Identification of brain functional connectivity during acute transcutaneous tibial nerve stimulation: A 3T fMRI study

OBJECTIVES

A feasibility proof-of-concept study was conducted to assess the effects of acute tibial nerve stimulation (TNS) on the central nervous system in healthy volunteers using functional magnetic resonance imaging (fMRI).

MATERIALS AND METHODS

Fourteen healthy volunteers were included in a prospective, single-site study conducted on a clinical 3T MRI scanner. Four scans of functional MRI, each lasting 6 min, were acquired: two resting-state fMRI scans (prior and following the TNS intervention) and in-between two fMRI scans, both consisting of alternating rest periods and noninvasive acute transcutaneous TNS (TTNS). Whole brain seed-based functional connectivity (FC) correlation analysis was performed comparing TTNS stimulation with rest periods. Cluster-level familywise error (FWE) corrected p and a minimal cluster size of 200 voxels were used to explore FC patterns.

RESULTS

Increased FC is reported between inferior frontal gyrus, posterior cingulate gyrus, and middle temporal gyrus with the precuneus as central receiving node. In addition, decreased FC in the cerebellum, hippocampus, and parahippocampal areas was observed.

CONCLUSIONS

Altered FC is reported in areas which have been described to be also involved in lower urinary tract control. Although conducted with healthy controls, the assumption that the underlying therapeutic effect of TNS involves the central nervous system is supported and has to be further examined in patients with incomplete spinal cord injury.

Immune Status of Individuals with Traumatic Spinal Cord Injury: A Systematic Review and Meta-Analysis

Individuals with spinal cord injury (SCI) have higher infection rates compared to those without SCI. In this review, the immune status difference between individuals with and without traumatic SCI is investigated by examining their peripheral immune cells and markers. PubMed, Cochrane, EMBASE, and Ovid MEDLINE were searched without language or date restrictions. Studies reporting peripheral immune markers' concentration and changes in functional capabilities of immune cells that compared individuals with and without SCI were included. Studies with participants with active infection, immune disease, and central nervous system (CNS) immune markers were excluded. The review followed the PRISMA guidelines. Effect estimates were measured by Weighted Mean Difference (WMD) using a random-effects model. Study quality was assessed using the National Heart, Lung, and Blood Institute Quality Assessment Tool. Fifty-four studies (1813 with SCI and 1378 without SCI) contributed to the meta-analysis. Leukocytes (n = 23, WMD 0.78, 95% CI 0.17; 1.38, I2 83%), neutrophils (n = 11, WMD 0.76, 95% CI 0.09; 1.42, I2 89%), C-reactive protein (CRP) (n = 12, WMD 2.25, 95% CI 1.14; 3.56, I2 95%), and IL6 (n = 13, WMD 2.33, 95% CI 1.20; 3.49, I2 97%) were higher in individuals with SCI vs. without SCI. Clinical factors (phase of injury, completeness of injury, sympathetic innervation impairment, age, sex) and study-related factors (sample size, study design, and serum vs. plasma) partially explained heterogeneity. Immune cells exhibited lower functional capability in individuals with SCI vs. those without SCI. Most studies (75.6%) had a moderate risk of bias. The immune status of individuals with SCI differs from those without SCI and is clinically influenced by the phase of injury, completeness of injury, sympathetic innervation impairment, age, and sex. These results provide information that is vital for monitoring and management strategies to effectively improve the immune status of individuals with SCI.

Percutaneous Tibial Nerve Stimulation in the Treatment of Refractory Idiopathic Overactive Bladder Syndrome: A Retrospective Cohort Study

BACKGROUND

Overactive bladder (OAB) is a syndrome defined as urinary urgency, accompanied by increased frequency and nocturia with or without urge incontinence, in the absence of urinary tract infection or other obvious pathology. The standard therapies are anticholinergic agents, selective beta-3 adrenoreceptor agonists, or intradetrusor injections of botulinum toxin (BTX-A). For patients with contraindications for BTX-A or drug therapies, percutaneous tibial nerve stimulation (PTNS) may be used. PTNS shows fewer side effects than anticholinergic drugs and costs less than BTX-A. The primary outcome of this study was to assess the efficacy of PTNS in women with refractory OAB.

METHODS

Women with refractory OAB undergoing PTNS at our tertiary referral center from 2017 to 2019 were included. The validated German Female Pelvic Floor Questionnaire and a micturition protocol were filled out before and after PTNS. PTNS was applied weekly for 12 weeks.

RESULTS

Improvements in OAB symptoms were seen in daily micturition frequency, urgency, and urgency incontinence from pre- to post-PTNS (p < 0.006). Impairments to quality of daily life were significantly (p < 0.0002) less severe after PTNS. There was a significant reduction in daytime voiding frequency from a median of nine to five (p < 0.0001).

CONCLUSIONS

Substantial reductions in OAB symptoms, daily micturition frequency, urgency, and urgency incontinence were found in patients with refractory OAB after PTNS.

Impact of Defined Risk Factors on Degree of Urinary Stress Incontinence and Sling Outcome: A Retrospective Cohort Analysis

Urinary stress incontinence is a distressing condition that has a severe impact on quality of life for most affected women. The insertion of the suburethral tension-free vaginal tape (TVT) is regarded as the gold-standard surgical treatment option. It is unclear whether all women with severe SUI benefit equally from TVT. Thus, the aim of our study was to identify risk factors for severe SUI and determine whether successful the resolution of incontinence after a TVT procedure was different in women with a higher degree of SUI. In total, 168 women were included in this retrospective cohort study. Women with severe SUI showed a significantly lower maximum urethral closure pressure (MUCP) (median 53 cmH2O in moderate vs. 39 cmH2O in severe, p = 0.001) and higher BMI (median 26.1 kg/m2 in moderate vs. 28.5 kg/m2 in severe, p = 0.045). Sonographic bladder neck funneling was detected significantly more often in women with severe SUI (27% in moderate vs. 57% in severe, p = 0.004). Lower MUCP and higher BMI were identified as significant predictors of severe SUI (p < 0.032). There was no difference in parity, age, functional urethral length and negative urethral stress pressure. Overall postoperative continence after the insertion of TVT was 91.9%. We found no significant difference in postoperative continence between women with severe vs. moderate SUI, suggesting that in our cohort the success of TVT was not significantly affected by the severity of SUI. In our cohort, low MUCP and high BMI were shown to be significant predictors of SUI severity. Nevertheless, treatment success of SUI with TVT did not differ substantially in women with more severe SUI.

Satisfaction with Homeopathic Service and Care for Persons with Spinal Cord Injury

BACKGROUND

The aim of the study was to investigate the satisfaction of individuals with spinal cord injury (SCI) with a homeopathic service at an SCI rehabilitation center.

PATIENTS AND METHODS

A cross-sectional questionnaire study was performed at an SCI rehabilitation center in Switzerland. It included patients with chronic SCI who presented themselves to a homeopathic service offered by the hospital in a 12-months period. The participants filled in standardized questionnaires in German: "Measure Yourself Medical Outcome Profile" (MYMOP), Treatment Satisfaction Questionnaire for Medication (TSQM-9), the European Project on Patient Evaluation of General Practice Care (EUROPEP) questionnaire, and a self-administered questionnaire.

