epididymitis

[ silence ] >> hello and welcome to thespinal cord injury forum. i'm stephen burns,medical co-director of the northwest regionalspinal cord injury system. the forums, the videorecordings, and our online media contentare made possible by a grant from the nationalinstitute on disability and rehabilitation research. tonight, i will be talking aboutmanaging neurogenic bladder.

after my presentation, wewill hear from two individuals with sci about the bladdermanagement methods they use, todd stabelfeldtand tammy wilber. we will have questionsafter the presentation. so with that, i'll get startedhere, a little change of title. and i'll start withthe disclaimer. i was at a va meeting last week and all the speakers weregiving disclaimers saying, "oh, you know, this is justmy personal opinion,

it might not reflect the va," and i was kind oflaughing at them. and then as i put thispresentation together i was thinking, well, i willput something in here because there are guidelinesthat we have at the va, va policies aboutwhat's done and some of it very sensible stuff. i'll leave it at that, but thisis kind of a mix of things based on my experience for the last 13years treating people with sci

at the seattle va hospital. â  so just starting with alittle bit of the history and why this is all important. so, going back 60 yearsor so, 70 years or so, people with spinal cordinjuries did not live long. most people died in thefirst month, or definitely in the first year andone of the leading causes of death was urinarytract infections.

of course there were noantibiotics available then. so during the 1940's,antibiotics were introduced and people startedsurviving for longer, but what became apparent is that renal complicationswere still occurring. people were developingkidney failure and it was a leadingcause of death early on. now, with currentmanagement for bladder and the periodic testingthat's recommended,

i would say this is success. it's a very small percentageof people who die due to complicationslike renal failure. and this is in spite of the factthat there's really no agreement on the best way tomanage things. different centers thinkthat one thing is the best and that's what theypush everyone to do, another place has adifferent opinion. and really we seepretty universally

with just a few exceptions, all of these things aremaking a big difference that people are not sufferingthe same long-term complications as far as having ashortened life expectancy. so we're doing things muchbetter now even though we're not quite sure what's theideal way to do it. so, just starting witha bit on the anatomy, so the upper urinary tractrefers to the kidneys and then the tubesthat are connecting

down from there, the ureters. in this part of the urinarytract, it's really unaffected by spinal cord injury. it's not greatlyaffected at all. the kidneys of course dothe filtering of the blood and produce the urine. now the lower urinary tracthas muscles which are affected by the spinal cord injury. so the bladder muscle whichis also known as the detrusor,

and then the valve muscle ormuscles that are at the bottom of the bladder, sothe sphincter muscles. and then there is the urethrawhich connects to the outside of the body, so wherethe urine passes through. now how it works starting fromthe bottom, the urinary tract down and forgettingabout the nerves, it's actually pretty simplewhat the bladder does. we just really have to thinkabout the two parts, the bladder and sphincter andthen what they do.

they just do twodifferent things. the bladder can bein its filling mode where the bladder muscle is justrelaxed and it allows itself to expand and expand asurine is-- urine is made. the sphincter is staying close so that the urinedoesn't leak out. and then if you moveinto the emptying phase, the opposite thing happens. the bladder musclestarts contracting

and the sphincter opens up. so this is normal urination, you're either fillingor you're emptying. most of the time you're filling. there are a wholebunch of nerves and it's all prettycomplicated, what's going on. so i'm not going todwell on the details. it's more than most of us needto think about at a basic level but it's coming in off thespinal cord at different levels

and arriving at the bladder byall different, different routes and it's autonomicand it's somatic. it's quite complicated. now keep in mind, sothis is different parts of the nervous system. they each have a littledifferent nerve supply and different neurotransmitters. and because of that, we canselectively affect one part or another of the systemwith different medications.

so, trying to changethe muscle activity, increasing it or decreasing it. and to some degree, thereare medicines to do all of those things somewhatbetter than others. so an example wouldbe something like the so called anticholinergicmedicine like ditropan. so that relaxes the bladdermuscle and that's the spot where it's acting in the system. so with normal urine collectionand then urine emptying,

there's got to becoordination going on, that the bladder muscle, the sphincter muscles are doingsomething in a coordinated way. and the way that this works, it's really hardwiredinto the spinal cord. so in a normal situationwithout a spinal cord injury, everything worksthe way it should. the bladder is relaxing and thenfilling while the sphincter is closed and then theopposite will happen

when you want to empty. so all of that, it'sreally working just like a reflex the sameway we think that some of walking is hardwiredinto the spinal cord. so if the spinalcord is injured, a few things canhappen to these muscles. so, they could be weakened,they're not contracting to a normal degree or theycould be so called overactive, something that-- some of themedicines that are advertised

on tv for overactive bladder, so a bladder muscle that'scontracting too much. or the other thing thatcould be going on is that there's just very poorcoordination of the muscles. for example, the bladder iscontracting and trying to empty, at the same time the sphincteris contracting and trying to hold urine in, whichis not a good thing. now, the actual patternthat someone will have, it really depends on the levelof the spinal cord injury,

how complete the injury is, andwhich of the nerves and which of the reflexes are affected. and it's going to varyfrom person to person. something to keep in mind is that a stable pattern cantake a few months to form, especially in somebody with acomplete spinal cord injury. so early on, there might notbe much muscle activity at all. but going out a couple ofmonths, there could be more. so, when we do test early on,

it doesn't always tellus what things will be like further down the road. so i mentioned the two thingsgoing on, filling and emptying. it's a good way to thinkabout the different problems that can occur afterspinal cord injury. so thinking of filling problems, so the bladder could becontracting inappropriately and not allowingfilling to happen, the sphincter might notbe contracting enough

to keep the urinefrom coming out. or you could thinkof emptying problems, the bladder is notcontracting hard enough to empty the urine out, or the sphincter justwon't, won't relax. so that's basically theproblems that can be occurring and what we think about whenwe're trying to problem solve to get the urine outwhen we want it to. now, when we approach tryingto figure out what's going on,

we don't automatically jump to the most expensive,invasive test. we can get a lot of theinformation just starting with the history, whenis there incontinence, what are the circumstancesgoing on there. going to the neurological examdeciding what is happening with the whole nervoussystem, what's happening with the muscles in the legs,are there reflexes down there, does it seem that there's-- thatthere is spasticity going on,

