Nursing the immobile: a preliminary study

Permanent loss of mobility has profound physical and mental consequences for both sufferers and carers, and is a major challenge to the National Health Service. A recent study has shown that 42% of beds in departments of Geriatric Medicine are occupied by people with longstanding immobility. These people are highly dependent on nursing staff for their daily activities and quality of life. The assessment of mobility, as a single parameter of dependency, and the measurement of allocated nursing hours are both rapidly and easily performed on geriatric wards. It is felt that a simple correlation of these two variables might highlight areas where more detailed audit is desirable. This study demonstrates that the more immobile patients on a ward, the less the hours allocated to Registered and Learner grade nurses. Some possible reasons for this are suggested and the effects of this deployment on nursing practice and staff recruitment are discussed. It is felt that provision of appropriate nursing care to the most dependent patients in continuing care areas is essential, and that high levels of trained staff are needed to ensure this.

Doctors' knowledge of the cost of common medications

Fifty doctors completed a questionnaire which assessed their knowledge of the basic National Health Service cost of 15 commonly prescribed medications. Nearly half the estimates exceeded twice the actual cost of the drug. As well as ignorance of absolute prices, the study demonstrated imperfect knowledge of the relative prices of drugs of the same type. Estimates of the costs of commonly prescribed medications were no more accurate than those for rarely prescribed drugs. Self perception of cost consciousness was not related to the accuracy of the responses.

Cytogenetic changes at 11q11, 11q23, and 17q11 in myelodysplastic syndrome

Cytogenetic studies were performed on two patients with myelodysplastic syndromes. One patient was a 68 year old Japanese male in whose bone marrow cells two translocations were established, i.e., t(4;11)(q13;q23) and t(11;17)(q11?;q11), as well as other karyotypic changes (-6,-18,15p+). The other patient was a 74 year old white male whose bone marrow cells showed six marker chromosomes, i.e., der(5),t(5;17)(q12;q11), der(6),t(6;5)(q27;q22), der(8),t(8;11;?)(q11;q11----q23;?), der(11),t(11;?)(q11;?), an isochromosome of the long arm of chromosome #8, and a small G-group sized marker chromosome of unknown origin. Though the translocation patterns in the abnormal cells in these two cases were different, the breakpoints of the marker chromosomes were almost the same, i.e., 11q11, 11q23, and 17q11. Also, changes of chromosome #6 were observed; the first case showed monosomy 6 and the second a 6q+ marker chromosome. In these two cases of myelodysplastic syndromes, common sites of chromosome breakage and reunion of 11q23 and 17q11 were close to recently established sites of human cellular oncogene homologs, c-ets (11q23) and c-erbA (17q21----24). These associations draw attention to a possible relationship between chromosome changes in myelodysplastic syndromes and oncogene (or other gene) activation and/or dysfunction.

Acute response of urinary N-acetyl-beta-D-glucosaminidase to mannitol infusion in the dog

Urinary activity of N-acetyl-beta-D-glucosaminidase (NAG) has been used as an indicator of subtle renal injury in a variety of conditions. Such enzyme activity has been shown to be increased in human and other animals with diabetes mellitus. The mechanism of this increase in urinary NAG activity is not known. To determine if the osmotic diuretic effect of the glycosuria could stimulate urinary NAG activity, mannitol was infused into the left renal artery of six dogs to cause a unilateral osmotic diuresis and compared to the right side. During three control periods of 20 minutes, each urinary NAG excretion (expressed in units as the ratio of NAG activity to urinary creatinine, NAG/Cr) was equal from both left and right kidneys, 5.0 +/- 1.5 vs 6.0 +/- 3.6 units, respectively. During the 11 mannitol infusion periods urine volume and sodium excretion rose significantly from the left kidney, .50 +/- 2 to 1.5 +/- .3 ml/min and 21 + 5 to 99 +/- 16 u Eq/min, respectively. However urinary NAG/Cr did not change, 5.0 +/- 1.5 to 5.1 +/- 1.0 units. In six control dogs not infused with mannitol, urinary NAG/Cr tended to rise with time from control to experimental collection periods, 4.7 +/- 2.0 to 8.1 +/- 3.0 respectively; however these are not significantly different. In all dogs urine volume and sodium excretion tended to rise throughout the course of the study due to hydration with normal saline; thus it is possible that the tendency for urinary NAG activity to rise may have been due to the increase in sodium excretion. However, these studies demonstrate that the osmotic diuresis induced by mannitol produced no significant change in urinary NAG activity. Thus it may be that the hyperglycemia itself, and not the glycosuria, produces the increase in urinary NAG activity seen in the diabetic.

