in highest expired pressure. RESULTS: The mean (+/-SEM) MEP, ERV, and FEF generated by FMS were 66.40 +/- 6.69 cmH2O, .77 +/- .14 L, and 5.28 +/- .42 L/sec, respectively. They were 118%, 169%, and 110% of voluntary maximum efforts. MC placement at the T10 to T11 spinous process and stimulation intensity at 80% produced the highest MEP and FEF. CONCLUSION: FMS of the expiratory muscles produced significant expired pressures, volumes, and flow rates when compared with voluntary maximum efforts; therefore, FMS can be used as an effective method to restore cough in tetraplegic patients.