Severe hyponatraemia in a quadriplegic

A young quadriplegic patient developed convulsions and brain damage due to severe hyponatraemia. Potential causes of severe hyponatraemia in quadriplegics include excessive water intake (because of the low threshold for vasopressin release) and asymptomatic renal tract infection causing sodium loss. Mild hyponatraemia, occurring in up to 10% of quadriplegics, is due to a reset osmostat.

Combined 17 alpha-hydroxylase/17,20-lyase deficiency caused by heterozygous stop codons in the cytochrome P450 17 alpha-hydroxylase gene

OBJECTIVE

To determine the genetic defect underlying congenital adrenal hyperplasia due to 17 alpha-hydroxylase deficiency in a genetic female.

DESIGN

Blood samples were used as a source of genomic DNA. A library of size selected genomic DNA sequences was prepared. In addition, portions of the 17 alpha-hydroxylase gene were amplified by the polymerase chain reaction and the gene products sequenced.

PATIENTS

Samples were obtained from a patient with sexual infantilism, lack of secondary sexual characteristics and hypertension. Streak gonads were found on laparoscopy.

RESULTS

Two point mutations were found, one in exon 3 and one in exon 4 which generate premature stop codons at codons 194 and 239 in place of glutamate and arginine respectively. The mutation in exon 3 has not previously been reported in patients with 17 alpha-hydroxylase deficiency.

CONCLUSION

The protein product of these defective genes could be expected to be severely truncated with no catalytic activity. This is in keeping with the complete lack of cortisol and sex steroid output in this patient. The polymerase chain reaction provides faster access to gene sequence information than previous procedures based on library screening prior to sequencing.

Further studies on the feasibility of one-day Salmonella detection by enzyme-linked immunosorbent assay

A model system previously developed for the rapid detection of Salmonella typhimurium in foods was improved and extended to many other Salmonella serotypes. The original protocol, which consisted of an overnight nonselective culture followed by a specific enzyme-linked immunosorbent assay (ELISA), was modified and improved. A sandwich ELISA which used polyclonal antibodies for the capture stage and a cocktail of monoclonal antibodies for the detector stage was developed. The assay recognized a wide range of Salmonella serotypes; S. enteritidis, the most important serotype in the United Kingdom had a detection limit in the ELISA of about 4 x 10(2) cells ml-1. The cultural stage prior to the ELISA was either a single nonselective broth (incubated for 28 h) or a preenrichment broth (incubated for 7 h) plus a selective broth (incubated for 21 h). Antibodies which bind to cells grown in the unfavorable conditions of a selective medium were selected. It was concluded that, in the future, the shortened protocols for the detection of Salmonella spp. in foods described here will be of considerable value.

Milk-alkali syndrome due to Caved-S

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Lack of correlation between IgG T-lymphocyte flow cytometric crossmatches with primary renal allograft outcome

The flow cytometric crossmatch (FCXM) has been reported to be more sensitive and capable of detecting very low levels of antibodies than the normally used complement dependent cytotoxicity test. We studied both the two colour IgG T cell FCXM and CDC-XM in 146 renal allograft recipients, 111 primary and 35 regrafts, of which 26% (29/111) of 1st and 20% (7/35) of regrafts had a positive FCXM. There was no overall correlation between the FCXM results and early graft outcome in primary renal allografts. The FCXM did not appear to have any advantage over the CDC-XM in predicting graft outcome in unsensitized first grafts. In the small number of regrafts studied, a positive FCXM was associated with a higher degree of graft failure. FCXM can exhibit false negative results if sera are used solely neat although these prozone phenomena do not influence subsequent graft outcome.

Uraemia: is urea more important than we think?

Urea is accumulated as an osmolyte by some groups of animals even though it impairs protein function. These organisms can withstand high internal urea concentrations because they also accumulate other low-molecular-weight osmolytes, the methylamines, which can offset the effects of urea on proteins. Methylamines have also been found in the medulla of the mammalian kidney (where urea concentrations are high) and in the plasma of human subjects with chronic renal failure. These findings suggest that previous investigations of the potential contribution of urea to the syndrome of uraemia may have been confounded because of the presence of variable concentrations of protective substances. That naturally occurring methylamines or related substances may prove to have a useful therapeutic role in uraemia is also possible.

Bartter's syndrome and diabetes mellitus

We here report a case of Bartter's syndrome occurring in association with diabetes mellitus. The patient, an insulin-dependent diabetic, presented with hypokalaemia, inappropriate kaliuresis and metabolic alkalosis. He had high plasma renin activity, relatively low plasma aldosterone, and resistance to infused angiotensin II. A high potassium diet raised total body potassium and serum potassium, did not affect plasma renin activity, but raised plasma aldosterone significantly and did not alter the resistance to angiotensin II. Indomethacin administered acutely reduced urinary potassium and kallikrein excretion and, on chronic administration, lowered plasma renin activity, urinary chloride excretion, and raised serum potassium. Salt restriction resulted in a prompt and significant reduction in urinary sodium and chloride excretion. Urinary kallikrein excretion was very high throughout, increased with sodium restriction, and decreased with sodium loading. Oral potassium supplementation partially corrected the hypokalaemia, but did not affect blood sugar control. In this patient the primary defect appears to have been primary urinary potassium wasting, rather than sodium or chloride wasting. The striking effects of indomethacin suggest that prostaglandins may play a fundamental role in the genesis of the syndrome.

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.