Membranous nephropathy associated with angiomatoid fibrous histiocytoma in a pediatric patient

Background

Though membranous nephropathy is a much more common cause of nephrotic syndrome in the adult population, it accounts for only a small fraction of cases in pediatrics.

Case-Diagnosis/Treatment

We report a case of a 16-year-old boy with nephrotic syndrome due to membranous nephropathy in the setting of a rare tumor, angiomatoid fibrous histiocytoma. This patient’s nephrotic-range proteinuria completely resolved following resection of this tumor. Angiomatoid fibrous histiocytoma, while known to cause other paraneoplastic syndromes such as anemia, has never been reported to cause membranous nephropathy.

Conclusions

This case highlights a novel and treatable secondary cause of membranous nephropathy. Because secondary causes are more common in children than in adults, a high index of suspicion for other underlying pathology including malignancy should be considered. It also suggests that urinalysis may be a helpful screening tool in cases of angiomatoid fibrous histiocytoma.     

A three-step method of self-reflection using reflective journal writing

Fiscal and financial constraints present a challenge for nurse educators to broaden the diversity and scope of teaching/learning methodologies. One method designed to promote autonomy and self-direction of nursing students is self-reflection combined with reflective journal writing. This paper describes a three-step process of self-reflection encompassing critical appraisal, peer group discussion and self-awareness. This process of self-reflection was initiated with one group of clinical nursing students. Using student and teacher feedback, implications for employing this teaching/learning strategy in clinical practice are suggested.     

The effects of aerobic exercise on glucose and counterregulatory hormone concentrations in children with type 1 diabetes

OBJECTIVE: To examine the acute glucose-lowering effects of aerobic exercise in children and adolescents with type 1 diabetes. RESEARCH DESIGN AND METHODS: Fifty children and adolescents with type 1 diabetes (ages 10 to <18 years) were studied during exercise. The 75-min exercise session consisted of four 15-min periods of walking on a treadmill to a target heart rate of 140 bpm and three 5-min rest periods. Blood glucose and plasma glucagon, cortisol, growth hormone, and norepinephrine concentrations were measured before, during, and after exercise. RESULTS: In most subjects (83%), plasma glucose concentration dropped at least 25% from baseline, and 15 (30%) subjects became hypoglycemic (< or = 60 mg/dl) or were treated for low glucose either during or immediately following the exercise session. The incidence of hypoglycemia and/or treatment for low glucose varied significantly by baseline glucose, occurring in 86 vs. 13 vs. 6% of subjects with baseline values <120, 120-180, and >180 mg/dl, respectively (P < 0.001). Exercise-induced increases in growth hormone and norepinephrine concentrations were marginally higher in subjects whose glucose dropped < or = 70 mg/dl. Treatment of hypoglycemia with 15 g of oral glucose resulted in only about a 20-mg/dl rise in glucose concentrations. CONCLUSIONS: In youth with type 1 diabetes, prolonged moderate aerobic exercise results in a consistent reduction in plasma glucose and the frequent occurrence of hypoglycemia when preexercise glucose concentrations are <120 mg/dl. Moreover, treatment with 15 g of oral glucose is often insufficient to reliably treat hypoglycemia during exercise in these youngsters.     

Effect of the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88) on the incidence of invasive cervical cancer.

The Clinical Laboratory Improvement Act of 1988 (CLIA '88) mandates strict, new quality-control measures for laboratories that interpret cervical cytology smears. Proposed regulations include proficiency testing of cytotechnologists and remediation for technologists and laboratories that fail to meet proposed proficiency standards. Proponents of the new regulations argue that these measures will reduce deaths from cervical cancer by reducing the false-negative rate of the Papanicolaou (Pap) test, but opponents argue that the regulations will increase the price of processing Pap tests and thereby reduce access to cervical cancer screening for high-risk, vulnerable populations. To examine these claims the authors used David Eddy's published simulation to model the natural history and detection of cervical neoplasia, and developed a new model to examine the health consequences of diminished access to Pap testing. The authors estimated the false-negative rate of the Pap test and the price elasticity of demand for preventive services on the basis of the published literature, and modeled the entire range of published or quoted predictions about the impact of CLIA '88 on accuracy and price. The results show that, if effects on access are ignored, reducing the false-negative rate from 15% to 5% would prevent 66 invasive cancers per 100,000 average risk women screened. However, under moderate assumptions regarding the effect of price on access, the regulations would prevent only 11 (instead of 66) cancers per 100,000 eligible women. The regulatory effect is very sensitive to the degree of improvement in the false-negative rate and increase in price that the regulations cause. Over the range of assumptions and predictions encountered in the literature and tested in our analysis, the proposed regulations could greatly reduce or greatly increase the incidence of invasive cancer, especially among high-risk and uninsured women. The implementation of the regulations should be delayed until new information regarding the actual false-negative rate of the Pap test allow a more precise estimate of the potential impact on the incidence of cervical cancer.     

