Pressure ulcer in patients with severe traumatic brain injury: significant factors and association with neurological outcome.

AIMS AND OBJECTIVES: To assess the factors associated with development of pressure ulcer in patients with severe traumatic brain injury (TBI) and study its prognostic significance with respect to neurological outcome at three months. BACKGROUND: Patients with severe TBI are prone to develop pressure ulcer due to various factors, which have never been studied in detail. DESIGN: Prospective longitudinal study. METHODS: Eighty-nine patients of TBI in age group 20-60 years admitted with Glasgow Coma Scale (GCS) 4-8 without serious systemic disorder were enrolled for the study. Patient characteristics, haemoglobin, serum albumin levels at admission and their weekly changes till 21 days were noted along with daily assessment for presence of pressure ulcer. Mortality was assessed at 21 days and neurological outcome at three months through telephonic interview. RESULTS: Of 89 patients studied, pressure ulcer was observed in 6 (7%) and 14 (16%) at the end of two and three weeks, respectively. Pressure ulcer in univariate analysis was significantly associated with poorer GCS (p = 0·05), delayed enteral feeding (p = 0·005) and fall in haemoglobin at two weeks (p = 0·005). Only the latter two were found significant in multivariate analysis. Age, gender, surgical intervention, tracheostomy, prolonged fever and change in albumin had no significant association with pressure ulcer development. Presence of pressure ulcer was significantly associated with mortality at 21 days (p = 0·006) and unfavourable neurological outcome at three months (p = 0·01). CONCLUSIONS: The significant factors influencing pressure ulcer development in patients with TBI were delayed enteral feeding and fall in haemoglobin. Pressure ulcer had significant association with mortality at 21 days and recovery status at three months. RELEVANCE TO CLINICAL PRACTICE: Early nutritional supplementation and monitoring of haemoglobin should be an important part of nursing care interventions for patients at increased risk of developing pressure ulcer.

Detrusor myectomy: long-term functional outcomes.

OBJECTIVES: Detrusor myectomy is a recognized method of bladder augmentation for treating refractory detrusor overactivity. Herein we report the long-term outcomes of this procedure at the University Hospital of Wales in Cardiff, UK. METHODS: Detrusor myectomy was carried out in 33 patients (7 males, 26 females) with urodynamically proven detrusor overactivity between 1995 and 2002. The mean patient age was 33 years (range 5-62). A total of 18 patients had idiopathic detrusor overactivity, whereas 15 had neurogenic detrusor overactivity. RESULTS: A total of 24 patients had a detrusor myectomy alone, whereas eight patients had a detrusor myectomy with implantation of artificial urinary sphincter. One patient had detrusor myectomy with transuretero-ureterostomy. The mean follow up was 148 months (range 108-192). A total of 10 of the 18 patients with idiopathic detrusor overactivity (55.5%) and six of the 15 patients with neurogenic detrusor overactivity (40%) showed marked improvement in symptoms. Detrusor overactivity was completely abolished in 11 patients and significantly reduced in five. Postoperatively, mean cystometric capacity improved from 290 to 458 mL, whereas mean maximum amplitude of detrusor contraction was reduced from 44 cm/H(2) O to 20 cm/H(2) O. An overall success rate of 48.5% (16/33 patients) was achieved. Intermittent self catheterization was needed to achieve bladder emptying in 12 of the 16 (75%) patients. Of the remaining 17 patients who did not improve, six had CLAM enterocystoplasty carried out and two await the operation. An ileal conduit diversion and suprapubic catheter insertion was carried out in one patient each, whereas seven patients declined any further intervention. CONCLUSIONS: Detrusor myectomy offers a reasonable long-term success rate to patients undergoing surgical treatment for refractory detrusor overactivity.

A proposed guideline for the urological management of patients with spinal cord injury.

OBJECTIVE: To develop a guideline for the urological management of patients with spinal cord injury (SCI). METHODS: The existing practice in the UK was evaluated by a series of expert meetings. Previous publications on the subject were evaluated, and the information synthesized to produce a proposed guideline. RESULTS: The literature review showed limited good-quality data. As a result of the process a series of research questions was produced, the answers to which would allow a guideline to be established based on good-quality evidence. In the absence of high-quality evidence, the guideline was constructed using expert opinion. Urological care is described in the immediate, intermediate and long-term phases after SCI. CONCLUSION: The urological consequences of SCI can be devastating. Urological care is an important part of the holistic care of these patients, and should be delivered from SCI centres through a network of qualified clinicians.

