Inder Perkash

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 persons 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 persons 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.

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.

Reproductive Biology of Paraplegics: Results of Semen Collection, Testicular Biopsy and Serum Hormone Evaluation

The fertility and urological status of 30 male paraplegics between 20 and 47 years old with lesions between the T2 and L3 levels were examined by studying serum hormone levels (estradiol-17 beta, testosterone, prolactin, and follicle-stimulating and luteinizing hormones), sperm and semen characteristics via testicular biopsy and rectal probe electrostimulation, and urodynamic evaluation. Of the patients 13 had reflexic, 4 hyperreflexic and 13 areflexic bladders. Nine of the 13 patients with reflexic and all 4 with hyperreflexic bladders had a positive external sphincter electromyogram with detrusor-sphincter dyssynergia. When catheters were not used to collect semen during rectal probe electrostimulation, retrograde semen flow into the bladder was the rule. A total of 22 patients could tolerate rectal probe electrostimulation, while 6 who could not were injured at the T12 level or lower. Seminal emissions were obtained from 35 to 42 studies in these 22 patients. Total sperm count was variable; in 22 studies it was greater than 20 million. Progressive motility usually was low; 77 per cent of the patients had less than 20 per cent motility. Of 13 biopsy specimens obtained 6 suggested normal testicular morphology, with tubule atrophy and spermatogenic activity only mildly reduced in 6 of the remaining 7. Serum testosterone and luteinizing hormone values were significantly higher (p less than 0.05) among the paraplegic patients than among intact male volunteers of the same age range. Other serum hormone levels were unchanged. Outcome of rectal probe electrostimulation and biopsy did not relate to the number of years of patient injury. Thus, the principal deterrent to the use of semen collected by rectal probe electrostimulation from paraplegics for artificial insemination resides in a predominantly low sperm motility. Suggestions for improvement of motility include 1) great care to minimize or prevent urinary tract infections, 2) selection of medications for urinary tract care that do not compromise sperm survival and 3) prevention of sperm stagnation in lower tract storage sites, perhaps by use of periodical rectal probe electrostimulation.

Clean Intermittent Catheterization in Spinal Cord Injury Patients: A Followup Study

A followup study on nonhospitalized spinal cord injury patients using clean intermittent catheterization was conducted to evaluate long-term clean intermittent catheterization for any genitourinary complications, and to institute and evaluate prompt management. A total of 50 patients (36 paraplegics and 14 quadriplegics) was followed for 3 months to 6.5 years (average followup 22 months). All patients had a baseline urodynamic study and renal scan before they were discharged from the hospital. Patients with a reflex bladder and sustained, high intravesical pressures (greater than 40 cm. water) were placed on anticholinergic medication to lower voiding pressures and maintain continence. Those on clean intermittent catheterization and condom drainage were also given alpha-blockers to achieve low pressure voiding and to control autonomic dysreflexia. Of 50 patients 43 (86%) acquired a total of 364 events of significant bacteriuria (10(4) or more colony-forming units per ml.) at a rate of 13.63 infections per 1,000 patient-days on clean intermittent catheterization. Subclinical symptoms for urinary tract infection were noted in 22 of the 43 patients (51%), whereas clinical symptoms for urinary tract infection were recorded in 16 of 43 (37%). These symptoms included fever in 8 patients, chills in 3, hematuria in 3 and flank pain in 2. There were 31 genitourinary complications in 21 patients noted during periodic diagnostic evaluations, with 6 classified as upper tract. Of 50 patients 4 (8%) required rehospitalization for urological problems. One patient died of questionable sepsis. Transurethral sphincterotomy was performed in 15 of the 50 patients (30%) and transurethral prostatectomy was done in 1 for multiple reasons, for example high intravesical voiding pressures, difficult catheterization, repeated symptomatic urinary tract infections or per patient request to discontinue clean intermittent catheterization. Of 7 patients who were catheterized by others 4 elected to discontinue long-term clean intermittent catheterization after an average of 13 months. Overall, 33 patients (66%) discontinued clean intermittent catheterization and 17 are still being followed on a long-term basis. Clean intermittent catheterization is a successful long-term option to drain bladders in spinal cord injury patients who can perform catheterization independently.