RESULTS

The data of 14 patients were analyzed. Symptom severity as well as bother by the symptoms that led to homeopathic treatment decreased under homeopathic treatment (severity: from 4.3 to 3.3; bother: from 4.2 to 2.9) and remained lower over time (severity: 2.6; bother: 2.7), suggesting a sustained effect. Irrespective of the test instrument used, satisfaction rates were higher for homeopathic service than for homeopathic medication, which was rated as successful by 50% of the participants.

CONCLUSION

Persons with SCI suffering from secondary complications of SCI who accessed homeopathic care reported high satisfaction rates with the service. Therefore, homeopathic service can be considered as an additive measure in persons with SCI suffering from recurrent symptoms.

Hintergrund

Evaluierung der Zufriedenheit von Personen mit Querschnittlähmung (QSL) mit einer homöopathischen Betreuung an einem Rehabilitationszentrum für QSL.

Patient*innen und Methodik

An einem Rehabilitationszentrum für QSL in der Schweiz wurde eine Querschnittserhebung mittels Fragebögen durchgeführt. Eingeschlossen wurden Personen mit chronischer QSL, die sich in einer von der Klinik angebotenen homöopathischen Sprechstunde in einem 12-Monats-Intervall vorstellten. Die Teilnehmenden füllten standardisierte Fragebogen in deutscher Sprache aus: "Measure Yourself Medical Outcome Profile" (MYMOP), Treatment Satisfaction Questionnaire for Medication (TSQM-9), den "European Project on Patient Evaluation of General Practice Care (EUROPEP)" Fragebogen sowie einen selbst-erstellten Fragebogen.

Ergebnisse

Die Daten von 14 Teilnehmenden wurden ausgewertet. Der Schweregrad der Symptome sowie die Belastung durch die Symptome die zur homöopathischen Behandlung geführt haben, wurden unter der homöopathischen Therapie geringer (Schweregrad: von 4.3 auf 3.3; Belastung: von 4.2 auf 2.9) und blieben über den Untersuchungszeitraum geringer (Schweregrad: 2.6; Belastung 2.7), was einen anhaltenden Effekt nahelegt. Unabhängig von dem verwendeten Testinstrument waren die Zufriedenheitsraten für die homöopathische Betreuung höher als diejenigen für die homöopathische Medikation, die von 50% der Teilnehmenden als erfolgreich bewertet wurde.

Schlussfolgerung

Personen mit QSL, die wegen Sekundärkomplikationen eine homöopathische Sprechstunde aufsuchten, berichteten eine hohe Zufriedenheit mit dieser Betreuung. Daher kann eine homöopathische Betreuung als zusätzliche Massnahme bei Personen mit QSL mit persistierender Symptomatik in Betracht gezogen werden.

Prevalence of an insufficient vitamin D status at the onset of a spinal cord injury - a cross-sectional study

STUDY DESIGN

A cross-sectional study.

OBJECTIVE

This study aimed to investigate the vitamin D status after acute spinal cord injury (SCI) onset.

SETTING

Specialized SCI rehabilitation center in Switzerland.

METHODS

Patients admitted to the center after an acute SCI onset were included. The prevalence of a deficient (25(OH)D ≤ 50 nmol/l), insufficient (50 < 25(OH)D ≤ 75 nmol/l) and sufficient (25(OH)D > 75 nmol/l) vitamin D status were determined after admission. Vitamin D status was compared between different patient groups based on demographic and SCI characteristics. The occurrence of bed rest, falls and pressure injuries were also assessed.

RESULTS

In total, 87 patients (median (interquartile range); 53 (39-67) years, 25 females, 66 traumatic SCI, 54 paraplegia) were included. Assessed a median of 15 (9-22) days after SCI onset, median vitamin D status was 41 (26-57) (range 8-155) nmol/l. The majority of patients had a deficient (67%, 95% confidence interval (95% CI) 0.56-0.76) or insufficient (25%, 95% CI 0.17-0.36) vitamin D status. A moderate negative correlation was found between vitamin D status and body mass index (p = 0.003). A moderate positive correlation was found between vitamin D and calcium status (p = 0.01).

CONCLUSION

A deficient or insufficient vitamin D status directly after SCI onset is highly prevalent. Vitamin D status should be carefully observed during acute SCI rehabilitation. We recommend that all patients with recent SCI onset should receive vitamin D supplementation with a dosage depending on their actual vitamin D status.

One-year follow-up of the CAPSID randomized trial for high-dose convalescent plasma in severe COVID-19 patients

BACKGROUNDResults of many randomized trials on COVID-19 convalescent plasma (CCP) have been reported, but information on long-term outcome after CCP treatment is limited. The objectives of this extended observation of the randomized CAPSID trial are to assess long-term outcome and disease burden in patients initially treated with or without CCP.METHODSOf 105 randomized patients, 50 participated in the extended observation. Quality of life (QoL) was assessed by questionnaires and a structured interview. CCP donors (n = 113) with asymptomatic to moderate COVID-19 were included as a reference group.RESULTSThe median follow-up of patients was 396 days, and the estimated 1-year survival was 78.7% in the CCP group and 60.2% in the control (P = 0.08). The subgroup treated with a higher cumulative amount of neutralizing antibodies showed a better 1-year survival compared with the control group (91.5% versus 60.2%, P = 0.01). Medical events and QoL assessments showed a consistent trend for better results in the CCP group without reaching statistical significance. There was no difference in the increase in neutralizing antibodies after vaccination between the CCP and control groups.CONCLUSIONThe trial demonstrated a trend toward better outcome in the CCP group without reaching statistical significance. A predefined subgroup analysis showed a significantly better outcome (long-term survival, time to discharge from ICU, and time to hospital discharge) among those who received a higher amount of neutralizing antibodies compared with the control group. A substantial long-term disease burden remains after severe COVID-19.Trial registrationEudraCT 2020-001310-38 and ClinicalTrials.gov NCT04433910.FundingBundesministerium für Gesundheit (German Federal Ministry of Health).

A Prediction Model for Various Treatment Pathways of Upper Extremity in Tetraplegia

Upper extremity function is essential for the autonomy in patients with cervical spinal cord injuries and consequently a focus of the rehabilitation and treatment efforts. Routinely, an individualized treatment plan is proposed to the patient by an interprofessional team. It dichotomizes into a conservative and a surgical treatment pathway. To select an optimal pathway, it is important to define predictors that substantiate the treatment strategy. Apart from standard assessments (Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), the manual muscle test (MRC), and lower motoneuron integrity of key actuators for hand function performed by motor point (MP) mapping might serve as a possible predictor. Type of damage (upper motor neuron (UMN) or lower motor neuron (LMN) lesion) influences hand posture and thus treatment strategy as positioning and splinting of fingers, hands, arms, and surgical reconstructive procedures (muscle-tendon or nerve transfers) in choice and timing of intervention. For this purpose, an analysis of a database comprising 220 patients with cervical spinal cord injury is used. It includes ISNCSCI, MRC, and MP mapping of defined muscles at selected time points after injury. The ordinal regression analysis performed indicates that MP and ASIA impairment scale (AIS) act as predictors of muscle strength acquisition. In accordance with the innervation status defined by MP, electrical stimulation (ES) is executed either via nerve or direct muscle stimulation as a supplementary therapy to the traditional occupational and physiotherapeutic treatment methods. Depending on the objective, ES is applied for motor learning, strengthening, or maintenance of muscle contractile properties. By employing ES, hand and arm function can be predicted by MP and AIS and used as the basis for providing an individualized treatment plan.

