Azathioprine and allopurinol: a potentially dangerous combination

We report the association of leucopenia and anaemia in five patients given a combination of azathioprine and allopurinol. Three subjects were renal transplant recipients with mild to moderate impairment of graft function. The complication appeared between 4 and 6 weeks following initiation of the combination therapy. Discontinuation of one of the two drugs resulted in full recovery within 4-8 weeks.

Enzyme-linked immunosorbent assay for Salmonella typhimurium in food: feasibility of 1-day Salmonella detection

A microtitration plate, antibody-capture, enzyme-linked immunosorbent assay was developed for detection of Salmonella typhimurium. The assay utilizes a monoclonal detector antibody which shows no cross-reactions with non-Salmonella species and only a slight cross-reaction with one other Salmonella serotype. By using only one cultural stage (in a nonselective, chemically defined medium) prior to the enzyme-linked immunosorbent assay, low numbers of cells in food (10 cells 25 g-1) were detected in 19 h. Non-Salmonella competing organisms did not interfere with detection of S. typhimurium even when present in the ratio of 10(6):1 (non-Salmonella/Salmonella spp.). The assay shows the feasibility of rapid, 1-day testing for Salmonella spp. with antibody technology.

The effect of surgery and nutritional regimen on plasma lipoproteins and fat metabolites in man

Plasma lipoproteins and fat metabolites were measured before and during the first five post-operative days in patients undergoing elective abdominal surgery of moderate severity. They received nutrition as total parenteral nutrition (TPN) or 4% dextrose saline (D S ) or isotonic aminoacids (IAA). Surgery caused an immediate fall in total and very low density lipoprotein triglyceride and total high density lipoprotein cholesterol but a rise in the high density lipoprotein subfraction 2 cholesterol. The increase in total triglyceride after 5 post-operative days was due principally to changes in triglyceride not carried by very low density lipoprotein and was related to the type of nutrition provided. There was no evidence of impaired intra-vascular lipolysis.

Life-style changes in a cardiac rehabilitation program: the client perspective

Major life-style changes are required after an acute coronary event, although the vast majority of patients are unsuccessful in maintaining these changes. This study examines factors clients view as enabling or disabling their life-style changes for health promotion. Ten patients in a cardiac rehabilitation program were interviewed using grounded theory methodology. Both health protection and health promotion stimulated life-style change, as did instructions from the physician and life enjoyment. Enabling and disabling factors affecting the process of repatterning were individually defined, but changes in beliefs, attitudes, and plans facilitated repatterning. Specific precipitants to change, forces influencing change, and methods of repatterning life style are discussed, as are nursing implications.

The use of nursing diagnoses for health promotion in community practice

The use of nursing diagnosis contributes to health promotion by helping nurses define and organize knowledge for community practice. When community nurses assess clients' responses to life and health events, clinical judgment frequently requires formulation of both positive and problem-oriented nursing diagnoses. Clinical examples and research findings are used to illustrate the use of nursing diagnoses for health promotion in community practice.

Severe hypertension with absent secondary sex characteristics due to partial deficiency of steroid 17 alpha-hydroxylase activity

A genotypically female patient with 17 alpha-hydroxylase deficiency, and typical symptoms of hypertension, hypokalaemia and lack of secondary sex characteristics, is described. Plasma 17 alpha-hydroxycorticosteroid levels (cortisol, 11-deoxycortisol) and oestradiol were low. Those of 11-deoxycorticosterone, corticosterone, their 18-hydroxy- derivatives, ACTH and gonadotrophins were high and, with the exception of the gonadotrophins, suppressed to normal with dexamethasone which also corrected blood pressure (BP) and electrolyte abnormalities. Plasma aldosterone levels, initially suppressed, increased during treatment but, at 3 months, showed some signs of subnormal responsiveness. Possible reasons for this are discussed. The patient remains well after 9 years on dexamethasone and oestrogen therapy.

A blind controlled trial of phase-contrast microscopy by two observers for evaluating the source of haematuria

Two observers, unaware of each other's findings and of the diagnosis, examined red cells in the urine of 109 patients by phase-contrast microscopy. All specimens were examined uncentrifuged by inverted microscopy, and 48 of the 109 were also examined under a light microscope after centrifugation. We were unable to confirm with either method the close correlation between red-cell morphology and diagnosis reported in previous studies, and our 2 observers differed in their interpretation on 38% of occasions. Proteinuria associated with the presence of casts in uncentrifuged urine examined by inverted microscopy was a better indication than red-cell morphology of renal parenchymal disease.

High-dose methylprednisolone sodium succinate (pulse therapy) in the treatment of renal disease: plasma and urine concentrations

Methylprednisolone hemisuccinate (MPS) and methylprednisolone (MP) concentrations in plasma and urine were monitored in renal transplant and glomerulonephritis patients who were given i.v. infusions of 0.5 g or 1 g of MPS. A marked individual variation of peak plasma levels of both MPS and MP was observed after the same dose and MPS disappeared from plasma more rapidly than MP. Their clearances from the circulation, however, did not appear to be significantly influenced by the peak plasma levels of the drug, creatinine clearance, administration of previous pulses of MPS or the urinary excretion of unconjugated MPS and MP. Even in patients with profoundly reduced renal function, no accumulation of the drug was apparent when repeated doses of MPS were administered at 48-h intervals.

