Oral prednisolone supplement abolishes the acute adverse effects following initiation of depot bromocriptine therapy

OBJECTIVE

Although an effective treatment for hyper-prolactinaemia, initiation of bromocriptine therapy may be associated with significant acute side-effects in some patients, particularly nausea, vomiting and postural hypotension. These may be minimized by initial treatment with i.m. depot bromocriptine (Parlodel-LAR, Sandoz, Basel, Switzerland), but adverse effects following the first injection may still be a significant problem. Following the observation that cortisol deficient patients were subject to an increased incidence of severe side-effects on initiation of bromocriptine therapy, we have evaluated whether concurrent administration of oral prednisolone to patients without cortisol deficiency might reduce adverse effects.

DESIGN

Double-blind placebo-controlled trial with prednisolone (20 mg) prior to, and 16 hours after, depot injection of i.m. bromocriptine (50 or 100 mg).

PATIENTS

Twenty-one consecutive patients with hyperprolactinaemia (serum prolactin > 1000 mU/l on 3 separate occasions) who were due to start depot bromocriptine and who had a normal cortisol response to insulin-induced hypoglycaemia.

MEASUREMENTS

Symptoms at 0, 16 and 40 hours after injection were assessed using visual linear analogue scales and both inter and intra-group scores were compared by non-parametric tests.

RESULTS

Depot bromocriptine was associated with the significant occurrence of light-headedness and lethargy in the placebo-administered group by 16 hours, and also with nausea and nasal congestion by 40 hours. These symptoms did not occur in the prednisolone-administered group.

CONCLUSIONS

Concurrent oral administration of prednisolone significantly reduces the incidence of acute adverse effects following depot bromocriptine. Two 20 mg doses of prednisolone given at 12-hour intervals may be used to avoid dopamine-agonist-induced adverse effects at the initiation of treatment with depot bromocriptine, and may also be of value in the treatment of side-effects associated with other dopamine agonist drugs.

FcgammaRII-mediated adhesion and phagocytosis induce L-plastin phosphorylation in human neutrophils

L-Plastin is a calcium-regulated actin bundling protein expressed in leukocytes and some transformed cells, which is phosphorylated on serine in response to several different leukocyte-activating stimuli. Adhesion to immune complexes induced L-plastin phosphorylation in neutrophils, as did phagocytosis of IgG-opsonized particles, but insoluble immune complexes in suspension were very inefficient activators of L-plastin phosphorylation. Neutrophils express two IgG Fc receptors, the transmembrane FcgammaRII and the glycan phosphoinositol-linked FcgammaRIIIB. Use of monoclonal antibodies that distinguished the two Fc receptors demonstrated that FcgammaRII ligation was 100-fold more potent at signaling L-plastin phosphorylation than occupancy of FcgammaRIIIB. Depletion of intracellular calcium did not affect FcgammaRII-activated L-plastin phosphorylation, demonstrating that any potential regulation of plastin function by calcium did not affect its phosphorylation. Adhesion to immune complexes caused L-plastin to localize to podosomes, since it colocalized with actin to discrete, punctate Triton X-100-insoluble sites on the adherent neutrophil surface in a pattern indistinguishable from vinculin and alpha-actinin. Nonetheless, localization to podosomes was not required for L-plastin phosphorylation, since both neutrophils from a patient with leukocyte adhesion deficiency (CD18 deficiency) and neutrophils treated with anti-CD18 F(ab')2, which do not form podosomes upon adhesion to immune complexes, phosphorylated L-plastin normally. Indeed, L-plastin was normally phosphorylated in response to adhesion to immune complexes even when the actin cytoskeleton was disrupted with cytochalasin D. We conclude that efficient FcgammaRII-mediated phosphorylation of L-plastin requires cell adhesion but does not require IgG-induced rearrangements of the actin cytoskeleton. These data suggest a model in which plastin phosphorylation and localization to the actin cytoskeleton can act as two distinct mechanisms regulating L-plastin functions in neutrophils adherent to immune complexes.

