Inder Perkash

All Publications

• POSTERIOR LEDGE AT THE BLADDER NECK - CRUCIAL DIAGNOSTIC ROLE OF ULTRASONOGRAPHY UROLOGIC RADIOLOGY Perkash, I., Friedland, G. W. 1986; 8 (4): 175-183

  Abstract

  A posterior ledge at the bladder neck was seen in 158 patients (107 of whom were undergoing intermittent catheterization) on a sonographic voiding cystourethrogram. In 117 patients, the ledge was 0.5 cm or longer; 66 patients were on intermittent catheterization, and 51 experienced difficulty with catheterization, including vigorous bleeding in 4. Ledges less than 0.5 cm were discovered in 41 patients, all on intermittent catheterization, none of whom had difficulty with this procedure. The duration of intermittent catheterization and of detrusor-sphincter dyssynergia was shown statistically to be an important factor leading to the formation of the longer obstructing ledges (P less than 0.0005, Mann-Whitney test). Sphincterotomies were performed in 74 patients through the periurethral striated sphincter at 10 and 2 o'clock and extended to the bladder neck. The operation was a success in 73 (98%), all of whom were catheter-free, and in all of whom sonography revealed that the ledge had receded and the catheter was no longer obstructed.

  View details for Web of Science ID A1986F295500001

  View details for PubMedID 3541341

• International Spinal Cord Injury Pulmonary Function Basic Data Set SPINAL CORD Biering-Sorensen, F., Krassioukov, A., Alexander, M. S., Donovan, W., Karlsson, A., Mueller, G., Perkash, I., Sheel, A. W., Wecht, J., Schilero, G. J. 2012; 50 (6): 418-421

  Abstract

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

  View details for DOI 10.1038/sc.2011.183

  View details for Web of Science ID 000304721100005

  View details for PubMedID 22270192

• Transurethral Sphincterotomy JOURNAL OF UROLOGY Perkash, I. 2009; 181 (4): 1539-1540

  View details for Web of Science ID 000264448200007

  View details for PubMedID 19230921

• International bowel function basic spinal cord injury data set SPINAL CORD Krogh, K., Perkash, I., Stiens, S. A., Biering-Sorensen, F. 2009; 47 (3): 230-234

  Abstract

  International expert working group.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.Working group consisting of members appointed by the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS).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.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.An International Bowel Function Basic SCI Data Set has been developed.

  View details for DOI 10.1038/sc.2008.102

  View details for Web of Science ID 000263906100008

  View details for PubMedID 18725887

• International bowel function extended spinal cord injury data set SPINAL CORD Krogh, K., Perkash, I., Stiens, S. A., Biering-Sorensen, F. 2009; 47 (3): 235-241

  Abstract

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

  View details for DOI 10.1038/sc.2008.103

  View details for Web of Science ID 000263906100009

  View details for PubMedID 18725886

• International standards to document remaining autonomic function after spinal cord injury SPINAL CORD Alexander, M. S., Biering-Sorensen, F., Bodner, D., Brackett, N. L., Cardenas, D., Charlifue, S., Creasey, G., DIETZ, V., Ditunno, J., Donovan, W., Elliott, S. L., Estores, I., Graves, D. E., Green, B., Gousse, A., Jackson, A. B., Kennelly, M., Karlsson, A., Krassioukov, A., Krogh, K., Linsenmeyer, T., Marino, R., Mathias, C. J., Perkash, I., Sheel, A. W., Shilero, G., Schurch, B., Sonksen, J., Stiens, S., Wecht, J., Wuermser, L. A., Wyndaele, J. 2009; 47 (1): 36-43

  Abstract

  Experts opinions consensus.To develop a common strategy to document remaining autonomic neurologic function following spinal cord injury (SCI).The impact of a specific SCI on a person's neurologic function is generally described through use of the International Standards for the Neurological Classification of SCI. These standards document the remaining motor and sensory function that a person may have; however, they do not provide information about the status of a person's autonomic function.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.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.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.

  View details for DOI 10.1038/sc.2008.121

  View details for Web of Science ID 000262297000003

  View details for PubMedID 18957962

• Transurethral sphincterotomy provides significant relief in autonomic dysreflexia in spinal cord injured male patients: long-term followup results JOURNAL OF UROLOGY Perkash, I. 2007; 177 (3): 1026-1029

  Abstract

  An evaluation of the results of transurethral sphincterotomy in spinal cord injured patients for the relief of autonomic dysreflexia is presented.The study describes experience with the treatment of 46 consecutive spinal cord injured males presenting with frequent symptoms of autonomic dysreflexia and inadequate voiding. The selection criteria include patients injured above the thoracic 6 level with subjective symptoms of autonomic dysreflexia who did not want to be catheterized or were unable to perform intermittent catheterization. Patients were studied with complex urodynamics before and at least 3 months after undergoing transurethral sphincterotomy. During cystometrogram the maximum increase in systolic and diastolic blood pressure was recorded. After transurethral sphincterotomy patients were followed for a mean of 5.4+/-3.1 years (range 1 to 12).There was subjective relief in autonomic dysreflexia following transurethral sphincterotomy in all patients, which correlated well with a significant decrease in systolic and diastolic blood pressure (p<0.0001). Mean decrease in maximal systolic and diastolic blood pressure after transurethral sphincterotomy was 55+/-25 and 29+/-17 mm Hg, respectively. Mean post-void residual urine decreased significantly from 233+/-151 to 136+/-0.34 ml after transurethral sphincterotomy. However, there was no significant change in mean maximum voiding pressures.Blood pressure monitoring during cystometrogram provides an objective assessment of the presence of autonomic dysreflexia due to neurogenic bladder dysfunction, enabling better therapeutic management to control autonomic dysreflexia. Persistence of significant autonomic dysreflexia needs urodynamic evaluation if other factors for autonomic dysreflexia have been excluded.

  View details for DOI 10.1016/j.juro.2006.10.066

  View details for Web of Science ID 000244211600056

  View details for PubMedID 17296404

• Reproducibility of noninvasive cardiac output during arm exercise in spinal cord injury JOURNAL OF REHABILITATION RESEARCH AND DEVELOPMENT Myers, J., Brown, H., Smith, S., Perkash, I., Kiratli, B. J. 2007; 44 (4): 547-552

  Abstract

  The carbon dioxide (CO(2)) rebreathing method is a noninvasive technique to estimate cardiac output during exercise, but few data are available on the validity and reliability of this measure in individuals with spinal cord injury (SCI). Sixteen male subjects with SCI (mean age 45 +/- 9, seven paraplegic and nine tetraplegic) underwent three submaximal steady state arm ergometer exercise tests. We estimated cardiac output using the exponential CO(2) rebreathing technique at an individualized exercise intensity approximating 50% of peak oxygen uptake. Mean values for the cardiac output measurements were 13.0 +/- 2.4, 13.3 +/- 2.0, and 13.4 +/- 1.7 L/min; the difference among the trials was not significant (p = 0.54). The typical error was 1.80 +/- 0.85 L/min, the limits of agreement were 11.3 to 15.3 L/min, the coefficient of variation was 5.4% +/- 3.4%, and the intraclass correlation coefficient was 0.85 (95% confidence interval = 0.70-0.94). The test-to-test variation in estimated cardiac output during arm ergometry in individuals with SCI is similar to that observed in studies that used this technique in ambulatory persons. The 5% relative variation between tests suggests that the CO(2) rebreathing technique for estimating cardiac output can be performed in SCI individuals with acceptable reproducibility.

  View details for DOI 10.1682/JRRD.2006.08.0103

  View details for Web of Science ID 000250350700008

  View details for PubMedID 18247251

• Aortoiliac hemodynamic and morphologic adaptation to chronic spinal cord injury 20th Annual Meeting of the Western-Vascular-Society Yeung, J. J., Kim, H. J., Abbruzzese, T. A., Vignon-Clementel, I. E., Draney-Blomme, M. T., Yeung, K. K., Perkash, I., Herfkens, R. J., Taylor, C. A., Dalman, R. L. MOSBY-ELSEVIER. 2006: 1254–65

  Abstract

  Reduced lower limb blood flow and resistive hemodynamic conditions potentially promote aortic inflammation and aneurysmal degeneration. We used abdominal ultrasonography, magnetic resonance imaging, and computational flow modeling to determine the relationship between reduced infrarenal aortic blood flow in chronic spinal cord injury (SCI) subjects and risk for abdominal aortic aneurysm (AAA) disease.Aortic diameter in consecutive SCI subjects (n = 123) was determined via transabdominal ultrasonography. Aortic anatomic and physiologic data were acquired via magnetic resonance angiography (MRA; n = 5) and cine phase-contrast magnetic resonance flow imaging (n = 4) from SCI subjects whose aortic diameter was less than 3.0 cm by ultrasonography. Computational flow models were constructed from magnetic resonance data sets. Results were compared with those obtained from ambulatory control subjects (ultrasonography, n = 129; MRA/phase-contrast magnetic resonance flow imaging, n = 6) who were recruited at random from a larger pool of risk factor-matched individuals without known AAA disease.Age, sex distribution, and smoking histories were comparable between the SCI and control groups. In the SCI group, time since injury averaged 26 +/- 13 years (mean +/- SD). Aortic diameter was larger (P < .01), and the prevalence of large (> or = 2.5 cm; P < .01) or aneurysmal (> or = 3.0 cm; P < .05) aortas was greater in SCI subjects. Paradoxically, common iliac artery diameters were reduced in SCI subjects (< 1.0 cm; 48% SCI vs 26% control; P < .0001). Focal preaneurysmal enlargement was noted in four of five SCI subjects by MRA. Flow modeling revealed normal flow volume, biphasic and reduced oscillatory flow, slower pressure decay, and reduced wall shear stress in the SCI infrarenal aorta.Characteristic aortoiliac hemodynamic and morphologic adaptations occur in response to chronic SCI. Slower aortic pressure decay and reduced wall shear stress after SCI may contribute to mural degeneration, enlargement, and an increased prevalence of AAA disease.