how much is sensation affected. that gives us a good picture ofwhat is likely to be happening with the nerves, what is working and what's contractingand what's not. a very simple test we can dois something called a postvoid residual or it couldbe just a random check of the urine volumeeither putting a catheter in the bladder to see howmuch urine is resting there. or if you have anultrasound machine,

what's called a bvi machine,just doing a quick scan to see what's in there. now, if we need to find out moreprecisely what are the nerves doing and what is thebladder doing as it's filling, we can do a group of teststhat is called urodynamics. and it answers questionslike the ones listed here. so is the bladderrelaxing enough to allow it to fill itself up with urine,is the sphincter opening at the right time or isit closing at the time

when it should be open,and things like that. this is a diagram of the setupand i'm not going to point out everything that's on here. but there's pressurecatheter that's in the bladder and some other measurementsthat go on that tell us whatthe muscles are doing and is it the bladder muscle,is it abdominal muscles, what's producing the pressure. the tracing, i'm not going

to explain everythingthat's going on here. we just kind of trace out abunch of different signals over time as the bladder isfilled and filled with urine, what's happeningwith the pressures, what's happeningwith the muscles. so it's sort of a rapidfilling of the bladder to see what is the reactionof the nervous system, what is the bladder, what isthe sphincter trying to do as filling is going on.

so it's a test that'ssometimes needed to sort out what's happening. now, the choice of method. this is a common question. what's the best thing to dofor managing the bladder, how to drain the urineout of there, what's going to be the best, bestthing over the long run. so we start with reallywhat the goals are, starting with continenceand how we're going

to collect, collect the urine. so we want to keep the skin dry. if the skin is always wet, it's going to predisposesomebody to skin breakdown. >> also just for general hygienein community reintegration, it's not socially acceptableto be smelling of urine in our society and we don't-- we don't want to behaving any incontinence. we don't want to beinterrupting our day.

we want something that'sgoing to be convenient where our life doesnot have to revolve around managing our bladderand staying, staying dry. of course we also want tominimize complications. we want to be doing somethingthat gives us a low rate of urinary tract infections because nobody likesfeeling sick with one. and a serious one canreally be life threatening. we want to avoid some problems

that can affect thelower urinary tract, especially the urethra,some nasty complications that can happen associatedwith catheters for example. and then really the bottomline, we want to prevent loss of kidney function towhatever degree we can. so this can happen fromrecurrent kidney infections, it can happen from astone that's up there that directly damagesthe kidney. we want to be avoidingkidney failure.

so what i want when i'm choosingthis, i want the simplest thing, i want it to be convenient. i want it to be least expensivebecause that is a consideration. we want to stay dry, we want toavoid the serious complications. we also want to avoid the sideeffects of these treatments and preserve the kidneys sothat your kidneys last longer than the rest of you. we don't want people'slives to be shortened by the kidneys runningout of function.

we want the kidneys tolast for your entire life. so people have lookedat this and saying, what gives the lowestrate of complications, what's the best way to go. and there is an answerbut unfortunately it's one that we can't reallydo anything about. so people with spinalcord injuries who have a pretty muchunaffected bladder, people who have good controldon't have abnormal contraction

of the bladder andsphincter but are, you know, essentially normal control. surprise, surprise, theyhave the lowest rate of complications,the lowest rate of urinary tract infections, thelowest rate of forming stones. so if you have a spinal cordinjury and you're fortunate to have good controlover your bladder, you have a very lowrate of complications. of course we can't-- we can'tdo anything to steer people

in that direction ifthey're not fortunate enough to have that function. but then the good news is thatas i mentioned at the beginning, almost all of the othermethods give good outcomes with just a few exceptions. so i'll start to runthrough some of the options. so we'll start withoptions where no catheter is in the bladder at all. so, what i was mentioning there,

just voluntary voidingunder normal control. you might need somemedications to sort of tamper down the activity ofthe bladder muscle if it's a little bitso called overactive. or there could beinvoluntary voiding. so this could justgo on spontaneously. the bladder fills to a certainpoint, kicks off and empties. that could be inresponse to some things where you're generating alittle pressure in the bladder

and that causes it tokick off and empty. maneuver is called a crede,where there are some tapping on the bladder, or a valsalvawhere sort of bear down. the problem is, theseare not recommended. this is the one thingwhere it seems like there are morecomplications, more problems that can happen with the kidney. so it's something that wedon't steer people toward. for example, if the sphincteris not opening correctly

and the bladder is beingtriggered to squeeze, that can cause high pressurethat can damage the kidneys. of course, you know,involuntary voiding. it will just be incontinenceunless you can collect it somehow. so, for example in males where the condom catheteris what would be done if you are using that method. kind of a variation on this,not having a catheter that goes

into the bladder butusing a condom catheter. so this is an option formales having a sphincterotomy, so the sphincter musclesare cut and opened up and then this allows the urineto flow out more freely provided that the bladder does contract. so some people will just kind ofcontinuously be draining urine. sometimes it will fillfor a little while and then the bladder startscontracting and it comes out. traditionally, thiswas done surgically

but there are other options. this is being done with botox. it seems like everythingis done with-- you can do anythingwith botox these days. it's not fda approved for thatbut most of what botox is used for is not fda approved. you can put in a stent, sosort of a little steel tube that will keep things openwhere the sphincter is. urolume was one of the brandsthat was on the market.

so for any of theseto work well, the bladder has to contract. if it's a bladder muscle thatdoesn't really contract, well, the urine is not going todrain out well and you're going to be a setup for infections. there's really no greatadvantage over having a catheter in your-- that goes into you allthe time, say a foley catheter, as far as infections go. there is infected urine orcolonized urine that will come

in through the condom catheter. it is not a guarantee of nothaving a urinary infection just because there's not atube passing all the way into the bladder. and then with thesphincterotomies and we do see complications. so, urinary retention candevelop over time, the bladder, in a lot of people just overtimet just loses its squeeze and it's not effectivelyemptying anymore.

it can be hard to maintaina condom catheter in place. some patients will need tohave a penile prosthesis put in really just sothere's enough penis there to keep the condom attached on. with the surgicalsphincterotomies, they tend to scar down overtime and sometimes need to be repeated because theurine flow is blocked off. erectile dysfunctionis frequently worsened by cutting in that area.

those stents that i mentioned to pop things open,they can block off. tissue can grow, grow into them. they can move around. if they have to be takenout, it can be challenging. these botox sphincterotomies, probably 3 to 9 months is howoften you would need it repeated and you'd be going intosome urinary retention by the time it wasbeing repeated possibly.