The association between objective and subjective caregiver burden

Major consequences of the deinstitutionalization movement of the 1960s are the objective and subjective burdens for caregivers of individuals with chronic mental illness. The purpose of this report is to describe the association between the objective and subjective caregiver burdens. Objective caregiver burden is comprised of those tasks required to care for the client, whereas subjective caregiver burden indicates the extent to which the caregiver "minds" performing these tasks. The design is a longitudinal, quasi-experimental study over a 3-year period, i.e., three waves of data were collected between 1991 to 1994. Data were collected via a telephone interview schedule. Both quantitative and qualitative data are reported. The association between objective and subjective burdens is complex. Findings show that although there are many tasks required in the taking care of the client, the caregiver accepts these tasks. The problem occurs with the uncooperative nature of the client in allowing the caregiver to carry out the tasks. The caregiver-client conflict involving excessive demands and embarrassment results in increased subjective burden.

Prevalence of Helicobacter pylori in acromegalic patients during treatment with octreotide

BACKGROUND

Octreotide, a synthetic long-acting analogue of somatostatin, now has an established role in the treatment of acromegaly. In acromegalic patients treated with octreotide there is an increased incidence of gallstones and possibly gastritis.

OBJECTIVES

(1) To compare the seroprevalence of Helicobacter pylori (H. pylori) infection, in acromegalic patients treated with octreotide to that in patients given other treatment modalities. (2) To study retrospectively the temporal relation between H. pylori acquisition and octreotide treatment.

PATIENTS

Three groups of acromegalic patients were studied; 35 (20 M) had been treated with octreotide, 17 (10 M) with bromocriptine and 19 (12 M) had received no pharmacological intervention (untreated, surgically treated or treated with radiotherapy).

DESIGN/MEASUREMENTS

The presence of H. pylori infection was assessed serologically (Bio-Rad GAP test for IgG), using stored serum, on the most recent sample from each patient and on serial samples from patients treated with octreotide.

RESULTS

The prevalence of H. pylori seropositivity was similar in each treatment group, 34, 35 and 37%, respectively. Mean age and duration of acromegaly were similar in the first two groups. Patients who had never received medical treatment were slightly younger. GH levels were similar in all three groups. Patients on octreotide who were seropositive for H. pylori did not differ from those with negative serology with respect to age, duration of acromegaly, duration of octreotide treatment or serum GH level. Serial samples in octreotide treated patients showed a change in status in only one patient; 18 patients continued with negative serology during a mean period of 30 (range 4-62) months. In each of the 6 patients with persistently positive serology during octreotide treatment, stored samples predating octreotide therapy were shown to have already been positive.

CONCLUSIONS

The seroprevalence of H. pylori infection in acromegalic patients does not appear to be increased in a manner dependent on the type or duration of medical treatment. In particular, octreotide therapy, while causing the development of histological gastritis in some patients, does not appear to induce the development of H. pylori infection.

Validity of the Peabody Developmental Gross Motor Scale as an evaluative measure of infants receiving physical therapy

BACKGROUND AND PURPOSE

The purpose of this study was to examine the validity of the Peabody Developmental Gross Motor Scale (PDMS-GM) as an evaluative measure of infants receiving physical therapy.

SUBJECTS AND METHODS

Infants who attended an early intervention program (N = 124) were grouped by diagnosis: cerebral palsy, Down syndrome, hydrocephalus, preterm with developmental delay, full term with developmental delay, and other. The PDMS-GM was administered to each infant three times over a 6-month period by a therapist who did not provide treatment.

RESULTS

Mean scaled scores and age-equivalent scores increased for each group. Individual change was examined using the reliable change index. The results indicated that the change in total raw score for 62% of the infants was greater than what could be attributed to measurement error. When minimal clinically important change was defined as 10 scaled score points, the index of responsiveness was equal to 0.5. This finding indicates that a sample size of 68 subjects per group would be needed when the PDMS-GM is used as an outcome measure in research.

CONCLUSION AND DISCUSSION

The mean change scores for each group support the use of the PDMS-GM as an evaluative measure. For many infants, particularly infants with cerebral palsy, the PDMS-GM was not responsive to change over a 6-month period. The index of responsiveness suggests that the PDMS-GM should be used only as an outcome measure in large clinical trials. The PDMS-GM is not recommended for evaluating the direct effects of physical therapy but is recommended for providing a global measure of change in motor development as part of a multidimensional assessment.

