Radiation dose from DXA scanning to reproductive tissues of females

The objective of this study was to use an anatomically arrayed whole-body phantom to measure radiation exposure to the ovaries and uterus during standard dual-energy Xray absorptiometry (DXA) scanning. DXA instrument manufacturers' published entrance skin exposure is about 3 mR (0.77 microC/kg), which is equivalent to the radiation exposure received during a transcontinental plane trip. Nonetheless, since DXA scanning is used more frequently with very young females, the need for pregnancy testing has become an issue that requires attention and formulation of research guidelines. We attached thermoluminescent dosimeters (TLDs) to anatomically arrayed balloon models for ovaries and the uterus, and placed these in the appropriate sites within a small human skeleton along with appropriate amounts of aqueous and fat soft tissue equivalents. Whole-body scanning with a Hologic QDR-2000W was performed 10 times with the pencil beam mode and, using separate TLD detectors, 10 times with the fan beam mode. Overall, the average exposures at skin entrance were 0.89 mR (0.23 microC/kg) with doses for the ovaries of 0.52 mrad (5.2 microgy) and 0.59 mrad (5.9 microgy) for the uterus. These doses are equivalent to 2 d of ambient background radiation in central Pennsylvania or 1 h of flying at 39,000 ft. Although different DXA models by Hologic and DXA instruments by other manufacturers will have different radiation outputs, we believe that these low radiation levels do not require pregnancy testing or questioning of whether the scan subject might be pregnant.

Contrast venography in young haemophiliacs with implantable central venous access devices

To assess the risk of deep vein thrombosis in haemophiliacs with long-term central venous catheters, we studied haemophiliacs followed at our centre with implantable venous access devices (ports) in place for > 6 months. Medical records were reviewed for a history of catheter-related complications. Each patient was examined for physical stigmata of thrombosis. Patency of the vessels was evaluated by contrast venography. Of 21 males with ports, 19 had factor VIII deficiency and two factor IX deficiency. Nineteen ports were evaluable (i.e. were in place for > 6 months). Seventeen patients have their original ports in place; two ports were replaced for mechanical dysfunction (1) and recurrent infection (1). Difficulty withdrawing or infusing occurred with three ports, two of which were cleared with urokinase. Physical examination was normal on all 19 patients. Venograms were performed in 13 of 19 patients. Parents of the remaining six patients refused venography because of the need for peripheral venipuncture. One patient had a small nonocclusive thrombus on the same side as his functioning catheter, and another had minimal narrowing of the subclavian vein at the site of a prior catheter. The overall prevalence of clinically relevant upper venous system thrombosis identifiable by contrast venography was zero (95% CI, 0-23%). We conclude that haemophiliacs do not have as high a risk of thrombosis as other populations of patients with central venous catheters. The theoretical risk of thrombosis should not preclude use of central venous catheters in patients with haemophilia.

Pelvic floor electrical stimulation for the treatment of urge and mixed urinary incontinence in women

OBJECTIVES

To determine the efficacy of daily or every-other-day electrical stimulation in treating detrusor instability (urge) or urge plus genuine stress (mixed) urinary incontinence in women.

METHODS

A multicenter, prospective, nonrandomized study enrolled subjects with urge and mixed urinary incontinence assigned to daily or every-other-day treatments (15 minutes twice daily) using pelvic floor stimulation. Outcome measures assessed were (1) leakage episodes, nocturnal episodes, voiding frequency, total voids, and pad count, and (2) patient subjective assessment and quality of life.

RESULTS

Seventy-two subjects were enrolled. Sixty-eight subjects completed the 20-week protocol: 33 treated daily and 35 treated every other day. The entire study group (n = 68) experienced a significant decrease in total leaks (P < 0.001), nocturnal episodes (P = 0.001), pad count (P = 0.002), and total voids (P = 0.003) and on visual analog scales. Sixty-nine percent (n = 46) of subjects with urge or mixed incontinence were cured or improved by at least 50%, with 28% (n = 19) being cured. There were no significant differences between daily and every-other-day users. Nonresponse was correlated with number of previous therapies (P < 0.001) and number of vaginal deliveries (P = 0.007). Overall, subjects were 93% compliant with device use, and 72% (n = 47) were satisfied with the therapy.