Pain perception following different neurosurgical procedures: a quantitative prospective study.

BACKGROUND: Pain following neurosurgery has never been given due attention. OBJECTIVE: This was a prospective study to assess pain following various neurosurgical procedures. METHODS: Patients underwent pain assessment on 11-point scale(0-10) for 24 hours following neurosurgery, and analyzed in relation to various factors. RESULTS: Among total 159 patients, 88(55%), 58(37%) and 13(8%) had undergone cranial, spinal and peripheral nerve procedures respectively. The mean pain score within 12 hours was 3.51(SD ± 2.53), which increased significantly during 13-24 hours to 5.06(SD ± 2.6)(P<0.001). During 13-24 hours, the pain score among those who underwent infratentorial procedures (8.02 ± 2.77) was significantly higher than among those who underwent supratentorial procedures (3.48 ± 1.99)(P<0.001). The pain score of patients who underwent lumbar surgery (6.5 ± 1.93) was significantly higher than of those who underwent cervical surgery (4.04 ± 2.43)(P<0.001). Age and gender did not show any significant influence on pain. CONCLUSION: Pain is significantly greater during 13-24 hours after neurosurgery, especially after infratentorial and lumbar surgical procedures, compared to others.

Bladder Smooth Muscle Cells Differentiation from Dental Pulp Stem Cells: Future Potential for Bladder Tissue Engineering.

Dental pulp stem cells (DPSCs) are multipotent cells capable of differentiating into multiple cell lines, thus providing an alternative source of cell for tissue engineering. Smooth muscle cell (SMC) regeneration is a crucial step in tissue engineering of the urinary bladder. It is known that DPSCs have the potential to differentiate into a smooth muscle phenotype in vitro with differentiation agents. However, most of these studies are focused on the vascular SMCs. The optimal approaches to induce human DPSCs to differentiate into bladder SMCs are still under investigation. We demonstrate in this study the ability of human DPSCs to differentiate into bladder SMCs in a growth environment containing bladder SMCs-conditioned medium with the addition of the transforming growth factor beta 1 (TGF-ß1). After 14 days of exposure to this medium, the gene and protein expression of SMC-specific marker (α-SMA, desmin, and calponin) increased over time. In particular, myosin was present in differentiated cells after 11 days of induction, which indicated that the cells differentiated into the mature SMCs. These data suggested that human DPSCs could be used as an alternative and less invasive source of stem cells for smooth muscle regeneration, a technology that has applications for bladder tissue engineering.

Contaminated operating room boots: the potential for infection.

BACKGROUND: Dirty operating room boots, often contaminated with blood and other infected material, are not only a source of discontent among surgeons and other surgical personnel, but they also pose a potential risk of transmission of viral or bacterial diseases to the wearer and cleaner of the boots. METHOD: Operating room boots were examined for the presence of blood by visual inspection; the presence or absence of blood was confirmed by a specific biochemical test. Bacterial isolation and quantification from boots were performed with conventional methodology. RESULTS: In this study, a spot check revealed that 44% of all operating room boots tested were contaminated with blood and that the majority were contaminated with bacteria. Sixty-three percent of surgeons using the facility had blood-contaminated boots, and a significant number of boots belonging to other surgical personnel were also contaminated with blood and bacteria normally associated with skin microbiota or the environment. Comfort shoes with perforations on their upper surface and plastic boots commonly found in operating rooms were most heavily contaminated, whereas Wellington boots and clogs had less contamination. CONCLUSION: The present practice of manual cleaning of boots is unsatisfactory, and it is recommended that boots be washed in automatic washing machines.

The false vocal folds: shape and size in frontal view during phonation based on laminagraphic tracings.

The geometry of the false vocal fold region during phonation is important to the understanding of the aerodynamics and acoustics of voice. The shape and dimensions of this region during phonation were estimated using laminagraphic tracings of the larynx. Laminagrams from two previous studies, one with non-singer subjects (Experiment I, Hollien and Colton, 1969) and the other with singers (Experiment II, Wilson, 1972), were traced, photocopied, and measured. Statistical analysis showed significantly greater false vocal fold height in males than females for both experiments. The false vocal fold gap was also significantly greater in males than females for Experiment II, but reached only borderline significance for Experiment I. For each gender, most of the linear measures were greater in Experiment I when compared to Experiment II; these differences may be passive in nature (due to actual differences in subject size) or active (due to muscle contraction that displaced the false vocal folds during singing).

