Pulmonary function in spinal muscular atrophy

We present the first prospective study on pulmonary function in spinal muscular atrophy patients. Seventy-seven spinal muscular atrophy patients, ages 5 to 18 years, from three centers, were studied with regard to forced vital capacity, using height as a predictor. Patients were categorized into four motor function categories. The highest-functioning group had normal or near-normal values, and those who sat with support had the lowest values. Those with intermediate function had intermediate values. Forced vital capacity was studied longitudinally in 40 spinal muscular atrophy patients for 1.1 to 4.4 years. Eighty-eight percent of patients grew in height, but only 35% showed an increase in height-adjusted forced vital capacity percent. In those patients with the least function, 100% lost height-adjusted forced vital capacity over time. In those patients with the highest function, 57% lost height-adjusted forced vital capacity. In addition, the basic forced vital capacity, not correlated to height, decreased in 43% of cases. These pulmonary function alterations appear to be important determinants for function and survival in spinal muscular atrophy patients.

Independent regulatory elements in the nestin gene direct transgene expression to neural stem cells or muscle precursors

Changes in intermediate filament gene expression occur at key steps in the differentiation of cell types in the mammalian CNS. Neuroepithelial stem cells express the intermediate filament protein nestin and down-regulate it sharply at the transition from proliferating stem cell to postmitotic neuron. Nestin is also expressed in muscle precursors but not in mature muscle cells. We show here that in transgenic mice, independent cell type-specific elements in the first and second introns of the nestin gene consistently direct reporter gene expression to developing muscle and neural precursors, respectively. The second intron contains an enhancer that functions in CNS stem cells, suggesting that there may be a single transcriptional mechanism regulating the CNS stem cell state. This enhancer is much less active in the PNS. The identification of these elements facilitates analysis of mechanisms controlling the switch in gene expression that occurs when muscle and brain precursors terminally differentiate.

Metastatic prostate cancer to the optic canal

PURPOSE

Optic neuropathies represent a common cause of blindness among patients with cancer. The authors present the clinical and imaging findings and discuss the management of optic nerve involvement from metastatic prostate cancer to the optic canal.

METHODS

Five patients with advanced metastatic prostate cancer had visual loss. Neuro-ophthalmologic examination and pre- and post-gadolinium orbital and brain magnetic resonance imaging (MRI) were performed. Compressive optic neuropathy secondary to extensive optic canal involvement was demonstrated in all of the patients. Neuropathologic examination was accomplished in two cases. A combination of steroid and focal radiation therapy was used for treatment in four patients.

RESULTS

Imaging and neuropathologic findings demonstrated a compressive optic neuropathy secondary to both epidural metastases and to deformity and hypertrophy of the optic canal due to metastatic cancer. Treatment was of benefit in three cases.

CONCLUSION

Acute and subacute unilateral or bilateral optic neuropathy in patients with prostate cancer may be the result of optic canal metastases. Magnetic resonance imaging shows a characteristic pattern of bone hypertrophy and deformity with optic nerve compression. Early combination steroid and radiation therapy may induce long-lasting improvement.

Spinal muscular atrophy: new thoughts on the pathogenesis and classification schema

We have established the first prospective, collaborative study of spinal muscular atrophy, the second most common neuromuscular disease of childhood. One hundred and forty-one patients have been evaluated on at least four occasions over a 3-year period. The patients have been grouped by age of onset, as well as by function at the time of initial evaluation. The muscle strength of 96 patients aged 5 years or older was evaluated at 6-month intervals using a fixed myometry system. The new observations made are: (1) The present classification schema is not valid; for example, 49 patients with onset of weakness before 6 months of age (type I or Werdnig-Hoffmann disease), whose life span is said to be only 2 to 4 years, participated in the study and are 4 months to 31 years of age. (2) Thirty-seven patients were evaluated over an 18-month period. None lost strength during this time but four lost function. Although the period of observation was short, the results suggest that the loss of function in patients with spinal muscular atrophy might be explained by a process other than cell death that allows patient strength to be maintained and simultaneously prevents the motor unit from achieving its normal adult potential.