so not an ideal approach,it's not one that we pursue quite a bit. but at other centersit's a method of choice. next we'll look at intermittentcatheterization frequently known as icp, intermittentcatheterization program, cic, clean intermittentcatheterization, i and o, in and out catheterization. all of these are the same. what it means is temporarilyputting the catheter

into the bladder aboutevery 4 to 6 hours and when you put it in, youcompletely drain out the urine. there's essentiallynothing left. we try to keep the urine volumeanytime that you cath less than 500 which is about as much as anyone's normalbladder would like to hold. so of course to do this, you need to restrictyour fluid intake. usually around 2 liters perday is what we recommend

or otherwise you might becathing just too frequently to make this practical. now, this is a preferred method because it's reallythe closest thing to the normal bladder function. usually what the bladder isdoing is filling, filling, filling, filling and thenit empties all at once. so that's really what you get with intermittentcatheterization.

and some people actually willmaintain pretty sterile urine with this. not everyone. some people are colonized very-- you know frequentlypeople are colonized. the theory why, whyyou don't get sick, why you don't get symptomaticurinary tract infection as much. so, when we empty the urine out, maybe let's say there's just1 milliliter of urine left

in there with some bacteria and then you startfilling and filling again. the bacteria are doing theirusual thing, they're doubling and doubling and doubling butthe bladder is filling with more and more urine, so the bacteria in there never becomeconcentrated. you never have concentratedbacteria in there and then by the time the-- it wouldbe time to cath again, you empty things out andjust leave a small number

of bacteria again. so, it keeps things undercontrol by clearing it out all the way and the bacteriajust never have a chance to reproduce enoughto get symptoms, so it's not trulysterile in there. there are bacteria but it'sjust not getting to a level that would give mostpeople symptoms. now, to do this yourself, you need to have enoughhand function to be able

to manipulate the catheter, aswell as manage your clothing. so, it said c7 or somepeople with a c6 level if you have a motorcomplete injury, that's really what's required. for somebody with a c5motor level with a complete, usually will not haveenough hand function to do this your self. so, you need to do more than just the cathetervery frequently,

so you might need one of these so called anticholinergicmedicines to relax the bladder muscle so that it's notcontracting so much. so, commonly used ones,oxybutynin known as ditropan. there's a gel form of this that possibly has lessside effects that's been marketed recently. i don't have any experienceusing it in my population.

tolterodine or detrolis another choice. there're a number ofmedicines that do this. you can inject botox into thebladder muscle to relax it. it's another non-fdaapproved use of it. so, at our center, we recommenddoing intermittent cath really only if it can performedindependently. if you're not able-- if youdon't have the hand function to do it independently, typically your careneeds are pretty high.

you have a lot of need forassistance during the day. it can be complicated. if you're going to go out and beworking, you've got to arrange for somebody to be able tocome and cath you a couple of times during the day. it is an obstacle to being--to being independent for time that you're-- that you're up. so-- and with other methodsthat give a similar benefit, it's hard to-- hard to make anargument that this must be done

by everyone, butit's controversial who it should be done with. it's not without complications,so the urethra can get narrowed from passing the catheterthrough frequently. epididymitis in malesand infection of part of the lower urinary tract,but it's not quite as common as with an indwelling catheter. >> hydronephrosis and reflux,essentially urine that's backing up or the bladder is contractingand the urine is going backwards

up toward the kidneys, itdoesn't happen commonly but we need to monitor for it. so, because it's the closestthing to normal voiding and can be maintainingpretty sterile urine, it's really our goal thateveryone should be doing that provided that you havethe hand function to do it and provided you have thebrain function to do it, that you can rememberto do this on schedule, that you're not going tobe letting the bladder fill

up with more than it should, and that we're not having highpressure and that you're going to have regular followup to makesure this is working for you. so, it's potentiallythe best way to go but it's not for everybody. so, now we move toindwelling catheters, the two types are foleycatheter, one that's going in just through the urethra,or what's called an sp tube which stands forsuprapubic catheter,

so going in through a holein your belly going directly into the-- into thebladder instead of going in through the urethra. the advantages, well, thisis always a good choice in the sense that it treatsessentially all the problems. it doesn't matter whatthe bladder is doing, it usually doesn't matterwhat the sphincter is doing, it will-- it willcollect the urine, it will keep somebody dry.

so-- and it's also, it'sa potential for somebody to be completely independentduring the day time. once you're set up with this, even if you have ahigh level injury, you could be using an electricleg bag opener to empty out urine and not needassistance from anybody for that time that you'reup and about and outside. so it's potentiallya good way to go. but there of course,there are disadvantages.

having a catheter sittingin the urethra all the time, it causes erosions, it can causejust some very nasty problems where urine's leakingwhere it shouldn't be, and that's often a reason whywe switch to a suprapubic tube. just getting the catheter out of the urethra entirely isoften a good way to go if a-- indwelling cathetersin the long-term plan. now, if you have suprapubic tubeplaced, it does require surgery. sometimes you need to have thebladder neck closed so it has

to be shut so that theurine won't keep leaking out the urethra. and you think thatmight be an easy surgery but it's actually fairlycomplicated surgery to do. it's not a minorprocedure to do that. so with either of these, you dohave a bag of urine that's going to be with you duringthe time that you're-- that you're, youknow, up in your chair and you have a night bagwhen you're down in bed.

you have a cathetercoming out of your body. so, some people want toavoid that and that's' enough of a reason to dosomething different. we know that there's anincreased risk of bladder cancer with anyone with anindwelling catheter probably because of inflammationin the bladder. and also an increased riskof developing bladder stones. and there are moreinfections that need treatment than doing intermittentcatheterization.

so, little questionfor our talk here. so males and females, forthe purpose of this talk, so what's the importantdifference, anyone? so, it's in the slides. yes, the penis. females do not have a penis. and a penis, yes, yes. you were going to say that. so, it tends to be somethinghandy when it comes to managing,

managing the bladderand managing the urine. so, females, unfortunatelythere's really no good external collection device thatworks the same way that a condom catheter does. there's more difficultymaintaining continence because the urethra is longerin a male because of the penis, because it's goingthrough the prostate, it's easier for mento remain continent. in people withoutspinal cord injuries,

it's women who are more likelyto have, have incontinence because the urethra is short. and then complications, womenget different complications from having an indwellingfoley catheter for a long time. the urethra can become dilated. put in a larger catheter,it just dilates more. it can just be a struggle tomaintain continence that way, and that's one reason why asuprapubic tube is actually a very good option for a woman

who otherwise would beusing a foley catheter. so, when we get to thischoice, what's going to be best for a patient over the long run? these are the thingswe're considering. so number 1, do theyhave the hand function to do intermittentcath independently? if they do, that's whatwe're going to try. that would be thebest way to go. how much mobility doessomeone need here?