Impact of sacrocolpopexy for the management of pelvic organ prolapse on voiding dysfunction and uroflowmetry parameters: a prospective cohort study

PURPOSE

Voiding difficulties in the context of pelvic organ prolapse are often neglected or underestimated. To date, there are heterogeneous data available on the outcome of a surgical correction of pelvic organ prolapse and the impact on concomitant voiding dysfunction. The primary aim of this study was to evaluate whether laparoscopic sacrocolpopexy would resolve preoperative voiding dysfunction and the impact on objective uroflowmetry parameters.

METHODS

Data from 103 women undergoing sacrocolpopexy for prolapse stage ≥ II with concurrent objective and/or subjective voiding dysfunction were prospectively evaluated. All women underwent full urogynecological examination, and completed a validated questionnaire pre- and postoperatively. Objective uroflowmetry parameters and subjective outcome data regarding voiding functions were compared pre- and postoperatively.

RESULTS

All points of the POP-Q system improved significantly pre- to postoperatively (p < 0.001). Preoperatively, 42 of 103 women showed a postvoid residual ≥ 100 ml, whereas only six women had a relevant postvoid residual postoperatively. In total, the postoperative postvoid residual in all women decreased significantly (p < 0.001). Voiding time decreased significantly postoperatively (p < 0.001) with no significant change in the voided volume (p = 0.352). The maximum flow rate increased postoperatively, reaching no statistically significant change (p = 0.132). Subjective outcome measurements (weak or prolonged stream, incomplete bladder emptying, and straining to void) improved significantly (p < 0.001 for all the questions).

CONCLUSION

Our prospective study demonstrates that sacrocolpopexy to correct pelvic organ prolapse can successfully resolve voiding dysfunction, as both objective and subjective parameters improved significantly after surgery.

Low-Frequency Entrainment to Visual Motion Underlies Sign Language Comprehension

When people listen to speech, neural activity tracks the entropy fluctuation in the acoustic envelope of the signal. This signal-based entrainment has been shown to be the basis of speech parsing and comprehension. In this electroencephalography (EEG) study, we compute sign language users’ cortical tracking of changes in visual dynamics of the communicative signal in the time-direct videos of sign language, and their time-reversed counterparts, and assess the relative contribution of response frequencies between.2 and 12.4 Hz to comprehension using a machine learning approach to brain state classification. Lower frequencies of EEG response (.2–4 Hz) yield 100% classification accuracy, while information about cortical tracking of the visual envelope in higher frequencies is less informative. This suggests that signers rely on lower visual frequency data, such as envelope of visual signal, for sign language comprehension. In the context of real-time language processing, given the speed of comprehension responses, this suggests that fluent signers employ a predictive processing heuristic based on sign language knowledge.

Immunomodulation for primary prevention of urinary tract infections in patients with spinal cord injury during primary rehabilitation: protocol for a randomized placebo-controlled pilot trial (UROVAXOM-pilot)

BACKGROUND

Urinary tract infections (UTIs) are common in individuals with neurogenic lower urinary tract dysfunction (NLUTD) following spinal cord injury (SCI). They are not only a great burden for affected individuals, but also cause considerable health costs. Furthermore, recurrent antibiotic treatments of UTIs contribute to the growing problem of bacterial resistance to antimicrobial compounds. Even though there is a multitude of different measures to prevent UTIs in individuals with NLUTD, no clear evidence exists for any of these. Oral immunomodulation with UTI-relevant Escherichia coli lysate may be a promising preventative measure with a good safety profile in individuals with NLUTD. However, currently available data are sparse.

METHODS

This is a randomized, quasi-blinded, placebo-controlled, mono-centric pilot trial investigating the feasibility of a main trial regarding the effects of a lyophilized lysate of E. coli strains for oral application (Uro-Vaxom®, OM Pharma SA, Meyrin, Switzerland). There will be two parallel groups of 12 participants each. Individuals with acute SCI (duration SCI ≤ 56 days) from 18 to 70 years of age admitted for primary rehabilitation will be eligible. Blood and urine samples will be taken prior to intervention start, at the end of the intervention, and 3 months after intervention termination. The trial intervention will last 90 days. The participants will not be informed regarding the treatment allocation (quasi-blinded). The nursing staff will prepare the daily dose of the allocated treatment from the original packaging. The trial personnel and the biostatistician will be blinded. Feasibility (e.g., recruitment rate, patient attrition), clinical (e.g., number of symptomatic UTIs), and laboratory parameters (e.g., urinary culture, urinary proteo- and microbiome, blood cell counts) as well as adverse events will be collected.

DISCUSSION

Effective and efficient measures for the prevention of UTIs in individuals with NLUTD are urgently needed. If the conclusion of this pilot is positive regarding feasibility, the effects of oral immunomodulation with a E. coli lysate will be investigated in a larger, sufficiently powered, multi-center trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04049994 . Registered on 8 August 2019.

Risk factors for hospital acquired pressure injury in patients with spinal cord injury during first rehabilitation: prospective cohort study

STUDY DESIGN

Prospective observational cohort study.

OBJECTIVES

First, describe pressure injury (PI) and associated risk factors in individuals with spinal cord injury/disorder (SCI/D) during first rehabilitation. Second, evaluate a prediction model for hospital acquired PI (HAPI) development.

SETTING

Acute care and rehabilitation clinic specialized in SCI/D.

METHODS

Patients ≥18 years of age with SCI/D were included during first rehabilitation between 08/2018 and 12/2019. We performed a systematic literature search to identify risk factors for PI development. Patients were classified according to HAPI developed. Between group differences of patients' characteristics and risk factors were analyzed using descriptive statistics. Logistic predictive models were performed to estimate HAPI development and receiver operator characteristic (ROC) curve was used to test the model.

RESULTS

In total, 94 patients were included, 48 (51.1%) developed at least one HAPI and in total 93 were observed, mainly stage I and stage II HAPI according to the European Pressure Ulcer Advisory Panel. We found nine significantly associated risk factors: completeness of SCI/D, pneumonia, sedative medications, autonomic dysreflexia, Braden ≤12 points, SCIPUS ≥9 points, lower admission SCIM and lower admission FIM-cognition, longer length of stay (LOS) (p ≤ 0.0005). In a predictive model, none of the risk factors was associated with HAPI development (AUC = 0.5).

CONCLUSION

HAPIs in patients with SCI/D during first rehabilitation are a frequent and complex condition and associated with several risk factors. No predictive model exists but with the identified risk factors of this study, larger studies can create a tailored and flexible HAPI risk prediction model.

Changes in Bacterial Spectrum and Resistance Patterns Over Time in the Urine of Patients with Neurogenic Lower Urinary Tract Dysfunction Due to Spinal Cord Injury

INTRODUCTION

Urinary tract infections (UTI) are among the most common complications in persons with neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI). As both asymptomatic bacteriuria and UTI are frequently treated with antibiotics, concerns about multidrug resistance arise. Therefore, we analyzed the bacterial spectrum in the urine and the resistance patterns of the strains over time in patients with NLUTD due to SCI.

METHODS

In a systematic chart review, we identified all microbiologic urine test results including resistance patterns of persons with SCI in a tertiary referral hospital at 2 time periods (2010-2011 and 2017-2018). We assessed the frequency of the bacterial strains, the resistance patterns of the 5 most frequent bacteria, and the use of antibiotics for in- as well as for outpatients.