Physical function in men with prostate cancer on androgen deprivation therapy

BACKGROUND AND PURPOSE: Androgen deprivation therapy (ADT) has become an increasingly standard intervention for both early and advanced stages of prostate cancer; however, decreased physical function and hypogonadism have been reported in men receiving ADT. The objectives of this study were: (1) to determine whether ADT (and hypogonadism) resulted in decreased strength and mobility and (2) to examine the effect of ADT on an associated test of cognitive and motor function by assessing visuomotor performance. SUBJECTS AND METHODS: Physical function, walking speed, visuomotor performance, gonadal status, body composition, and Comorbidity Disease Index (CMDI) scores were assessed in a cohort of 100 participants that included: (1) men with prostate cancer who were not on ADT, (2) men with prostate cancer who were on short-term ADT (<6 months), (3) men with prostate cancer who were on long-term ADT (> or =6 months), and (4) control subjects who did not have prostate cancer. RESULTS: Walking speed varied significantly across the 4 groups, even after adjusting for age, CMDI, and percentage of body fat. Age and CMDI were significantly associated with measurements of physical performance. Adjusted for covariates, men on long-term ADT walked 0.18 m/s slower than the control subjects. Physical function also varied significantly across the 4 groups. Androgen deprivation therapy did not have a significant effect on visuomotor performance. DISCUSSION AND CONCLUSION: The results suggest that ADT has a significant effect on walking speed and physical performance in men with prostate cancer.     

McKenzie classification of mechanical spinal pain: profile of syndromes and directions of preference

The purpose of this study was to develop a profile of the use of McKenzie classifications of diagnosis and treatment, by physiotherapists credentialed in the McKenzie method in New Zealand. This system has been in common use for more than 20 years and the inter-rater reliability of the assessment has been previously established for therapists at this level of training. Prior studies identifying the classification of patients according to syndrome and directional preference have been mainly for the lumbar spine. The 34 participants for this study each assessed and classified 10 consecutive spinal patients during a 10-week period. Of the 340 patients assessed, 19 were excluded. Of those with pain arising from the lumbar spine; 140/187 were classified as reducible derangement syndrome, 11/187 were classified as irreducible derangement, 11/187 as dysfunction syndrome, 1/187 as posture syndrome and 24/187 as 'other'. For treatment in the reducible derangement syndrome; 98/140 were given extension, 8/140 were given flexion and 34/140 were given lateral movements of either side gliding or rotation. Classifications and treatment for the cervical and thoracic spine groups followed similar patterns. These findings add to the external validity of the McKenzie method, and support mechanical evaluation of spinal patients according to directional preference.     

Management of pain during abortion

The purpose of this study was to determine the effects of three cognitive behavioural strategies in the management of abortion pain. The interventions were drawn from the multidimensional model of pain suggested by the gate control theory. Forty patients undergoing abortion with local anaesthesia were instructed in one of four interventions: relaxation, pleasant imagery, analgesic imagery, and a pain discussion (attention control) group. Pain was measured using Johnson's two-dimensional graphic rating scales labelled sensation and distress. Speed of recovery and analgesic use were included as objective dependent measures. No significant differences were found among the four groups on any dependent measures although subjects receiving the pleasant imagery intervention reported the lowest subjective ratings of pain sensation and distress. Findings are discussed in terms of past research and implications for the management of acute pain experienced during abortion.     

Experienced and Less-Experienced Nurses Diagnostic Reasoning: Implications for Fostering Students' Critical Thinking

PURPOSE. To compare the use of mental representations (heuristics) in diagnostic reasoning of expert (≥5 years' experience) and novice (<5 years' experience) emergency nurses.
METHODS. Clinical simulations were completed by a nationwide randomly selected sample of 173 experienced and 46 less-experienced emergency nurses ( N = 229).
FINDINGS. Experienced nurses used the heuristic, Judging by Causal Systems (diagnostic inferences deduced from systems of causal factors) significantly more did than less-experienced nurses.
PRACTICE IMPLICATIONS. Standardized nursing diagnoses may cut short the time needed to develop representational thinking and spare cognitive reserves for reasoning needed for complex patients. Faculty need to promote students' cognitive development through strategies that promote active, reflective, and integrative learning.
Search terms: Clinical experience, diagnostic reasoning