The change process in alcoholics: client motivation and denial in the treatment of alcoholism within the context of contemporary nursing

Despite being constantly cited as a critical intervening variable in the recovery from alcohol problems, there is a paucity of literature on client motivation. This paper reviews the current literature which impacts on motivation and its importance in treatment and develops in a stepwise manner the revised expectancy/motivation hypothesis, tentatively explaining both motivation and denial as a natural process in behavioural change. Because of the revised expectancy/motivation hypothesis' distinctly defined stages which closely relate to the process of nursing and the qualitative and quantitative measurement it entails which the nursing process demands, it offers a particularly appropriate model for treatment within nurse practice.     

Therapeutic effects of bezafibrate and gemfibrozil in hyperlipoproteinaemia type IIa and IIb

Fifty-nine patients with hyperlipoproteinaemia Type IIa and IIb who had failed to respond to 1-month's dietary therapy were treated over a 4-month period with either bezafibrate (600 mg/day) or gemfibrozil (1200 mg/day) in addition to their diet. Fasting serum lipid (cholesterol, HDL-cholesterol and triglycerides) and blood glucose levels were measured on entry and at monthly intervals, and routine laboratory investigations were carried out before and after treatment to monitor hepatic, renal and haematic tolerance. The results showed that whilst both drugs produced significant reductions from baseline in total cholesterol, LDL-cholesterol and triglyceride levels from Day 30 onwards, the reductions were more marked in the bezafibrate group. There was a trend for HDL-cholesterol levels to increase. Fasting blood glucose levels decreased significantly in the bezafibrate group and to a greater extent than in patients on gemfibrozil. Only 1 patient on bezafibrate did not tolerate bezafibrate whereas 13 patients on gemfibrozil reported side-effects, mainly gastro-intestinal, and 4 had to withdraw from the study during the first or second month.     

Pharmacological characterization of the receptor mediating the adrenergic inhibition of responses to substance P in the cingulate cortex

The excitatory responses of neurones in the anterior cingulate cortex of the rat to iontophoretically applied substance P (SP) are reduced by noradrenaline (NA) applied iontophoretically or released from noradrenergic pathways. In order to determine the receptor involved in this inhibitory effect we have studied the effects of a number of receptor-specific adrenergic agonists and antagonists on responses of cingulate neurones to SP in rats anaesthetized with chloral hydrate. Low iontophoretic currents (0-15 nA) of NA, adrenaline and the beta-agonist, clenbuterol, all strongly reduced responses to SP. Isoprenaline was also effective but less consistently so, although problems were experienced with its iontophoretic release from micropipettes. The alpha 1-agonists, phenylephrine and methoxamine were also able to reduce responses to SP. However, this reduction required higher iontophoretic currents (15-60 nA) and was associated with depressant effects on baseline firing rate. The alpha 2-agonist clonidine was only weakly active at high currents and this too was associated with depression of baseline firing. Similar weak effects were noted with dopamine. The inhibitory effects of NA on SP responses were convincingly blocked or reversed by the beta-antagonist, practolol, but not by the alpha 1-antagonist, prazosin. The reduction of SP responses by phenylephrine was also blocked by practolol but unaffected by prazosin. Finally, reduction of SP excitations by activation of the coeruleocortical pathway was also blocked by practolol applied iontophoretically to the cortical cells. These results are consistent with the hypothesis that the effect of NA on SP responsiveness in the cingulate cortex is mediated by beta-adrenoreceptors.     

Giant hepatic hemangiomas: diagnostic and therapeutic dilemmas

This report describes four cases of surgically treated giant hepatic hemangiomas which illustrate some diagnostic and therapeutic difficulties encountered in the management of this condition. An important diagnostic triad has emerged, which should alert the physician to the possibility of a complicated hepatic hemangioma: the clinical signs of an acute inflammatory liver process contrasted with a normal white blood cell count and liver function tests. Hemangiomas of the left lobe were either missed or poorly demonstrated on selective hepatic angiographic examination, and in two patients the diagnosis was made only at the time of laparotomy. Hepatic resection was successfully performed in all patients; there was minimal morbidity and none of the patients died. In two patients with multiple hemangiomas, only symptomatic or easily resectable lesions were removed. All patients are alive and well; three have been followed up for more than 5 years. We conclude that resection in asymptomatic cases should be carried out only in those cases that require a diagnostic laparotomy and in those where the lesion is easily resectable. The majority of patients with symptomatic and complicated tumors should undergo resection, but even in these patients continued conservative treatment is appropriate when the risk of major resection outweighs the small risk of live-threatening bleeding.     

