Validity of cognitive complaints in substance-abusing patients and non-clinical controls: The Patient's Assessment of Own Functioning Inventory (PAOFI)

To determine the validity of substance-abusing (SA) patients' self-reports of cognitive impairments, we assessed the independent contributions of depression, actual neurocognitive performance and an index of cognitive decline, in predicting cognitive complaints in groups of SA patients and normal controls. The SA sample comprised 74 veterans enrolled in day treatment. The non-clinical sample consisted of 150 English-speaking adults. Assessment instruments were as follows: A modified version of the Patient's Assessment of Own Functioning Inventory (PAOFI) containing three subscale on: Memory, Language and Communication, and Higher Cognitive Functions; the Beck Depression Inventory; a battery of neuropsychological tests that measured domains of executive function, processing speed, verbal fluency and verbal and visual memory; and a measure of premorbid intellectual functioning. SA patients reported twice as many PAOFI complaints as non-clinical controls. SA patients' neuropsychological performance was lower than that of non-clinical controls. A higher percentage of SA patients had significant cognitive decline. The SA sample reported more depression. There was no association between PAOFI scores and neuropsychological performance for either group. PAOFI results were not associated with cognitive decline. BDI scores accounted for 12% of the variance in PAOFI total score for the SA sample and 44% for the non-clinical sample in multiple regression analysis. Cognitive complaints were related more to depression than cognitive performance for both SA and non-clinical samples. The results do not support self-report as a valid means of neuropsychological assessment in SA samples, although self-reports may provide other information about perceived cognitive difficulties that may be relevant to clinical evaluation.     

Intravenous aminoglycoside usage and monitoring of patients with cystic fibrosis in Australia. What's new?

Background: The aim of this study was to determine the current situation regarding aminoglycoside use and monitoring in patients with cystic fibrosis (CF) throughout Australia.
Methods: A questionnaire was sent out to all CF units. Information gathered included patient characteristics, aminoglycoside use, dosing, therapeutic drug-monitoring methods, toxicity monitoring and incidence of occurrence.
Results: Responses were obtained from 27 of the 28 units identified. Tobramycin was the aminoglycoside of choice. All but three centres were using once-daily dosing for aminoglycoside administration. Initial dosing in tobramycin-naïve patients was based on bodyweight (range 7–12 mg/kg). Patients being readmitted were mainly prescribed the dose that they had received on their previous admission. All units gave i.v. doses by infusion with five units using bolus dosing as well. The method of therapeutic drug monitoring varied greatly. A computer programme was used by 15 units. Toxicity monitoring usually coincided with therapeutic drug monitoring. Nephrotoxicity was reported as having occurred in 13 units and ototoxicity in 15 units. The highest incidence of toxicity was ototoxicity in 20% of patients in one CF unit.
Conclusion: Aminoglycoside dosing regimens have changed since the last survey was carried out in 1999. There has been an increase in the use of once-daily dosing from 54 to 88% of units. The reporting of both ototoxicity and renal toxicity has also increased (from 27 to 75% and from 19 to 65%, respectively). Standardization of management protocols for antibiotic use and patient monitoring may help reduce the risk of cumulative toxicity to aminoglycosides in CF patients.     

Efficacy of a premixed semisynthetic human insulin regimen

Sixty-one insulin-requiring non-insulin-dependent (type II) diabetic patients who had been transferred from a regimen of mixed intermediate and short-acting insulin to a fixed regimen of premixed insulin (70% neutral protamine Hagedorn and 30% regular, human semisynthetic insulin) given twice daily were studied retrospectively. The average age was 65 years (range, 35 to 84) and the average duration of their diabetes was 13.8 years (range, 1.5 to 33 years). Thirty-one percent were men, 69% women. Hemoglobin A1c (HbA1c) dropped significantly after transfer from a mean of 12.3% to a mean of 9.2% (P less than 0.001). After an average of 14.1 months, 40 patients still had a lower HbA1c (P less than 0.01), showing sustained improvement. The mean HbA1c at the last visit was 10.2% (normal range, 5.5% to 8.5%) with the average reduction in HbA1c being 2.1%. This sustained improvement occurred without a significant gain in weight (P = 0.63) or a significant increase in total insulin doses (median, 2 units), and was independent of the type of insulin used previously. Hypoglycemic episodes actually declined from an average of 1.0 to 0.6 per month. Of those patients who had previously not reported hypoglycemia, only 28% reported hypoglycemic events, and of those reporting previous hypoglycemia, 57% experienced a reduction. This surprising improvement in glycemic control was not due to compliance with insulin injections or remote premixing of insulin but possibly due to the increased accuracy of measuring the premixed insulin dose. The convenience and stability of a premixed insulin regimen results in better glycemic control in the insulin-requiring non-insulin-dependent diabetic population.     