RESULTS

From 2010 to 2011, 1,308 (outpatients) and 2,479 (inpatients) bacterial strains were detected in the urinalyses performed; these numbers rose to 3,162 and 6,112 during 2017-2018, respectively. The most frequently detected bacteria during both time periods were Escherichia coli, Enterococcus faecalis, Klebsiella pneumoniae/variicola, Streptococcus viridans, Pseudomonas aeruginosa, and coagulase negative Staphylococci. Fluoroquinolones were the most frequently used antibiotics during both time periods. Despite its frequent use, no relevant increase in resistance against fluoroquinolones was detected. The most prominent increase in resistance appeared in E. coli against amocixillin/clavulanic acid in inpatients (from 26.0 to 38.5%).

DISCUSSION AND CONCLUSIONS

Although fluoroquinolones were used frequently, we did not observe an increased resistance against these antibiotics over time in the urine of patients with SCI.

Outcome of perineoplasty and de-adhesion in patients with vulvar Lichen sclerosus and sexual disorders

OBJECTIVE

Vulvar Lichen sclerosus (LS) is a chronic inflammatory disease in which architectural changes and symptoms like itching, soreness, pain and dyspareunia can affect quality of life and sexual activity. Perineoplasty has been shown to be effective as a supportive surgical treatment in women with refractory dyspareunia in addition to the standard topical immunosuppressive treatment. The aim of this study was to evaluate retrospectively general complaints, patient satisfaction concerning sexual activity, reduction of dyspareunia/apareunia, orgasm ability and recurrence of LS after perineoplasty.

STUDY DESIGN

This study is a retrospective monocentric observational study, in which patients with vulvar LS who had undergone perineoplasty were invited to fill out a standardized questionnaire during the follow-up time. The main outcome measure is the overall patient satisfaction after surgical therapy of vulvar LS.

RESULTS

Forty-one of the 70 invited patients with a median age at surgery of 58 years (18-74 years) and a median 60 years (19-76 years) at the last follow-up were evaluated. The median follow-up time was 2.3 years (1-5 years). There was a significant (p < 0.001) reduction in general complaints after surgery. Twenty-two patients were very satisfied, 15 were satisfied and 3 were not satisfied with the outcome of the surgery. Only 2 patients would not recommend the surgery. Although, there was a significant (p = 0.02) reduction in dyspareunia after surgery, 10 patients still felt pain during sexual intercourse.

CONCLUSION

This is one of the largest studies reporting on long-term results of perineoplasty. It showed that perineoplasty is a safe surgical treatment option with a high satisfaction rate in patients with dyspareunia due to LS and a desire to regain sexual activity. Perineoplasty can improve sexual activity and achieve overall satisfaction in selected patients even though the recurrence rate of LS in sexually active patients remains high.

Real-World Effects of Mirabegron in Patients with Chronic Neurogenic Detrusor Overactivity - A Retrospective Cohort Study

PURPOSE

To investigate the tolerability and the effects of the β-3-adrenoceptor-agonist mirabegron on urinary incontinence and urodynamic parameters in patients with chronic neurogenic detrusor overactivity (NDO).

PATIENTS AND METHODS

The patient database of a spinal cord injury rehabilitation center in Switzerland was screened for patients with chronic (>12 months) NDO, who had been prescribed mirabegron. Patient characteristics, data regarding bladder management, urinary incontinence and concurrent medication for NDO as well as urodynamic parameters were collected retrospectively. The changes in the urodynamic parameters and the occurrence of urinary incontinence over time were investigated.

RESULTS

The data of 63 patients with a median age of 48 years and a median NDO duration of 8.9 years at the initiation of the mirabegron treatment were analyzed. A median 3.0 and 12.7 months had elapsed from the initiation of the mirabegron therapy to the first and second follow-up evaluation, respectively. The majority of patients (73%) received mirabegron in combination with an established antimuscarinic or onabotulinum toxin therapy. The number of patients suffering from urinary incontinence decreased significantly (p≤0.005) from 60.3% (95% CI 47.2/72.4%) to 38.1% (95% CI 23.6/54.4%). Furthermore, the maximum detrusor pressure during the storage phase was significantly (p≤0.04) lower at the second follow-up evaluation (29.5cmH₂O, 95% CI 22/40cmH₂O) compared to before the mirabegron treatment (35cmH₂O, 95% CI 29/41cmH₂O). The bladder capacity and detrusor compliance were significantly (p≤0.005) increased during the mirabegron treatment. No patient had discontinued the mirabegron treatment as a result of side effects.

CONCLUSION

Mirabegron demonstrated a clinically relevant effect and a good safety profile. Concomitant treatment of NDO with mirabegron may allow reduction in the dose of antimuscarinic medication and thus, improve the long-term persistence of NDO treatment.

Increased mobilization of mesenchymal stem cells in patients with acute respiratory distress syndrome undergoing extracorporeal membrane oxygenation

Background

The acute respiratory distress syndrome (ARDS) is characterized by pulmonary epithelial and endothelial barrier dysfunction and injury. In severe forms of ARDS, extracorporeal membrane oxygenation (ECMO) is often the last option for life support. Endothelial progenitor (EPC) and mesenchymal stem cells (MSC) can regenerate damaged endothelium and thereby improve pulmonary endothelial dysfunction. However, we still lack sufficient knowledge about how ECMO might affect EPC- and MSC-mediated regenerative pathways in ARDS. Therefore, we investigated if ECMO impacts EPC and MSC numbers in ARDS patients.

Methods

Peripheral blood mononuclear cells from ARDS patients undergoing ECMO (n = 16) and without ECMO support (n = 12) and from healthy volunteers (n = 16) were isolated. The number and presence of circulating EPC and MSC was detected by flow cytometry. Serum concentrations of vascular endothelial growth factor (VEGF) and angiopoietin 2 (Ang2) were determined.

Results

In the ECMO group, MSC subpopulations were higher by 71% compared to the non-ECMO group. Numbers of circulating EPC were not significantly altered. During ECMO, VEGF and Ang2 serum levels remained unchanged compared to the non-ECMO group (p = 0.16), but Ang2 serum levels in non-survivors of ARDS were significantly increased by 100% (p = 0.02) compared to survivors.

Conclusions

ECMO support in ARDS is specifically associated with an increased number of circulating MSC, most likely due to enhanced mobilization, but not with a higher numbers of EPC or serum concentrations of VEGF and Ang2.

Changes in skin-physiology after local heat application using two different methods in individuals with complete paraplegia: a feasibility and safety trial

STUDY DESIGN

Interventional feasibility study.

OBJECTIVES

To evaluate safety and effects of local heat preconditioning on skin physiology using water-filtered infrared-A radiation (wIRA) or warm water therapy (wWT) in individuals with spinal cord injury (SCI).

SETTING

Acute and rehabilitation center, specialized in SCI.

METHODS

A convenience sample of 15 individuals (3 women, 12 men) with complete paraplegia from thoracic levels ranging between T2 and T12 received local heat applications either with wIRA or wWT on the thigh (paralyzed area) and on the upper arm (non-paralyzed area). Local heat was applied during three 30-min cycles, each separated by 30 min rest; thus, the treatment lasted for 180 min. Temperature, blood perfusion, and skin redness were measured at baseline, before and after heat application and 24 h after the last application.