transferring on to atoilet, is that required for some of these techniques? how much of the daysis going to be devoted to bladder management? what happens if somebodydoesn't do a hundred percent of what we asked them to? is it going to cause aproblem where it's going to make them really sick or isthis kind of a fail-safe method. are they living somewherethat's a very remote location

with no followup around,or are they in an area where there's a lot ofmedical care available? and what's the likelihood thatthey're going to really benefit from one of the more complicatedmore time-intensive techniques? or are they going to do-- finewith something that's simpler? so, that's what we'll consider when we're making arecommendation on the way to go. i want to briefly touch onsome other surgical options. there is an artificial urinarysphincter that can be placed

if someone is having troublewith incontinence that's due to the sphincter being open. in general, it's a bad ideahaving any foreign bodies near the urinary tract in somebodywith sci because they tend to get infected, but for somepeople this is a good way to go. bladder augmentation is aprocedure that's been done for quite a while and maybebeing done a little less frequently now. so, this will be forsomebody doing intermittent

catheterization and theirbladder just cannot hold enough volume. you know, even in spite ofmedications being tried, it just won't hold enoughto make it practical. what's done is a pieceof bowel is sewed on to the bladder essentiallyto give it more capacity so that someone canhold more, more urine. and then there are number ofurinary diversion procedures. i've kind of categorizedthese all together.

let's say a non-continent onewould be-- it's a urostomy. it's essentially the same assomeone who has a colostomy for stool but it's bringinga connection from the bladder to the outside ofthe body a large tube where the urine will just drainout and be collected into a bag. so, usually this isbeing used now just when someone has hadmajor complications or they're having some-- likea cancer that needs treatment, it's usually not done as aprimary management strategy.

but if problems haveoccurred, it's something that we can fall back on. there's something called acontinent catheterizable stoma, and this is creating a tract where somebody can dointermittent catheterization through, but not doingit through the urethra, putting it in a more convenientposition on the belly, and that's called amitrofanoff procedure. and i've got a drawing here.

if anyone is sitting close,they can see that all of this is in german and i don'tspeak german but i can see the wordstoma and navel here. so, what it's showing is alittle tube on the inside made of part of your insides,bowel or appendix, that comes out to the outside and then a catheter wouldbe placed through this to empty the bladderinstead of having to put it i want to mention functionalelectrical stimulation.

this allows someone toempty without a catheter. of course you would need to either be using acondom catheter or transfer onto a toilet when thesystem is turned on. it was on the market in theus for a fairly short time. it was called the vocare system. a related device has beenavailable in europe and still is and it's more than 2,000 peoplewho've had one implanted. it requires a surgery of course.

this is showing wherethe stimulator is placed. they need to cut some ofthe sensory nerve roots, the sacral nerve roots, toeliminate a reflex that happens and then electrodes areput around the motor nerves that are coming offessentially the sacral roots. and that's the setup on the system. and it's pretty easy touse one that it's in. you have an external stimulatorthat you need to turn on. you put it on setting number1, and that's triggers a type

of stimulation that causesthe bladder to empty. so it sort of squirts the urine out by giving the bladderan electrical squeeze. or you can do a moreprolonged squeeze. it's the same nervesthat are going-- same nerve roots going tothe bladder and the bowel and it seems to help speedup the time of bowel care. so it's a more prolonged squeezewhen it's on setting number 2. they removed it fromthe us market.

i think mostly based on the factthat they were not selling a lot of them and it wasexpensive to be marketing. one thing that's under development nowis using an electrode to block those sacral sensoryroots so that you wouldn't need to cut the nerve roots. nobody is too keen onhaving nerve roots cut even if they have a completespinal cord injury if they can avoid it.

and somebody with an incompletespinal cord injury could potentially use this,this method. so it's under developmentat case western in cleveland and it really lookspromising at this point. but right now, the deviceis not on the market. i mentioned botox to thebladder a bit earlier. this is being usedmore frequently. so it's not an fdaapproved use of it. it will be done iforal medicines,

anticholinergic medicines justwere not relaxing the bladder muscle enough for somebody tobe able to do intermittent cath and hold enough urinein their bladder. up here it's showing30 different spots where botox is injectedinto the bladder muscle. it's effective forprobably 6 to 9 months. if it starts losingits effectiveness, you would start havingincontinence. so, it's not so risky asfar as it wearing off.

people would get a sense thatthey need to have it redone. so, before we leaveurinary management, just to hit on some numbershere, what's most commonly used? so i've got males andfemales over here. so, suprapubic tube, 10 percentof males, 7 percent of females. >> this is people who are5 years out from injury, exactly 5 years out, and is people treatedin the model systems. foley, 10 percent of males,23 percent of females.

kind of surprising to me thatit's that high in females. condom catheter, ofcourse zero percent females since there's no penisas we discussed earlier. intermittent catheterization,so a little over a quarter. normal voiding, also inthat same sort of range. so, it varies. it's not everybodyusing one-- one method. different centersprefer different things. most centers should beindividualizing the choice.

now, i want to hit onsome of the complications and then the screeningtests that we do to try to pick up on them. so, start with stones, kidneystones, bladder stones. it's quite common. it can happen actually early on. there's such a great lossof calcium from the body in the first coupleof months after injury that that can be the mainthing forming stones.

most people, that'snot what causes them. and most people with sci,it's ones that develop more in the chronic phase andit relates to infection, often something called proteusis the bacteria that does this, but there's someothers that do this too. they break down the urea,something that's in urine and it tends to precipitateout and start forming stones. it's also something that canmake people's urine look really cloudy and milkyall of a sudden.

so that stuff just startsgunking up the system and turning into big stones. this is a problembecause it can be leading to recurrent infections. the antibiotics don'treally penetrate the inside of the stone well, soyou never really clear that bacteria out of there. if they're large stones,they can damage the kidneys. smaller stones can move intothe ureter and block it.