Zinc supplementation attenuates insulin secretory activity in pancreatic islets of the ob/ob mouse

The purpose of this study was to establish whether a relationship may exist between the hyperinsulinemia, the exaggerated insulin secretion, and the resistance to insulin characteristic of the obese-hyperglycemic syndrome and the zinc status of the ob/ob mouse. To this end, mice were given control and zinc-supplemented diets, and the effects of zinc supplementation on insulin secretion in vivo and in vitro as well as on glucose tolerance were studied. These data were compared with those obtained with oxytetracycline treatment, which is known to ameliorate the insulin sensitivity and glucose tolerance of these animals. The levels of zinc were measured in several tissues of lean and obese mice and the results show that zinc supplementation attenuated the exaggerated insulin secretion in vivo and in vitro without improving the tolerance to glucose. Zinc levels were significantly higher in the tissues of the obese than of the lean mice, with the exception of bone and pancreas. The results suggest a maldistribution of zinc in the tissues of the obese mouse.

Significance of brown and/or green amniotic fluid at the time of second trimester genetic amniocentesis

During a two-year period, 83 discolored fluids (77 green, six brown) were obtained during genetic amniocenteses of 1227 patients. When compared with case-matched control subjects, those patients with discolored fluid had no differences in the incidence of spontaneous abortions, abnormal fetal karyotypes, infant abnormalities, occurrence of preterm labor, or requirement for delivery by cesarean section. The only statistically significant difference between control and test patients was that one in 83 versus 32 of 83 reported bleeding before amniocentesis (P less than .001). Both green and brown fluids had spectrophotometric peaks at 400 to 408 nm, similar to that reported for meconium. However, discolored fluid had measurable free hemoglobin, whereas meconium-stained fluid from term gestations did not, suggestive of an in utero hemorrhage. Further, when fetal blood, in concentrations calculated to yield a hemoglobin content similar to those measured in the discolored fluids, was incubated in amniotic fluid the spectrophotometric peak and absorbance units at 400 to 408 nm were similar to those for the discolored fluids. These observations are supportive of the hypothesis that blood breakdown products from an episode of intrauterine bleeding are responsible for the discolored fluid. Discolored amniotic fluid during second trimester, as an isolated finding, does not prognosticate a poor pregnancy outcome.

Hypophosphatemia and hypercalciuria in small premature infants fed human milk: evidence for inadequate dietary phosphorus

Phosphorus and calcium balance was measured prospectively in stable premature infants (less than or equal to 1600 gm) fed human milk or a standard commercial formula. Throughout the study, the P and Ca intakes of the infants fed human milk were two to three times less than those of infants fed formula. Infants fed human milk showed low serum P and normal serum Ca concentrations, complete renal reabsorption of P, and elevated renal Ca excretion. The net effect in infants fed human milk was a 50% reduction in the P and Ca retention, compared with the formula-fed group. Despite the unfavorable P and Ca balance in the group fed human milk, the only evidence of rickets was elevated alkaline phosphatase activity. Nevertheless, based on the biochemical changes in these infants, low serum P values, and excess urinary calcium losses, we conclude that the stable small premature infant fed human milk exclusively is deficient in phosphorus and only slightly more sufficient in calcium.

Prognostic value of the electroencephalogram in neonatal asphyxia

In order to determine whether an EEG early in the course of asphyxia neonatorum is of any more value than the neurological examination in predicting outcome we reviewed case histories of 38 infants with asphyxia neonatorum. The EEG background activity was valuable in predicting outcome. Normal and maturationally delayed EEGs were associated with normal outcomes while low voltage, electrocerebral inactivity and burst suppression EEGs were highly correlated with severe neurological sequelae. Epileptiform activity was not as predictive of outcome as background activity. Although initial normal neurological examinations were associated with normal developmental and neurological outcomes, moderately and severely abnormal infants had more variable courses. A single EEG done early in the course of asphyxia neonatorum is a more sensitive predictor of outcome than the neurological examination.

Plasma renin activity in normal human pregnancy and in pregnancy-associated hypertension, with reference to cryoactivation

1. Because hypertension is the central feature of pre-eclampsia, and because plasma renin activity is known to be elevated in normal pregnancy (with conflicting results published for pre-eclampsia), a prospective study of plasma renin activity was conducted in pregnancy, under conditions of a fixed sodium intake, in 178 initially normotensive volunteer subjects. Thirty of these women developed pregnancy-associated hypertension (pre-eclampsia) in the third trimester.

2. There was a significant elevation of plasma renin activity from the published values for non-pregnant women, throughout gestation in normotensive women. There was no significant difference, at any stage of gestation, between the values for normal women and those who developed pregnancy-associated hypertension.

3. The extent of cryoactivation of renin, produced by usual collection procedures, was investigated in a subgroup of the total population. It was highly significant and quite variable, but was similar in those who developed pregnancy-associated hypertension and in normal pregnant women. The mean increase in plasma renin concentration in maximally cryoactivated samples was 16-fold.

4. Neither measurement of peripheral plasma renin activity nor of cryoactivatable plasma renin concentration is of value in distinguishing between normal pregnant women and those destined for, or with pregnancy-associated, hypertension.