Nurse-led epilepsy follow-up clinic in India: is it feasible and acceptable to patients? A pilot study.

PURPOSE: India has an epilepsy treatment gap of up to 90%. Shortage of doctors, especially in rural communities makes getting epilepsy treatment almost impossible for the vast majority. Nurses are relatively more in number and available even in smaller cities and villages. This pilot study investigated if a nurse-led epilepsy follow-up clinic is feasible in India and is acceptable to patients. METHOD: A II year Nursing postgraduate student was given 8h of didactic teaching tailored for epilepsy patient follow-up, followed by supervised observation time in the epilepsy clinic with a neurologist before conducting epilepsy follow-up clinics independently. Epilepsy patients ≥ 10 years of age and in follow-up for ≥ 6 months were included. They were independently followed-up both in the nurse-led clinic and in the neurologist's clinic. Outcome was measured in terms of interrater agreement (kappa) between the recommendations of the neurologist and the nurse in five domains. Patient satisfaction for nurse-led clinic was also evaluated. RESULTS: The interrater agreement between the trained nurse and neurologist in following-up 175 enrolled patients was 76-94%; most unanimity (κ=94%) seen in identifying AED adverse effects while least agreement (κ=76%) was present regarding decisions to modify AED. The mean patient satisfaction score was 37.63 ± 3.26 (maximum possible score 40). CONCLUSION: It is feasible for trained nurses to run epilepsy follow-up clinics in India and patients are likely to be satisfied with this approach.

The prognostic significance of the timing of total enteral feeding in traumatic brain injury.

BACKGROUND: To study the effect of timing of total enteral feeding on various nutritional parameters and neurological outcome in patients with severe traumatic brain injury (TBI). METHODS: One hundred and fourteen patients, in the age group of 20-60 years, admitted within 24 h of TBI with Glasgow Coma Scale (GCS) 4-8 were enrolled for the study. Nineteen patients who had expired before the attainment of total enteral feeding were excluded from the analysis. Total enteral feeding was attained before 3 days, 4-7 days, and after 7 days in 12, 52, and 31 patients, respectively, depending on gastric tolerance. They were prospectively assessed for various markers of nutrition and outcome was assessed at 3 and 6 months. RESULTS: Prospective assessment of 67 hospitalized patients at 3 weeks revealed significant differences in anthropometric measurements, total protein, albumin levels, clinical features of malnutrition, and mortality among the three groups. 80% of those fed before 3 days had favorable outcome at 3 months compared to 43% among those fed later. The odds ratio (OR) was 5.29 (95% CI 1.03-27.03) and P value was 0.04. The difference between those fed before 3 days and 4-7 days was not significant at 6 months even though patients fed before 7 days had still significantly higher favorable outcome compared to those fed after 7 days (OR 7.69, P = 0.002). Multivariate analysis for unfavorable outcome showed significance of P = 0.03 for feeding after 3 days and P = 0.01 for feeding after 7 days. CONCLUSIONS: In severe TBI, unfavorable outcome was significantly associated with attainment of total enteral feeding after 3 days and more so after 7 days following injury.

A comparative study to assess the effect of amikacin sulfate bladder wash on catheter-associated urinary tract infection in neurosurgical patients.

BACKGROUND: The indwelling urinary catheter is an essential part of modern medical care. Unfortunately, when poorly managed, the indwelling catheter may present a hazard to the very patients it is designed to protect. Catheter-associated urinary tract infection (CAUTI) is the most common nosocomial infection in hospitals and nursing homes. AIMS AND OBJECTIVES: The primary objective was to study the effect of amikacin sulfate bladder wash on CAUTI in neurosurgical patients. The other objectives were to study the various organisms causing CAUTI and their antibiotic sensitivity and resistance pattern. MATERIALS AND METHODS: This was a prospective randomized controlled study performed on 60 patients who met the inclusion criteria at the neurosurgical intensive care of the All India Institute of Medical Sciences between June and December 2006. The patients were randomized into two groups - one was the trial group which received amikacin bladder wash, while the other was the control group that did not receive any bladder wash. RESULTS: Forty percent of the subjects in the control group developed CAUTI, while none of the subjects in study group developed CAUTI. (Fisher's exact test, P value < 0.001) Pseudomonas aeruginosa (51%) was the commonest pathogen. CONCLUSIONS: Amikacin sulfate bladder wash was effective in preventing CAUTI. It can thus decrease the antibiotic usage thereby preventing the emergence of antibiotic resistance.