it can leave a very seriousinfection behind there. it needs to be treated as anemergency and have a tube put in through your flank to drain--drain out the urine from above and then go in andtreat the stone. so, it's a very seriouscomplication and that's a main reason whywe're screening for stones. hydronephrosis and reflux, theseare referring to similar things, either a blockage ofurine or a backwards flow of the urine up towardthe kidney.

and it can be causedby multiple things. the bladder is contracting a lot and the sphincter isn'topening, for example. this diagram on thebottom is just supposed to show what's happeningwith the kidney. it's refilling more and more. all the fluid is backed up here. there's less kidney todo any sort of filtering. so, the treatment is to removesomething that's blocking the

system and do whatever you need to to reduce thebladder pressures. bladder cancer, imentioned earlier. we know that it's associatedwith chronic inflammations. so for example anindwelling catheter, it still is a fairly low risk. and it's controversial, some people do recommendperiodic screening, so putting a cystoscope,a little telescope

up in the bladderand taking a look. the parts that are controversialis exactly who needs to be screened, how soon after injury shouldyou start screening, and how frequently should youscreen if you're going to do it. these tend to be reallyaggressive cancers and even with the yearly screening,you may not catch all of them. so, even in the courseof a year they can go from a normal bladder to havingone that's very advanced.

the fortunate thing is thatthey're really not common. so it's something weneed to think about but it shouldn't steer usaway from a management solely because there's anelevated risk of this. now, moving to screeningtest here. there's some lab tests thatwe do looking at the kidney, kidney filtering, imaging testsand then some fancier tests like urodynamics or cystoscopy. a bit on the lab tests,there's two things

that are commonly done, so ablood test or serum creatinine. creatinine is something that'sfiltered out by the kidneys. so if you have a high levelof that in your blood, it means the kidneys arenot filtering enough. the caution really tohealthcare providers is that this could be elevated, or you could be losing somekidney function even though this is not very elevatedon the test. it has to do with where thecreatinine is coming from

and people havingless muscle mass. what's really important isfollowing this over time and looking at theolder results. so suddenly it's rising, that's a sign something isnot right with the kidneys. the creatinine clearanceis a test where we need theblood test done but then we also collect24 hours worth of urine. what we end up estimating is howmuch filtering the kidneys are

doing over the course of24 hours or over a minute, however you wantto calculate it. so, a higher number is better, the kidneys are doingmore filtering. the problem, and this issome research that we did at my va hospital, just to show. i actually have doneresearch in this area. by the way, i'm not a urologist,i'm a physical medicine and rehabilitation doctor but wehave done some research on this.

we found so muchvariability year to year. this test really didn'tseem all that useful. somebody could have a normal one and then it could be almostrenal failure and then bump back up to normal, so we didn'tfind it all that helpful. we really look a lotat the blood test and follow that over time. so then, imaging tests. up on the top here isshown an ultrasound.

what's really nice aboutthis, zero radiation, it's a risk-free test. it's very good for picking upon stones that are forming there and blockage of fluid. in the middle here isshowing a cat scan. what's typically done isone that's called ct kub. kub is an x-ray of thekidneys, ureter and bladder, so it's a cat scanversion of that. but it's kind of-- withany of these cat scans,

there's really a whopping dose of radiation comparedto other things. it might be as muchas a 1 in 3,000 chance of getting a fatal cancerfrom getting a cat scan, so i don't think it'ssuch a hot test for doing in somebody who's 20 years old,who might be having, you know, 50 of these over thecourse of their life. so, it's not ourscreening test of choice. if we need to see something inmore detail, it's a great test

but i don't think it'sgreat for screening because of the radiation risk. and then renal scans, thisis a nuclear medicine study or "nucular" if you'refrom texas. and it's kind of easy, sortof fuzzy pictures down here. so it gets the-- thestuff that's injected, it gets filteredout by the kidneys. they see it in thesefuzzy pictures. and, you know, if therewas a big hole in this,

then maybe there'sa stone there. it's not as-- it's not as prettya picture as the other ones, but it does give you an indexof how much filtering is going on so it's not-- i'm notsaying that it's a bad test, it's just-- if we're gettingimaging, we want a picture, you know, i thinkultrasound is the way to go. how often shouldthe test be done? so, there's no-- really noresearch to say what's the-- what's the best wayof doing this,

and i really think it shouldprobably depend on the patient. we should do individualize it. if you're having no symptoms, ifyou have fairly normal control of bladder, if you havegood sensation in your body, doing it yearly isprobably excessive. if you're havingproblems, then doing it-- doing it frequently makes sense. so, there is a va policy that essentially tells useverything we're supposed

to be doing bladdercare and otherwise. so what they recommend isa certain group of tests that are done annuallyon everyone with spinal cord injury. that's nice in black and whiteand that's basically what we do. there's a guideline forphysicians from the consortium for spinal cord medicine, and what they say is it'susually performed annually, then they just left it at that.

so, frequently done annually,it's not to say that it has to be done annuallyfor everyone. now, i want to hitinfections versus colonization and urinary tract infections. so, if someone has a high numberof bacteria in their urine, the way we measure it in thelab, and they have symptoms that are consistentwith infection. it might be spasticity. it might be a fever.

we would say that that isa symptomatic infection. but if you have bacteriain your urine on the test but have absolutely no symptoms, we would say that'scolonization. there are bacteria that areliving inside the urine. they're attaching themselvesto the inside of the bladder but they're not causingsymptoms. and if it's colonization, youreally shouldn't be treating that with antibiotics.

you're just chasing your tail. you cannot maintainsterile urine in everyone. and in fact, thereare some bacteria that just don't cause anysymptoms, and having something in there that's not givingyou symptoms, that's better than having anotherbacteria come in there and then give you--give you symptoms. and this is actually a strategythat's being looked at as a way to prevent urinarytract infections.

it's called bacterialinterference where a specific bacteriawould be inoculated into you and it would just sort ofoccupy all the real estate in the bladder, keepanything else from moving in. if you started toget sick with it, it's one that would be very easyto treat because it's sensitive to lots of antibiotics. and so far, it seems likethis is probably going to be an effective--effective strategy.

but, you know, keep in mindyou know any bacteria that are in there that are not causing-- causing any symptoms that mightbe doing the same thing for you. so, when we're deciding totreat, it's got to be based on signs and symptoms. so, systemic infection, you aresick with a urinary infection, you're feeling lousy, yourspasticity has increased, you're having dysreflexia,dysuria, uncomfortable sensation when urine is passing,if you have sensation,

not just the change in theappearance and not just based on the fact that there'ssomething growing out of there. now, what about justputting people on prophylactic antibiotics, just taking antibioticsall the time? well, when people have lookedat this in big studies, it doesn't seem likethis is beneficial. you're selecting outfor resistant bacteria and you'll nevermaintain sterile urine.

on average, it's notan effective way to go. some other prophylacticthings that have been looked at are cranberry tablets,methenamine which turns into formaldehydein the bladder. so, these are all things that have been usedfrom time to time. and i'll get to this butit's really trial and error when it comes towhat's going to work to keep my infection rate down.

