The impact of stoma for bowel management after spinal cord injury.

STUDY DESIGN: Multi-centre, retrospective self-report postal survey. OBJECTIVES: To characterise spinal cord injured (SCI) individuals with a stoma, their stoma management and outcomes, to identify sources of information and support for decision making and to explore the impact of a stoma on life satisfaction. SETTING: Five UK spinal cord injury centres. METHODS: A study-specific questionnaire accompanied by self-concept, life satisfaction and mood measures, and three simple rating scales for satisfaction, impact and restriction on life were sent to all known ostomates at five participating centres. RESULTS: Respondents were 92 individuals, mean age 56 years, mean duration of injury 26 years, 91% with colostomy. Multiple sources of information were utilised in deciding on surgery; discussion with other SCI ostomates was important. Duration of bowel care, faecal incontinence, bowel-related autonomic dysreflexia, dietary manipulation and laxative use were all significantly reduced following surgery. Rectal mucous discharge was the most common and bothersome post-stoma problem. Satisfaction with stoma was high; provision of sufficient information preoperatively was important, those with ileostomy were more dependent and less satisfied. Life satisfaction and physical self-concept were both lower in this sample than in previously reported samples of SCI individuals without reported bowel difficulties or stoma. CONCLUSION: The findings of this study of self-selected respondents with a stoma for bowel management after SCI emphasised the benefits of stoma in selected individuals and the importance of timely intervention, the complexity of the associated decision-making and of preoperative counselling. The impact of bowel dysfunction on physical self-concept warrants investigation.

A new grading for easy and concise description of functional status after spinal cord lesions.

BACKGROUND: Disability scales do not enable the transmission of concise, meaningful and daily function description for clinical purposes. STUDY DESIGN: Cross-sectional statistical analysis of 328 patients' Spinal Cord Independence Measure (SCIM) III item scores (SIS). OBJECTIVE: To develop a concise and clinically interpretable data-based characterization of daily task accomplishment for patients with spinal cord lesions (SCLs). SETTING: Multi-center study at 13 spinal units in 6 countries. METHODS: Patients were grouped into clusters characterized by smaller differences between the patients' SIS within the clusters than between their centers, using the k-medoides algorithm. The number of clusters (k) was chosen according to the percent of SIS variation they explained and the clinical distinction between them. RESULTS: Analysis showed that k=8 SIS clusters offer a good description of the patient population. The eight functional clusters were designated as A-H, each cluster (grade) representing a combination of task accomplishments. Higher grades were usually (but not always) associated with patients implementing more difficult tasks. Throughout rehabilitation, the patients' functional grade improved and the distribution of patients with similar functional grades within the total SCIM III score deciles remained stable. CONCLUSIONS: A new classification based on SIS clusters enables a concise description of overall functioning and task accomplishment distribution in patients with SCL. A software tool is used to identify the patients' functional grade. Findings support the stability and utility of the grades for characterizing the patients' functional status.

SCIM III is reliable and valid in a separate analysis for traumatic spinal cord lesions.

STUDY DESIGN: A multi-center international cohort study. OBJECTIVE: To evaluate the reliability and validity of the third version of the Spinal Cord Independence Measure (SCIM III), separately for patients with traumatic spinal cord lesions (SCLs). SETTING: A total of 13 spinal cord units in six countries from North America, Europe and the Middle-East. METHODS: SCIM III and Functional Independence Measure (FIM) were assessed for 261 patients with traumatic SCLs, on admission to rehabilitation and before discharge, by two raters. Conventional statistical measures were used to evaluate the SCIM III reliability and validity. RESULTS: In almost all SCIM III tasks, the total agreement between the paired raters was >80%. The κ coefficients were all >0.6 and statistically significant. Pearson's coefficients of the correlations between the paired raters were >0.9, the mean differences between raters were nonsignificant and the intraclass correlation coefficients (ICCs) were ≥ 0.95. Cronbach's α values for the entire SCIM III scale were 0.833-0.835. FIM and SCIM III total scores were correlated (r=0.84, P<0.001). SCIM III was more responsive to changes than FIM. In all subscales, SCIM III identified more changes in function than FIM, and in 3 of the 4 subscales, differences in responsiveness were statistically significant (P<0.02). CONCLUSION: The results confirm the reliability and validity of SCIM III for patients with traumatic SCLs in a number of countries.