  View details for DOI 10.1016/j.jvs.2006.08.026

  View details for Web of Science ID 000242564400022

  View details for PubMedID 17145427

• Homocysteine and hypertension in persons with spinal cord injury SPINAL CORD Lee, M. Y., Myers, J., Abella, J., Froelicher, V. F., Perkash, I., Kiratli, B. J. 2006; 44 (8): 474-479

  Abstract

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

  View details for DOI 10.1038/sj.sc.3101873

  View details for Web of Science ID 000239495900002

  View details for PubMedID 16331308

• Heart rate as a predictor of energy expenditure in people with spinal cord injury JOURNAL OF REHABILITATION RESEARCH AND DEVELOPMENT Hayes, A. M., Myers, J. N., Ho, M., Lee, M. Y., Perkash, I., Kiratli, B. J. 2005; 42 (5): 617-623

  Abstract

  This study evaluated the accuracy of heart rate calibrated from a maximum exercise test for predicting energy expenditure during five activities of daily living (ADL) in participants with spinal cord injury (SCI). Thirteen individuals with SCI underwent maximum exercise testing, followed by portable heart rate and metabolic testing during five ADL. A regression equation was developed from heart rate and oxygen uptake responses during the maximum exercise test for each subject. Based on this individualized equation, heart rate measured during the ADL was used to estimate energy expenditure for each participant. Predicted energy expenditure from heart rate was compared with that measured by indirect calorimetry with the use of oxygen uptake. Heart rate derived from the individualized regression equations explained 55% of the variance in measured energy expenditure, compared with only 8.3% from heart rate alone. However, calibrated heart rate consistently overestimated the actual kilocalories used; on average, the estimated energy expenditure was roughly 25% higher than that measured by oxygen uptake. Heart rate can be used as a gross estimate of energy expenditure during higher-intensity ADL in people with SCI when individual calibration of heart rate from maximum exercise testing is used.

  View details for DOI 10.1682/JRRD.2004.12.0150

  View details for Web of Science ID 000237069100007

  View details for PubMedID 16586187

• Donald Munro Lecture 2003. Neurogenic bladder: past, present, and future. journal of spinal cord medicine Perkash, I. 2004; 27 (4): 383-386

  Abstract

  The foundation of the management of neurogenic bladder can be attributed to a pioneer in spinal cord injury medicine. Dr. Donald Munro, a neurosurgeon, who also had experience in urologic surgery, established the first Spinal Cord Injury Service of 10 beds in the Boston City hospital in the 1930s. He later became adviser to the US Army and the Veterans Administration (VA). On his recommendation, paraplegic centers were created in US army hospitals and later in the VA hospitals from 1943 to 1945. This article reviews the evolution of the management of neurogenic bladder in patients with spinal cord injuries from the past century to the present. The role of urodynamics in defining neurologic lesions is critical to the appropriate management of the voiding dysfunction. Key advances, such as the diagnosis of detrusor sphincter dyssynergia (DSD), recognition of its association with autonomic dysreflexia, and its definitive management, have been emphasized. The role of transrectal linear array sonography using a rectal probe was found useful for defining bladder outlet dysfunction during urodynamics. It also helped to recognize secondary bladder neck obstruction and diagnose false passages in the urethra. Clean technique intermittent catheterization (IC) was evaluated and recommended. In about 28% patients with DSD that led to secondary bladder neck obstruction, a consequence of IC was reported. Transurethral laser sphincterotomy (TURS) was first reported by me in 1991, and later, durable 7-year follow-up results were reported in 78% of the first 99 patients. We reported a surgical technique to lengthen the penis. We also reported the long-term success with semirigid implants in 92% of patients with SCI. This technique helped maintain external condom drainage on a small phallus and improved the sex life of patients, as well as their quality of life. The author's pertinent areas of interest in the past one-half century were aimed at recognizing specific urologic problems associated with neurologic impairment. Management was aimed at preventive care, early recognition, and timely management to reduce secondary complications and enhance quality of life.

  View details for PubMedID 15484669

• Which stoma works better for colonic dysmotility in the spinal cord injured patient? 27th Annual Surgical Symposium of the Association-of-VA-Surgeons Safadi, B. Y., Rosito, O., Nino-Murcia, M., Wolfe, V. A., Perkash, I. EXCERPTA MEDICA INC-ELSEVIER SCIENCE INC. 2003: 437–42

  Abstract

  The formation of an intestinal stoma is very effective in the treatment of colonic dysmotility associated with spinal cord injury (SCI). Little is known about the difference in the long-term outcome among left-sided colostomies, right-sided colostomies, and ileostomies in this patient population.The records of 45 SCI patients with intestinal stomas at our institution were reviewed retrospectively. Operative details and preoperative colonic transit times (CTT) were recorded. Patients who were alive and available were interviewed using a questionnaire designed to assess the quality of life (QOL), health status, and time to bowel care before and after stoma formation.Between 1976 and 2002, 45 patients underwent a total of 48 intestinal stomas. A left-sided colostomy (LC) was formed in 21 patients, right-sided colostomy (RC) in 20, and ileostomy (IL) in 7. Three of the patients in the RC group ultimately underwent total abdominal colectomy and ileostomy. The indications for stoma formation and CTT were different in the three groups. Bloating, constipation, chronic abdominal pain, difficulty evacuation with prolonged CTT was the main indication in 95% of patients in the RC group, 43% of patients in the LC group, and 29% in the IL group. Management of complicated decubitus ulcers, perineal and pelvic wounds was the primary indication in 43% of patients in the LC group, 5% in the RC group, and none in the IL group. Preoperative total and right CTTs were longer in the RC group compared with the LC group: 127.5 versus 83.1 hours (P <0.05) and 53.7 versus 28.5 hours (P <0.05), respectively. Eighty-two percent of patients (37 of 45) were interviewed at a mean follow-up of 5.5 years after stoma formation. Most patients who were interviewed were satisfied with their stoma (RC, 88%; LC, 100%; IL, 83%) and the majority would have preferred to have the stoma earlier (RC, 63%; LC, 77%; and IL, 63%). The QOL index significantly improved in all groups (RC, 49 to 79, P <0.05; LC, 50 to 86, P <0.05; and IL, 60 to 82, P <0.05), as well as the health status index (RC, 58 to 83, P <0.05; LC, 63 to 92, P <0.05; IL, 61 to 88, P <0.05). The average daily time to bowel care was significantly shortened in all groups (RC, 102 to 11 minutes, P <0.05; LC, 123 to 18 minutes, P <0.05; and IL, 73 to 13 minutes, P <0.05.).Regardless of the type of stoma, most patients had functional improvement postoperatively. Patients who underwent RC had longer CTT and more chronic symptoms related to colonic dysmotility, reflecting the preoperative selection bias. The successful outcome noted in all groups suggests that preoperative symptoms and CTT studies may have been helpful in optimal choice of stoma site selection.

  View details for DOI 10.1016/j.amjsurg.2003.07.007

  View details for Web of Science ID 000186307300005

  View details for PubMedID 14599603

• Displacement sequence and elastic properties of anterior prostate/urethral interface during micturition of spinal cord injured men ULTRASOUND IN MEDICINE AND BIOLOGY Constantinou, C. E., Damaser, M. S., Perkash, I. 2002; 28 (9): 1157-1163

  Abstract

  The management of complex micturition problems frequently encountered in patients with spinal cord injury (SCI) may be facilitated by characterization of the elastic properties of the prostate. To this end, we have developed a method of evaluating changes in prostate biomechanics using ultrasound (US) images obtained during routine diagnostic urodynamic evaluations. Ultrasound video sequences of the prostate and urethra during voiding were digitized simultaneously with bladder pressure measurement on 76 patients with spinal cord injury, having a mean age of 47 +/- 16 years. Computer enhancement of the bladder/prostate/urethral interface from sequences of 2-D US images facilitated measurement of midprostatic urethral displacement during micturition. Of 76 patients, 21 were able to initiate voiding. Maximum urethral diameter was 12.0 +/- 1.3 mm, with corresponding maximum voiding pressure of 61.6 +/- 1.9 cmH(2)O. Urethral/prostatic pressure strain elastic modulus (Ep) was 960 +/- 624 N/m(2) and stiffness (beta) calculated as the inverse of compliance was 2.8 +/- 0.1. The diameter of the urethra at P(det50+), during the opening phase, was 0.4 +/- 0.1 mm and, during the closing phase, was 0.7 +/- 0.1 mm. During voiding, the anterior prostate was displaced to a greater extent than the posterior prostate. These observations suggest that distension of the prostate/urethra during micturition is hysteretic and nonuniform and indicates regional differences in compliance within the prostate/urethra interface. These regional differences lend support to the concept that the posterior prostate is implicated in the active process of micturition involving the fibromuscular stroma. Clinical application of this method could include quantification of the biomechanics of micturition consequent to spinal injury, prostatic enlargement, and the impact of targeted evaluation of pharmacological interventions.