>> so just to summarizewhat i went through before we hearfrom our speakers. so, i really feel likethe choice of the way to manage the bladder foranybody, it's really going to be individualizedconsidering a lot of factors. icp is not automaticallythe best choice. some people do haveless infections when they use something we don'tthink is necessarily effective for everybody.

they switch to differenttype of catheter. they take prophylacticantibiotics, some dietary supplement. so, when people do research onthis in a big group of people, it doesn't seem effective. but i have certain patientswhere we found that this works and something else works forthem and that's what we-- what we recommendfor that person. it's just trial and error.

then for the followup studies, most people with spinal cordinjury should have some sort of periodic testingof their urinary tract to detect problems beforethey become big problems. but as far as whatthe testing should be and how often, that's debatable. now, there will be a consumerguide coming very soon. so it's a companion to thatphysician guide i mentioned. paralyzed veterans ofamerica will be publishing it.

it's supposed to beout in december 2009. i just checked with thomasstripling from pva yesterday. and if you look atwww.pva.org, it should be there under publications some time inthe-- in the next few months. so, i just acknowledge the vapuget sound for giving me time to work on this presentationand then the grant from nidrr that also support someof my time as well. so, that concludesmy part of the talk. now, i would like to hearfrom our two panelists.

who would like to go first? >> my name is tammywilber and i've been-- i have a spinal cord injury. i'm a t5 complete, and iwas injured when i was 17. and when i had my car accident,i also lost my right kidney. so that was a big deal. obviously in the presentationhe talked a lot about kidneys and how they can affect yourlife with a spinal cord injury. first couple of yearsafter my injury,

i had a lot of problemswith cathing. considering i have no penis, ihad to learn how to, you know, transfer onto the toilet, tryto hit the right hole and-- and it was very frustratingbut-- and when i was in the rehabhospital for 2 months, by the time that i went home,i still was not independent in cathing my self, whichis very frustrating. and on top of that, i alsohad an allergic reaction to a medication calledmacrodantin.

and i don't want toscare you from taking it, but it made my hair fall out. so when i left therehab, i had bald spots on my head and my hair fell out. i was incontinent all the time. no medications wereworking for me. i wasn't drinking enoughbecause i was just constantly-- as a woman we havesmaller bladders and mine was justcompletely spastic and--

so basically, a summary for my--you know, i go back to my senior in high school and i'mwearing diapers and peeing in my pants all the time andit was just-- it was such a-- those first coupleyears was just-- i have said it wasjust-- it just sucked. i mean just trying to wakeup everyday like 4 hours, couldn't even get through anight sleep, until i found out about bladder augmentations. a friend of mine got--

now i originally grew up in theeast coast, from new hampshire. and a friend of mineat boston had looked into getting a bladderaugmentation. so after she got herbladder augmentation done, i kind of want to see-- did aresearch on it and see how-- how it changed her life. and so it's a bigprocedure to get done, in anyway that's nearly injured. a lot more women get it than mendo, the bladder augmentations,

but what i found is that, forme, it was a big surgery to have and it's definitely somethingthat you need to research and make sure that it'sgoing to be right thing. but they did use part--a piece of my intestines to increase my bladder 10times the size that it was. they used my appendix tocreate a canal from a-- so i do have a stoma,i use a catheter, a straight cath, 14 french long. and it goes rightinto my-- and i--

and it just looks like alittle second belly button. and i don't leak out of it. it kind of works as likea sphincter where once i-- the stoma which is downhere insert the catheter and nothings leaksout of the stoma. i've heard other people say thatthey've gotten surgery done. they've had issues with it. i've been very lucky. i'm on no bladder medication.

i am-- i don't leak. basically they just kindof rerouted everything, and so basically i'm kind of like a guy now,i can pee anywhere. so, for me [laughter]it's increased my quality of life a lot betterbecause i mean if i have to, like i just flew in from boise. if i'm kind of spacey tonight,i've been up for hours, i was in boise for2 days for work.

so, i'm really tired but-- you know the biggest thing forme was that i need to figure out what was going tobe the best way for me to improve my quality of life. and with that fact thati only have one kidney. and your kidney, whenyou do lose a kidney, your other kidney can function--it enlarges itself and it can-- it can do the workof two kidneys but having spinal cordinjury, i was really at risk

for bladder infections and i wasnot drinking enough those first few years because i was soworried about peeing my pants. and who wants to do thatwhen you're, you know, teenagers of 17 or 20. and so i didn't drinkenough water and i was always dehydrated. now, i've-- i havemaybe a couple of bladder infections a year. i have been hospitalizeda couple of times

for kidney infectionsbut that's when i've like missed the bladderinfection and then it went to my kidney. so-- but otherwise, i mean it'sjust really improved my quality of life. i-- when i cath, i just-- like i said, i just insertthe catheter into my stomach. i don't have to pull downmy pants and transfer onto the toilet or whatever.

for me, it just works--it worked great. i mean i can sleepthrough the entire night. people often ask me like howmuch does your bladder hold? and basically, well,here is easier way to-- give you a visualization. i recycle, so i carry oneof these around with me and i can fill up like a bottleand a half of one of these. like if i sleep throughthe night and i drink a lot of water, then-- and pluswho wants-- you know.

one time i was carrying around aurinal and it fell out of my bag and they're doing a bagcheck at this [inaudible]. like i'm never using a-- i'm never using a urinal again'cause it was just embarrassing having them go through my bag. but you know the thingis, is for me as a woman, it really changed how i was able to just get aroundand do things. i didn't always have to seekout and plan where am i going

to go pee next, you know. whether that meant that iwas getting up in the morning and going somewhere, makestraveling a lot easier. i mean half the time i don'teven have to get out of the car. i could pee in the car, i can-- you know, on longflights if i have to, i mean i can pee under--you know i'll just take a-- my jacket or somethingand person sitting next to me has no idea except for thefact that they may hear a stream

and go look at me andlike, what's that noise? but it's-- it's-- ifanybody is ever looking into having a bladderaugmentation, do your research on it and definitelyresearch the doctors. i had one of the bestdoctors in the country. he had already-- when i had mysurgery done in 1995 or '96, this was a doctor that hadalready been doing bladder augmentations forabout 15 years. i had my surgery doneat [inaudible] hospital.

to do the surgery, it is abig deal because of the fact that from start to finish, iwas on bed rest for a month and a half and then iended up-- i did have to-- have a like bag for walks. i had to heal and-- you know, it was a big surgery,basically overall. but then result wasthat i have-- i'm healthier, mykidney is healthy, and it's just been great.

