Large-volume Paracentesis versus Dialytic Ultrafiltration in the Treatment of Cirrhotic Ascites

We compared the clinical efficacy and safety of large-volumeparacentesis and dialytic ultrafiltration in the treatment ofrefractory ascites in cirrhotic patients. A group of cirrhoticsubjects (age 49–80 years) were randomly allocated toeither continuous paracentesis (1–1.5 1/hour) or dialyticultrafiltration until disappearance of ascites. Each patientwas maintained on bed rest, fluid restriction (1 1/day) anda low (25 mmol/day) sodium diet for 14 days. Five patients (threein the paracentesis group and two in dialytic ultrafiltrationgroup) developed massive ascites 3–5 months later, andreceived the crossover treatment. The average volume of fluidremoved was similar in the two groups (4.70±1.47 1 fordialytic ultrafiltration versus 4.69±1.84 1 for paracentesis),but the treatment period was significantly shorter with dialyticultrafiltration. The plasma creatinine significantly increasedthree days after paracentesis but did not increase in patientstreated with dialytic ultrafiltration. There was an initialfall in mean arterial pressure during the first two hours ofeither treatment; a further fall in blood pressure was observedwith paracentesis but not with dialytic ultrafiltration. Pretreatmentplasma renin activity was elevated, but was not altered by eithertreatment. Plasma atrial natriuretic peptide levels were inthe high-normal range before treatment. Paracentesis was associatedwith a delayed fall in plasma atrial natriuretic peptide, whiledialytic ultrafiltration induced a modest but significant rise.No complication was experienced with dialytic ultrafiltrationin the two weeks following treatment, but four of the eightpatients who underwent paracentesis had developed severe complications.Dialytic ultrafiltration of ascitic fluid is a safe procedurein cirrhotic patients. Large-volume paracentesis without intravenouscolloid reinfusion causes complications and carries the potentialrisk of reducing the effective intravascular volume.     

Barriers to the effective management of bipolar disorder: a survey of psychiatrists based in the UK and USA

Objective:  To identify and prioritize barriers, challenges, and unmet needs in the management of patients with bipolar disorder, as perceived by their psychiatrists.
Methods:  A total of 500 US- or UK-based psychiatrists were surveyed by telephone using a validated, semi-structured questionnaire. Both preidentified and participant-elicited barriers, challenges and unmet needs were ranked on a 0–6 point scale in four phases of management: I, entry into care; II, the manic/hypomanic phase; III, the depressive phase; and IV, the long-term/maintenance phase.
Results:  Education and support for patients and families as well as earlier referral to specialist care were the highest ranked needs at entry into care. During treatment of acute episodes and long-term management the highest ranked needs were for treatments with improved effectiveness and patient adherence, in addition to improved long-term safety in the maintenance phase. Patients with comorbid alcohol and/or substance use disorders, followed by patients with a rapid-cycling disease course, were rated as having the highest level of unmet need. Similarities were predominantly seen between the overall pattern of responses from UK- and US-based psychiatrists.
Conclusions:  The highest priority items across the spectrum of treatment related to the need for clinically effective therapeutic agents with broad efficacy and favorable tolerability. At the time of initial diagnosis, patient education, family support, and earlier referral to specialist care were the highest priority needs.     

Upper urinary tract calculi: extrusion into perinephric and periureteric tissues during percutaneous management

While the goal of percutaneous management of renal and ureteral calculi is stone extraction or disintegration, perforation of the renal pelvis or ureter may allow stones or stone fragments to become extruded during endourologic manipulations. The authors have encountered six such patients: two with renal and four with ureteral calculi. Three stones were extruded into the perinephric or periureteric tissues during nephroscopy, two during attempted dislodgement with a balloon catheter, and one during antegrade passage of a ureteral catheter. All patients were managed conservatively by means of nephrostomy drainage and, in the four cases of ureteral laceration, ureteral stenting. Follow-up study, ranging from 12 to 24 months, has documented a benign clinical and radiological course. No ureteral strictures have ensued. In the absence of infected urine, urothelial laceration with calculus extrusion appears to be a benign occurrence and may be managed conservatively.     

Increased airway responsiveness in children of low birth weight at school age: effect of topical corticosteroids

The effect of treatment with topical inhaled corticosteroids was assessed in 15 children of low birth weight (mean (SD) birth weight 1435 (268) g, gestational age 30.5 (2.9) weeks, age at study 8.2 (0.4) years) who were symptomatic and showed a positive airway response to histamine aerosol. The study was of a double blind, placebo controlled, crossover design with four week long treatment periods with inhaled beclomethasone dipropionate (400 micrograms daily) or placebo. Daily symptom scores were recorded and physiological measurements were performed at the beginning and end of each treatment period. There was no significant difference in respiratory symptom score, baseline airway function, or the airway response to histamine between treatment periods. The findings argue against an inflammatory basis for airway hyper-responsiveness in these children and raise questions as to its pathophysiological basis.     

Impact of chronic undernutrition on higher mental functions in Indian boys aged 10–12 years

Undernourished rural children 10–12 years of age demonstrated the following, when compared to normal nourished children: (i) a relative deficit of memory quotients assessed by the Wechsler memory scale; (ii) lower scores for abilities related to personal and current information, orientation, mental control, logical memory, digit span, visual reproduction and associative learning; (iii) impaired set formation and flexibility in attention as assessed by the card sorting test; and (iv) impairment in conditional learning on maze and conditional associative learning tests. The performance on the finger dexterity test for fine motor coordination was not affected in undernourished children.     

Perspectives in Femininity

This article is adapted from an address given at a meeting of the Texas Section of The Nurses Association of The American College of Obstetricians and Gynecologists, in February, 1973, at San Antonio.
Society no longer demands that women fit the old image of "femininity"—passivity, wifeliness, physical attractiveness, and anti-intellectualism. Women are now freer to fulfill their full human potential. The change in the concept of femininity has affected nursing practice in two ways. First, with different roles and different morality, clients bring different problems to the nurse-counselor. Secondly, the change has divided nurses themselves into two opposing camps. Some adhere to the traditional nursing role which correlates with the old ideas of femininity, including nonparticipation in decision-making and subservience to authority figures. They may thwart the efforts of their professional counterparts to gain acceptance as professionals in their own right.     

Conjunctival-limbal autograft for primary and recurrent pterygium

Background: It has been postulated that pterygium results from hypo function of limbal stem cells. Therefore conjunctival-limbal autograft has been advocated for the treatment of this condition. This study was undertaken to evaluate the results of conjunctival-limbal autograft procedure in primary and recurrent pterygia.