Naftidrofuryl and the nitrogen, carbohydrate, and lipid responses to moderate surgery

The effect of twice daily infusions of 200 mg naftidrofuryl on the six day cumulative losses of urinary nitrogen after moderate surgery was studied in 32 patients maintained on an intravenous infusion of 4% dextrose and saline. A previous report of the ability of naftidrofuryl to reduce loss of nitrogen was not substantiated, although changes in metabolism in the immediate postoperative period suggested that the drug might exert some advantageous metabolic effect. Further investigations with other nutritional regimens are warranted.

Loa loa: the use of a blood cell separator to reduce microfilaraemia before specific chemotherapy

Three years after returning to the U.K. a 58-year-old British engineer, who had worked in the Nigerian oilfields for 24 years, was found to have Loa loa. His midday microfilarial count ranged between 12 X 10(6) and 16 X 10(6) parasites per litre. Before starting treatment, I litre of leucocyte/platelet-rich plasma was removed by means of a blood cell separator. Six intermittent cycles of blood separation were performed during a single 4-h session around midday in order to coincide with the period of maximum microfilarial presence in the peripheral circulation. This resulted in a 50% reduction of the microfilaraemia. Where facilities for blood cell separation are available, this procedure, together with appropriate chemotherapy, should be particularly beneficial in the management of heavy filarial infections.

The effect of probucol and cholestyramine combination therapy in severe familial hypercholesterolaemia

The relative effects of cholestyramine and probucol, alone and in combination, on serum total cholesterol (TC), high density lipoprotein cholesterol (HDL-C) and the ratio of TC to HDL-C (T/HDL-C) have been studied in a group of 10 subjects with severe familial hypercholesterolaemia. The combination of cholestyramine plus probucol was more potent than either agent alone in reducing TC. The use of probucol either alone or in combination reduced the HDL-C concentrations, but the ratio of T/HDL-C was not consistently affected. The effect of the combination therapy did not diminish after periods of at least 6 months and in some cases led to partial regression of long-standing xanthomata. The combination of probucol with cholestyramine did not give rise to additional side effects and it is considered to be a valuable addition to the regimens available for the treatment of severe familial hypercholesterolaemia.

Plasma exchange in acute renal allograft rejection. A controlled trial

A controlled trial was carried out to assess the value of intensive plasma exchange in 27 renal transplant recipients with clinical and histological evidence of acute vascular rejection. In addition to standard immunosuppression, 13 patients received plasma exchange on six consecutive days at a mean exchange volume of 40.6 ml/kg of body weight each day using an intermittent cell separator. A further 14 patients received standard immunosuppression only. In addition, 10 patients exchanged prior to the controlled trial have been studied. Analysis of short-term benefit, as evidenced by a reduction in serum creatinine, and by subsequent graft survival revealed no significant difference in these parameters between the two groups in the controlled trial. This regimen of plasma exchange has not, therefore, been shown to modify acute renal allograft rejection.

Metabolic studies with 'Nutrauxil', an enteral feed preparation

A metabolic study was carried out in 6 patients requiring enteral feeding to investigate the effectiveness and tolerance of 'Nutrauxil', a ready-made liquid nutritional preparation, over a period of 8 days. The results of anthropometric and laboratory measurements, made initially and at the end of two 4-day periods, showed that the basic provision of 2000 kcal and 60 g protein per day with 'Nutrauxil' maintained patients in metabolic, electrolyte and nitrogen balance. No adverse effects were noted and the preparation was easy to administer. It was concluded that 'Nutrauxil' compared favourably with other enteral feed preparations with respect to its nutritional effectiveness on clinical, biochemical and economic grounds.

Ventriculo-atrial shunt nephritis

A case of immune complex glomerulonephritis with reversible renal insufficiency following ventriculoatrial shunting is described and the English language literature is reviewed. The importance of recognizing this reversible glomerulonephritic lesion is emphasized.

The role of propranolol therapy and proteinuria in the etiology of post renal transplantation hyperlipidemia

The effects of propranolol and proteinuria on the fasting lipoprotein profiles of 33 male renal allograft recipients have been studied. By isolating the two variables by division of the patients into four groups according to propranolol dose and proteinuria, i.e. 1. propranolol = 0 mg/24 hr, proteinuria; less than 0.5 g/24 hr; 2. propranolol less than 0 mg/24 hr, proteinuria; less than 0.5 g/24 hr; 3. propranolol = 0 mg/24 hr, proteinuria; less than 0.5 g/24 hr; and 4. propranolol greater than 0 mg/24 hr, proteinuria; greater than 0.5 g/24 hr, it has been shown that propranolol treatment elevates the very low density lipoprotein triglyceride and decreases the high density lipoprotein cholesterol and that proteinuria (greater than 0.5 g/24 hr) increases low density lipoprotein cholesterol. The possible significance of these results in terms of transplantee management is discussed.

Effect of xipamide in oedema of renal disease with varying degrees of renal insufficiency: a comparative trial with frusemide

In an open crossover trial, 15 patients with evidence of renal impairment, defined by proteinuria, raised serum creatinine or impaired creatinine clearance, were randomly allocated to treatment with either 40 mg frusemide or 40 mg xipamide daily for 7 days. After a 3-day mid-point wash-out period, patients were changed the alternative drug for a further 7 days. Assessment measures involved a wide range of clinical and biochemical parameters. Whilst both drugs significantly reduced oedema, xipamide was more effective than frusemide, and this was associated with a significantly greater effect on sodium excretion with xipamide. With the exception of standing systolic blood pressure where the reduction was significantly more pronounced with xipamide, no significant changes in resting systolic, resting diastolic or standing diastolic pressure were observed to be associated with change of treatment. Three patients noticed minor side-effects during xipamide therapy. There were no adverse reactions inpatients taking frusemide.