CONCLUSIONS

Twenty weeks of pelvic floor electrical stimulation therapy is effective in treating urge and mixed urinary incontinence, regardless of daily or every-other-day treatments.

Symptom management outcomes. Do they reflect variations in care delivery systems?

OBJECTIVES

Symptom management is increasingly recognized as a critical element of patient care, particularly in managing chronic illness. However, research on outcomes related to symptom management is in its infancy, except for the symptom of pain. This symptom was therefore chosen as a prototype to review the state of the science regarding relations between organizational variables and symptom management outcomes and to illustrate the issues regardless of the symptom managed. This article discusses pain outcome measures appropriate for acute and cancer pain, proposes attributes of the care delivery system that may affect outcome measures, and identifies challenges associated with this type of research.

METHODS

Review of quality assurance studies raises issues concerning the adequacy of currently used outcomes for pain and satisfaction with pain management. Although considerable effort has been expended in developing pain measurement in adults and children, critical issues for examining pain management outcomes include deciding what perspectives should be used as the most valid indicator of the pain outcome and when the measures should be obtained.

RESULTS

Critical concerns are raised about the measure of satisfaction with pain management and its appropriateness as the end-result outcome. A key issue is whether respondents actually disentangle satisfaction with pain management from satisfaction with other aspects of care, including caring dispositions of health-care providers. Finally, the question is raised: Are pain outcomes affected by organizational context?

CONCLUSIONS

Although the answer to this question is unknown, a few research studies suggest that organizational context is likely to influence pain outcomes. It is clear, however, from ongoing work that until several conceptual, methodological, and analytic challenges are resolved, research is unlikely to capture the influence of variations in care delivery systems on symptom management outcomes.

Operating on the elderly woman--what are her special needs?

Current studies verify the safety of surgery in the elderly. Delirium is a costly complication, but its incidence and severity can be reduced by pre- and postoperative interventions. Avoidance of even mild hypothermia has now been shown to reduce cardiovascular morbidity. New information available on the cardiovascular response of elderly patients to laparoscopic surgery highlights the importance of avoiding preoperative dehydration. Proper pain management minimizes complications and promotes recovery.

Chloroform-induced olfactory mucosal degeneration and osseous ethmoid hyperplasia are not associated with olfactory deficits in Fischer 344 rats

Adult female F-344 rats were trained (avoidance rate > 70%) over four days with a coupled tone- (n = 10 rats/dose) or 2 ppm acetaldehyde-cued (n = 6 rats/dose) foot shock paradigm. Rats were gavaged with chloroform dissolved in corn oil for 5 days/week for 3 week at 0 or 400 (tone-cued) or 0, 34, 100, or 400 (odor-cued) mg/kg body weight/day. Tone-cued response was reevaluated 6, 16, and 38 days after the first chloroform dose (day 1). Olfaction was assessed on days 6-7, 20-21, and 41-42 using 2 or 0.0002 ppm acetaldehyde. Nasal histopathology (n = 4-5 rats/dose) was assessed on days 6, 20, and 42. Significantly decreased body weights were observed following a single 100 or 400 mg/kg chloroform dose. Body weights in the 400 mg/kg/day chloroform group remained depressed for 17 days. Histopathology revealed degenerative changes in olfactory mucosa and underlying ethmoid turbinate bones that were essentially identical in nature and severity, including dose-response and progression, to those reported previously for chloroform gavage (Larson et al., Food Chem. Toxicol., 1995;33:443 456). At all dose level and sacrifice timepoints, however, regions of morphologically normal olfactory mucosa were present, especially in dorsal medial and ventral lateral regions of the nose. Neither odor- nor tone-cued avoidance behaviors were affected, indicating that even fairly severe and extensive chloroform-induced olfactory mucosal degeneration is not associated with a detectable olfactory deficit in rats.