Induction of cyclooxygenase-2 in human umbilical vein endothelial cells by lysophosphatidylcholine

Lysophosphatidylcholine (lysoPC), a component of atherogenic lipoproteins and atherosclerotic lesions, has been recently suggested to play a role in atherogenesis. LysoPC is known to induce several endothelial genes involved in leukocyte recruitment, mitogenesis, and inflammation. Cyclooxygenases (prostaglandin H2 synthases) are rate-limiting enzymes involved in the endothelial synthesis of prostacyclin, an antiplatelet, vasorelaxant, and vasoprotective molecule. We investigated the effect of lysoPC on the endothelial expression of cyclooxygenases. Our results demonstrate that, in cultured human umbilical vein endothelial cells, lysoPC induces cyclooxygenase-2 mRNA and protein levels. Increased expression of cyclooxygenase-2 is accompanied by the enhancement of both basal- and calcium ionophore A23187-induced synthesis of prostacyclin. Nuclear runoff experiments demonstrated an increased rate of transcription of the cyclooxygenase-2 gene by lysoPC. In contrast, lysoPC did not affect the expression of constitutive cyclooxygenase-1. Our results suggest that the induction of endothelial cyclooxygenase-2 by lysoPC may be an important vasoprotective mechanism that limits progression of atherosclerotic lesions and promotes their regression.

Quantitative structure-activity relationships for estimating the no-observable-effects concentration in fathead minnows (Pimephales promelas)

Quantitative structure-activity relationships, based on hydrophobicity measured as the 1-octanol/water partition coefficient (Kow), have been developed for predicting the acute no-observable-effects concentration (NOEC) for fathead minnows (Pimephales promelas), using a mechanism/mode of action approach. Models were developed for nonpolar narcotics, amine narcotics, polar narcotics, ester narcotics, and respiratory uncouplers. A set of bioreactive chemicals were evaluated, but models based on hydrophobicity alone are inadequate for these chemicals. Additionally, a strong correlation was observed between the acute NOEC and acute lethality measured as the 50% lethal concentration (LC50) for 407 chemicals, regardless of the mechanism/mode of action. This relationship is modeled by the equation log NOEC-1 = 1.007 (log LC50) + 0.246; n = 407, r2 = 0.989, s = 0.142, f = 38095.6, and Pr > f = 0.0001. Examination of the relationship between the acute NOEC and the subchronic NOEC for four mechanisms/modes of action implies that the acute to subchronic ratio is not independent of mechanism of action. The resulting ratios were 6.42 (+/- 3.01) for nonpolar narcosis, 80.00 (+/- 17.78) for polar narcosis, 10.05 (+/- 4.59) for respiratory uncoupling, and 3.94 (+/- 1.72) for bioreactivity.

Renal functional reserve in subjects with diabetes mellitus

Diabetic nephropathy develops in approximately 35% of patients with insulin-dependent diabetes mellitus (IDDM) and in a similar proportion of patients with non-insulin-dependent diabetes mellitus (NIDDM). However, we remain at present unable to identify the susceptible subset prior to the development of microalbuminuria. Up to 25% of IDDM patients and a variable proportion of NIDDM patients manifest glomerular hyperfiltration in the first few years of diabetes. It has been debated whether this basal hyperfiltration is predictive of future renal disease and whether better prediction can be achieved by the use of the renal haemodynamic response to a protein meal, defined by some authors as renal reserve. The concept of renal functional reserve in patients with diabetes mellitus is complicated by the dependence of the GFR response on basal GFR, the influence of the prevailing metabolic conditions, and because the response differs to different stimuli. We review the factors affecting renal hemodynamics and renal hemodynamic responses in the context of supranormal, normal, and impaired renal function in diabetes. We conclude that although the measurement of renal functional reserve may help clarify important pathophysiological mechanisms, the assessment of basal GFR in clinical practice is all that is required for predictive and monitoring purposes.