>> i'm todd stabelfeldt. i guess that realquick before i start. i'm german and i'm southern and your western medicinedoesn't really line up with me. so, i'm just sort of bitstubborn and do my own thing. so, it's taken me many,many years to figure out the right physician and theright facility to work with. and so, i would again sort of stress what the doctorsaid here and tammy.

you got to find the right peopleto work with you, who can line up with your quality of care. so with that being said,i start with a joke. i've been workingout for 9 months. that's what i do, i write jokes. so it's all up at delivery and the joke is simplytwo quads walk in a bar. >> alright, pretty funny. no? alright.

it's a quad joke. you know, you all get it later. i was paralyzed back in1987 due to a gunshot wound. i was 8 years old. a cousin shot me by accident, so the result was a c4complete quadriplegia. so i can move and feel, youknow, from the shoulders up. anything else is just, youknow, pretty much dead. started with the condomcatheter approach,

i did that for a number ofyears and i could talk hours on, you know, catheters but thebottom line is the condom catheter added about 45minutes to my morning routine, making sure it wouldstay on correctly. i also grew up in a reallysort of independent household where i was alonea lot and whatnot and i just couldn't reallyrely on people to be around, you know, to change you knowwet pants, et cetera, et cetera. and then when i got into mybusiness, when i was about 16,

17 years old, most of my lifewas sitting down with clients and physicians, you know, andit just doesn't really look good when you're at ahigh-end restaurant and get all your woolslacks are full of piss. it just, it didn't happen. and so i need tofigure out something. you know it was-- at thatpoint in my life beginning to have lots of bladderinfections, had the spastic bladder.

i couldn't reallyempty it all the way and did all the differenturodynamics and went through all the urologists and you know the listwas-- went on a while. it's actually to the point wherei could smell just, you know, the aroma of e. coliversus pseudomonas, and i could tell the physicianwhich bacteria was in my bladder and then i couldprescribe myself which antibiotic i should be on.

and then after the 3-day sort oftest they would come back with "hey, you're actuallyright," you know, go figure. so, it was really thosethings where it begin to-- you know where i had to bealways on antibiotics, you know, sort of full strength andit just was not working. multiple urologists had, youknow, sort of suggested the-- the sphincterotomy and thenwhen i sort of read into that and was very concerned aboutmy life and then, you know, marriage and things like that,and it just didn't line up.

so i got connected witha wonderful urologist who was trained bythe greatest man who ever lived on this earth. he was in that field asmichael mayo, who retired-- trained up a wonderfulwoman named elizabeth miller who spent some time here atuw but now is at overlake. and so, i now see herat the overlake system, and she put in a suprapubiccatheter which got back in october of like '07.

and it's been just one hugeblessing from that point forward to retire the-- youknow, a dollar 80. every time i want the catheter,a 35-dollar bottle of adhesive, an 18-dollar urine bag. you know, it was just one ofthose things where you just go, this is ridiculous people. and i found that the sp thingwas a huge, huge asset for me. there were lots to learn,and it took me about 6 months to get comfortable withmy sp tube on, you know,

what's it like now and tryingto understand how much water to drink and, you know, legbag straps and, you know, whether it's going tobe latex or silicon, you know what sizecatheter do i put in there, et cetera, et cetera. and then i wouldsay that, you know, to understand me is i look at-- i look at life as a series ofsort of manageable projects and my life as awhole is a project.

and the differentparts that make up my life were the smallerprojects and i use a sort of a process of elimination,the very objective thinking to isolate and thenresolve a particular issue. and the bladder for me was yet this one moreparticular project to resolve. and i feel very comfortablewith it now. i'm able to tell if mybladder becoming spastic. i can tell if i'msymptomatic for an infection

if i need antibioticsfor a couple days, when my sp needs to be change. you know, i sort offollow a very specific set of algorithms everydayto make sure that i'm always doingthe same thing. for me it's always independence,alone time and ensuring that i'm never going to piss myself due to the fact, you know, i sit down a lot andwork with a lot of folks. and my whole world this can't beme living a urine trail behind

me when i wheel around. it's just not acceptable. >> and now we'll moveto some questions. any questions forany of us up here? >> so the question has todo with urethral strictures and intermittentcatheterization. so it is a relativelyuncommon complication. but it is more common in someonedoing that than say somebody who has a condom catheteron, so just the trauma

of passing the catheterin and out can do that. so it's not something thatmost of us should worry about but people can get somedifficulty just passing the catheter. another thing that canhappen is a false passage where the catheteris trying to go a way that just doesn't go through. and that can happen with different bladdermanagement as well.

usually it can all be sortedout by urologist taking a look up there with a cystoscopeseeing what the problem is and doing a little-- alittle bit of repair. so just something we needto monitor for, it's just, i guess my point is that intermittent cathis not complication free. so the question is whether thereis a medicine like ditropan that does the same thing, relaxthe bladder but doesn't have-- doesn't have side effects.