Multisite clinical research: a challenge for nursing leaders

The need for the application of research-based data to diversified healthcare systems has led to more attempts by nurse researchers to investigate phenomena across clinical sites. Nurse executives increasingly are asked to justify resource allocation among organizations, and must compare patient-care practices within complex systems that are often geographically distant. This article describes the pitfalls encountered and the progress made by researchers during a 4-year multisite, multimethod clinical investigation collecting clinical outcome and organizational context data from seven hospitals.

Hormone replacement therapy in the elderly

Hormone replacement therapy improves the quality of life and prolongs life for many elderly women, whether it is initiated at menopause or much later. Counseling about hormone replacement therapy should be given to all postmenopausal women. Patients should be advised that estrogen will lower the chances of death and disability from cardiovascular disease and osteoporosis. Those with low bone density or risks for cardiovascular disease, including smoking and hypertension, will benefit more than those without. Older age may predispose a woman to the carcinogenic potential of estrogen. But this should be placed in statistical perspective for the patient, with estrogen's benefit still clearly outweighing the risk. By evaluating her personal history and attitudes, the physician should help the patient decide if the potential benefit is worth either the risk or the inconvenience of side effects. Although the available data bespeak the general advantages of estrogen replacement, optimum dose, type of estrogen, time of initiation, and duration of therapy need further study in the geriatric population.

Urinary tract infections: children are not little adults

Urinary tract infection (UTI) is a commonly diagnosed condition in pediatric practice caused by a wide variety of organisms and conditions. Presenting with multiple signs and symptoms, UTI is frequently unrecognized and has the potential to cause permanent renal damage if recurrent or untreated. Nurses have a unique opportunity to prevent this condition, assist in the diagnosis, and contribute to management.

Self-perceptions of preschool children with spina bifida

The purpose of this study was to compare self-perceptions of 21 preschoolers with spina bifida with those of 21 physically able preschoolers. Each child was asked to draw a self-portrait, fill in the most important body parts on an outline of a child, complete the Pictorial Scale of Perceived Competence and Social Acceptance for Young Children, and rate feelings about self, family, peers, and health care professionals. The spina bifida group drew significantly fewer legs, feet, and trunks than physically able children. The preschoolers with spina bifida rated themselves as significantly different on physical and cognitive competence but not on maternal or peer acceptance. Clinical nursing implications of these data are discussed.

Pelvic floor electrical stimulation: a comparison of daily and every-other-day therapy for genuine stress incontinence

OBJECTIVES

To compare the effectiveness of daily and every-other-day electrical stimulation in treating genuine stress incontinence.

METHODS

Subjects with genuine stress incontinence were enrolled in a multicenter, prospective, nonrandomized study and underwent daily or every-other-day pelvic floor stimulation treatments for 15 minutes twice a day. Outcome measures assessed were (1) leakage episodes and pad count; (2) leakage amount, and (3) subject subjective assessment and quality of life. Thirteen subjects treated daily and 15 treated every other day completed the 20-week protocol. One-year follow-up data were available for 21 subjects.

RESULTS

No significant differences in primary outcome variables were found between the groups. Subjects treated every other day had significant decreases in total leakage episodes (P = 0.04), pad count (P = 0.04), total voids (P = 0.02), and visual analog scale scores, with stress incontinence cured or improved by 50% in 73% (n = 11). Subjects treated every day had significant decreases in urge episodes (P = 0.03), pad count (P = 0.05), and visual analog scale scores, with 62% (n = 8) cured or improved by 50%. Compliance was higher for subjects treated every other day (P = 0.05). Satisfaction with therapy was 75% (n = 10) for daily treatment and 77% (n = 12) for every-other-day treatment. At 1 year, 70% (n = 7) of subjects who continued device use maintained their cure or improvement status.