Hydrops uteri in a caprine doe pregnant with goat-sheep hybrid fetuses

A 5-year-old caprine doe was examined for abdominal enlargement and inability to stand. Hydrops uteri was diagnosed via ultrasonography, and was determined to be the cause of hind limb paresis. The placentomes appeared to be abnormal in shape and number. Uterine fluid electrolyte concentrations were similar to fluid from cows and sheep with hydrops amnion. Two fetuses were dead at the time of induced parturition. Hydrops uteri is rare in goats and, in the goat of this report, was believed to be caused by pregnancy with an unusual goat-sheep hybrid. The placental abnormalities discovered by ultrasonography may have been responsible for the abnormal accumulation of fluid, but a fetal abnormality also was considered to be possible.

Noxious heat-evoked Fos-like immunoreactivity in the rat medulla, with emphasis on the catecholamine cell groups

The objectives of the present study were 1) to utilize Fos immunohistochemistry as a marker for neuronal activity in order to examine the population of neurons in the medulla that is engaged by activation of nociceptive peripheral afferents and 2) to determine whether catecholamine-containing neurons in the medulla also express noxious heat-evoked Fos-like immunoreactivity. Noxious heating of the hindpaw evoked specific patterns of Fos-like immunoreactivity in the medulla in regions known to be involved in both nociceptive processing and cardiovascular regulation. Noxious heating of the hindpaw significantly increased the mean number of neurons expressing Fos-like immunoreactivity in the contralateral ventrolateral medulla. Increased numbers of Fos-positive neurons also were observed in both the ipsilateral and the contralateral A1 catecholamine cell groups. Similarly, in the contralateral medullary dorsal reticular fields, noxious heating of the hindpaw significantly increased the mean number of neurons expressing Fos-like immunoreactivity. In contrast, in the paramedian reticular nucleus, noxious heating of the hindpaw resulted in a significant decrease in the mean number of neurons expressing Fos-like immunoreactivity. No significant differences in the mean numbers of neurons expressing Fos-like immunoreactivity were noted in the A2, C1, or C2/C3 medullary catecholamine cell groups. These results suggest that noxious stimuli affect pools of neurons in the medulla with multiple physiological functions.

Effect of demographic and behavioral variables on burden of caregivers of chronic mentally ill persons

OBJECTIVE

Persons who provide care for individuals with chronic mental illness experience both objective burden (observable, tangible cost) and subjective (perceived) burden. This study sought to determine the relative power of behaviors of chronic mentally ill clients, behaviors required of caregivers, and demographic characteristics of both groups in predicting burden.

METHODS

A total of 189 caregiver-client dyads were studied using a cross-sectional, correlational design. Caregivers were interviewed by phone about clients' needs for help in nine areas and about seven potentially troublesome client behaviors. Correlation and regression analyses were used to determine relationships among variables.

RESULTS

Caregivers reported much less subjective than objective burden, although the relationship between the two types of burden was not consistent across the various areas in which clients needed help. Overall, more of the reported burden was related to caregivers' behaviors (their day-to-day tasks) than to clients' behaviors. Burden was greatly increased for caregivers who lived with the client. Caregivers most at risk for burden were those who lived with male clients who threatened suicide.

CONCLUSIONS

Caregivers become accustomed to the stabilized behavioral profile of the client. Mental health professionals should be sensitive to profiles and situations that may produce increased objective and subjective caregiver burden.

Establishment of an in vitro model for cisplatin resistance in human neuroblastoma cell lines

Two unique cisplatin-resistant neuroblastoma (NB) cell lines have been derived from the established lines IMR-32 and SK-N-SH by treatment with escalating doses of cisplatin. IMR/CP.20 was 6.6-fold and SK/CP.15 was 3.8-fold more resistant to the cytotoxic effects of cisplatin than the parent lines. The parent SK-N-SH cells were 16.6-fold more resistant to the effects of cisplatin than IMR-32 cells. The cisplatin-resistant cell lines demonstrated alterations to their morphology, but there was no change in the cell growth characteristics of the resistant compared to the sensitive lines. Cytogenetic analysis revealed that clonal selection of parental subclones had occurred with additional chromosomal changes in both resistant lines. Both IMR/CP.20 and SK/CP.15 lines were cross-resistant to aphidicolin and to L-phenylalanine mustard. The IMR/CP.20 line was 7.3-fold more resistant to mitomycin C than the parent line. Neither cisplatin-resistant NB line was cross-resistant to 5-fluorouracil, etoposide or doxorubicin. All NB lines had low levels of DNA repair compared to HeLa or CHO-K1 cells. However, the IMR/CP.20 cell line showed a significantly higher ability to effect DNA repair than the parent IMR-32 line, indicating that the increased resistance to cisplatin observed in this line may, in part, be due to an enhanced DNA repair capacity.