[ inaudible remark ] >> yes. so i would say,there is a medicine that does the same thing withoutthe dry mouth and constipation and other side effectsand that would be botox, because it's just actingdirectly on the bladder if you put it in there. the gel looks promising whenyou read the theory behind it. it has to do with the waythat medication is taken up by the skin and the wayit's processed by the liver

and how it metabolite. ditropan is what givesmore the side effects. but i would say time will tell. the thought was that detrolwould definitely have way less side effects thanditropan when you sort of look closely at the studies. it seemed to me that they werecomparing a sort of a low does of detrol with a highdose of ditropan. and once you got somebody upon a high dose of the detrol,

it had its side effects, too. so that whole classof medicine is the anticholinergic medications. it's essentiallyis the side effect of the medicine iswhat we're doing. the side effect of the medicineis that it relaxes the bladder so it's that wholegroup of side effects. the thought is that itmaybe more selective. and there are host of thingsthat are under development now

with that same goal tryingto get more selective for the bladder and less ofthe unwanted side effects. so to be determined, i haveno experience using it. since it's brand new,it means it's expensive. if it's expensive then it'snot going to be our first line at the va especially whenthere are other alternatives that are just pennies a day. but you know, we shouldn'tdiscount, you know, the side effects even givingpeople a dry mouth all the time

and having effects on yourteeth over the long run. it's not just, you know,a small inconvenience to have serious dry mouth allthe time from those medications. so the question is whetherthere are side effects to botox. so rarely when someone hasbotox injected somewhere in their body, we seedistant effects from that where they developweakness somewhere else. it's quite rare. it usually gets, you know,reported in a journal,

here is our interestingpatient where this happened. the fda recently put out awarning to physicians saying, "oh, we think that this doeshappen maybe a little more commonly than what,what we thought." but you know, it's usually justsort of a local side effect, things that are inthat, in that same area when it's been other partsof the body injecting muscles in the neck area and gettingmore weakness than you wanted. but from the bladder,for its spreading widely

and causing major side effects,that wouldn't be a reason to be concerned about it. you know, if anything has sideeffect from being injected is that if it's donemore than a few times, the muscle will probably-- the bladder muscle willprobably tend to stay weaker for a little longerand a little longer. that's what we'd seen whenit's injected into limb muscles to treat spasticity that usually

over time you do geta more lasting effect, sort of more permanent effect where the muscle doesn'tcome back quite as well. but it's not to say that thebladder will react exactly the same way. the bladder is alittle different muscle than the limb muscles theway that it's put together, so probably a verysafe treatment. it might be that peoplestart getting problems

with antibodies forming overtimeespecially if it's going to be injected, youknow, that frequently. but there's more than onetype on the market now and the antibody problemis specific for type. so the question has to do withwhat other natural substances or supplements can beused for preventing-- getting urinary tractinfections. so cranberry juice or especiallythe cranberry tablets is what's been looked at the most.

there is a sort ofactive ingredient in that that has direct actionagainst bacteria. the problem, withthe plain juice, is that cranberry juicehas so much sugar. people will just be taking inexcess calories right there. so most people who are findingthat effective will switch to the tablets whereit's superconcentrated with that substancethat's active against them. there is-- that's really themain supplement that's been

studied by westernmedicine and has some-- some evidence, some evidencefor, some evidence against, is actually the studiesdone in people with spinal cord injuries arenot all that convincing with-- that it's beneficial onaverage for everyone. but as i said, it'sreally trial and error. there are some peoplewhere, you know, it sure seems tomake a difference. >> so i'm sure thereare other supplements

that have been reported but really the one that'sgot the most study is the cranberry tablets. some people take vitaminc to acidify their urine. that's often done in conjunctionwith other medicine that needs to have an acid environmentto work. it's the only other onethat really comes to mind but it's a host ofthings that are reported to have beneficial effects.

the question had to do withgetting very frequent utis, so that sounds likeabout 15 a year. so, hardly off antibioticsbefore starting again. so it sounds-- >> yeah. so it sounds like a lot of the most likelythings have been tried. we would, you know, be lookingfor something that's source of recurrent infectionespecially if it's the samebacteria coming back,

something that mightnot be apparent on just the screening test,but a small stone or something where the bacteria nevercan clear out entirely. some people justtend to have symptoms with a low grade infection aswell and just seem to be more-- it's just more apparent tothem when the bacteria are in the bladder thansomeone else. it really tends tobe just a trial and error approachunless there is--

unless we can pinpoint a cause. you know, it turns out thatpeople's bladders have a different ability for thebacteria to stick to them. some people, the liningis just more sticky. other people, the bacteriadon't adhere as well. so it might just bethat you're unfortunate that you're somebodywho sticks there. you know, what i'veseen most typically, i'm not saying thisis your case,

but typically someonewho's getting treatment that often once a month oreven more frequently than that. it's often been a misperceptionby their healthcare provider or by the patient thatany time there's a change in the appearance of the urine or any time the bacterialcount is above a certain number that it must be treated. you know, also for you,maybe you're somebody who would do wellwith that approach

of bacterial interferenceintentionally putting any e. coli in there that doesn't seemto give people symptoms and see if that will keepsomething else out. that's a great strategy ifit turns out that it works when those studies are donebecause we wouldn't be running into this problem withantibiotic resistance. we could just always usethat same bacteria in there to keep something out. so, you know, i'd say that'sthe most promising strategy

but it's not availableat this time. the studies are stillcoming out now. >> what about acupuncture? >> so the questionis about acupuncture. well, i'm sure thereare some people where it would be beneficial. it's not something wherei've seen any studies to report on it. it obviously has effects

that are not very wellunderstood by western medicine. so you know, in thetrial and error approach, i wouldn't say don't try it,there's no chance it will work. but i can't point to somethingthat says that it does. and one uti a year, wewould say that's success. we would like to see two or lessper year would really be ideal. so you know, three in oneyear or four in one year, that doesn't meanfailure but, you know, anything that's starting tobe, you know, in that range,

we have to look at whatelse could be done to try. the comment had todo with how many-- well, getting supplies approved and specifically thenumber of catheters. so this is reallya national decision that some people pointed out that the fda neverapproved the catheters for reuse that people havebeen reusing and lots of people are getting by,really getting by just fine

on four catheters a monthwith washing, you know, washing them out, they'dhave their pool of catheters. they would kind ofbuild up their stock, clean them out with whatevermethod was working for them and seem to be doing fine. some people would definitelybenefit from single use. but then people whenthey pointed out, these devices aren'treally approved that way. it's a medical device,it's a potential issue

so suddenly a lot of-- a lot of groups startedsupplying four or five a day. and some patients initiallyrefused that saying, "where am i goingto put, you know, the 2000 catheters you'resending me for the year?" and maybe that at some pointthere is a catheter that's approved for reuse but somebodywill have to do the studies to show that that'sa safe strategy. but in, you know,much of the world,

catheter reuse isstandard and a lot of people have beentaught to do the reuse. so for most peoplewho reuse does work but insurers should not beinsisting on that at this point until there is onethat's approved for reuse.

Thursday, January 12, 2017