CONCLUSIONS

Both daily and every-other-day therapy with pelvic floor electrical stimulation are effective in treating genuine stress incontinence. Subjects who continue device use maintain a higher curve or improvement rate.

Diabetes insipidus

Diabetes insipidus (DI), an acute or chronic condition, results from either of two situations: An inadequate secretion of antidiuretic hormone (ADH) from the posterior pituitary gland or an insufficient renal response to adequate levels of ADH. Characterized by massive urinary output despite progressive serum hyperosmolality, hypernatremia, and dehydration, DI can be life-threatening if not promptly diagnosed and appropriately managed. Individuals with renal disease, surgical patients, and persons with cerebral trauma are at risk to develop this condition.

A novel role for the Fc receptor gamma subunit: enhancement of Fc gamma R ligand affinity

The Fc receptors (FcR), which belong to the immunoglobulin (Ig) superfamily, bind to specific Ig isotypes with varying affinities triggering complex immune defense responses. Several of the FcR that lack signaling motifs in their cytoplasmic domains rely on associated subunits to transmit signals. Two classes of FcR that bind the Fc portion of IgG, Fc gamma RI, and Fc gamma RIIIa associate with a subunit shared among several FcR, the gamma chain, which is involved in receptor expression and signal transduction. In this report, we propose that a novel role for gamma chain is to enhance the affinity of Fc gamma R for ligand. Our findings demonstrate that Fc gamma RI requires gamma -chain association to attain high affinity binding for monomeric IgG, and suggest that the intermediate binding affinity of the Fc gamma RIIIa isoform results from its association with gamma chain. The affinity increase conferred by gamma chain appears to be mediated through the transmembrane domain of the Fc gamma R, with no requirement for the cytoplasmic domain of the receptor.

Selective expression and rapid regulation of GABAA receptor subunits in geniculocortical neurons of macaque dorsal lateral geniculate nucleus

Monocular deprivation in adult macaques produces a rapid down-regulation in GABA and GABAA receptor subunit immunoreactivity in deprived-eye columns of primary visual cortex (VI) but a significantly delayed GABA reduction in deprived layers of the dorsal lateral geniculate nucleus (LGN). These findings, suggesting that normal inhibitory neurotransmission persists in LGN at a time when VI inhibitory mechanisms are greatly altered, are consistent with physiological studies that have demonstrated a greater degree of functional plasticity in VI than in LGN. Nonetheless, functional adaptation to partial loss of visual input has been detected in the LGN, indicating that synaptic plasticity takes place in this nucleus. In the present study, evidence for early changes in inhibitory neurotransmission were examined with immunocytochemical methods to determine if, in the absence of early GABA regulation, GABAA receptor subunits in macaque LGN are affected by adult deprivation. Immunoreactivity for alpha 1 and beta 2/3 subunits of the GABAA receptor was intense within the magnocellular layers and more modest in the parvocellular layers and intercalated layers. In all layers, immunoreactivity was present in the cytoplasm and along the surfaces of relatively large somata and in dense tangles of processes in the neuropil. Double-labeling experiments demonstrated that somata and processes immunoreactive for alpha 1 and beta 2/3 were surrounded by GABA terminals but no cell intensely immunoreactive for either subunit expressed immunoreactivity for GABA, itself. Following periods of monocular deprivation by tetrodotoxin (TTX) injection for 4 days or longer, layers deprived of visual activity displayed levels of alpha 1 and beta 2/3 immunoreactivity markedly lower than those displayed by the adjacent, normally active layers. Such changes were greater as the period of deprivation increased. The changes included a loss of immunostaining in and around somata and in many neuropil elements of deprived layers. These data indicate that GABA and GABAA receptor subunits alpha 1 and beta 2/3 are expressed by separate populations of neurons in macaque LGN that are differentially regulated by visual activity. The findings suggest that rapid, activity-dependent regulation of postsynaptic receptors represents one mechanism for altering synaptic strength in the adult macaque visual system.