Ciliated respiratory-like epithelium forming cystic conjunctival lesions in a patient with Stevens-Johnson syndrome

A woman with severe cicatricial conjunctival changes secondary to allopurinol-induced Stevens-Johnson syndrome developed bilateral palpebral conjunctival cysts. Pathologic examination of these lesions revealed respiratory-like pseudostratified ciliated epithelium in the walls of several cysts of one eye. To our knowledge, this is the first report of this phenomenon.

The relationship of SPECT scans to behavioral dysfunction in neuropsychiatric patients

The authors describe 20 neuropsychiatric inpatients consecutively evaluated in the context of routine clinical care. Patients had both a neurological and psychiatric disorder. Each was clinically evaluated as part of a psychiatric hospitalization. DSM-III-R diagnoses, electroencephalograms, magnetic resonance imaging (MRI) or computed tomography (CT) scans of the brain, single photon emission computed tomography (SPECT) scans of the brain, and cognitive testing are reported. In only three cases were SPECT, MRI (or CT), and electroencephalogram all normal. SPECT abnormalities were associated with behavioral and cognitive presentations and with the hypothesized anatomical areas of dysfunction in 16 cases. In six cases SPECT and MRI were equivalent, involving structural lesions or normal scans. In only one case did MRI (or CT) detect deficits not revealed by SPECT, which were nonspecific white matter lesions and atrophy. The authors conclude that SPECT scans may be superior to structural brain scans in detecting clinically relevant deficits in neuropsychiatric patients, particularly when physiological lesions are involved.

Pain and psychological distress in patients undergoing autologous bone marrow transplantation

The major goal of this descriptive study with repeated measures was to better understand the pain and psychological distress of patients undergoing autologous bone marrow transplantation (ABMT). A second goal was to gain insight into potential treatment strategies by examining the pattern of locus of control and coping strategies used by the subjects. The sample was composed of 17 people (12 men and 5 women) diagnosed with Hodgkin's lymphoma and pretreated with high-dose chemotherapy prior to ABMT. Data collection instruments were the Pain-O-Meter (POM) (Gaston-Johansson, Omaha, NE), the State-Trait Anxiety Inventory (STAI), the Beck's Depression Inventory (BDI), the Multidimensional Health Locus of Control (MHLC), and the Coping Strategy Questionnaire (CSQ). The instruments were administered two days prior to the ABMT and 5, 10, and 20 days following the ABMT. The data were analyzed using descriptive statistics and an ANOVA for repeated measures. The study showed that the patients experienced a low-grade, persistent pain that was multifocally located. Mild to moderate anxiety and depression were present throughout the hospitalization. The patients used inadequate coping strategies and reported that they had little ability to control or decrease their pain. These findings indicate a need for clinicians to develop treatment strategies to deal with pain and psychological distress experienced by patients undergoing ABMT.

Variations among nurses in behavioral intentions toward the dying

The purposes of this study were to describe nurses' behavioral intentions toward the dying and to determine if they were related to selected characteristics of nurses caring for the dying. A questionnaire containing behavioral intention items and a characteristics profile was completed by 372 registered nurses working in a variety of settings in one midwestern state. Analyses of the data suggested that although nurses were very likely to provide general nursing care and to communicate openly with the dying, they were not likely to provide continuing care for bereaved family members. Major implications of the study were that the continuing care needs of bereaved family members are not being met by nurses in traditional health care settings, and that different groups of nurses have different approaches to care of the dying as well as different learning needs.