Expected spinal cord independence measure, third version, scores for various neurological levels after complete spinal cord lesions.

STUDY DESIGN: Multicenter international cohort study. OBJECTIVE: The objective of this study was to establish target values for Spinal Cord Independence Measure (SCIM) III scoring in rehabilitation for clinically complete spinal cord lesion (SCL) neurological levels. SETTING: In total, 13 spinal cord units in six countries from North America, Europe and the Middle East were taken. METHODS: Total SCIM III scores and gain at discharge from rehabilitation were calculated for SCL levels in 128 patients with American Spinal Injury Association Impairment Scale (AIS) grade A on admission to rehabilitation. RESULTS: Median, quartiles, mean and s.d., values of discharge SCIM III scores and SCIM III gain for the various SCL levels are presented. Total SCIM III scores and gain were significantly correlated with the SCL level (r=0.730, r=0.579, P<0.001). CONCLUSIONS: Calculated discharge SCIM III scores can be used as target values for functional achievements at various neurological levels in patients after AIS A SCL. They are generally, but not always, inversely correlated with SCL level.

The Spinal Cord Independence Measure (SCIM) version III: reliability and validity in a multi-center international study.

PURPOSE: To examine the third version of the Spinal Cord Independence Measure (SCIM III) for reliability and validity in a multi-center cohort study. METHOD: Four hundred and twenty-five patients with spinal cord lesions from 13 spinal cord units in six countries from three continents were assessed with SCIM III and the Functional Independence measure (FIM) on admission to rehabilitation and before discharge. RESULTS: Total agreement between raters was above 80% in most SCIM III tasks, and all kappa coefficients were statistically significant (P<0.001). The coefficients of Pearson correlation between the paired raters were above 0.9, and intraclass correlation coefficients were above 0.94. Cronbach's alpha was above 0.7. The coefficient of Pearson correlation between FIM and SCIM III was 0.790 (P<0.01). SCIM III was more responsive to changes than FIM in the subscales of Respiration and sphincter management and Mobility indoors and outdoors. CONCLUSIONS: The results support the reliability and validity of SCIM III in a multi-cultural setup. Despite several limitations of the study, the results indicate that SCIM III is an efficient measure for functional assessment of SCL patients and can be safely used for clinical and research trials, including international multi-center studies.

Efficacy and safety of oral sildenafil (Viagra) in men with erectile dysfunction caused by spinal cord injury.

OBJECTIVE: To evaluate the efficacy and safety of 50-mg doses of sildenafil during a 28-day period in patients with erectile dysfunction caused by spinal cord injury (cord level range, T6 through L5). BACKGROUND: Sildenafil is an orally active, potent, and selective inhibitor of phosphodiesterase type 5, an important regulator of cyclic guanosine monophosphate in the human corpus cavernosum. METHODS: To be included in this double-blind, placebo-controlled study, all patients had to be able to achieve at least a partial reflexogenic erectile response to penile vibratory stimulation. The study utilized a single triangular sequential trial design. A total of 27 patients were randomized to receive 50 mg of sildenafil or placebo, taken orally as required (not more than once daily) approximately 1 hour before sexual activity. RESULTS: After 28 days of treatment, nine of 12 patients (75%) on sildenafil and one of 14 patients (7%) on placebo reported that treatment had improved their erections (p=0.0043). Furthermore, eight of 12 patients (67%) on sildenafil and two of 13 patients (15%) on placebo indicated that they wished to continue treatment (p=0.018). A significant improvement in satisfaction with their sex life was reported by patients taking sildenafil (p=0.012). No patients discontinued treatment due to adverse events. CONCLUSION: Oral sildenafil, taken as required (not more than once daily), significantly improves the quality of erections and satisfaction with sex life in men with erectile dysfunction caused by a spinal cord injury between T6 and L5.

Antibody coated bacteria in urine of patients with recent spinal injury.