  View details for Web of Science ID 000178732200009

  View details for PubMedID 12401386

• Intracranial dural arteriovenous fistula causing a myelopathy SPINAL CORD Perkash, I., Punj, V., Ota, D. T., Lane, B., Skirboll, S. 2002; 40 (9): 438-442

  View details for DOI 10.1038/sj.sc3101355

  View details for Web of Science ID 000177892100003

  View details for PubMedID 12185604

• Electrocardiographic findings in patients with chronic spinal cord injury AMERICAN JOURNAL OF PHYSICAL MEDICINE & REHABILITATION PRAKASH, M., Raxwal, V., Froelicher, V. F., Kalisetti, D., Vieira, A., O'Mara, G., Marcus, R., Myers, J., Kiratli, J., Perkash, I. 2002; 81 (8): 601-608

  Abstract

  To demonstrate the prevalence and prognostic value of electrocardiographic abnormalities in patients with chronic spinal cord injury.All electrocardiographs obtained in the Palo Alto Veterans Affairs Medical Center since 1987 have been digitally recorded and stored in a computerized database. For this study, only the first electrocardiograph was considered for analysis. The subjects were divided according to age and level of spinal cord injury. The Social Security Death Index was used to ascertain vital status as of December 1999.Annual mortality was similar in those with chronic spinal cord injury and the able-bodied. However, individuals with a higher level of injury had a significantly higher death rate than those with a lower level of injury. The prognostic characteristics of electrocardiographic abnormalities were similar in both the able-bodied and those with spinal cord injury.In general, electrocardiographic abnormalities had the same prevalence in the spinal cord injury subjects as in the able-bodied ones. The prognostic value of electrocardiographic abnormalities in subjects with spinal cord injury is similar to that observed in able-bodied subjects.

  View details for PubMedID 12172070

• Early repolarization in patients with spinal cord injury: prevalence and clinical significance. journal of spinal cord medicine Marcus, R. R., Kalisetti, D., Raxwal, V., Kiratli, B. J., Myers, J., Perkash, I., Froelicher, V. F. 2002; 25 (1): 33-38

  Abstract

  The objective was to examine the prevalence of early repolarization in a spinal cord injury (SCI) clinic and the relationship of level of injury to this electrocardiogram (ECG) finding.ST elevation on the resting ECG can be either a normal variant or a sign of acute ischemia, evolving myocardial infarction, or pericarditis. It is frequently seen as a normal variant (early repolarization) in healthy individuals, but has also been reported in individuals with SCI. While the etiology of benign ST elevation (early repolarization) has not been clearly defined, current opinion is that this finding is seen in individuals with high vagal tone.Retrospective analysis was made of 31 5 individuals with SCI at T5 or above (140 with complete injuries), and 1 98 with SCI at T6 or below, and who had ECGs in the computerized database at the Palo Alto VA Medical Center. A comparison cohort of 32,841 able-bodied male controls also was identified in the same ECG database. Patient demographics and computerized ST measurements were analyzed.The prevalence of ST elevation was significantly higher in both the total high-level injury group (19%) and the complete high-injury group (24.5%) than in either the low-injury (6.5%) or control groups (13%), with P < 0.001 for comparisons between both high- and low-injury groups and high injury vs control. The magnitude of ST elevation was also higher in the high-injury groups vs the low-injury and control groups.There is a higher prevalence of early repolarization in individuals with SCI at levels of injury that can disrupt central sympathetic command of the heart. It appears that either enhanced vagal tone or loss of sympathetic tone is responsible for ST elevation.

  View details for PubMedID 11939464

• Occult maxillary sinusitis as a cause of fever in tetraplegia: 2 case reports ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION Lew, H. L., Han, J., Robinson, L. R., Britell, C., Perkash, I. 2002; 83 (3): 430-432

  Abstract

  Common causes of fever in tetraplegia include urinary tract infection, respiratory complications, bacteremia, impaired autoregulation, deep vein thrombosis, osteomyelitis, drug fever, and intra-abdominal abscess. We report 2 acute tetraplegic patients who presented with fever of unknown origin. After extensive work-up, they were diagnosed with occult maxillary sinusitis. A search of current literature revealed no reports of sinusitis as a potential source of fever in recently spinal cord--injured patients. Patients with tetraplegia, especially in the acute phase of spinal cord injury, often undergo nasotracheal intubation or nasogastric tube placement, which may result in mucosal irritation and nasal congestion. All of the previously mentioned factors, in combination with poor sinus drainage related to supine position, predispose them to developing maxillary sinusitis. The 2 consecutive cases show the importance of occult sinusitis in the differential diagnosis of fever in patients with tetraplegia.

  View details for DOI 10.1053/apmr.2002.29627

  View details for Web of Science ID 000174277900022

  View details for PubMedID 11887128

• Functional magnetic stimulation facilitates colonic transit in rats ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION Lin, V., Hsiao, I., Goodwin, D., Perkash, I. 2001; 82 (7): 969-972

  Abstract

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

  View details for Web of Science ID 000169742800018

  View details for PubMedID 11441387

• Functional magnetic stimulation of the colon in persons with spinal cord injury ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION Lin, V. W., Nino-Murcia, M., Frost, F., Wolfe, V., Hsiao, I., Perkash, I. 2001; 82 (2): 167-173

  Abstract

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

  View details for DOI 10.1053/apmr.2001.18215

  View details for Web of Science ID 000166846000004

  View details for PubMedID 11239306

• Functional magnetic stimulation for conditioning of expiratory muscles in patients with spinal cord injury ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION Lin, V. W., Hsiao, I. N., Zhu, E. C., Perkash, I. 2001; 82 (2): 162-166

  Abstract

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

  View details for Web of Science ID 000166846000003

  View details for PubMedID 11239305

• Progressive decrease in bone density over 10 years of androgen deprivation therapy in patients with prostate cancer 95th Annual Meeting of the American-Urological-Association Kiratli, B. J., Srinivas, S., Perkash, I., Terris, M. K. ELSEVIER SCIENCE INC. 2001: 127–32

  Abstract

  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.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.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.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.

  View details for Web of Science ID 000166663000025

  View details for PubMedID 11164157

• Bone mineral and geometric changes through the femur with immobilization due to spinal cord injury JOURNAL OF REHABILITATION RESEARCH AND DEVELOPMENT Kiratli, B. J., Smith, A. E., Nauenberg, T., Kallfelz, C. F., Perkash, I. 2000; 37 (2): 225-233

  Abstract

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

  View details for Web of Science ID 000165733400016

  View details for PubMedID 10850829

• Functional magnetic stimulation: A new modality for enhancing systemic fibrinolysis ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION Lin, V. W., Perkash, A., Liu, H. J., Todd, D., Hsiao, I., Perkash, I. 1999; 80 (5): 545-550

  Abstract

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

  View details for Web of Science ID 000080171700014

  View details for PubMedID 10326919

• Prostate cancer: a hazard also to be considered in the ageing male patient with spinal cord injury SPINAL CORD Wyndaele, J. J., Iwatsubo, E., Perkash, I., Stohrer, M. 1998; 36 (5): 299-302

  View details for Web of Science ID 000073557600001

  View details for PubMedID 9601107

• Use of contact laser crystal tip firing Nd : YAG to relieve urinary outflow obstruction in male neurogenic bladder patients JOURNAL OF CLINICAL LASER MEDICINE & SURGERY Perkash, I. 1998; 16 (1): 33-38

  Abstract

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

  View details for Web of Science ID 000076079000007

  View details for PubMedID 9728128

• Limb salvage surgery in spinal cord injury patients 11th Annual Meeting of the Western-Vascular-Society Dalman, R. L., Harris, E. J., Walker, M. T., Perkash, I. ELSEVIER SCIENCE INC. 1998: 60–64

  Abstract

  Advances in the care and rehabilitation of patients with spinal cord injuries (SCI) have resulted in extended survival following injury. Increasingly, we are faced with difficult chronic lower extremity ischemic complications in SCI patients. Recognizing limitations associated with amputation in these nonambulatory patients, we report the preliminary results of a program of selective limb salvage via arterial reconstructive surgery. Retrospective chart review was performed on the records of the Veterans Affairs Palo Alto Health Care System SCI unit. Since 1989, 15 revascularization procedures were identified in 10 SCI patients. All patients suffered from ischemic ulceration and/or gangrene. Procedures performed included femorotibial bypass (8), aortofemoral bypass (4), femoro-femoral bypass (2), and axillobifemoral bypass (AXF) (1). All patients were men. The mean age was 56 (range 43-73). Follow-up was available on 10 procedures performed in seven patients since 1992. Mean follow-up was 17 months. One patient died 3 months following distal bypass. The AXF occluded within 1 month. One distal bypass occluded in the immediate postoperative period and could not be salvaged. All other grafts remain patent, and all wounds have healed following successful bypass. One patient developed pressure ulceration following AXF grafting due to postoperative upper extremity limitations. No other complications were encountered. Standard arterial reconstructive procedures can be performed safely and successfully in SCI patients, despite diminished limb blood flow due to inactivity, and atrophic arteries, muscle, and fascia. Axillobifemoral bypass grafting may not be suitable in SCI due to requirements for upper extremity-based mobility. Confirmation of benefit of limb salvage versus amputation awaits comparison between patients eligible for either procedure.