Keeping the care in nursing care: our biggest challenge

Although caring is the essence of nursing practice, many nurses are concerned that their ability to care is being compromised by the tumultuous changes occurring in the current healthcare environment. The author explores the challenge of caring in nursing practice, reviews what recent research has shown us about caring in nursing and identifies what we as nurse executives can do to enhance our own caring skills and the caring expertise of clinical nurse colleagues.

Physicians' practices in screening for the development of diabetic nephropathy and the use of glycosylated hemoglobin levels

OBJECTIVE

To compare outpatient screening of diabetic patients for nephropathy and measurement of glycosylated hemoglobin (GHb) levels to published American Diabetes Association (ADA) guidelines.

RESEARCH DESIGN AND METHODS

We reviewed charts from 157 diabetic patients followed for 27 months at the University of Washington's primary care clinics. The number of screening urinalyses, 24-h urine measurements, and GHb measurements were obtained. From these values, the frequency of screening tests, normalized by patient-year, could be compared with the ADA guidelines.

RESULTS

Forty-two percent of the patients received at least one urinalysis, and 5% had 24-h urine measurements. There were 0.48 urinalyses and 0.05 24-h urine measurements per patient-year. Of 14 type I diabetes patients, 5 had a urinalysis and 1 received a 24-h urine measurement. At least one GHb was measured for 85% of patients, and there were 1.66 GHb measurements per patient-year. Only 29% of patients received GHb concentrations as recommended by ADA guidelines.

CONCLUSIONS

Diabetic patients at this institution are not screened for nephropathy and do not receive GHb measurements according to the ADA guidelines. Because of recent advancements in the treatment of diabetic nephropathy and the results of the Diabetes Control and Complications Trial (DCCT), further efforts are needed for educating primary care physicians about standards of care of patients with diabetes.

Endocrine disorders in critically ill children

Endocrine disorders in critically ill infants and children can be the manifestation of an existing but previously unrecognized condition, or hormonal derangements precipitated by deleterious effects on endocrine function of a critical illness or its prescribed therapy. To achieve successful resolution of these crises, a general understanding of various endocrine dysfunctions, clinical symptomatology, diagnosis, and medical and nursing management is essential.

Bactericidal/permeability-increasing protein and lipopolysaccharide (LPS)-binding protein. LPS binding properties and effects on LPS-mediated cell activation

We have previously shown that human bactericidal/permeability-increasing protein (BPI) is able to inhibit serum-dependent lipopolysaccharide (LPS)-mediated activation of human monocytes and neutrophils in vitro, and to counteract the lethal effects of LPS challenge in vivo. Lipopolysaccharide-binding protein (LBP) is a serum protein which participates in LPS-mediated activation of cells (Tobias, P. S., Mathison, J., Mintz, D., Lee, J. D., Kravchenko, V., Kato, K., Pugin, J., and Ulevitch, R. J. (1992) Am. J. Respir. Cell. Mol. Biol. 7, 239-245). We have proposed that BPI functions in a negative feedback loop which opposes this activation (Marra, M. N., Wilde, C. G., Collins, M. S., Snable, J. L., Thornton, M. B., and Scott, R. W. (1992) J. Immunol. 148, 532-537). We have now cloned and expressed recombinant forms of human BPI and LBP. Here we demonstrate that purified recombinant human LBP can replace the serum requirement for both LPS binding to human monocytes and LPS-mediated secretion of tumor necrosis factor alpha from these cells. These activities of LBP are inhibited by a neutralizing anti-CD14 monoclonal antibody. We further demonstrate that purified recombinant human BPI can inhibit LBP-mediated LPS binding to cells and their subsequent activation. Comparison of the LPS binding properties of BPI and LBP in enzyme-linked immunosorbent type assays and in the Limulus amebocyte lysate assay suggest that BPI has a stronger affinity for LPS than does LBP. Direct competition between BPI and LBP for LPS may explain the inhibition by BPI of the proinflammatory effects of LBP in the presence of LPS.