Twenty patients with an acute spinal injury were prospectively studied to assess the clinical importance of antibody coated bacteria (ACB) in the urine and the association among the different bacterial species with a positive antibody coated bacteria test. Clinical urinary tract infection was associated with a positive ACB test on 45% of occasions. Three hundred and ninety nine urine samples containing 541 bacterial isolates were assessed for the presence of ACB; 13% were found to be positive and 87% negative for ACB; 67% of urines contained a single bacterial isolate. Pseudomonas aeruginosa was most commonly associated with clinical urinary tract infection, found in 25% of episodes, followed by Proteus mirabilis (17.5%), Klebsiella sp (12.5%), and Proteus morganii (10%). Providencia stuartii, however, was most commonly associated with a positive ACB test (found in 17%). Other bacteria associated with a positive ACB test included Klebsiella sp (14%), Acinetobacter sp (12.5%), Pseudomonas aeruginosa (12%), Citrobacter sp (11.5%). A positive ACB test is not to be expected from a patient with spinal injury who has a catheter in place, and the test may provide a useful guide to identify those patients with an invasive infection. It is doubtful that a decision to treat or not treat bacteriuria could rest on the identification of the bacterial species alone.

Serial concentrations of C-reactive protein as an indicator of urinary tract infection in patients with spinal injury.

C-reactive protein (CRP) was measured serially in 16 patients with an acute spinal injury. Twelve episodes of acute urinary tract infection (UTI) occurred during the study period. These were all associated with an increased concentration of CRP greater than 50 mg/l, which returned to normal after successful treatment. Thirteen episodes of asymptomatic bacteriuria associated with increased concentrations of CRP greater than 20 mg/l occurred, indicating tissue damage. More commonly, significant bacteriuria was associated with normal concentrations of CRP, and presumably, simple colonisation of the urinary tract, which, we suggest, does not require treatment with antibiotics. Serial measurement of CRP in patients with spinal injury may help distinguish between urinary tract colonisation and infection and be useful in monitoring the response to the treatment of clinical UTI.

Conjunctival lymphocytic nodule associated with the Epstein-Barr virus.

Infection with Epstein-Barr virus has been reported to have numerous systemic and ocular manifestations. In this study, a 38-year-old man with acute infectious mononucleosis was examined for a painless left red eye of three days' duration. The patient had a two-week history of fatigue, low-grade fever, sore throat, and lymphadenopathy. Serologic evaluation was indicative of an acute primary infection with Epstein-Barr virus. A large, salmon-colored, supranasal bulbar conjunctival mass was observed in the left eye. No associated conjunctivitis was present. Biopsy of the conjunctival lesion disclosed a dense leukocytic infiltrate, which consisted primarily of mature lymphocytes and plasma cells. Immunocytochemical evaluation of the tissue with monoclonal antisera disclosed Epstein-Barr latent membrane protein and nuclear protein 2 in a small fraction of the cells constituting the infiltrate. The conjunctival infiltrate resolved completely within one month, paralleling the regression of the patient's lymphadenopathy.

An adjustable double running suture technique for keratoplasty.

In a retrospective analysis, we examined 30 consecutive cases of penetrating keratoplasty in which a double running 10-0/11-0 nylon suture technique was used and the 10-0 suture was adjusted early in the postoperative period to reduce astigmatism. When the response to suture adjustment was inadequate, the presence of the 11-0 suture allowed for early (ten to 18 weeks) removal of the 10-0 suture. Rapid visual recovery (12.3 +/- 0.95 weeks; mean +/- standard error) and low levels of final astigmatism (2.66 +/- 0.24 diopters) were achieved. Visual acuity was 20/20 to 20/40 in 25 of the 28 patients (89%) who were visually rehabilitated. In these 28 patients, visual acuity remained stable for the remainder of the study. All patients had a minimum of six months' follow-up from the time of surgery; mean follow-up was 10.6 +/- 1.70 months.

Mobilization of patients after spinal surgery for acute spinal cord injury.