C-reactive protein, metabolic syndrome, and insulin resistance in individuals with spinal cord injury.

Abstract Background/Objective: High-sensitivity C-reactive protein (hsCRP) has been shown to be indicative of elevated risk of cardiovascular disease (CVD). We examined this blood marker in persons with spinal cord injury (SCI) in order to determine its potential for predicting elevated cardiac risk. Methods: In a cross-sectional analysis, we examined the relationship between hsCRP and insulin resistance and metabolic syndrome among 93 individuals with SCI (50.2 ± 13 years). Fasting lipids, insulin, glucose, plasma hsCRP, and anthropometric data were gathered from each subject. Comparisons were made with population reference values. Results: Metabolic syndrome and insulin resistance were present in nearly one quarter of the SCI population (22.6%). Subjects with fasting insulin resistance had significantly higher mean hsCRP (4.29 ± 3.25 mg/L) than those who were not insulin resistant (2.24 ± 2.02) (P ± 0.05). Moreover, hsCRP was significantly elevated in individuals who presented with high cardiovascular risk including severe dyslipidemia (≥ 4 abnormal lipid values) and Framingham Risk scores ≥ 6 (P ± 0.05 for both values). In addition, the homeostasis model assessment of insulin resistance was mildly correlated with hsCRP (r = 0.33). Conclusions: In individuals with SCI who are insulin resistant and/or display components of the metabolic syndrome, hsCRP is elevated suggesting a clinically important association with cardiovascular risk in this population.

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.

Initiation of erection and semen release by rectal probe electrostimulation (RPE).

Instrumentation and methodology are described for rectal probe electrostimulation (RPE) in human males to elicit erection and allow semen collection. This system virtually eliminates shock hazard; the simultaneous monitoring of current, voltage and impedance ensures reliability and repeatability. It was tested with 8 neurologically intact subjects, and 12 paraplegic patients with lesions between T4 and L2. Platinum electrodes delivered current (density never exceeding 0.37 mA per mm. at the electrode) at frequencies of 60 Hz, 20 Hz, and 0.25 Hz. Erection was elicited repeatably in only 1 of the intact subjects, and no seminal emissions or ejaculations occurred. Discomfort prevented current delivery beyond levels even 50 per cent of those safely acceptable. Six of 10 paraplegic patients (2 others had penile implants) developed erections with 20 Hz; the other 2 frequencies were much less effective. The extent of RPE-induced penile tumescence varied directly with electrode surface area and applied current intensity. Discomfort was minimal. Retrograde seminal emission in 5 of the 12 paraplegics was verified by post-stimulation recovery of sperm via voiding or bladder irrigation via catheter. Although motility was very low, 4 of 8 recovered bladder-urine/seminal fluid specimens indicated sperm counts and morphology consonant with use in artificial insemination. Thus, RPE, if combined with techniques to allow antegrade semen collection, may be a useful technique for spinal cord-injured men who, as part of their sexual rehabilitation, are interested in siring children.

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.

Experience with the management of thromboembolism in patients with spinal cord injury: part I. incidence, diagnosis and role of some risk factors

Fifty acute SCI patients are reviewed retrospectively for incidence of deep vein thrombosis and pulmonary embolism and the problems encountered in the diagnosis. The possible role of some risk factors in triggering thromboembolism and the consequent implications in anticoagulant therapy are discussed.

Micturition by functional magnetic stimulation.

Effectiveness of functional magnetic stimulation (FMS) technology on bladder contraction and bladder emptying was evaluated in twenty-two spinal cord injured subjects. FMS of the bladder was performed by stimulating the sacral nerves or the suprapubic region using a commercially available magnetic stimulator with a round coli. With sacral stimulation, the mean change in bladder pressure (Pves) was 24.4 +/- 4.88 cm H2O; with suprapubic stimulation, the mean change in Pves was 16.5 +/- 4.44 cm H2O. The change in Pves with sacral stimulation was higher than with suprapubic stimulation (p < .01). Seventeen subjects demonstrated voiding, either with sacral or suprapubic stimulation. Using a water-cooled coli, one subject demonstrated complete bladder emptying. FMS of the bladder has the potential to be a useful non-invasive technology for bladder emptying and bladder training in patients with neurogenic bladders.