Repair of cisplatin-DNA adducts by protein extracts from human ovarian carcinoma

Human ovarian carcinoma exhibits a spectrum of responses to treatment with cisplatin, ranging from marked sensitivity to relative resistance. Variations in the efficiency with which cells repair cisplatin-DNA adducts may in part determine cisplatin sensitivity. We have investigated the use of a novel cell-free assay of nucleotide excision repair of platinated DNA to assess the DNA repair capacity of direct biopsies of untreated human ovarian carcinoma. In this pilot study, ovarian carcinoma extracts performed in vitro excision repair of platinated DNA. Moreover, tumors from different individuals varied as much as 10-fold in their repair capacity in this assay.

Heterogeneous repair of platinum-DNA adducts by protein extracts from mammalian tissues

Cis-diamminedichloroplatinum (II) (cisplatin) is a mainstay of human cancer chemotherapy. In addition to its antitumour effects however, cisplatin is toxic to normal tissues, causing dose-limiting nephrotoxicity and neurotoxicity. On the other hand, myelosuppression is uncommon. In the light of data suggesting a role for DNA repair mechanisms as determinants of cellular cisplatin sensitivity, we postulated that varying DNA repair capacities between tissues could explain the patterns of organ toxicity seen in clinical practice. Using a novel cell-free assay of repair of cisplatin-DNA adducts, we find that the DNA repair capacity of protein extracts from different tissues varies significantly in our assay, but does not directly correlate with the organ toxicity profile of cisplatin.

Effects of vagal afferent nerve stimulation on noxious heat-evoked Fos-like immunoreactivity in the rat lumbar spinal cord

Electrophysiological and behavioral studies have described modulation of nociception by vagal afferent fibers. The objectives of this study were to 1) use Fos-like immunoreactivity as a marker for neuronal activity to examine populations of neurons in the spinal cord that are activated by a noxious heat stimulus, 2) determine whether heat-evoked Fos-like immunoreactivity can be modulated by vagal afferent stimulation, and 3) determine whether vagally-mediated effect on heat-evoked Fos-like immunoreactivity can be blocked by intrathecally administered serotoninergic receptor and alpha-adrenergic receptor antagonists. Neurons demonstrating Fos-like immunoreactivity were located in the ipsilateral superficial and deep dorsal horn laminae extending from the caudal L3 through the rostral L6 region of the spinal cord. Stimulation of the right cervical vagus nerve attenuated significantly (42%) heat-evoked Fos-like immunoreactivity in the superficial laminae. The reduction in Fos-like immunoreactivity by vagal stimulation was abolished by intrathecal administration of methysergide, a nonselective serotoninergic receptor antagonist, but not by phentolamine, a nonselective alpha-adrenoceptor antagonist. These results suggest that vagal afferent modulation of spinal nociceptive transmission is mediated, at least in part, by serotonin receptors.

An audit of the insulin tolerance test in adult subjects in an acute investigation unit over one year

OBJECTIVE

We audited our practice of insulin tolerance testing (ITT) in terms of safety and technical success. We reviewed the results of those tests performed over a 12-month period. By relating peak cortisol response to 0900 h screening cortisol level, we determined whether we could reduce the number of tests performed.

DESIGN

The results of all ITTs performed on our unit between 1 January and 31 December 1991 were reviewed.

PATIENTS AND MEASUREMENTS

Patients were prescreened by measurement of serum cortisol and thyroxine, and recording of an electrocardiogram. A subnormal serum thyroxine (< 58 nmol/l), 0900 h serum cortisol (< 100 nmol/l) or an abnormal ECG were taken as contraindications to the test. Minimum glucose and maximum cortisol levels were recorded, along with peak GH responses when measured. The peak cortisol response was compared to the screening and basal cortisol levels.