Reduction in the plasma clearance rate of warfarin induced by cimetidine

The interaction between the histamine H-2 receptor antagonist, cimetidine, and warfarin sodium was prospectively studied in 14 patients who were previously anticoagulated for five years. The patients received warfarin and cimetidine concomitantly for a minimum of ten days. Seven of the patients experienced increases in plasma warfarin concentrations. This correspondingly resulted in abnormal prolongation of their prothrombin times. In these patients the elevation in the steady-state warfarin concentration demonstrates that coadministration of cimetidine significantly reduces the plasma clearance rate of warfarin. The serum and urine metabolite levels of warfarin were not qualitatively different in the absence in contrast to the presence of cimetidine. It is apparent that cimetidine can act as an inhibitory influence on the catabolic degradation of warfarin.     

Pathophysiology involved in autonomic dysreflexia

Autonomic dysreflexia has potentially life-threatening consequences in quadriplegics and high paraplegics. Seizures, subarachnoid hemorrhage, and fatal stroke may result. This article explains the pathophysiology of autonomic dysreflexia. Appropriate nursing interventions to prevent serious complications are described.     

Discourse performance in older adults

Thirty-three elderly women, whose mean age was 76.2 years, and eighteen middle-aged women, whose mean age was 45.6 years, were assessed on a number of linguistic discourse tasks. The women were well educated, and most of them were or had been engaged in the teaching profession. Each woman was given narrative discourse tasks involving recall of stories, summarizing stories, giving the morals of the stories, procedural discourse tasks, interview to assess cognitive functioning and communicative abilities, and the following cognitive tests: Block Design, Symbol-Digit, Raven Coloured Progressive Matrices, and Word Fluency. The findings were that the older group generally performed more poorly than did the middle-aged group on most of the discourse tasks and cognitive tests. Within the older group, measures of quality of discourse were generally negatively related to age and positively related to scores on cognitive tests.     

Multicentre clinical trial of low volume fresh frozen plasma therapy in acute pancreatitis

Fresh frozen plasma (FFP) has been proposed as a specific therapy for acute pancreatitis. Reduced mortality encountered in an uncontrolled clinical study and a controlled experimental study may be attributable to replenishment by FFP of the naturally occurring antiprotease system. To investigate this potential therapy further, 202 patients presenting with acute pancreatitis were randomized to receive FFP (2 units daily for 3 days) or a similar volume of colloid control as part of their intravenous fluid therapy. Clinical progress was monitored and the major serum antiproteases (alpha 1-antiprotease and alpha 2-macroglobulin) were measured on days 1, 3 and 7. There was no significant difference between the two groups in terms of clinical outcome. alpha 1-Antiprotease levels rose significantly from day 1 to day 3 in both groups (P less than 0.0001) and remained elevated at day 7. alpha 1-Antiprotease is an acute phase protein in man and raised serum levels would be anticipated. FFP appears to have no effect on the magnitude of this rise. Serum alpha 2-macroglobulin levels were reduced in both groups on day 1 and continued to fall significantly from day 1 to day 3 in the colloid control group (P less than 0.005) whilst remaining substantially unaltered in patients receiving FFP (P = 0.6527). alpha 2-Macroglobulin plays a central role in the elimination of proteases during acute pancreatitis and the ability of relatively low volumes of FFP to reduce the fall in serum alpha 2-macroglobulin levels seen during the early stages of this disease may have therapeutic implications.     

Symptomatic Arnold-Chiari malformation: review of experience with 22 cases

Twenty-two patients with closed myelomeningoceles, shunted hydrocephalus, and symptomatic Arnold-Chiari malformations were studied retrospectively. Seventeen of the 22 patients were aged 6 months or younger; five patients were aged 3 to 23 years. Patients in the younger group presented with stridor, apnea, and/or feeding difficulty; those in the older group presented with hemiparesis, quadriparesis, oscillopsia, nystagmus, or opisthotonos. Fourteen of the 17 younger patients underwent surgical decompression of the Arnold-Chiari malformation: 10 within 18 days following the onset of symptoms and four on Day 19 or later. Of the 10 infants with early treatment, five eventually died secondary to continued symptoms and five survived. Of those surviving, three were asymptomatic and two had continuing symptoms but were improved over their preoperative state. Among the four patients undergoing surgery later, two died, one had lessening of stridor, and one had complete relief of symptoms. Of the three infants not undergoing decompression, two died and one eventually became asymptomatic. All five of the older patients underwent decompression and all had complete resolution of their preoperative symptoms and signs. The authors conclude that while decompression of a symptomatic Arnold-Chiari malformation may be effective in children and adults, this treatment does not always improve the clinical condition of infants. This may be the result of ischemic/hypoxic effects on the infant's brain stem, which may not be organized normally at birth.