RESULTS

Heat applications with wIRA and wWT were well-tolerated. No burns or any other side effects were detected. Skin temperature (p ≤ 0.008) and blood perfusion (p ≤ 0.013) significantly increased after heat application. Local skin temperature (arm p = 0.004/leg p < 0.001) and blood perfusion (arm p = 0.011/leg p = 0.001) after the first and the second application cycle, respectively, were significantly higher during heat application with wIRA than with wWT. However, skin redness did not change significantly (p = 0.1). No significant differences were observed between the paralyzed and non-paralyzed areas for all parameters immediately, as well as 24 h after the treatment.

CONCLUSIONS

Although both heating methods have been confirmed as safe treatments in this study, further investigations with regard to their efficacy in the context of preconditioning are warranted.

SPONSORSHIP

The use of the instruments Hydrosun® 750 Irradiator (Hydrosun Medizintechnik, Germany) and Hilotherm-Calido 6 (Hilotherm GmbH, Germany) was sponsored by the Dr. med. h. c. Erwin Braun Foundation and by Hilotherm GmbH, respectively.

Usefulness of classical homeopathy for the prophylaxis of recurrent urinary tract infections in individuals with chronic neurogenic lower urinary tract dysfunction

Context/Objective: to investigate the usefulness of classical homeopathy for the prevention of recurrent urinary tract infections (UTI) in patients with spinal cord injury (SCI). Design: prospective study. Setting: rehabilitation center in Switzerland. Participants: patients with chronic SCI and ≥3 UTI/year. Interventions: Participants were treated either with a standardized prophylaxis alone or in combination with homeopathy. Outcome measures: The number of UTI, general and specific quality of life (QoL), and satisfaction with homeopathic treatment were assessed prospectively for one year. Results: Ten patients were in the control group; 25 patients received adjunctive homeopathic treatment. The median number of self-reported UTI in the homeopathy group decreased significantly, whereas it remained unchanged in the control group. The domain incontinence impact of the KHQ improved significantly (P = 0.035), whereas the general QoL did not change. The satisfaction with homeopathic care was high. Conclusions: Adjunctive homeopathic treatment lead to a significant decrease of UTI in SCI patients. Therefore, classical homeopathy could be considered in SCI patients with recurrent UTI. Trial registration: ClinicalTrials.gov. (NCT01477502).

High-Definition Zoom Mode, a High-Resolution X-Ray Microscope for Neurointerventional Treatment Procedures: A Blinded-Rater Clinical-Utility Study

BACKGROUND AND PURPOSE

Quality of visualization of treatment devices during critical stages of endovascular interventions, can directly impact their safety and efficacy. Our aim was to compare the visualization of neurointerventional procedures and treatment devices using a 194-μm pixel flat panel detector mode and a 76-μm pixel complementary metal oxide semiconductor detector mode (high definition) of a new-generation x-ray detector system using a blinded-rater study.

MATERIALS AND METHODS

Deployment of flow-diversion devices for the treatment of internal carotid artery aneurysms was performed under flat panel detector and high-definition-mode image guidance in a neurointerventional phantom simulating patient cranium and tissue attenuation, embedded with 3D-printed intracranial vascular models, each with an aneurysm in the ICA segment. Image-sequence pairs of device deployments for each detector mode, under similar exposure and FOV conditions, were evaluated by 2 blinded experienced neurointerventionalists who independently selected their preferred image on the basis of visualization of anatomic features, image noise, and treatment device. They rated their selection as either similar, better, much better, or substantially better than the other choice. Inter- and intrarater agreement was calculated and categorized as poor, moderate, and good.

RESULTS

Both raters demonstrating good inter- and intrarater agreement selected high-definition-mode images with a frequency of at least 95% each and, on average, rated the high-definition images as much better than flat panel detector images with a frequency of 73% from a total of 60 image pairs.

CONCLUSIONS

Due to their higher resolution, high-definition-mode images are sharper and visually preferred compared with the flat panel detector images. The improved imaging provided by the high-definition mode can potentially provide an advantage during neurointerventional procedures.

Respiratory muscle training in individuals with spinal cord injury: effect of training intensity and -volume on improvements in respiratory muscle strength

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To investigate the effect of training intensity and -volume on improvements in respiratory muscle strength in individuals with spinal cord injury (SCI).

SETTING

SCI rehabilitation center in Switzerland.

METHODS

Inpatients with SCI, lesion level C4-T12, who had at least 10 individualized inspiratory muscle training sessions with respiratory function measurements before and after the training period. Multiple regression analysis with natural logarithmic (ln) transformation of the outcome values was used to examine the effect of training intensity and -volume, lesion level and completeness, and baseline respiratory muscle strength on improvements in respiratory muscle strength.

RESULTS

Overall, 67 individuals were analyzed. Variation in PI_max was explained by PI_max at baseline and training intensity. This adjusted effect size suggested a 7% (95% CI 2.8 to 11.6%) increase in PI_max per 10 units of increase in training intensity. Controlling for the variation in baseline PE_max, the effect of training intensity on PE_max was conditional on AIS (p < 0.021). While individuals with motor complete lesions showed a 6.8% (95% CI 2.1 to 11.7%) increase in PE_max per 10 units of increase in training intensity, the corresponding adjusted effect size in those with motor incomplete lesions was 0.1% (95% CI -4.3 to 4.5%). The full models explained 57 and 60% of the variance of lnPI_max and lnPE_max, respectively.

CONCLUSION

The intensity of inspiratory muscle training was more relevant than training volume for the improvement of respiratory muscle strength in individuals with SCI. Thus, training intensity should be chosen as high as possible.

Effects of oral immunomodulation therapy on urinary tract infections in individuals with chronic spinal cord injury-A retrospective cohort study

AIMS

To investigate the effect of an oral immunomodulation therapy with E. coli fractions on the frequency of urinary tract infections (UTIs) in patients with spinal cord injury (SCI) in a retrospective cohort study with a follow-up of 12 months.

METHODS

The patient database of a tertiary urologic referral center was screened for patients with chronic (>12 months) SCI who were taking a lyophilized lysate of 18 E. coli strains from 2008 to 2016. Patient characteristics, annual number of patient-reported UTIs and urine culture results were collected. The change in the number of UTIs, categorized as no UTIs, sporadic UTIs (1-2/year) and recurrent UTIs (≥3/year), from before to during immunomodulation therapy was investigated. Furthermore, the effect of different possible confounders (eg, age, duration of SCI, use of catheters, and concurrent antibiotic treatment) was investigated.

RESULTS

The data of 136 individuals with a mean age of 49 ± 14 years and a median time since SCI of 18 (15-22) years were analyzed. The proportion of patients with recurrent UTIs decreased significantly (P < 0.0001) from 93.4% (87.8-96.9%) to 59.6% (50.8-67.9%) during immunomodulation therapy, whereas the proportion of patients without UTIs increased significantly (P < 0.0001) from 2.2% (0.5-6.3%) to 20.6% (14.1-28.4%). The investigated confounders had no significant (P ≥ 0.15) effect on the outcome.