Factors influencing patient entrance into a cardiac rehabilitation program

The purpose of this descriptive pilot study was to identify factors that influence patient participation in a cardiac rehabilitation program. Thirty-nine patients who were admitted to a midwestern hospital with a coronary problem and who were candidates for cardiac rehabilitation completed the Patient Entrance Into a Cardiac Rehabilitation Program (PECRP) questionnaire. The PECRP evaluates a subject's responses to Health Belief Model-based statements. Analysis by t test revealed significant differences for perceived benefits and barriers, indicating that patients who participated in a cardiac rehabilitation program perceived more benefits and fewer barriers to entering such a program than those who did not. No significant differences were found between groups for perceived susceptibility and perceived severity constructs. Analysis of demographic variables revealed significant differences for income and marital status on the perceived benefits and barriers construct, indicating that those who had an income greater than $20,000 and those who were married perceived more benefits and fewer barriers than those whose income was less than $20,000 and who were not married. Nursing implications for these patients are discussed, particularly those related to patient teaching before discharge.

A comparison of frequency and sources of nursing job stress perceived by intensive care, hospice and medical-surgical nurses

This study compared the frequency and sources of nursing job stress perceived by 35 intensive care (ICU), 30 hospice and 73 medical-surgical nurses. Analysis of variance revealed no significant differences among the three groups of nurses on the overall frequency of job stress. Post-hoc Tukey tests demonstrated a significant difference in three stress subscales among the three groups. ICU and hospice nurses perceived significantly more stress than medical-surgical nurses related to death and dying; ICU and medical-surgical nurses perceived significantly more stress than hospice nurses related to floating; and medical-surgical nurses perceived significantly more stress than ICU and hospice nurses related to work-overload/staffing. Spearman-Rank Correlation revealed no significant correlations among the three groups in their rank-ordering of the eight stress subscales. Death and dying situations were the most stressful to ICU and hospice nurses, while work-overload/staffing situations were the most stressful to medical-surgical nurses. Results of the study, although not generalizable, have implications for nurse managers.

Similarities in pain descriptions of four different ethnic-culture groups

The purpose of this study was to identify pain terms commonly used by Hispanics, American Indians, blacks, and whites to describe painlike experiences. Subjects were asked to rate the intensity of the terms pain, ache, and hurt on a Visual Analogue Scale. Following this procedure, they were given three separate copies of the McGill Pain Questionnaire and asked to choose the words that represented pain, ache, and hurt, respectively. The results showed that all cultural groups rated pain as the most intense terms, followed by hurt; ache was rated least intense. There was a significant difference between the intensity level of the three terms (p less than 0.001). Word descriptors that distinguished pain from ache and hurt are presented. The importance of these findings for clinical practice is discussed.

Pain description by nurses and physicians

The purpose of this study was to determine if nurses and physicians selected similar words to describe painlike experiences and to determine how they rated terms commonly used to describe pain. Thirty-seven registered nurses and 21 physicians comprised the sample. The Visual Analogue Scale (VAS) was used to measure the terms ache, hurt, and pain. The McGill Pain Questionnaire (MPQ) provided a list of word descriptors from which the subjects selected words that best represented the terms ache, hurt, and pain. There was no significant differences between the nurses and physicians in the mean rating of any of the pain terms on the VAS. The nurses and physicians chose very similar word descriptors from the MPQ to discriminate one pain term from another. These findings suggest that nurses and physicians may have a common understanding of the language used to describe painlike experiences.

Phenylacetylglutamine and hippuric acid in uremic and healthy subjects

Phenylacetyglutamine (PAG) and hippuric acid (HA) were determined in protein-free filtrates of plasma and urine from patients with chronic renal failure and healthy subjects, using reverse phase high performance liquid chromatography. Plasma accumulation of the metabolites was detected when the creatinine clearance was below 15 ml/min. Protein-binding studies showed that PAG was not bound to plasma proteins but that HA was partly bound. Concentrations of PAG and free HA in plasma did not correlate with values of serum urea or creatinine. Hemodialysis decreased the plasma concentration of PAG and free HA to about the same extent as that of urea and creatinine. The average renal clearances of PAG and HA were about 1.4 and 5 times higher, respectively, than the creatinine clearance. The daily excretion rates of PAG, HA, urea, and creatinine were similar in non-dialysis patients with a creatinine clearance higher than 15 ml/min and in healthy subjects, whereas patients with a creatinine clearance below 15 ml/min had lower excretion rates of urea, creatinine, and HA. However, the average excretion rate of PAG was in the same range in uremic and healthy subjects. The excretion rate of HA, but not of PAG, correlated with that of urea and creatinine.