  View details for Web of Science ID 000071300900010

  View details for PubMedID 9451998

• Effect of alpha 1 adrenoceptor antagonist on the urodynamics of the upper and lower urinary tract of the male rat NEUROUROLOGY AND URODYNAMICS Lee, J. Z., Tillig, B., Perkash, I., Constantinou, C. E. 1998; 17 (3): 213-229

  Abstract

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

  View details for Web of Science ID 000073297200008

  View details for PubMedID 9590473

• Chronology and urodynamic characterization of micturition in neurohormonally induced experimental prostate growth in the rat 26th Annual Meeting of the International-Continence-Society Lee, J. Z., Omata, S., Tillig, B., Perkash, I., Constantinou, C. E. WILEY-LISS. 1998: 55–69

  Abstract

  The purpose of this study was to evaluate the impact of chronic urinary tract obstruction which was produced in the rat using neurohormonally induced experimental prostate growth. In this model, we considered the chronology of changes in the micturition characteristics of awake rats relative to prostate weight and stiffness. The corresponding urodynamic characteristics of both the upper and lower tracts were evaluated in anesthetized animals relative to the development and extent of the obstruction produced. Prostate growth was produced by capitalizing on the synergistic properties afforded by the combined administration of dihydrotestosterone propionate (DHT) and the alpha1 adrenoreceptor antagonist prazosin (PRZ). DHT (1.25 mg/kg/day) was dissolved in 0.1 ml sesame oil (SO) and coadministered with PRZ 30 microg/kg/day subcutaneously for 14 days to 12 experimental rats. SO alone was given to 8 control rats. Micturition studies were first performed using all 20 awake rats, which were placed unrestrained in metabolic cages. Urodynamics of the upper and lower urinary tracts were repeated following anesthesia at the 5th, 10th, and 15th weeks after initiation of hormonal or SO treatment. Following the urodynamic studies, the rats were killed and prostates were removed and weighed, and stiffness was measured. Studies with awake rats show that hormonal treatment produces a significant and progressive increase in mean frequency of micturition, ranging from 0.63+/-0.16 in controls and reaching the maximum of 2.15+/-0.40/hr by the 10th wk. Results from urodynamic studies with anesthetized rats also show typical and progressive obstructive characteristics: maximum detrusor voiding pressure (Pdetmax) increased from 52.7+/-2.03 in controls to a maximum of 77.5+/-2.2 cm H2O by the 10th week; urethral opening pressure Puo likewise increased from 52.6+/-2.7 in controls to 73.3+/-2.1 cm H2O in experimental rats. The duration of time during which the detrusor sustains contraction during voiding also rose, from 16.8+/-1.8 sec in controls to 32.0+/-3.2 sec by the 10th week. There were no significant changes in bladder capacity, baseline filling pressures, or arterial pressures. Prostate weight increased significantly from 0.76+/-0.05 g in controls to 1.17+/-0.1 g by the 15th week. Similarly, stiffness increased from control values of 1.33+/-0.18 g/cm to a maximum of 3.59+/-0.14 g/cm by the 10th week. It is concluded that neurohormonally stimulated prostate growth in the rat is a suitable animal model for the study of the development of urinary tract obstruction. Obstructive characteristics were validated in both awake rats by the increase in the frequency of micturition and urodynamically under anesthesia in terms of elevations in maximum detrusor pressures, urethral opening pressure, detrusor contraction time, and prostatic stiffness. The effect of obstruction was further shown to be associated with vesicoureteral reflux during micturition and elevated upper tract pressures.

  View details for Web of Science ID 000071350800008

  View details for PubMedID 9453692

• Detrusor-sphincter dyssynergia and vesico urethral reflux: management SPINAL CORD Perkash, I., Linsenmeyer, T. A., Bodner, D. R., Anderson, R. U. 1998; 36 (1): 2-5

  View details for Web of Science ID 000071539600002

  View details for PubMedID 9471129

• Modulation of detrusor contraction strength and micturition characteristics by intrathecal baclofen in anesthetized rats JOURNAL OF UROLOGY Watanabe, T., Perkash, I., Constantinou, C. E. 1997; 157 (6): 2361-2365

  Abstract

  The effect of intrathecal (i.t.) baclofen in modulating the micturition reflexes, detrusor contraction strength, and micturition efficiency was evaluated in anesthetized rats.Female Wistar rats (n = 14, 337 +/- 8 gm.) were anesthetized with urethane (1.2 gm./kg. s.c.). Cystometrograms were done through a lower midline incision made to expose the bladder and a catheter was inserted through the bladder dome to record pressure during filling with saline at the rate of 0.038 ml./min. During the micturition phase of cystometrogram, the measurement of voided volume was made synchronously with the intravesical pressure. Baclofen was given intrathecally at the increasing doses of 0.05, 0.10, 0.5 microgram. and pressure/flow parameters were measured.The measured urodynamic parameters show that baclofen produced a significant dose dependent increase in bladder capacity and a decreases in voiding efficiency, detrusor pressure and maximum and average flow rate. Baclofen (0.1 microgram.) significantly decreased detrusor contractility reducing both Wmax from 3.7 +/- 0.1 (control) to 2.0 +/- 0.1 W/m2 and Wisv,max from 5.9 +/- 0.3 to 5.5 +/- 0.4 W/m2 respectively. Baclofen altered the characteristic pattern of the micturition reflex by suppressing high frequency pressure oscillations during voiding which was completely abolished after 0.1 microgram. in 75% of the rats. Furthermore, urinary dribbling incontinence was evident at a dose of 0.5 microgram. in 58% of all rats.These results demonstrate that i.t. baclofen has a significant inhibitory effect on the micturition reflex, depressing detrusor contraction strength and micturition efficiency, while increasing bladder capacity.

  View details for Web of Science ID A1997WY05000114

  View details for PubMedID 9146671

• Ablation of urethral strictures using contact chisel crystal firing neodymium:YAG laser JOURNAL OF UROLOGY Perkash, I. 1997; 157 (3): 809-813

  Abstract

  The technique for ablation of urethral strictures using the contact crystal tip firing neodymium:YAG laser was evaluated for adequacy and long-term durability of the ablation.A total of 42 male spinal cord injured patients with suspected urethral strictures approximately 1 to 4 cm. long was evaluated. The strictures were localized and the men underwent endoscopic laser ablation using a contact laser chisel probe (2.5 or 3.5 mm.) screwed onto the end of a semirigid fiber. The usual power setting was 25 to 35 watts. Circumferential vaporization of fibrous tissue was done to achieve complete ablation. For pinpoint strictures with dense fibrosis, subsurface buttonholes were also made to vaporize and ablate expediently all fibrous tissue. A catheter was usually left indwelling overnight only. Estimated blood loss was 25 to 50 ml.All patients were followed for a mean of 28.2 months (range 12 to 46). Of the patients 39 (93%) have adequate voiding and have maintained durability of the stricture ablation. Laser ablation was successfully repeated in 1 patient with initial failure and in 2 with partial failure. Both patients were well for 7 to 18 months. No patient required bougie dilation.For strictures of the urethra the success rate following ablation was greater than that after other reported techniques. Contact laser ablation is simple to perform, with the least morbidity following the procedure, and it can be easily repeated for lasting results.

  View details for Web of Science ID A1997WG21400014

  View details for PubMedID 9072572

• Efficacy and safety of terazosin to improve voiding in spinal cord injury patients. journal of spinal cord medicine Perkash, I. 1995; 18 (4): 236-239

  Abstract

  A total of 28 male spinal cord injury (SCI) patients were enrolled in an open label study to evaluate the efficacy and safety of terazosin to improve voiding. All patients were started on 1 mg daily dose at bedtime. The dosage was gradually increased to 1-2 mg twice daily, depending upon patient tolerance and a minimum acceptable systolic blood pressure of 90 mm Hg. Urodynamic evaluation was done in 24 patients prior to and one week after a maximum tolerated dose was established for at least 48 hours. The maximum dose varied from 1 to 5 mg daily. Subjective improvement in voiding was noticed in 50 percent of patients. Objective assessment with urodynamics showed a mean drop in maximum voiding pressure of 35 cm H2O (range 9-65 cm H2O) in only 42 percent of patients. Subjective improvement in voiding occurred in 14 of 17 patients with absent detrusor sphincter dyssynergia. The drug was discontinued in three patients with side effects of syncope in one patient, lethargy in another and body rash in the third. Because the tolerance dose of terazosin is variable and the therapeutic response is unpredictable, urodynamic monitoring is recommended to accomplish a useful outcome.

