Correspondence

Report of a visit to the Division of Urology at the University of Pennsylvania School of Medicine and the Rocky Mountain Spinal Injury System, Denver, Colorado, USA. Historically, the management of spinal cord injury (SCI) has been developed largely empirically. The success of this approach is attested by a nearly normal life expectancy in patients with SCI, particularly through improved urological care. Unfortunately, understanding of the pathophysiological processes in the bladder remains limited in SCI, where collaboration between clinicians and scientists in the ®eld of smooth muscle function is rare. The Oxford Continence Group, set up by Professor Alison Brading, has examined various aspects of detrusor dysfunction. As a member of the group I have concentrated on studying structural changes in the bladder in SCI. The Shackman Fellowship provided an opportunity to visit two pre-eminent centres. Professor Samuel Chacko's group at the University of Pennsylvania has examined the contractile apparatus in detrusor pathology, establishing that BOO alters molecular isoforms, with potential clinical consequences. The Rocky Mountain Spinal Injury Center in Denver has achieved wide recognition for its integrated approach. For the last 9 years a team from the centre has visited Stoke Mandeville as part of a multicentre study of ageing. My visit took place in August 1999; the schedule was necessarily ambitious from the outset, because I was inexperienced with molecular techniques. I received personal supervision from the Associate Professor, Michael diSanto, an enthusiastic and talented teacher. On successive days I learned how to extract RNA, generate complementary DNA, amplify speci®c areas of interest using the PCR and extract contractile proteins. The intensive, personalized course was an excellent introduction. Slightly surprisingly, there were no great differences in the myosin isoforms for samples from patients with SCI. However, the sample size was small, so we intend to pursue the studies further. The Rocky Mountain Spinal Injury Centre is in Denver, at an altitude of 1600 m. It is part of a Level 2 trauma centre, which received several victims from Columbine High School after the shooting incident. The ethos of the unit is to tailor care for the individual, optimising the chance of an independent and rewarding life. In essence, the approach resembles that of enlightened centres in the UK, with little apparent difference in clinical management, and a similar chronic lack of nursing staff. The Rocky Mountain Centre sets an outstanding example with its research department. Twelve researchers, including doctors, computer staff and a statistician, obtain and analyse information in collaboration with other centres in the USA and UK, resulting in a substantial clinical database. Urologically, all aspects outside urodynamics are covered, providing detailed information on the effects of various management methods. As no member of the research department has a urological interest, this part of the database was little used before my visit. A large part of my time was consequently spent collating and checking the urological information for statistical analysis and interpretation. The visit was a good mix of laboratory and clinical research, from which will ensue publishable work on the long-term sequelae of bladder management. After further work, we will also be able to report on changes in the detrusor contractile apparatus in SCI. The visits emphasized the need for cooperation across the clinical/scienti®c interface. Only by exposing individuals to both aspects can it be anticipated that new management approaches will be developed. I am indebted to the Ralph Shackman Fellowship Trust for this opportunity.