Identification and determination of phenylacetylglutamine, a major nitrogenous metabolite in plasma of uremic patients

Phenylacetylglutamine, a constituent of normal urine, was identified and quantitated in plasma ultrafiltrates from uremic patients. Its concentration ranged from 18 to 366 mumol/l, which shows a greater individual variation than those for the concentrations of urea and creatinine. The plasma level was reduced by hemodialysis. In ultrafiltrates from healthy subjects phenylacetylglutamine could not be detected with the methods used. Thus, it is a major nitrogenous metabolite that accumulates in uremia. A reverse phase HPLC method for the quantitative determination of phenylacetylglutamine in plasma ultrafiltrates is described.

Clinicopathological findings in a growing optic nerve melanocytoma

We present an unusual case of a melanocytoma of the optic disc that showed documented progressive growth over a period of six years. It reached the largest size of any reported optic nerve melanocytoma and the eye was enucleated because of the possibility of malignant degeneration. Optic nerve melanocytomas are locally invasive but are not known to undergo transformation into malignant melanoma. Follow-up should remain the primary approach in the management of patients with optic nerve melanocytomas, as previously advocated by Zimmerman.

Elevated concentration of 5-hydroxytryptamine in ultrafiltrate of human liver vein plasma after infusion of amino acids

Intragastric infusion of amino acids causes the release from the liver of a factor with stimulatory effect on smooth muscle. The effect of liver vein plasma ultrafiltrate was tested on isolated preparations of rat fundus. The ultrafiltrates collected after amino acid infusion had a 3-5 times higher stimulatory effect on smooth muscle contraction than those collected from control plasma. The active principle was isolated, purified by different chromatographic procedures and identified as 5-hydroxytryptamine (serotonin). No other compound with contractile effect on smooth muscle was detected.

The Development and Validation of a Scale Measuring Effective Clinical Teaching Behaviors

The purpose of this methodological study was to describe the development and validation of an instrument that would measure effective clinical teaching behaviors of nursing faculty. Two hundred eighty-one nursing students evaluated their clinical instructors using a 43-item Likert scale entitled "Effective Teaching Clinical Behaviors" (ETCB), and data were used to test the validity and reliability of the instrument. Content validity of the scale is adequately documented, and factor analysis suggests that the tool is measuring one major factor, "effective clinical teaching behaviors." Internal consistency and test-retest reliability coefficients achieved satisfactory standards for reliability. Alternate scales reliability coefficient was also satisfactory. The ETCB fills a void in the instrumentation available for clinical instructors. Since students are the direct recipients of instruction, it seems imperative that a valid and reliable scale be available for them to evaluate their instruction.

Potential role of a liver-derived factor in mediating renal response to protein

Increases in renal blood flow and glomerular filtration rate occur following the ingestion of a protein-rich meal. It has been postulated that this renal response is stimulated by some hormonal factor. Glucagon has been proposed as a probable mediating hormone, but results of recent studies argue against a direct mediating effect of glucagon. It is postulated that glomerular hyperfiltration induced by various stimuli (protein ingestion, amino acid infusion, glucagon infusion, diabetes mellitus) is associated with increased secretion by the liver of a factor that increases glomerular filtration rate. Preliminary data suggest that serotonin might play a role in mediating the postprandial increases in renal hemodynamics following protein ingestion.