Disorders of the autonomic nervous system: Part 2. Investigation and treatment

Autonomic function may be adequately tested with noninvasive tests of sympathetic and parasympathetic pathways, including: the response of blood pressure to change in posture and isometric contraction, heart rate response to standing, variation in heart rate with respiration, Valsalva ratio, sweat tests, and plasma noradrenaline measurements. Abnormal results in two or more of these tests indicate autonomic dysfunction. Intraarterial catheterization and tests of vasomotor function are usually required only in doubtful cases or for research purposes. Treatment of autonomic dysfunction is focused primarily on bladder control and control of orthostatic hypotension. Orthostatic hypotension is best treated with physical measures, pharmacologically with 9-alpha-fluorohydrocortisone and dihydroergotamine mesylate. A number of other agents may be tried but results have been less effective.     

Creutzfeldt--Jakob Disease in Recipients of Human Growth Hormone in the United Kingdom: A Clinical and Radiographic Study

In the past 3 years there have been five further cases, in additionto one case reported in 1985, of Creutzfeldt-Jakob disease inrecipients of human growth hormone in the United Kingdom. Theclinical findings of two of these cases are described, demonstratinga typical presentation with a predominantly cerebellar syndromeat onset which is not commonly a presenting feature of sporadicCreutzfeldt-Jakob disease. In one case a ^99mTc hexamethylpropylenaminesingle photon emission tomographic scan showed marked impairmentof tracer uptake in the basal ganglia and cerebral cortex ata time when the clinical picture was predominantly cerebellar.This technique may be useful in early diagnosis. In the othercase post mortem examination of the brain showed prominent amyloiddeposition in the cerebellum, which has not been described previouslyin pituitary-hormone related Creutzfeldt-Jakob disease. Thepreviously published cases of growth hormone-related Creutzfeldt-Jakobdisease are reviewed and reasons for the particular clinicalpattern seen are discussed.     

Sequential responses of the renin-angiotensin-aldosterone axis to acute postural change: effect of dietary sodium.

The simultaneous levels of plasma renin activity (PRA), angiotensin II (A II), and aldosterone (PA) were frequently assessed in 13 normal subjects following acute postural change (assumption of upright posture or returning to the supine position) on low (10 mEq.) and high (200 mEq.) sodium (Na+) intakes. The rate of response of aldosterone secretion was also correlated with changes in the metabolic clearance rate (MCR) of aldosterone. Significant increments of PRA and A II on either sodium intake occurred within 5 to 20 minutes; the peak values occurred within 90 minutes and tended to plateau until the end of the study (240 minutes). The mean absolute peak levels were approximately 2 to 3.5-fold greater than control. Increments of PA were initially delayed 20 to 30 minutes, but peak levels also were achieved by 90 minutes. The secretion rate of aldosterone increased 4-fold on the 10 mEq. Na+ and 2-fold on the 200 mEq. Na+ intake even though MCR declined 30 to 40 per cent in the upright posture. Sodium restriction enhanced the rate and magnitude of response of all parameters. Specifically, the slope of the regression relationship between PRA and PA was more than 4-fold steeper in the sodium-restricted than sodium-loaded subjects. From the rate of decline in PRA following resumption of supine posture, the half-life of PRA was estimated to be 14 to 15 minutes. The present study demonstrates that acute changes in posture are associated with closely correlated changes in PRA or A II. To varying degrees, it appeared that sympathetic activity, intravascular volume, diurnal secretion, and the sodium ion play a role in the sequential responses of these parameters to acute postural alterations.     

Monoamine metabolites in cerebrospinal fluid and serotonin uptake inhibition during treatment with chlorimipramine.

The effects of chlorimipramine on the concentrations of the main metabolites of serotonin (5-HT) norepinephrine (NE), and dopamine, i.e. 5-hydroxyindoleacetic acid (5-HIAA), 4-hydroxy-3-methoxyphenyl glycol (HMPG) and homovanillic acid (HVA), respectively, were studied in cerebrospinal fluid from 14 depressed patients, and related to the serotonin- and NE uptake inhibiting activity in vitro of plasma drawn from the patients. Chlorimipramine inhibited the uptake of both transmitter amines in all patients. During treatment, the levels of 5-HIAA and HMPG in cerebrospinal fluid (CSF) were significantly reduced. HVA levels were reduced in 6 patients and increased in 8 patients; there was no mean change. The decrease in 5-HIAA level in CSF was correlated to the uptake inhibition of 5-HT but there was no corresponding relationship between NE uptake and HMPG levels. The changes in HVA levels were also correlated to the uptake of 5-HT despite the absence of a unidirectional change of this metabolite.     

Research priorities in mental health nursing

This study determined nursing research priorities that focused on mental health nursing in the published literature from 1990 to 1996. Determination of which priorities were related to mental health was completed using 18 sources (experts, organizations, and individual research projects). A content analysis of the 18 sources was completed, and 56 mental health related research priorities were identified. Six categories emerged from the data analysis: support, holism, mental health nursing practice, quality care outcomes, mental health etiology, and mental health delivery systems. As mental health nursing embraces evidenced-based practice, the need for clear research priorities is imperative for knowledge development in the field.     

Nationwide survey of home transfusion practices

BACKGROUND: Limited information exists on home transfusion practices. STUDY DESIGN AND METHODS: In 1995, a survey requesting data for 1994 was sent to 1273 American Association of Blood Banks (AABB) institutional members and 113 non-AABB home health care agencies that provide out-of-hospital transfusions. RESULTS: Of 943 respondents, 102 provide blood to a home transfusion program, 37 provide blood and run a home transfusion program, and 13 run a home transfusion program only, for a total of 152 (16%) with some involvement in home blood transfusions. Most of the 50 respondents with a home transfusion program are licensed by their state and accredited by the Joint Commission on Accreditation of Healthcare Organizations. All respondents have written policies for home transfusion, and 90 percent require a signed informed-consent document before initiating transfusions in the home. Most have policies requiring that there be a second adult and a telephone in the home, that the home be deemed safe for transfusion, that the patient's physician be readily available, and that the patient have had prior transfusions. The most common component issued by the blood providers was red cells, followed by platelets. White cell-reduced components were always provided by 36 percent of respondents. The most common patient diagnosis was cancer. Home transfusions were provided primarily by registered nurses. Only 14 percent of respondents indicated that the medical director of the blood bank is responsible for approving a patient for home transfusion. A posttransfusion visit is performed by 46 percent of respondents. CONCLUSION: Although most facilities have policies for the administration of home transfusions, there remains marked heterogeneity among blood providers and transfusionists regarding home transfusion practices.     

Late-onset and atypical presentation of Pneumocystis carinii pneumonia in a renal transplant recipient

Pneumocystis jivorecii (formerly known as carinii) pneumonia (PCP) is potentially a life-threatening opportunistic infection after organ transplantation, occurring most frequently in the first 12 months, where the incidence rate is several-fold higher than in later years. PCP typically presents with fever, cough, dyspnoea and hypoxia. In organ transplant recipients, the onset of symptoms is generally more fulminant compared to patients infected with the human immunodeficiency virus. We present a patient who developed PCP five years after a renal transplantation. His presentation was characterised by atypical symptoms and an indolent onset. Previous acute vascular rejection, ongoing maintenance prednisolone usage, cytomegalovirus seropositivity and past tuberculous infection may have predisposed this patient to PCP.