  View details for PubMedID 8591069

• MODELING AND SIMULATION OF PARAPLEGIC AMBULATION IN A RECIPROCATING GAIT ORTHOSIS JOURNAL OF BIOMECHANICAL ENGINEERING-TRANSACTIONS OF THE ASME Tashman, S., Zajac, F. E., Perkash, I. 1995; 117 (3): 300-308

  Abstract

  We developed a three dimensional, four segment, eight-degree-of-freedom model for the analysis of paraplegic ambulation in a reciprocating gait orthosis (RGO). Model development was guided by experimental analysis of a spinal cord injured individual walking in an RGO with the additional assistance of arm crutches. Body forces and torques required to produce a dynamic simulation of the RGO gait swing phase were found by solving an optimal control problem to track the recorded kinematics and ground reaction forces. We found that high upper body forces are required, not only during swing but probably also during double support to compensate for the deceleration of the body during swing, which is due to the pelvic thrust necessary to swing the leg forward. Other stimulations showed that upper body forces and body deceleration during swing can be reduced substantially by producing a ballistic swing. Functional neuromuscular stimulation of the hip musculature during double support would then be required, however, to establish the initial conditions needed in a ballistic swing.

  View details for Web of Science ID A1995RZ15400009

  View details for PubMedID 8618383

• REGISTRATION ERROR QUANTIFICATION OF A SURFACE-BASED MULTIMODALITY IMAGE FUSION SYSTEM MEDICAL PHYSICS Hemler, P. F., Napel, S., Sumanaweera, T. S., PICHUMANI, R., VANDENELSEN, P. A., Martin, D., Drace, J., Adler, J. R., Perkash, I. 1995; 22 (7): 1049-1056

  Abstract

  This paper presents a new reference data set and associated quantification methodology to assess the accuracy of registration of computerized tomography (CT) and magnetic-resonance (MR) images. Also described is a new semiautomatic surface-based system for registering and visualizing CT and MR images. The registration error of the system was determined using a reference data set that was obtained from a cadaver in which rigid fiducial tubes were inserted prior to imaging. Registration error was measured as the distance between an analytic expression for each fiducial tube in one image set and transformed samples of the corresponding tube obtained from the other. Registration was accomplished by first identifying surfaces of similar anatomic structures in each image set. A transformation that best registered these structures was determined using a nonlinear optimization procedure. Even though the root-mean-square (rms) distance at the registered surfaces was similar to that reported by other groups, it was found that rms distances for the tubes were significantly larger than the final rms distances between the registered surfaces. It was also found that minimizing rms distance at the surface did not minimize rms distance for the tubes.

  View details for Web of Science ID A1995RK26900003

  View details for PubMedID 7565379

• LASER SPHINCTEROTOMY AND ABLATION OF THE PROSTATE USING A SAPPHIRE CHISEL CONTACT TIP FIRING NEODYMIUM-YAG LASER JOURNAL OF UROLOGY Perkash, I. 1994; 152 (6): 2020-2024

  Abstract

  I report a modified technique for use of a contact laser for urological endoscopic surgery in spinal cord injury patients. Instead of the usual technique of passing the laser probe for surface vaporization, subsurface buttonholes were drilled with subsequent incision of the overlying tissue. As a result, creation of an adequate channel was expedited with excellent hemostasis. A total of 40 spinal cord injury patients (mean age 50.1 years, range 28 to 76) underwent transurethral surgery for bladder outlet obstruction using a sapphire contact laser tip. Of the patients 50% had undergone previous transurethral surgery and were not voiding well. Urodynamic studies demonstrated detrusor-sphincter dyssynergia in 37 patients (92.5%). A voiding cystourethrogram was done in 83% of the patients and showed vesicoureteral reflux in 17%. On cystoscopic examination 32.5% of the patients had an associated enlarged prostate, 32% stricture of the bulbous urethra and 20% bladder neck stenosis. Apart from transurethral sphincterotomy in these patients, ablation of the prostate, stricture and eradication of bladder neck stenosis, as indicated, were also done with the contact laser. Blood loss was approximately 25 to 50 ml. per procedure except for 2 initial patients with a blood loss of 100 to 150 ml. Approximately 3,500 to 8,900 joules accumulated energy were used for transurethral sphincterotomy and 11,000 to 37,000 joules for transurethral resection of the prostate. An indwelling Foley catheter was placed postoperatively for a mean of 3 days (range 1 to 8). All patients were followed for 6 to 23 months (mean 13.1). Four patients failed laser transurethral sphincterotomy: 1 due to inadequate initial incision and 3 who initially underwent laser transurethral incisions of the prostate and had persistent detrusor-sphincter dyssynergia (all had relief following laser transurethral sphincterotomy). All subsequent patients are voiding well with a wide open bladder neck and posterior urethra as shown on a voiding cystourethrogram.

  View details for Web of Science ID A1994PR24500027

  View details for PubMedID 7966667

• Contact laser transurethral external sphincterotomy: a preliminary report. NeuroRehabilitation Perkash, I. 1994; 4 (4): 249-254

  Abstract

  We report here a new technique of external sphincterotomy in 30 spinal cord injury patients. Instead of electrocautery, the contact sapphire chisel probe firing Nd:YAG laser was used to ablate the external urethral sphincter. The major advantages of this procedure over electrocautery are (1) significantly decreased blood loss; (2) shorter, less morbid postoperative course and shorter hospital stay; and (3) durable results. Long-term follow-up of these patients is currently underway.

  View details for DOI 10.3233/NRE-1994-4408

  View details for PubMedID 24525411

• LONG-TERM UROLOGIC MANAGEMENT OF THE PATIENT WITH SPINAL-CORD INJURY UROLOGIC CLINICS OF NORTH AMERICA Perkash, I. 1993; 20 (3): 423-434

  Abstract

  The primary goal of bladder management in the patient with a spinal cord injury is to achieve adequate bladder drainage, low-pressure urine storage, and low-pressure voiding. This will help prevent urinary tract infections, bladder wall damage, bladder overdistention, vesicoureteral reflux, and stone disease. Bladder retraining is indicated in all patients with disorders of the spinal cord and the brain. The basic aim is to provide bladder drainage without indwelling catheters and, if possible, without leg bags. Bladder retraining is usually begun with intermittent catheterization, with the use of alpha blockers to improve drainage in patients who are wearing leg bags or with anticholinergic drugs to improve continence. However, bladder retraining may be contraindicated in patients with vesicoureteral reflux or stone disease and in patients with impending renal failure. It is therefore important to evaluate all patients with neurogenic bladder using urodynamics, nuclear scanning, renal ultrasound, and voiding cystourethrography. In patients with stone disease, intravenous urography may also be required. Understanding of the basic neurologic lesion and bladder dysfunction is therefore vital to bladder retraining or transurethral surgery to provide adequate voiding. The regular periodic follow-up of all patients is vital to protect renal function.

  View details for Web of Science ID A1993LT60500006

  View details for PubMedID 8351768

• CLEAN INTERMITTENT CATHETERIZATION IN SPINAL-CORD INJURY PATIENTS - A FOLLOW-UP-STUDY JOURNAL OF UROLOGY Perkash, I., Giroux, J. 1993; 149 (5): 1068-1071

  Abstract

  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.

  View details for Web of Science ID A1993LA46400031

  View details for PubMedID 8483212

• EVALUATION OF A VOCATIONAL ROBOT WITH A QUADRIPLEGIC EMPLOYEE ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION Hammel, J. M., VANDERLOOS, H. F., Perkash, I. 1992; 73 (7): 683-693

  Abstract

  A vocational robotic workstation capable of performing activities of daily living (ADL) and vocational tasks was placed for 18 months in the work site of an employee with C4 to C5 quadriplegia. A single-subject study was conducted to evaluate the performance of the robot vs that of a human attendant. The employee preferred the robot over the attendant for performance of all vocational tasks and ADLs, with the exception of feeding. Results indicated that the robot was capable of safely replacing the attendant for two five-hour periods during the workday, thus proving to be a cost-effective alternative to full-time, on-the-job attendant care. The study demonstrated the potential of robotics technology for returning independence and control to disabled employees and for offering corporate employers a solution to the problem of reasonable accommodation in the workplace.

  View details for Web of Science ID A1992JD13900015

  View details for PubMedID 1622327

• USE OF PENILE PROSTHESES TO MAINTAIN EXTERNAL CONDOM CATHETER DRAINAGE IN SPINAL-CORD INJURY PATIENTS PARAPLEGIA Perkash, I., Kabalin, J. N., Lennon, S., Wolfe, V. 1992; 30 (5): 327-332

  Abstract

  This is a retrospective analysis of 79 spinal cord injury patients who have had penile implants from one to 14 years. The primary indication for implants was the loss of condom catheter with a small retractile penis. Mean period after injury to when the implants were placed was 8.24 years (range 1-21 years). Mean total length of time the implants have been followed was 7.08 years (1-14 years). Sixty patients responded to our detailed questionnaire and they have been subjected to further analysis: prior to the implant 46 patients (77%) frequently lost their condoms. Fourteen of the patients (23%) had indwelling catheters, and 3 (5%) had a suprapubic cystostomy since they could not retain an external condom for urinary drainage because of retraction of a small penis. Post implant, 81% of patients had no accidents involving condom loss, while 19% still lost condoms. All indwelling catheters could be removed except for one patient who continued with a suprapubic catheter following transurethral sphincterotomy (TURS) and a penile implant. Sixty-eight percent used the implant for sex and felt their wives were satisfied. Patient satisfaction survey showed a markedly increased self esteem, increased mobility without fear of condom loss, and an improved sex life. Overall, the long term prosthesis failure rate was 8%. The specific infection complication rate was less than 2%. The Flexirod semirigid, hinged prosthesis proved ideal in meeting the requirements for these patients.