STUDY DESIGN: A retrospective review was conducted covering records of patients who underwent spinal surgery after acute spinal cord injury. OBJECTIVE: To study the relation between time of operation and mobilization of patients. SUMMARY OF BACKGROUND DATA: No such report has existed in the literature. METHODS: Reviews were conducted for the medical records of 102 consecutive patients with acute spinal cord injury admitted to the National Spinal Injuries Center whose spines had been stabilized surgically. The surgeries had been performed either in the National Spinal Injuries Center or in hospitals of the United Kingdom or Continental Europe not specialized in comprehensive care of spinal cord injury. For the patients in three groups, the date of operation and the date of mobilization were compared. The causes for delay in mobilization were identified. RESULTS: A trend of negative correlation was found between the mean number of days from injury to operation and the mean number of days from injury to mobilization. Conversely, a trend of positive correlation was found between the mean number of days from injury to admission or transfer to the National Spinal Injuries Center and the mean number of days from injury to mobilization. Long stay in bed was associated with complications. None of the patients in Group A stayed in bed longer than 77 days, whereas 13 patients in Groups B and C combined had a longer stay. The difference was statistically significant (P = 0.02, chi2). Eight of these patients had pressure sores. CONCLUSION: To ensure early mobilization, early spinal surgery must be supported by specialized comprehensive care.

Complement-derived anaphylatoxins in human donor corneas treated with excimer laser.

BACKGROUND AND OBJECTIVE: An inflammatory response produced by excimer laser photorefractive keratectomy (PRK) may be associated with the subsequent corneal haze and regressions in refractive error observed after treatment. Complement-derived anaphylatoxins, potent mediators of inflammation, may have a role in postoperative healing. MATERIALS AND METHODS: Twenty right human donor corneas underwent a 6-D excimer laser PRK treatment. The corresponding left donor corneas served as the controls. After incubation in tissue culture media for 6 hours and elution in phosphate-buffered saline with EDTA for 24 hours, complement-derived anaphylatoxins C3a, C4a, and C5a were measured in corneal eluates by radioimmunoassay. RESULTS: Compared with control corneas, the excimer PRK corneas failed to demonstrate a significant increase in C3a, C4a, or C5a levels (P > .05). CONCLUSIONS: These results suggest that the excimer laser at this dose does not activate significant complement in the cornea.

The case for early treatment of dislocations of the cervical spine with cord involvement sustained playing rugby.

The most common injury in rugby resulting in spinal cord injury (SCI) is cervical facet dislocation. We report on the outcome of a series of 57 patients with acute SCI and facet dislocation sustained when playing rugby and treated by reduction between 1988 and 2000 in Conradie Hospital, Cape Town. A total of 32 patients were completely paralysed at the time of reduction. Of these 32, eight were reduced within four hours of injury and five of them made a full recovery. Of the remaining 24 who were reduced after four hours of injury, none made a full recovery and only one made a partial recovery that was useful. Our results suggest that low-velocity trauma causing SCI, such as might occur in a rugby accident, presents an opportunity for secondary prevention of permanent SCI. In these cases the permanent damage appears to result from secondary injury, rather than primary mechanical spinal cord damage. In common with other central nervous system injuries where ischaemia determines the outcome, the time from injury to reduction, and hence reperfusion, is probably important. In order to prevent permanent neurological damage after rugby injuries, cervical facet dislocations should probably be reduced within four hours of injury.

A multicenter international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation.

BACKGROUND: A third version of the Spinal Cord Independence Measure (SCIM III), made up of three subscales, was formulated following comments by experts from several countries and Rasch analysis performed on the previous version. OBJECTIVE: To examine the validity, reliability, and usefulness of SCIM III using Rasch analysis. DESIGN: Multicenter cohort study. SETTING: Thirteen spinal cord units in six countries from North America, Europe, and the Middle-East. SUBJECTS: 425 patients with spinal cord lesions (SCL). INTERVENTIONS: SCIM III assessments by professional staff members. Rasch analysis of admission scores. MAIN OUTCOME MEASURES: SCIM III subscale match between the distribution of item difficulty grades and the patient ability measurements; reliability of patient ability measures; fit of data to Rasch model requirements; unidimensionality of each subscale; hierarchical ordering of categories within items; differential item functioning across classes of patients and across countries. RESULTS: Results supported the compatibility of the SCIM subscales with the stringent Rasch requirements. Average infit mean-square indices were 0.79-1.06; statistically distinct strata of abilities were 3 to 4; most thresholds between adjacent categories were properly ordered; item hierarchy was stable across most of the clinical subgroups and across countries. In a few items, however, misfit or category threshold disordering were found. CONCLUSIONS: The scores of each SCIM III subscale appear as a reliable and useful quantitative representation of a specific construct of independence after SCL. This justifies the use of SCIM in clinical research, including cross-cultural trials. The results also suggest that there is merit in further refining the scale.