Dithiocarbamate-induced biliary platinum excretion and the control of cis-platinum nephrotoxicity

Treatment with any one of six different dithiocarbamates subsequent to the administration of cis-platinum (CDDP) is shown to promote the biliary excretion of platinum. The administration of the most effective of these compounds, sodium diethyldithiocarbamate (DDTC) at 1.57 mmol/kg, led to a 30-fold increase in the biliary excretion of platinum. For the other dithiocarbamates investigated, a similar dosage led to increases ranging from approximately 5-fold for sodium iminodiacetic acid dithiocarbamate, to 26-fold for sodium sarcosine dithiocarbamate. The presence of alkyl groups on the nitrogen of the dithiocarbamate increased the effectiveness of the compounds. There is no increase in the platinum levels of the brain when DDTC is used in this manner. A histopathological evaluation of the kidneys of rats given 15 mg CDDP/kg in 6.3% saline with and without the use of dithiocarbamates for renal protection shows significant additional protection due to the use of the dithiocarbamates. Dithiocarbamates given at an appropriate dosing schedule can lead to a significant reduction in the renal damage which is revealed by microphotographs. It is suggested that part of the renal protection obtained by the use of dithiocarbamates may be due to this shift of platinum excretion to the bile which obviates additional renal exposure to platinum. It was also found that the simultaneous injection of a dithiocarbamate with the cis-platinum has no obvious effect on the anti-cancer action of cis-platinum against the Walker 256 carcinosarcoma in rats.     

Urinary calculi in children in Western Australia: 1972-86

Records of all children presenting with urinary calculi in the period 1972-86 were reviewed in order to detail clinical features, laboratory and radiographic findings and treatment. Of a total of 85 children, 59 were Aboriginal and 26 were Caucasian. The features of urolithiasis differed between these groups. In the Aboriginal patients, calculi consisted mainly of uric acid and urates. Important clinical characteristics of this group included a young age at presentation (median = 2.1 years) and frequent presentation with failure to thrive. Calculi were commonly located in the upper urinary tract and most required surgical removal. Documented sequelae included renal scarring and hypertension. Caucasian children presented at a later age (median = 10.5 years), frequently with abdominal pain, and most calculi were associated with an underlying urological or metabolic abnormality.     

Central corticotropin releasing factor reduces natural cytotoxicity. Time course of action

Corticotropin-releasing factor (CRF) administered intracerebroventricularly produced both a rapid, greater than 50% reduction in splenic natural killer (NK) cytotoxicity and a prolonged elevation in plasma corticosterone levels. In the first 60 minutes following CRF, fivefold increases in corticosterone levels were associated with the suppression of NK activity. However, NK activity returned to control levels at later time points even though elevated plasma corticosterone levels persisted. These data augment the findings that central CRF reduces natural cytotoxicity and establish a time course for the effect in acutely treated rats.     

Gastric and duodenal obstruction in patients with cholangiocarcinoma in the porta hepatis: increased prevalence after radiation therapy.

OBJECTIVE. Our objective was to study the imaging findings in patients who had gastric and duodenal obstruction as a long-term complication of cholangiocarcinoma and to determine if the obstruction was associated with radiation therapy. MATERIALS AND METHODS. Between 1973 and 1989, 96 patients had either curative resection or palliative stenting for cholangiocarcinoma involving the hepatic duct bifurcation. Sixty-three (66%) also received adjuvant radiation therapy ranging from 4960 to 7220 rad (cGy). Gastric outlet or duodenal obstruction or both developed subsequently in seven of the 63 patients treated with radiation therapy. Radiographic studies, including upper gastrointestinal series and CT, and medical and surgical records for these seven patients were retrospectively reviewed. RESULTS. Upper gastrointestinal series in the seven patients with obstruction showed narrowing of the lumen, deformity and enlargement of gastric and duodenal mucosal folds, and delayed gastric emptying. CT performed in five of the seven patients showed thickening of the wall of the gastric antrum and small bowel and retained food and fluid within the stomach. All seven patients required gastrojejunostomy; at surgery, dense adhesions and fibrosis were found, and it was not evident whether the obstruction was due to the tumor or to radiation fibrosis. However, because this complication was seen only after radiotherapy, it was presumed to be radiation fibrosis. CONCLUSION. Our experience suggests that radiation therapy increases the risk of postoperative gastric and duodenal obstruction in patients undergoing surgery for cholangiocarcinoma.     

Central alpha 2-adrenoceptor responsiveness in borderline hypertensive rats.

Increased dietary NaCl intake increases the responsiveness of central nervous system alpha 2-adrenoceptors which regulate the neural control of renal function in spontaneously hypertensive rats (SHR) but not Wistar-Kyoto (WKY) normotensive rats. The borderline hypertensive rat (BHR) is the first filial offspring of the SHR and the WKY. With increased dietary NaCl intake, the BHR develops hypertension and expresses other characteristics of the hypertensive SHR parent. This investigation sought to determine whether increased dietary NaCl intake in the BHR enhances the responsiveness of central nervous system alpha 2-adrenoceptors. Six weeks of increased dietary NaCl intake (8% versus 1% NaCl) in BHR augmented the depressor, bradycardic, renal sympatho-inhibitory and diuretic responses to intracerebroventricular administration of graded doses (5, 25 and 125 micrograms) of the alpha 2-adrenoceptor agonist, guanabenz. The results suggest that the potential for an increased responsiveness of central nervous system alpha 2-adrenoceptors is genetically transmitted to the BHR by the SHR and may be exposed in the BHR by increased dietary NaCl intake.