  View details for Web of Science ID A1992JV19100003

  View details for PubMedID 1598171

• INFERTILITY IN MEN WITH SPINAL-CORD INJURY ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION Linsenmeyer, T. A., Perkash, I. 1991; 72 (10): 747-754

  Abstract

  Infertility is a significant and frustrating problem for many men after spinal cord injury. The two major causes are poor semen quality and ejaculatory dysfunction. Factors attributed to poor semen quality include stasis of prostatic fluid, testicular hyperthermia, recurrent urinary tract infections, abnormal testicular histology, possible changes in the hypothalamic-pituitary-testicular axis, possible sperm antibodies, chronic long-term use of various medications, and type of bladder management. Further work is needed to define the impact and importance of each of these factors. Ejaculations are reported to occur in only 5% of men with spinal cord injury (SCI) who have complete upper motor lesions and 18% of those who have complete lower motor lesions. Ejaculations occur in up to 70% of men with incomplete lesions. Methods that have been used to induce an ejaculate include intrathecal neostigmine, subcutaneous physostigmine, direct aspiration of sperm from the vas deferens, vibratory stimulation, electroejaculation, and direct stimulation of the hypogastric nerve. The most commonly used methods in the United States are electroejaculation and vibratory stimulation; using these two methods, ejaculates can be obtained up to 85% and 59% of the time, respectively. Each of these methods has advantages and disadvantages. Particular care needs to be given to monitoring men undergoing these procedures who are prone to autonomic dysreflexia. The future outlook is encouraging once improved technology for obtaining semen and various methods to assist reproduction, such as in vitro fertilization, are available.

  View details for Web of Science ID A1991GE75500007

  View details for PubMedID 1929799

• CHRONIC GASTROINTESTINAL PROBLEMS IN SPINAL-CORD INJURY PATIENTS - A PROSPECTIVE ANALYSIS AMERICAN JOURNAL OF GASTROENTEROLOGY Stone, J. M., NINOMURCIA, M., Wolfe, V. A., Perkash, I. 1990; 85 (9): 1114-1119

  Abstract

  Detailed interviews of 127 consecutive patients seen by our spinal cord injury service were performed in order to determine the prevalence and characteristics of chronic gastrointestinal problems in spinal cord injury (SCI) patients. Chronic gastrointestinal problems were defined as recurring symptoms that were significant enough to alter lifestyle or require chronic treatment. Thirty-four (27%) of the patients had a significant chronic gastrointestinal problem. The limited manner through which SCI patients can manifest symptoms resulted in complaints which were characteristically quite vague. The most common problems that impaired quality of life were poorly localized abdominal pain (14%) and difficulty with bowel evacuation (20%). Hemorrhoids (74%), abdominal distention (43%), and autonomic hyperreflexia arising from the gastrointestinal tract (43%) were also very common, but had a lesser impact on lifestyle. Twenty-three percent of our population required at least one admission to the hospital for a gastrointestinal complaint following their injury. The prevalence of chronic gastrointestinal symptoms increased with time after injury, suggesting that these problems are acquired, and may therefore be avoided by the adoption of certain chronic care routines. Chronic gastrointestinal problems in SCI patients merit more study because they are: 1) very different from those in the general population, 2) responsible for a disproportionately great amount of morbidity in these patients, 3) potentially preventable.

  View details for Web of Science ID A1990DX53800012

  View details for PubMedID 2389723

• PENILE ADVANCEMENT AND LENGTHENING IN SPINAL-CORD INJURY PATIENTS WITH RETRACTED PHALLUS WHO HAVE FAILED PENILE PROSTHESIS PLACEMENT ALONE JOURNAL OF UROLOGY Kabalin, J. N., ROSEN, J., Perkash, I. 1990; 144 (2): 316-318

  Abstract

  Even in the presence of a penile prosthesis, a subset of spinal cord injury patients remains unable to maintain a condom catheter securely due to inadequate penile shaft length and disappearance of the corpora beneath the pubic fat pad when in the sitting position. We describe 3 patients in whom a successful resolution to this problem has been achieved with rational surgical management, including lysis of the suspensory ligament of the penis, approximation of the infrapubic soft tissues posterior to the corpora so as to advance the corpora anteriorly and buttress against posterior migration (retraction) in the sitting position, maximizing the length and fit of prosthetic rods, and, when indicated, release of infrapubic skin tethering with a modified Z-plasty technique.

  View details for Web of Science ID A1990DR45500025

  View details for PubMedID 2374198

• COLOSTOMY AS TREATMENT FOR COMPLICATIONS OF SPINAL-CORD INJURY ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION Stone, J. M., Wolfe, V. A., NINOMURCIA, M., Perkash, I. 1990; 71 (7): 514-518

  Abstract

  We reviewed our experience with colostomy performed in 20 spinal cord injury (SCI) patients to determine the effectiveness and safety of colostomy when it is performed for a late complication of SCI. Objective evaluation of gastrointestinal function, ie, colonic transit time and anorectal manometry, was performed in six patients with chronic gastrointestinal complaints to identify the site and severity of bowel dysfunction. Twelve patients had colostomy performed for chronic gastrointestinal problems, seven as an adjunct in the treatment of perineal pressure ulcers, and one for rectal cancer. When patients with difficult bowel evacuation or incontinence were considered, colostomy reliably simplified bowel care, relieved abdominal distention, and prevented fecal incontinence. The amount of time spent on bowel care decreased from an average of 98.6 min/day to 17.8 min/day (p less than .05) after colostomy. When performed as an adjunct in the treatment of pressure ulcers, colostomy provided a dry, clean environment, and seven of seven ulcers healed. Colostomy was well accepted by all patients; all patients with chronic gastrointestinal complaints reported that colostomy improved the quality of their lives. Objective testing differentiated between failure of the colon to adequately transport material to the rectum and inability to adequately evacuate the rectum. Testing was useful in choosing the level at which a colostomy was created, and, in one instance, it identified a specific syndrome (ischemic proctitis) which required colostomy.

  View details for Web of Science ID A1990DH15700014

  View details for PubMedID 2350223

• BENIGN VERSUS PATHOLOGICAL COMPRESSION FRACTURES OF VERTEBRAL BODIES - ASSESSMENT WITH CONVENTIONAL SPIN-ECHO, CHEMICAL-SHIFT, AND STIR MR IMAGING RADIOLOGY Baker, L. L., Goodman, S. B., Perkash, I., Lane, B., Enzmann, D. R. 1990; 174 (2): 495-502

  Abstract

  Differentiation of benign from pathologic compression fractures of vertebral bodies was evaluated with magnetic resonance imaging in a prospective study of 53 patients. Twenty-six patients had 34 benign posttraumatic compression fractures. Twenty-seven patients had metastatic disease to the vertebral column and seven pathologic fractures. T1- and T2-weighted spin-echo (SE) sequences (1.5 T) were performed in all patients. A presaturation technique was used to obtain "fat" and "water" images to better assess the degree of normal fatty marrow replacement in fractured vertebrae. Short inversion-time inversion-recovery (STIR) images were also obtained. Discrimination between benign and pathologic compression fractures was generally possible with the SE sequences. Chronic benign fractures demonstrated isointense marrow signal intensity (SI), compared with that of normal vertebrae with all sequences. Pathologic fractures showed low SI on T1-weighted images and high SI on T2-weighted images. Fat images revealed complete replacement of normal fatty marrow, shown as absent SI in the involved vertebral body. Water and STIR images showed diffuse high SI in pathologic fractures, with STIR images having the highest contrast between abnormal and normal marrow. Acute benign compression fractures also demonstrated high SI on T2-weighted, water, and STIR images, but the SI was less pronounced and the pattern was generally more inhomogeneous than that of pathologic compressions. In general, fat images showed only partial replacement of normal fatty marrow by low SI, in contrast to the complete absence of marrow SI typical of pathologic fractures.

  View details for PubMedID 2296658

• ELECTROEJACULATION IN SPINAL-CORD INJURY PATIENTS - SIMPLIFIED NEW EQUIPMENT AND TECHNIQUE JOURNAL OF UROLOGY Perkash, I., Martin, D. E., Warner, H., SPECK, V. 1990; 143 (2): 305-307

  Abstract

  A new simplified electrostimulation system for rectal probe electroejaculation has been developed and tested 17 times in 13 patients. Seminal emissions were obtained easily from 13 of 17 studies and partial emissions were obtained in 4. Patients with cauda equina and conus lesions with partial intact sensorium also could achieve successful ejaculation by longer stimulation from 2 to 5 minutes with lower currents that could be maintained easily and were tolerated by the patient--a feature unique to our new computerized equipment. The simplicity of operation reduces the number of trained personnel for an electrostimulation procedure, which can be done even in an outpatient setting.