RESULTS

A total of 161 tests were performed, 135 of which fulfilled our inclusion criteria. The test was technically successful in all but 5 of these; a significant adverse event occurred in one patient with full recovery after reversal of hypoglycaemia. Thirty-two patients had a suboptimal serum cortisol response to hypoglycaemia: screening cortisol level ranged from 128 to 493 nmol/l and 0900 h serum cortisol measured prior to the ITT from 97 to 431 nmol/l. The lowest level of screening cortisol above which all patients would be expected to achieve the normal peak cortisol of 580 nmol/l or over is therefore 494 nmol/l. If this cut-off level had been adopted, 10 (8%) ITTs need not have been performed if their only purpose had been to assess cortisol reserve. Altering the criterion for the necessary peak cortisol to 500 nmol/l did not affect the number of ITTs required. Our lower limit for testing could not be revised upwards from 100 nmol/l. Adequacy of cortisol reserve did not predict a normal GH response to insulin-induced hypoglycaemia.

CONCLUSIONS

When performed in an experienced endocrine unit with adequate supervision, the insulin tolerance test is a safe procedure. According to the current sample, fewer tests would be performed without detriment to patient care if those with a screening cortisol of greater than 500 nmol/l did not proceed to testing, unless the purpose of the test was also to exclude GH deficiency. A lower limit of 100 nmol/l appears reasonable and need not be revised upwards.

Assisted reproductive technologies: genetic and nursing implications

The convergence of the fields of clinical genetics and assisted reproductive technologies is providing couples at risk for transmitting a genetic disorder to their children with new reproductive alternatives. The ability to test the preimplantation embryo for genetic anomalies, sort for X- and Y-bearing sperm, and improve genetic screening of gamete donors and couples at risk for a genetic disorder, are examples of these alternatives. The scope of nursing practice will be affected by the integration of these technologies into the health care offered to consumers. Opportunities also will exist for nurses to assist in the redefinition of health and illness that will be the serendipitous outcome of these scientific advances.

Bromophenacyl bromide binding to the actin-bundling protein l-plastin inhibits inositol trisphosphate-independent increase in Ca2+ in human neutrophils

Ligation of IgG Fc receptors on polymorphonuclear leukocytes causes an increase in the concentration of free intracytoplasmic Ca2+ ([Ca2+]i) which arises from release of intracellular stores but is independent of inositol 1,4,5-trisphosphate. We found that bromophenacyl bromide (BPB), an alkylating agent which inhibits leukocyte degranulation, adherence, and phagocytosis, inhibited IgG-stimulated increases in [Ca2+]i with an IC50 of 0.2 microM. In contrast, BPB had no effect on inositol 1,4,5-trisphosphate-dependent [Ca2+]i increases induced by fMet-Leu-Phe, complement fragment C5a, ATP, or platelet-activating factor. Using a monoclonal antibody specific for BPB, we identified in polymorphonuclear leukocytes a single cytosolic protein of 66 kDa and isoelectric point pH 5.6 which bound BPB when intact cells were treated with the alkylating agent. This BPB-binding protein was identified as l-plastin, a Ca(2+)-regulated actin-bundling protein. l-Plastin was found associated with the Triton X-100-insoluble cytoskeleton in polymorphonuclear leukocytes adherent to immune complexes, suggesting that BPB affects Fc receptor-mediated signal transduction by altering the actin cytoskeleton. Consistent with this hypothesis, both cytochalasin B and cytochalasin D inhibited the IgG-dependent increase in [Ca2+]i, without any effect on fMet-Leu-Phe-induced Ca2+ release. These data suggest that the actin cytoskeleton is essential for signal transduction from plasma membrane Fc receptors and that l-plastin has a critical role in activation of this pathway.