CONCLUSIONS

Oral immunomodulation therapy with E. coli fractions resulted in a significant and clinically relevant decrease in the frequency of UTIs in patients with SCI and thus, seems to be a promising option for the prevention of UTIs.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Initial investigations of a special high-definition (Hi-Def) zoom capability in a new detector system for neuro-interventional procedures

Real-time visualization of fine details ranging to 100 um or less in neuro-vascular imaging guided interventions is important. A separate high-resolution detector mounted on a standard flat panel detector (FPD) was previously reported. This device had to be rotated mechanically into position over the FPD for high resolution imaging. Now, the new detector reported here has a high definition (Hi-Def) zoom capability along with the FPD built into one unified housing. The new detector enables rapid switching, by the operator between Hi-Def and FPD modes. Standard physical metrics comparing the new Hi-Def modes with those of the FPD are reported, demonstrating improved imaging resolution and noise capability at patient doses similar to those used for the FPD. Semi-quantitative subjective studies involving qualitative clinician feedback on images of interventional devices such as a Pipeline Embolization Device (PED) acquired in both Hi-Def and FPD modes are presented. The PED is deployed in a patient specific 3D printed neuro-vascular phantom embedded inside realistic bone and with tissue attenuating material. Field-of-view (FOV), exposure and magnification were kept constant for FPD and Hi-Def modes. Static image comparisons of the same view of the PED within the phantom were rated by expert interventionalists who chose from the following ratings: Similar, Better, or Superior. Generally, the Hi-Def zoomed images were much preferred over the FPD, indicating the potential to improve endovascular procedures and hence outcomes using such a Hi-Def feature.

Spectroscopy with a CdTe-based photon-counting imaging detector (PCD) having charge sharing correction capability

The spectroscopic capabilities of a newly upgraded version of a prototype imaging photon counting detector (PCD) was investigated. The XCounter Actaeon has four acquisition modes in which signal processing is varied including one mode having a charge sharing correction so that neighboring pixels that share a detected event will not be erroneously counted twice, hence it is designated the Anti-Coincidence Circuit On or ACC On mode. Since this CdTe-based direct conversion PCD has 100 μm pixels, such charge sharing may frequently occur for typical medical x-ray energies. Each pixel of this PCD has two scalers and two energy discriminators that enable counting without instrumentation noise of events above each threshold level; hence, a spectrum can be obtained by sequentially moving the thresholds of both discriminators. It became evident from the spectra for the various acquisition modes that only those obtained with the charge sharing correction enabled, compared favorably with theoretically predicted spectra. After verifying the energy calibration using the mono-energetic emissions from an Am-241 source, spectra at various kVps from a standard medical x-ray generator were obtained. The spectra generated by ACC On mode for 70 kVp and 110 kVp were the closest match to the theoretical spectra generated by SpekCal. For dual energy applications, ACC On mode with charge sharing correction circuitry would be the best choice among various acquisition modes. Also investigated was the dual energy imaging capability of the Actaeon PCD with ACC On mode to separate Aluminum and Iodine while imaging an artery stenosis phantom.

Evaluation of a clinical implementation of a respiratory muscle training group during spinal cord injury rehabilitation

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate the clinical implementation of a respiratory muscle training group during rehabilitation of individuals with spinal cord injury.

SETTING

Spinal cord injury rehabilitation center.

METHODS

Individuals with complete or incomplete lesions during inpatient rehabilitation, level C4-T12.Ten or more training sessions of either an inspiratory or a combined in- and expiratory muscle training were performed in a group setting with respiratory function measurements before and after the training period.

RESULTS

Analysis of 79 persons. Inspiratory muscle training was performed for 7 weeks with a median of 3.1 training sessions per week. Median training intensity was at 33% of baseline PImax and 58 repetitions were performed per training session. Respiratory mucle strength parameters improved by 18-68% of baseline values and lung function parameters by 11-31% after inspiratory muscle training.The combined respiratory muscle training was performed for 13 weeks with a median of 2.8 sessions per week and 88 repetitions per training session. Median inspiratory training resistance was at 39% of baseline PImax and median expiratory training resistance was at 27% of baseline PEmax. Respiratory muscle strength parameters improved by 14-51% of baseline values and lung function parameters improved by 15-34% after the combined in- and expiratory muscle training.

CONCLUSION

Respiratory resistance training improved respiratory function of individuals with acute spinal cord injury. Even if the combined respiratory muscle training was performed with more repetitions per training and nearly twice as long, relative improvements of respiratory function parameters were comparable with isolated inspiratory muscle training.

Functional outcome after laparoscopic nerve-sparing sacrocolpopexy: a prospective cohort study

INTRODUCTION

To date sacrocolpopexy is regarded as the reference standard treatment for primarily apical compartment prolapse and multicompartment prolapse. Most bladder and bowel dysfunction improves postoperatively after sacrocolpopexy; however, de novo bowel or de novo bladder dysfunction can occur. The inferior hypogastric nerve is commonly known among pelvic surgeons. However, the inferior hypogastric nerve and its fine fibers are difficult to identify; iatrogenic lesion is commonly tolerated although this can lead to bladder, bowel and sexual dysfunction. This study was performed to assess the functional outcome after nerve-sparing sacrocolpopexy.

MATERIAL AND METHODS

From 2014 to 2016 all women undergoing a laparoscopic sacrocolpopexy for apical or multicompartment prolapse stage >2 were included in this prospective study. Laparoscopic sacrocolpopexy was performed using the nerve-sparing approach. Objective outcome was assessed by preoperative and postoperative POP-Q changes. De novo bladder and de novo bowel dysfunction were subjectively and objectively evaluated.

RESULTS

In all, 137 women were included. Significant objective improvement for point Aa and C (p < 0.0001) preoperatively to postoperatively was seen. The posterior compartment remained unchanged with point Ba -2. De novo overactive bladder and de novo bladder outlet obstruction with elevated postresidual volume were seen for both in 0.7% (1/137). De novo stress urinary incontinence was seen in 0.7% (5/137). De novo constipation was seen in 5%, bowel incontinence in 0% and resolution of pre-existing obstipation in 14.5%. De novo laxative use (9%) in the first 12 weeks was the most common postoperative problem.

CONCLUSION

We could demonstrate that when a nerve-sparing technique is applied for sacrocolpopexy low de novo bladder (18%) and de novo bowel dysfunction can be seen.

Gantry rotational motion-induced blur in cone-beam computed tomography

As neuro-endovascular image-guided interventions (EIGIs) make use of higher resolution detectors, gantry rotational motion-induced blur becomes more noticeable in acquired projections as well as reconstructed images by reducing the visibility of vascular and device features whose visualization could be critical in the treatment of vascular pathology. Motion-induced blur in projections views is a function of an object's position in the field-of-view (FOV), gantry rotational speed, and frame capture or exposure time. In this work different frame rates were used to investigate the effects of blurring from individual projections on the reconstructed image. To test the effects of these parameters on reconstructed images, a regular pattern phantom of small objects was simulated and projection views were generated at various different frame rates for a given simulated rotational velocity. The reconstruction was made using a linear interpolation of filtered backprojections. Images reconstructed from lower frame rates showed significant blurring in the azimuthal direction, increasingly worse towards the periphery of the image. However, those reconstructed from higher frame rates showed significantly less blur throughout the entire FOV. While lower frame rates could be used with slower gantry speeds this would increase the risk of voluntary or involuntary patient motion contributing to blur over the entire FOV. A high frame rate used with high gantry speeds could reliable provide images without gantry-motion blur while reducing the risk of patient-motion blur. Frame rates exceeding 2000 fps available with photon counting detectors such as the X-counter Actaeon¹ are available.