  View details for Web of Science ID A1990CL50400021

  View details for PubMedID 2299721

• COLONIC TRANSIT IN SPINAL CORD-INJURED PATIENTS INVESTIGATIVE RADIOLOGY NINOMURCIA, M., Stone, J. M., Chang, P. J., Perkash, I. 1990; 25 (2): 109-112

  Abstract

  This report describes a study of transit time through the colon, as well as the caliber of the colon and distal small bowel, in 28 spinal cord-injured patients to see if there is a correlation between those findings and difficulty with bowel care and symptoms. In 15 of these 28 patients anorectal dynamic studies were also done. Each patient ingested 20 radiopaque markers, after which colon transit times were measured by multiple abdominal radiographs. The width of the ileum was measured and correlated with symptoms. The findings indicate that transit time was delayed in the left and rectosigmoid colon; four patients had a large and highly compliant rectum, whereas six had anorectal dyssynergia. All ten had difficulty with bowel care. The distal small bowel was dilated in ten patients, all of whom had symptoms and nine of whom had spinal cord lesions superior to T5.

  View details for Web of Science ID A1990CM63800002

  View details for PubMedID 2312245

• PRINCIPLES OF MODERN URODYNAMIC STUDIES INVESTIGATIVE RADIOLOGY Perkash, I., Friedland, G. W. 1987; 22 (4): 279-289

  Abstract

  Modern urodynamic equipment should have at least three channels to record the cystometrogram, the electromyogram of the periurethral striated sphincter, and intrarectal pressure. The addition of simultaneous transrectal ultrasonography is helpful. The bladder should not be irritated when introducing the urodynamics catheter. Variables affecting the performance of the catheter used for measuring the urethral pressure profile include the size of the lumen, the size of the side hole, the speed with which the catheter is withdrawn, and the rate of infusion. The entire curve of the cystometrogram should be examined, not simply initial rise. Initial overshoots can occur if older apparatus is used or if the urodynamics catheter is partially blocked; such overshoots should be disregarded.

  View details for Web of Science ID A1987G947900001

  View details for PubMedID 3294729

• ULTRASONOGRAPHIC DETECTION OF FALSE PASSAGES ARISING FROM THE POSTERIOR URETHRA IN SPINAL-CORD INJURY PATIENTS JOURNAL OF UROLOGY Perkash, I., Friedland, G. W. 1987; 137 (4): 701-702

  Abstract

  We report on false passages arising from the posterior urethra in 10 male spinal cord injury patients, of which 9 were well visualized on transrectal sonography, with real-time linear array equipment that was used to monitor a urodynamics catheter being introduced into the prostatic urethra. The only false passage not detected was at the bladder neck. Nevertheless the data show that transrectal sonography is an excellent tool to demonstrate false passages arising from the prostatic urethra. All 10 false passages were unroofed successfully with excellent results.

  View details for Web of Science ID A1987G649900025

  View details for PubMedID 3550151

• CATHETER-INDUCED HYPERREFLEXIA IN SPINAL-CORD INJURY PATIENTS - DIAGNOSIS BY SONOGRAPHIC VOIDING CYSTOURETHROGRAPHY RADIOLOGY Perkash, I., Friedland, G. W. 1986; 159 (2): 453-455

  Abstract

  In part 1 of this study, 77 consecutive patients with spinal cord injuries and reflex bladders were examined by combined urodynamic studies and sonographic voiding cystourethrography. Of the 15 (19%) who had hyperreflexic bladders (reflex bladders that contracted when containing 125 ml or less), eight (53%) had catheter-induced hyperreflexia (proved by sonographic voiding cystourethrography without catheterization). The significant overdiagnosis influenced patient care because catheter-induced hyperreflexia did not require treatment, whereas primary hyperreflexia caused by lesions above T-5 always required anticholinergic therapy to prevent potentially life-threatening autonomic dysreflexia. In part 2 of this study, 116 additional spinal cord injury patients with reflex bladders were studied, although in these patients the catheter was introduced under sonographic control. Seven (6%) of these patients had hyperreflexia, but in none was the hyperreflexia catheter induced, showing that use of sonography while introducing the catheter can prevent catheter-induced hyperreflexia.

  View details for Web of Science ID A1986C006700030

  View details for PubMedID 3515423

• REPRODUCTIVE-BIOLOGY OF PARAPLEGICS - RESULTS OF SEMEN COLLECTION, TESTICULAR BIOPSY AND SERUM HORMONE EVALUATION JOURNAL OF UROLOGY Perkash, I., Martin, D. E., Warner, H., BLANK, M. S., Collins, D. C. 1985; 134 (2): 284-288

  Abstract

  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.

  View details for Web of Science ID A1985AND4700015

  View details for PubMedID 3927013

• RADIOISOTOPE RENOGRAPHY IN SPINAL-CORD INJURY JOURNAL OF UROLOGY TEMPKIN, A., Sullivan, G., PALDI, J., Perkash, I. 1985; 133 (2): 228-230

  Abstract

  Isotope renography was compared to excretory urography, voiding cystourethrography and endogenous creatinine clearances in 52 spinal cord injury patients. Renogram abnormalities were detected in 86 per cent of the cases. The most common abnormality was the delay of isotope excretion from the renal cortex and pelvis. Anticholinergic medication significantly reduced these excretion delays. A subgroup containing 22 newly injured patients was evaluated separately. Renogram abnormalities in this subgroup were associated with normal excretory urography and normal creatinine clearances. We postulate that the defect producing upper tract deterioration in spinal cord injury begins early, is obstructive to renal drainage, does not increase with time and probably requires early intervention with anticholinergic medication or transurethral sphincterotomy to prevent upper tract damage.

  View details for Web of Science ID A1985AAV4600022

  View details for PubMedID 3968738

• USING TRANS-RECTAL SONOGRAPHY TO TEACH PATIENTS WITH SPINAL-CORD INJURIES TO RETRAIN THEIR BLADDERS RADIOLOGY Perkash, I., Friedland, G. W. 1984; 152 (1): 228-229

  Abstract

  When patients who have spinal cord injuries perform the Crede maneuver, the bladder neck tends to close. We suggest that these patients watch a video monitor during transrectal sonography and learn to tap the bladder appropriately, which allows voiding to occur with little increase in bladder pressure.

  View details for Web of Science ID A1984SW88400053

  View details for PubMedID 6729123

• SEXUAL EXPERIENCE AND PLASMA TESTOSTERONE LEVELS IN MALE VETERANS AFTER SPINAL-CORD INJURY ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION Phelps, G., Brown, M., Chen, J., Dunn, M., Lloyd, E., Stefanick, M. L., DAVIDSON, J. M., Perkash, I. 1983; 64 (2): 47-52

  Abstract

  Fifty men with spinal cord injuries (SCI) were asked to complete a questionnaire concerning their sexuality before and after injury. Medical examination confirmed the location and completeness of the injury and extracted information about genitourologic status. The respondents rated sexuality highly as a concern in living, and a wide variety of sexual techniques were reported. A marked decrease in sexual activity, satisfaction, and feelings of sexual adequacy was reported after injury, as compared to retrospective "before injury" responses, lack of opportunity being reported as causative by 66% of the subjects and insufficient personal satisfaction by 59%. Seventy-five percent of the subjects experienced sexual arousal from genital stimulation, and several methods of eliciting erection were cited. Orgasm was described by a variety of terms. Significant differences were found between quadriplegic and paraplegic patients in answers to several items, though there was generally no difference between cervical and thoracic groups, which were more specifically broken down with respect to motor or sensory/complete or incomplete lesions. Plasma testosterone levels were found to fall well within the normal adult male range, as were levels of free testosterone and serum sex binding protein. The resulting information demonstrated more sexual concern among men with SCI than the literature previously indicated.

  View details for Web of Science ID A1983QB70600001

  View details for PubMedID 6681699

• INITIATION OF ERECTION AND SEMEN RELEASE BY RECTAL PROBE ELECTROSTIMULATION (RPE) JOURNAL OF UROLOGY Martin, D. E., Warner, H., CRENSHAW, T. L., CRENSHAW, R. T., Shapiro, C. E., Perkash, I. 1983; 129 (3): 637-642

  Abstract

  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.

  View details for Web of Science ID A1983QK96200058

  View details for PubMedID 6834568

• TRANS-RECTAL SONOGRAPHIC VOIDING CYSTOURETHROGRAPHY - STUDIES IN NEUROMUSCULAR BLADDER DYSFUNCTION AMERICAN JOURNAL OF ROENTGENOLOGY Shapeero, L. G., Friedland, G. W., Perkash, I. 1983; 141 (1): 83-90

  Abstract

  To evaluate the efficacy of transrectal real-time gray-scale sonographic voiding cystourethrography in patients with neuromuscular dysfunction of the bladder, 32 men suspected of having neuromuscular dysfunction each underwent sonographic and radiographic voiding cystourethrography and urodynamic studies. The benefits accruing from the sonographic study included: (1) patients received no radiation; (2) it was as diagnostic as, and sometimes more diagnostic than, the radiographic study; (3) drug effects were easily studied; (4) accurate measurements of urethral length could be obtained; and (5) prostate diseases that might affect these patients were visible, such as benign prostatic hyperplasia, prostatic carcinoma; and prostatic calculi. In addition, sonography made one new observation possible: The seminal vesicles were enlarged in 10 patients receiving the alpha-adrenergic blocker, phenoxybenzamine. This enlargement may cause sterility.