Issues concerning parents after the death of their newborn

Thirty-five families were interviewed by members of the intensive care nursery staff 2-4 months after the death of their newborn. Of the families interviewed, 74% wanted to review the events leading to their child's death and ask questions about information they already knew. Most families who were interested in the autopsy findings used the results to find out "how normal everything else was." Topics frequently discussed by parents involved feelings of guilt and problems that arose after the infant's death (isolation by friends, somatic complaints, marital and sexual problems, memories of prior losses, problems with siblings and disposal of baby's things). One-third of the families were felt to need continuing emotional support due to their inability to assume previously accepted responsibilities. For many families, the physician may be the only individual who can tolerate listening to their distress.

Haemodynamic profile of angiotensin II antagonism in essential hypertensive patients

1. The haemodynamic response to antagonistic (10 microgram min-1 kg-1) and agonistic (40 microgram min-1 kg-1) doses of saralasin was studied in young essential hypertensive patients. Blood pressure behaviour alone was thought to be inadequate to describe the response pattern. 2. Pre-saralasin setting of the renin-angiotensin axis was varied with salt intake (15 and 290 mmol of Na+/day) each for 10 days. This failed to influence blood pressure or plasma volume. 3. Antagonist blockade after low salt lowered blood pressure in three patients with the highest plasma renin values. Cardiac output rose in two of these, but it dropped in all others. 4. Decreases in cardiac output occurred with both doses of saralasin and even with suppression of the renin-angiotensin axis. This response is therefore unlikely to be due to removal of myocardial or venous angiotensin effects. 5. The renin-angiotensin system played a part in maintenance of blood pressure only with severe salt restriction and in a small proportion of cases. 6. No heart rate effect was seen with sarcalasin. 7. Blood pressure and total peripheral resistance responses were dependent on pre-(antagonist/agonist) setting, but heart rate and cardiac output were not influenced by this factor.

Cryoactivation of renin in plasma from pregnant and nonpregnant subjects, and its control

Plasma renin activity increased by a mean of 7% from baseline values when blood from nonpregnant persons was kept at 0 degrees C for 5 h before incubation. Freezing chilled plasma and thawing it before incubation resulted in a mean increase of 11%. The same procedures used on plasma from normal pregnant women produced mean increases in plasma renin activity of 44 and 89%, respectively. If blood from pregnant women was kept at 0 degrees C for 5 h, and the plasma then separated, frozen, and thawed before incubation, the resulting mean increase in plasma renin activity from baseline values was 160%. We conclude that plasma from pregnant women should be handled at room temperature, or, if samples must be stored, they must be rapidly frozen, then thawed as rapidly as possible before incubation and assay if results are to be reproducible.

Do parents utilize physician follow-up after death of their newborn?

Numerous authors have advocated appropriate physician-patient counseling following a perinatal death. We examined, in a prospective manner, how many families utilized physician follow-up when such follow-up was offered. Seventy-six percent of the 108 families who experienced a neonatal death chose to have physician follow-up in the weeks after the death. A family's utilization of subsequent physician contact was not related to the distance they lived from the medical center, the duration of survival of the infant, or the racial background of the mother. Parents utilized follow-up visits whether or not an autopsy was performed or an interpreter was needed. Certain features distinguished the parents who did not utilize the physician follow-up service: parents were less likely to utilize the service if they were not married, the mother was a teenager, the head of the household was unemployed, or there was no phone at home.

Cryoactivation of renin in plasma from pregnant and nonpregnant subjects, and its control

Plasma renin activity increased by a mean of 7% from baseline values when blood from nonpregnant persons was kept at 0 degrees C for 5 h before incubation. Freezing chilled plasma and thawing it before incubation resulted in a mean increase of 11%. The same procedures used on plasma from normal pregnant women produced mean increases in plasma renin activity of 44 and 89%, respectively. If blood from pregnant women was kept at 0 degrees C for 5 h, and the plasma then separated, frozen, and thawed before incubation, the resulting mean increase in plasma renin activity from baseline values was 160%. We conclude that plasma from pregnant women should be handled at room temperature, or, if samples must be stored, they must be rapidly frozen, then thawed as rapidly as possible before incubation and assay if results are to be reproducible.

Symptomatic sick sinus syndrome due to guanethidine. Case report

A patient is described who developed symptomatic sinus bradycardia as low as 20 beats per minute and sinus arrest of up to 4.4 seconds while receiving guanethidine, 75 mg daily. The bradycardia resolved following discontinuation of the drug and reappeared upon challenge with it. Intrinsic disease of the sinoatrial and atrioventricular nodes was evidenced 3 weeks following discontinuation of the guanethidine by a borderline abnormally prolonged sinus node recovery time of 1500 msec and a PR interval of 0.28 seconds. Although sinus bradycardia is a known and not infrequent side effect of guanethidine, such an extreme form as seen in our patient appears to be quite rare, and may be related to the pre-existing disease of the conduction system.