Breaking through the 'Darleck syndrome'

This article shares the author's concern for the future of nurse education especially in relation to student nurses gaining clinical experience. In the light of Project 2000 there are varied and exciting basic nurse education courses being planned and implemented throughout the UK that aim to develop the student nurse into an open, responsive, caring professional. All the bright ideas and hard work that nurse educationalists are investing in the new courses will come to nought however, if equivalent time, energy and bright ideas are not invested in updating and refreshing experienced nurses. This article explores some of these issues.     

Variable hormonogenesis in Cushing's syndrome.

Four patients with Cushing's syndrome and variable cyclic hormonogenesis are reported and 40 other cases from the literature are reviewed. These cases were divided into four categories depending on regular or irregular cyclic adrenal hypersecretion and presence or absence of concomitant fluctuations in the clinical course. The manifestations of cyclic adrenal hypersecretion in these patients varied from daily to yearly intervals. Cyclic activity persisted for as long as 25 years, with cycle lengths varying from 12 hours to 85 days. Some patients demonstrated complex biochemical cyclic patterns. Clinical presentations varied from a single outstanding symptom, such as recurring oedema, to a complex clinical syndrome. The aetiology in these patients varied: 12 appeared to be pituitary dependent, 11 had corticotropin-producing tumours and another eight were described as showing 'adrenal hyperplasia'. A hypothalamic disorder was found in four, a benign adrenal adenoma in two, and an adrenal 'mass' and adrenocortical nodular dysplasia in single patients. Evaluation during the intercyclic phase may reveal normal pituitary function. Inconsistent responsiveness to administration of dexamethasone in different phases of cyclic activities may suggest the presence of cyclic Cushing's syndrome.     

'Not for resuscitation': guidelines for decision making and documentation

In 1991, the government's Chief Medical Officer made it clear that the responsibility for resuscitation policy lay with consultants, and that they should ensure this policy was understood by all staff caring for a patient, in particular junior medical staff. Since then, many hospitals and trusts have provided members of the multidisciplinary team with guidance on how to ensure that adequate and satisfactory communication is in place to record a patient's resuscitation status. However, as is common in the NHS, poor documentation is still evident. Guy's & St Thomas' Hospital Trust has been using a document since April 1998 which is clearly written, user friendly and does not contain ambiguous statements. With ongoing audit of this policy document we hope to reduce the incidence of inappropriate resuscitation attempts which are costly, both emotionally and financially, for all concerned.     

Endocrinopathies of hyperfunction: Cushing's syndrome and aldosteronism.

Increased function of the adrenal cortex is a normal response in times of physiologic and psychologic stress. Adrenal cortical secretions (e.g., glucocorticoids, aldosterone) orchestrate a multitude of internal processes aimed at maintaining homeostasis and psychologic integrity. Many patients admitted to a critical care unit will manifest some increase, even minor, in adrenal function. However, excessive secretions of these hormones can have a lethal effect of fluid and electrolyte balance, energy metabolism, and immune function. Cushing's syndrome denotes a disorder characterized by increased circulating levels of glucocorticoids (primarily cortisol). An easily recognizable disorder, it may arise from pathology of the adrenal cortex or the anterior pituitary glands, ectopic secretions from a nonendocrine tumor, or from excessive doses of exogenously administered glucocorticoids. Cushing's syndrome is rarely an admitting diagnosis to critical care but is a disorder that can seriously affect recovery from coexisting illnesses if not treated. Aldosteronism, although rare, will often be diagnosed after admission to a critical care unit for management of troublesome hypertension, hypokalemia, congestive heart failure, and various dysrhythmias. Suspicion of the diagnosis should always arise when these manifestations occur, particularly when hypokalemia is refractory to potassium supplementation. Without timely diagnosis and treatment, these patients will succumb to lethal dysrhythmias.     

Screening for Cushing's syndrome using early morning urine samples.

Urinary free 11-hydroxycorticosteroid/creatinine ratios (UFC/Cr)were determined in early morning urine samples from 138 obese subjects attending endocrine clinics in the Glasgow area. The majority of patients (128) had UFC/Cr ratios within the normal range for non-obese subjects (5-55 mumol/mol). Of those with elevated UFC/Cr ratios, further investigations of the hypothalamic-pituitary-adrenal axis confirmed a diagnosis of Cushing's syndrome due to bilateral adrenal hyperplasia in six of the cases and adrenal tumours in a further two patients. In the remaining two patients there was evidence of intermittent adrenal hyperactivity with inconsistent responses to insulin-induced hypoglycaemia tests.