Evaluation of a new photon-counting imaging detector (PCD) with various acquisition modes

The prospect of improved low noise, high speed, and dual-energy imaging that may be associated with the use of photon-counting imaging detectors (PCD) has motivated this evaluation of a newly upgraded version of a prototype PCD. The XCounter Actaeon was evaluated in its four acquisition modes each based upon varying signal processing firmware including a mode with charge sharing correction that enables neighboring pixels that share the energy from one incident x-ray photon detection to be counted only once at the proper summed energy in the pixel with the largest charge deposition. Since this PCD is a CdTe-based direct detector with 100 μm pixels, such charge sharing for typical medical x-ray energy photons may occur frequently and must be corrected to achieve more accurate counts. This charge sharing correction is achieved with an Anti-Coincidence Circuit (ACC) which prevents double pixel counting from one event as well as prevents counting from either event if they are below a preset threshold. Various physical parameters of the PCD were evaluated including linearity, sensitivity, pulse pile-up effects, dark noise, spatial resolution, noise power spectrum, and detective quantum efficiency.

Immunosenescence in persons with spinal cord injury in relation to urinary tract infections -a cross-sectional study

BACKGROUND

Individuals with a spinal cord injury (SCI), despite specialized rehabilitation and good health care, have a reduced life expectancy. Infectious diseases, such as pneumonias, infected pressure sores and urinary tract infections (UTI) have been identified as the leading causes of mortality. We hypothesise that a premature onset of immune frailty occurs in SCI, possibly caused also by recurrent urinary tract infections.A cross sectional study was performed comparing blood and urine samples between able bodied controls (n = 84) and persons with spinal cord injury (n = 85). The results were grouped according to age (below and above 60 years). Assessed were the abundancies of immune cells, the concentration of soluble biomarkers, the in vitro functioning of lymphocytes as well as phenotypic exhaustion of T-cells in blood and urine. Further, the leucocyte telomere length and the cytomegalovirus (CMV) serological status were compared between the groups.

RESULTS

We observed in people with SCI lower proportions of naïve T-cells, more memory T-cells, reduced T-cell proliferation and higher CMV prevalence compared to age-matched controls. SCI participants older than 60 years had a higher prevalence of UTI compared with SCI persons younger than 60 years.

CONCLUSION

The immune system of people with SCI shows traits of an increased immunological strain and a premature onset of immune frailty. The role of UTI in the onset of immune frailty remains to be elucidated as we did not see significantly higher abundancies of circulating UTI-bacteria specific T-cell clones in persons with SCI. We assume that any impact of UTI on the immune system might be compartmentalized and locally restricted to the urinary tract.

The effects of antimuscarinic treatment on the cognition of spinal cord injured individuals with neurogenic lower urinary tract dysfunction: a prospective controlled before-and-after study

STUDY DESIGN

Prospective controlled before-and-after study.

OBJECTIVES

To investigate the effects of antimuscarinic treatment of neurogenic lower urinary tract dysfunction on the cognition of individuals with spinal cord injury (SCI) during the early post-acute phase.

SETTING

Single SCI rehabilitation center.

METHODS

Patients with acute traumatic SCI admitted for primary rehabilitation from 2011 to 2015 were screened for study enrollment. Study participants underwent baseline neuropsychological assessments prior to their first urodynamic evaluation (6-8 weeks after SCI). Individuals suffering from neurogenic detrusor overactivity received antimuscarinic treatment, and those not requiring antimuscarinic treatment constituted the control group. The neuropsychological follow-up assessment was carried out 3 months after the baseline assessment. The effects of group and time on the neuropsychological parameters were investigated.

RESULTS

The data of 29 individuals were evaluated (control group 19, antimuscarinic group 10). The group had a significant (P≤0.033) effect on immediate recall, attention ability and perseveration. In the control group, individuals performed significantly (P≤0.05) better in immediate recall both at baseline (percentile rank 40, 95% CI 21-86 versus 17, 95% CI 4-74) and follow-up (percentile rank 40, 95% CI 27-74 versus 16, 95% CI 2-74). The time had a significant (P≤0.04) effect on attention ability, processing speed, word fluency and visuospatial performance. The individuals in both groups performed better at the follow-up compared to the baseline assessment.

CONCLUSION

Even though, we did not observe cognitive deterioration in the investigated, cognitively intact SCI individuals during the first 3 treatment months, the concerns regarding deleterious effects of antimuscarinics on cognition remain.

Cast aluminium single crystals cross the threshold from bulk to size-dependent stochastic plasticity

Metals are known to exhibit mechanical behaviour at the nanoscale different to bulk samples. This transition typically initiates at the micrometre scale, yet existing techniques to produce micrometre-sized samples often introduce artefacts that can influence deformation mechanisms. Here, we demonstrate the casting of micrometre-scale aluminium single-crystal wires by infiltration of a salt mould. Samples have millimetre lengths, smooth surfaces, a range of crystallographic orientations, and a diameter D as small as 6 μm. The wires deform in bursts, at a stress that increases with decreasing D. Bursts greater than 200 nm account for roughly 50% of wire deformation and have exponentially distributed intensities. Dislocation dynamics simulations show that single-arm sources that produce large displacement bursts halted by stochastic cross-slip and lock formation explain microcast wire behaviour. This microcasting technique may be extended to several other metals or alloys and offers the possibility of exploring mechanical behaviour spanning the micrometre scale.

Long-term course of sacral anterior root stimulation in spinal cord injured individuals: The fate of the detrusor

AIMS

To investigate the long-term course of the detrusor pressure during sacral anterior root stimulation in spinal cord injury (SCI) patients.

METHODS

Retrospective evaluation of 111 patients who had undergone sacral deafferentation and implantation of an anterior root stimulator at a single SCI rehabilitation center with a minimum follow-up time of 5 years.

RESULTS

The median follow-up time was 11.7 years (range 5.0-24.9 years). The maximum detrusor pressure (Pdet_max) during stimulation was higher in men compared to women (P = 0.0004) and decreased over time (P = 0.0006). However, there were no significant (P ≥ 0.06) differences in the median Pdet_max during stimulation between the first measurement time point and any follow-up time point. The Pdet_max during stimulation decreased from 62 cmH₂ O (95%CI 57-73 cmH₂ O) to 53 cmH₂ O (95%CI 47-69 cmH₂ O) (P = 0.9). The time had also a significant effect on Pdet_max during the storage phase (P < 0.0001) and bladder compliance (P = 0.0007). The Pdet_max during the storage phase decreased, whereas bladder compliance increased during the follow-up period. There were no significant (P ≥ 0.1) changes over time in bladder capacity, the number of daily stimulations and the residual urine volume after voiding.

CONCLUSIONS

The detrusor pressure during sacral anterior root stimulation decreases over time in SCI individuals. However, the changes do not seem to be clinically relevant during the first decade after surgery.

Nerve growth factor does not seem to be a biomarker for neurogenic lower urinary tract dysfunction after spinal cord injury

AIM

To prospectively investigate the association of bladder function with the nerve growth factor (NGF) concentration in the urine of individuals with neurogenic lower urinary tract dysfunction (NLUTD) after spinal cord injury (SCI).

METHODS

Individuals with chronic SCI and NLUTD presenting for a routine urologic examination at a tertiary urologic referral center were recruited for the study. Patient characteristics, the current bladder evacuation method and urodynamic parameters were collected. As controls, individuals with normal bladder function were recruited from the staff of a SCI rehabilitation center. The urinary NGF concentration was measured in triplicates by enzyme linked immunosorbent assay with a minimal sensitivity of 10 pg/ml.

RESULTS

The data of 10 and 37 individuals with normal bladder function and NLUTD, respectively, were analyzed. The urinary NGF concentration was below 10 pg/ml in all investigated samples.