Immunoglobulin clonality analysis. Resolution of ambiguities in immunofixation electrophoresis results by high-resolution, two-dimensional electrophoretic analysis of paraprotein bands eluted from agarose gels

This article describes evaluation of the clonality of origin of immunoglobulin (Ig) chains by strategies that include qualitative analysis of paraproteins with high-resolution, two-dimensional electrophoresis (2DE) and silver staining. This approach is helpful in evaluating specimens in which standard immunoelectrophoresis or immunofixation electrophoresis (IFE) techniques do not provide definitive Ig typing results. One method the authors developed involves a "band elution" procedure, in which proteins present in high-resolution agarose gel electrophoresis bands are cut from the agarose gel, eluted with a denaturing buffer, and subjected to 2DE. The microheterogeneity patterns of the Ig light chains, heavy chains, or both are evaluated for their relationship regarding mass, charge, and, by inference, number of genes of origin. When necessary, determination of charge relationships may be aided by urea-mediated carbamylation of lysine residues, which introduces single-charge shifts to the individual protein subunits. Overall, these adjunctive techniques are particularly useful in cases with multiple bands of identical immunologic types (eg, several IgG1 bands) on IFE before and after sulfhydryl reduction (with dithiothreitol or 2-mercaptoethanol). The authors present procedural details and examples of the 2DE band elution patterns of serum and urine samples from four patients with B-cell dyscrasias, including the first reported case of POEMS syndrome with biclonal gammopathy, to the best of their knowledge.

Alternatives to estrogen for menopausal symptoms

It is not within the scope of this chapter to discuss the long-term effects of menopause, such as osteoporosis or heart disease, or to disentangle the complex psychosocial complications and treatments of menopausal mood disorders. All long-term consequences of hypoestrogenism are more amenable to prevention than to cure, as are all the negative consequences of aging. Women should maintain regular physical activity, consume a diet low in fat and high in fiber, ensure adequate calcium intake, and possibly lower animal protein consumption. Moreover, they should know their cholesterol levels and undergo regular physical examinations with an emphasis on health maintenance. Despite the many advantages of estrogen replacement therapy, it is not appropriate for all women. Cultural, personal, and medical considerations may eliminate the use of estrogen, in which case it is important to offer alternative medical advice and direction to minimize bothersome symptoms of menopause and enhance the quality of life.

Alterations in erythropoiesis in TGF-beta 1-treated mice

Chronic treatment of mice with transforming growth factor beta 1 (TGF-beta 1) resulted in a dose-dependent inhibition of erythropoiesis. Following 14 daily s.c. injections of 5 or 25 micrograms of TGF-beta 1, a significant degree of anemia was observed. In addition, erythroid progenitor cells were present in reduced numbers in the bone marrow and spleen. Pluripotent stem cells were present in normal numbers in the bone marrow of mice treated with 25 micrograms of TGF-beta 1. However, significantly elevated levels were present in the peripheral blood. Adequate levels of erythropoietin were present in TGF-beta 1-treated mice. Following suspension of treatment with TGF-beta 1, erythropoiesis was restored, and TGF-beta-treated mice were able to compensate the anemia. One week following treatment, only mice treated with 25 micrograms of TGF-beta 1 continued to show evidence of anemia. However, in contrast to 1 day following treatment, these mice had levels of reticulocytes that were significantly above control values. In addition, erythroid progenitor cells had returned to normal levels in the bone marrow and were present in elevated levels in the spleen in both groups of TGF-beta 1 treated mice. The results provide evidence that the anemia associated with sustained TGF-beta 1 treatment is the result, in part, of a reversible inhibition of the maturation of erythroid progenitor cells.