  View details for Web of Science ID A1983QV95400017

  View details for PubMedID 6602535

• WARNING MAT TO SIGNAL AIR SEAT CUSHION FAILURE ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION Werner, P., Perkash, I. 1982; 63 (4): 188-190

  Abstract

  A warning mat that signals partial or total deflation of a pneumatic wheelchair cushion has been developed. The purpose of this device is to prevent pressure sores that occur when an inflatable seat cushion loses air gradually and causes ischial tuberosities of a spinal cord injured patient to "bottom out," ie, to come to rest on the hard wheelchair seat. Resulting ischemic necrosis in this anesthetized area is prevented when localized high seating pressure triggers a pressure sensitive warning mat under the wheelchair cushion to produce a high-pitched audio signal warning the patient to reinflate the cushion or leave the chair. Efficacy of this device has been demonstrated in clinical trials, but prevention of decubiti will need to be substantiated by a long-term controlled study.

  View details for Web of Science ID A1982NJ95200014

  View details for PubMedID 7082146

• CARDIOVASCULAR COMPLICATIONS DURING ANESTHESIA IN CHRONIC SPINAL-CORD INJURED PATIENTS ANESTHESIOLOGY SCHONWALD, G., Fish, K. J., Perkash, I. 1981; 55 (5): 550-558

  View details for Web of Science ID A1981MP58900013

  View details for PubMedID 7294411

• TRUE HETEROTOPIC BONE IN THE PARALYZED PATIENT SKELETAL RADIOLOGY Blane, C. E., Perkash, I. 1981; 7 (1): 21-25

  View details for Web of Science ID A1981MT70600003

  View details for PubMedID 6801770

• STABILITY OF THE UPPER LUMBAR SPINE FOLLOWING PROGRESSIVE DISRUPTIONS AND THE APPLICATION OF INDIVIDUAL INTERNAL AND EXTERNAL FIXATION DEVICES JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Nagel, D. A., KOOGLE, T. A., PIZIALI, R. L., Perkash, I. 1981; 63 (1): 62-70

  Abstract

  Five fresh human cadavera were tested to determine range-of-motion measurements at the interspace of the first and second lumbar vertebrae after progressive disruption of the joint followed by internal and external stabilization. The disruption progressed from posterior to anterior, leaving the anterior longitudinal ligament and anterior part of the annulus fibrosus intact. Flexion-extension range of motion was most sensitive to progressive disruptions and was significant following disruption of the facets. The Taylor-Knight brace was effective for limiting lateral motion, fair for limiting flexion-extension, and not effective for rotation. The three-point hyperextension brace was fairly effective for flexion-extension only. The body cast was effective in limiting all motions. Wire loops partially cut through the spinous processes in all cases with extreme flexion. Harrington distraction rods were effective in limiting motion if under proper tension, but they dislodged in three of the five specimens.Data from this study show that flexion of the second lumbar vertebra on the first of 20 degrees or a lateral bend of 10 degrees seen on a routine roentgenogram without vertebral fracture indicates that all posterior ligaments and at least part of the annulus fibrosus must be disrupted. Because internal fixation failed on occasion, we strongly urge the use of external fixation and careful mobilization of the patient to prevent flexion and rotation if internal stabilization is used for disruptions of the upper lumbar spine. The body cast was the most effective in limiting motion of the external fixation devices tested.

  View details for Web of Science ID A1981LA41100007

  View details for PubMedID 7451527

• PROBLEMS OF DECATHETERIZATION IN LONG-TERM SPINAL-CORD INJURY PATIENTS JOURNAL OF UROLOGY Perkash, I. 1980; 124 (2): 249-253

  Abstract

  There were 50 men with a mean age of 43.5 years subjected to urodynamic analysis and decatheterization. Of these 50 patients 41 had had indwelling catheters from 1 to 29 years, with a mean of 7.3 years, and 9 had suprapubic catheters from 1 to 14 years, with a mean of 9.8 years. Previous attempts at decatheterization in about 70 per cent of these patients had failed owing to severe autonomic dysreflexia and fear of progressive upper tract damage. Of the 50 patients 15 (30 per cent) had had vesicoureteral reflux and 16 (32 per cent) had been treated repeatedly for bladder and kidney stones. Detrusor-sphincter dyssynergia was detected in 58 per cent of the patients. All patients with suprapubic tubes had a contractile bladder, compared to only 33 per cent of the patients with indwelling catheters. After transurethral sphincterotomy all patients were decatheterized, which resulted in marked general improvement, amelioration of autonomic dysreflexia and easy control of urinary tract infection in 80 per cent of the cases.

  View details for Web of Science ID A1980KE95500022

  View details for PubMedID 7401241

• USE OF CEREBRAL EVOKED-POTENTIALS TO EVALUATE SPINAL SOMATOSENSORY FUNCTION IN PATIENTS WITH TRAUMATIC AND SURGICAL MYELOPATHIES JOURNAL OF NEUROSURGERY DORFMAN, L. J., Perkash, I., Bosley, T. M., Cummins, K. L. 1980; 52 (5): 654-660

  Abstract

  Cerebral somatosensory evoked potentials (SEP's) were elicited by electrical stimulation of the median nerve in the arm (SEPA) and of the posterior tibial nerve in the leg (SEPL) in 23 patients with incomplete localized lesions (including traumatic injuries, neoplasms, vascular malformations and infarcts) of the low cervical, thoracic, or lumbar spinal cord. In eight of 46 attempts (left and right sides), SEPL could not be recorded. Of the remaining 38 sides, spinal somatosensory conduction velocity (SSCV, indirectly estimated) was abnormally slow (less than 35 m/sec) in 20, and the amplitude of SEPL relative to SEPA (L:A ratio) was abnormally low (less than 0.5) in 20 (p less than 0.001 in each case, compared to normal controls). All three criteria yielded a combined 72% incidence of abnormality, correlating best with impairment of joint position sense. Serial postoperative studies in four cases documented an increase in the SSCV and L:A ratio following spinal decompression. These results demonstrate that the latency and amplitude characteristics of the cerebral SEP's from arm and leg permit quantitative evaluation of the functional status of the spinal somatosensory system.

  View details for Web of Science ID A1980JQ11800006

  View details for PubMedID 7373392

• URINARY-TRACT INFECTIONS OCCURRING IN RECENT SPINAL-CORD INJURY PATIENTS ON INTERMITTENT CATHETERIZATION JOURNAL OF UROLOGY Rhame, F. S., Perkash, I. 1979; 122 (5): 669-673

  Abstract

  During a 28-month interval 70 spinal cord injury patients in the initial rehabilitation hospitalization underwent 5,052 days of intermittent catheterization. Intermittent catheterization was done with a sterile technique and a neomycin-polymyxin irrigant. At the time of transfer to our facility 39 patients were using Foley catheter drainage but no difficulty was encountered when these patients were changed to intermittent cateterization. While on intermittent catheterization 52 urinary tract infections occurred, half caused by gram-positive cocci, 24 by gram-negative bacilli and 2 by Candida albicans. These infections occurred in 38 patients (54 per cent) at an over-all rate of 10.3 infections per 1,000 patient-days of intermittent catheterization. Only 2 infections were symptomatic and these occurred in patients on pass who unilaterally discontinued intermittent catheterization. Only 6 infections were not cured by antimicrobial therapy. Urinary tract infection was less common in patients who had incomplete spinal cord injuries. Infections caused by organisms susceptible to the irrigant containing neomycin-polymyxin occurred almost exclusively in patients catheterized 3 or fewer times daily. Infection was rare after 3 months on intermittent catheterization. Intermittent catheterization with our technique poses little infection hazard and can be introduced readily in acute spinal cord injury patients before transfer to specialized facilities.

  View details for Web of Science ID A1979HU92000027

  View details for PubMedID 501823

• ATTEMPT TO UNDERSTAND AND TO TREAT VOIDING DYSFUNCTIONS DURING REHABILITATION OF BLADDER IN SPINAL-CORD INJURY PATIENTS JOURNAL OF UROLOGY Perkash, I. 1976; 115 (1): 36-40

  Abstract

  An attempt to understand and treat dysfunctions during bladder rehabilitation in 150 spinal cord injury patients is presented. The 25 problem patients were further analyzed to identify and manage the dysfunctional bladder and bladder neck, dyssenergic pelvic floor, vesicoureteral reflux, areflexic detrusor muscle and also to discontinue prolonged intermittent catheterization. The initial excellent results with a modified approach to sphincterotomy and the bladder neck operation in 15 patients are presented. Early recognition of patients in whom intermittent catheterization may not be successful will allow one to intervene and establish an early catheter-free status. A new concept of the existence of receptors in the posterior urethra has been postulated.

  View details for Web of Science ID A1976BE23200010

  View details for PubMedID 1246110

• INTERMITTENT CATHETERIZATION AND BLADDER REHABILITATION IN SPINAL-CORD INJURY PATIENTS JOURNAL OF UROLOGY Perkash, I. 1975; 114 (2): 230-233

  Abstract

  A review was made of 111 spinal cord injury patients who underwent bladder rehabilitation. The essential mode of treatment was intermittent catheterization. About 91 per cent of the patients were free of the catheter after 3 to 168 days of intermittent catheterization. Acute patients given an initial dosage of 30 to 40 mg. bethanechol chloride 3 times daily for 2 to 3 weeks recovered reflex activity in almost half the period (average of 32 days compared to 79 days). Modified sphincterotomy at the bladder neck was performed in 10 patients. This procedure improved the results to 98 per cent catheter-free reflex bladder status in the group of patients.

  View details for Web of Science ID A1975AM68400017

  View details for PubMedID 1159915