CONCLUSIONS

The urinary NGF concentration did not differentiate between individuals with normal bladder function and those with NLUTD. At least in patients with SCI, the urinary NGF concentration does not seem to be a clinically relevant biomarker for NLUTD. Neurourol. Urodynam. 36:659-662, 2017. © 2016 Wiley Periodicals, Inc.

Risk factors for symptomatic urinary tract infections in individuals with chronic neurogenic lower urinary tract dysfunction

STUDY DESIGN

Retrospective investigation.

OBJECTIVES

To investigate the association of patient and injury characteristics, as well as bladder management, with the occurrence of patient-reported, symptomatic urinary tract infection(s) UTI(s) in patients with chronic neurogenic lower urinary tract dysfunction (NLUTD).

SETTING

Tertiary urologic referral center.

METHODS

The patient database was screened for patients with chronic (>12 months) NLUTD who had presented between 2008 and 2012. Patient characteristics, bladder evacuation management, the annual number of patient-reported, symptomatic UTIs and the type of prophylactic treatment to prevent UTIs were collected. Binary logistic regression analysis was used to investigate the effects of the investigated risk factors on the occurrence of symptomatic UTI(s) and recurrent symptomatic UTIs (⩾3 annual UTIs).

RESULTS

The data of 1104 patients with a mean NLTUD duration of 20.3±11.6 years were investigated. The evacuation method was a significant (P⩽0.004) predictor for the occurrence of symptomatic UTI and recurrent symptomatic UTIs. The greatest annual number of symptomatic UTIs was observed in patients using transurethral indwelling catheters, and the odds of experiencing a UTI and recurrent UTIs were increased more than 10- and 4-fold, respectively. The odds of a UTI or recurrent UTIs were also increased significantly (P⩽0.014) in patients using intermittent catheterization (IC). Botulinum toxin injections into the detrusor increased the odds of a UTI ~10-fold (P=0.03).

CONCLUSIONS

The bladder evacuation method is the main predictor for symptomatic UTIs in individuals with NLUTD. Transurethral catheters showed the highest odds of symptomatic UTI and should be avoided whenever possible.

Predictive Value of Upper Limb Muscles and Grasp Patterns on Functional Outcome in Cervical Spinal Cord Injury

Objective. To determine which single or combined upper limb muscles as defined by the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI); upper extremity motor score (UEMS) and the Graded Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP), best predict upper limb function and independence in activities of daily living (ADLs) and to assess the predictive value of qualitative grasp movements (QlG) on upper limb function in individuals with acute tetraplegia. Method. As part of a Europe-wide, prospective, longitudinal, multicenter study ISNCSCI, GRASSP, and Spinal Cord Independence Measure (SCIM III) scores were recorded at 1 and 6 months after SCI. For prediction of upper limb function and ADLs, a logistic regression model and unbiased recursive partitioning conditional inference tree (URP-CTREE) were used. Results. Logistic regression and URP-CTREE revealed that a combination of ISNCSCI and GRASSP muscles (to a maximum of 4) demonstrated the best prediction (specificity and sensitivity ranged from 81.8% to 96.0%) of upper limb function and identified homogenous outcome cohorts at 6 months. The URP-CTREE model with the QlG predictors for upper limb function showed similar results. Conclusion. Prediction of upper limb function can be achieved through a combination of defined, specific upper limb muscles assessed in the ISNCSCI and GRASSP. A combination of a limited number of proximal and distal muscles along with an assessment of grasping movements can be applied for clinical decision making for rehabilitation interventions and clinical trials.

Evaluation of pharmacokinetic properties and anaesthetic effects of propofol in a new perfluorohexyloctane (F6H8) emulsion in rats--A comparative study

Propofol (2,6-diisopropylphenol) is a safe and widely used anaesthetic, but due to low water solubility and high lipophilicity a difficult compound to formulate. The solubility of propofol in the semifluorinated alkane perfluorohexyloctane (F6H8) is very high (>300 mg/ml). In the present work we investigate if a F6H8-based emulsion could be used as a new intravenous drug delivery system for propofol from a pharmacokinetic, pharmacodynamic and safety point of view. The pharmacokinetic parameters were evaluated after an intravenous bolus injection of either Disoprivan(®) or a F6H8-based propofol emulsion in Wistar rats. The onset and end of sedation after multiple dosings (5, 10 and 15 mg/kg bw) were examined. Clinical chemistry and histology were assessed. No significant difference was found for any of the pharmacokinetic parameters. No differences in the onset nor the end of sedation in the tested dosages could be detected. Histology scores revealed no differences. A slightly increased alanine aminotransferase (ALT) was measured after multiple application of the F6H8-propofol emulsion. In conclusion, the F6H8-propofol emulsion showed no significant different pharmacokinetics and sedation properties, compared to a commercial soy-based propofol emulsion. Further, no toxic effects could be detected on the F6H8 emulsion indicating it was a safe excipient in rats.

The diagnostic value of magnetic resonance imaging measurements for assessing cervical spinal canal stenosis

OBJECT

The authors investigated the relevance of 2D MRI measurements for the diagnosis of critical cervical spinal canal stenosis. Among patients who had sustained a minor cervical spine trauma, they compared MRI measurements of the cervical spine between those with acute cervical spinal cord injury (CSCI) and those without. They also investigated the correlation between the MRI measurements and the severity of CSCI as well as classification accuracy concerning the diagnosis of critical spinal canal stenosis for acute CSCI after a minor trauma.

METHODS

The authors conducted a single-center retrospective radiological case-control study of patients who had sustained CSCI after a minor trauma to the cervical spine from January 2000 to August 2010. The controls were patients who had sustained a cervical trauma without clinical or radiological signs of cervical spinal cord pathology.

On axial T2-weighted MR images, the following were measured: the transverse spinal canal and cord area, the transverse and sagittal cord diameter, and the sagittal canal diameter of the cervical spine (C3–7). Using these measurements, the authors calculated the cord-canal-area ratio by dividing the transverse cord area by the transverse canal area, the space available for the cord by subtracting the sagittal canal diameter from the sagittal cord diameter, and the compression ratio by dividing the transverse cord diameter by its sagittal diameter.

The severity of CSCI was assessed by using the motor index scores of 10 key muscles at different time points (initially, 1, 3, and 12 months after injury) obtained from the clinical records.

The intra- and interobserver reliability of the MRI measurements, intra- and intergroup differences, and correlations between variables were also investigated. Receiver operating characteristic curves were calculated for evaluating the classification accuracy of the imaging variables for CSCI.

RESULTS

Data for 52 CSCI patients and 77 control patients were analyzed. The intra- and interobserver reliability regarding the MRI measurements ranged from good (0.72) to perfect (0.99). Differences between the CSCI group and the control group were significant (p < 0.001) for all parameters, except for the cord area. The most prominent differences between the groups existed for the spinal canal area, cord-canal-area ratio, and space available for the cord. The classification accuracy was best for the cord-canal-area ratio and the space available for the cord; areas under the curve were 0.99 (95% CI 0.97–1.0) and 0.98 (95% CI 0.95–0.99), respectively. There was no significant (p > 0.05) correlation between any of the imaging parameters and the motor index score at any time point.

CONCLUSIONS

The cord-canal-area ratio (> 0.8) or the space available for the cord (< 1.2 mm) measured on MR images can be used to reliably identify patients at risk for acute CSCI after a minor trauma to the cervical spine. However, there does not seem to be any association between spinal canal imaging characteristics and the severity of or recovery from CSCI after a minor trauma.