Renal dysplasia and benign ureteropelvic polyps associated with hydronephrosis in a foal

A 4-month-old male Trakehner foal with a history of hematuria, poor growth, and abnormal hair was found to have unilateral hydronephrosis and hydroureter, as determined by ultrasonography and surgical exploration. Nephrectomy and ureterectomy were performed as treatment. Gross examination of the ureter and kidney revealed renal pelvic and ureteral polyps causing obstruction and subsequent hydronephrosis. The histologic features were consistent with renal dysplasia. The polyps and renal dysplasia were likely to be congenital, but the etiopathogenesis is not known. The finding that urinary outflow obstruction can disrupt nephrogenesis and lead to renal dysplasia supports the view that the polyps developed, blocked urine flow, and caused the hydronephrosis and renal dysplasia in the foal.

Genetic-based and assisted reproductive technology of the 21st century

The scientific advances of human genetics and assisted reproductive technology are redefining the concepts of health and illness by revealing the mysteries of the human genome and the process of conception, implantation, and diagnostic testing of the human embryo. The effect of these discoveries and their clinical applications will move from the tertiary to primary care arena through the ability to readily screen, diagnose, and treat some disorders and offer cure as the end result for others. In addition, the ethical, legal, and social issues, along with the attendant implications for professional practice, will need to be identified. Only a small portion of nurses have had to address the knowledge and practice issues associated with these advances. "Brave new families" are being created. Perinatal nurses must be prepared to meet the emerging needs of these families through the art and science of nursing.

The Queen's Medical Center Honolulu, Hawaii

The Queen's Medical Center created and almost fully realized a vision of professional nursing practice. This vision was mission-driven and philosophically oriented in that our Hawaiian heritage and commitment to a patient-centered focus dictated the direction taken. Utilizing the nursing process, we listened to our patients in identifying the nursing model to best meet their needs: primary nursing. In order to achieve that, the nurse at the bedside had to be empowered to make decisions directly impacting patient care. We further committed to treating the whole patient and considering complementary therapies. We have established an evaluation baseline and are committed to a process that will carry us into the year 2000.

Caregiver burden: who the caregivers are, how they give care, and what bothers them

The present research describes the association between objective and subjective caregiver burden experienced by families and friends of individuals with chronic mental illness. Although there has been a significant quantity of research conducted about burden and mental illness, the findings have been equivocal because of varying definitions of burden and varying sampling procedures. The present research utilizes a standardized interview instrument for caregivers. Caregivers were named by a stratified random sample of clients who have been certified as severely mentally disabled and have received publicly-funded community mental health services in the state of Ohio during the 1990 fiscal year. Data were collected by the first author and a research assistant during telephone interviews between August 1991 and May 1992. One hundred and eighty-nine caregivers were interviewed. Findings showed that the majority of caregivers are female, white, and aged 50 years or more. Parents comprise the largest group of caregivers and slightly more than one third of clients live with the caregiver. The relationship between caregiver and client is generally described as positive; however, the interviews were conducted during a period when the clients' symptomatology was more under control than previously in the relationship. Caregivers state that the clients need help much more often than they ask for it in all categories of possible help. Considering caregiver burden in relation to caregiver behaviors, time management is a somewhat frequent problem that is very troublesome to the caregiver. Considering client behaviors in relation to caregiver burden, embarrassing behaviors are most troublesome and occur with moderate frequency. The surprise element of these behaviors seems to be the most problematic.

Clostridium septicum septicemia in a neonatal foal with hemorrhagic enteritis

Clostridium septicum was isolated by anaerobic culture of blood collected from a 3-day-old foal with hemorrhagic enteritis and signs suggestive of septicemia. The foal responded well to treatment with intravenous fluids, antibiotics, plasma, and oral gastrointestinal protectants. One month after apparent complete recovery from the septicemia and hemorrhagic enteritis, the foal was euthanized during an acute episode of colic that was caused by severe, strangulating intestinal adhesions, thought to have formed as a result of peritonitis secondary to the hemorrhagic enteritis. The value of anaerobic culture of blood in foals with signs suggestive of septicemia is emphasized by the case presented here, as is the importance of evaluating the presence and extent of peritoneal inflammation in foals with hemorrhagic enteritis. To our knowledge, Clostridium septicum has not previously been reported to cause septicemia in neonatal foals.