Hormone replacement therapy in women with spinal cord injury - a survey with literature review.

STUDY DESIGN: Postal questionnaire survey. OBJECTIVE: To examine the current use of hormone replacement therapy (HRT) in a sample of menopausal women with spinal cord injury (SCI). SETTING: National Spinal Injuries Centre (NSIC), Stoke Mandeville Hospital, Aylesbury, UK. METHOD: A postal questionnaire was sent to 94 women from the NSIC patient database who met the study inclusion criteria (wheelchair dependent, aged 49 years and above, last seen or heard from within the last 3 years). RESULTS: A total of 59 valid questionnaires were analysed. At the time of the survey, 50 women were menopausal and 11 of them were using HRT, six for menopausal symptoms and five for osteoporosis prevention. Another 11 had used HRT, eight for menopausal symptoms and three for osteoporosis prevention, but had discontinued it. The main reasons for stopping HRT were side effects. Of the 28 women who had never been on HRT, 20 had either enquired about it, or had been offered HRT, but decided against it. Of the nine women who were still premenopausal at the time of the survey, four would consider using HRT. CONCLUSIONS: Results show that 44% of the menopausal women in our sample have used HRT at some point and 22% still do, mostly for treatment of menopausal symptoms and for osteoporosis prevention. In view of the latest literature findings in able-bodied women, use of HRT for osteoporosis prevention in women with SCI may have to be reconsidered.

Prospective evaluation of urological effects of aging in chronic spinal cord injury by method of bladder management.

AIMS: Risk of treatment-related problems in spinal cord injury (SCI) mandates assessment of complication rates of different bladder management methods (BMMs). The current study evaluated aging-related complications of various BMMs over a 6-year period in a population with spinal cord injury for at least 20 years. MATERIALS AND METHODS: Clinical parameters were compared using a linear mixed effects model, controlling for various confounding variables, to establish complication trends with aging and their association with BMM. Results for people whose BMM was changed during the study were evaluated separately as well as in combination with the whole population. RESULTS: One hundred and ninety six people (mean age 57.4 and years post injury (YPI) 33) were evaluated on three occasions. Both age and YPI were significantly associated with rising complication rates regardless of BMM. The BMMs assessed differed in terms of complication rates. In comparison with balanced reflex voiding, straining was significantly better for renal structural abnormality. Intermittent catheterization was associated with significantly worse renal function, possibly for demographic reasons. Overall, 28.8% changed BMM during the study period, particularly, those using straining or balanced reflex voiding. The probability of change increased with age and YPI. Reasons for change of BMM were varied and there was no specific association between reason for change and BMM. CONCLUSIONS: Aging and duration of injury substantially influence urological complication rates, and BMM options differ in respect of prevalence and incidence of complications. At a late stage post injury there remains a high probability of change in BMM. The findings indicate the importance of long-term planning from the time of injury to minimize late complications.

Primary hepatocellular carcinoma arising in a renal transplant recipient with polycystic disease.

Malignant disease arises more commonly in renal transplant recipients than in non-transplanted individuals. Renal polycystic disease is the only cause of renal failure that has a statistically significant association with the acquisition of malignancy in renal transplant recipients. This patient, who had renal failure due to polycystic disease, is the first reported renal transplant recipient to develop a hepatocellular carcinoma in an otherwise completely normal liver. It is suggested that patients with polycystic renal disease may have an unidentified factor that predisposes to the development of malignancy in them after transplantation.