Perceived family reactions and quality of life of adults with epilepsy.

This study examined the perceived family reactions and the quality of life in adults with epilepsy in Harare, Zimbabwe. Perceived family reactions refers to behaviors that occur in response to epilepsy. Roy's Adaptation Model was used to conceptualize quality of life in the physiologic, self-concept, interdependence, and role-function modes. Face-to-face interviews were conducted on a convenience sample of 66 adults ages 18-45 years. A three-part structured interview schedule was used to describe demographic data, quality of life (using a modification of the disease-specific Quality of Life in Epilepsy 89 [QOLIE-89] instrument), and perceived family reactions. Quality of life was not adversely affected in the physiologic, self-concept, and interdependence modes but was affected in the role-function mode. Family reactions were positively correlated with the quality of life (r = .39, p = < .01). The effect of the independent variable, perceived family reactions (R2 = .15345, F = 11.60132, p = <.01), explained 15% of the variance in quality of life. Adults with epilepsy were uncertain about their families' reactions, such as overprotection, but felt accepted and supported by their families. Fear, isolation of the individual, secrecy, and concealment were negative strategies used by families and individuals to manage epilepsy. Roy's Adaptation Model was used to identify family reactions as significant and positively correlated to the quality of life of adults with epilepsy. To enhance the quality of life in adults with epilepsy, nurses need to encourage positive family reactions such as openness, acceptance, and support, while discouraging fear, isolation of the individual, secrecy, concealment, and overprotection.     

An Application of Endoscopic Color Doppler Ultrasonography (ECDUS) in the Diagnosis of Hemodynamics of Gastric Varices,and the Therapeutic Effect of Endoscopic Therapy

Abstract: We studied 14 patients using endoscopic color Doppler ultrasonography (ECDUS) to evaluate the hemodynamics of gastric varices, and evaluated the endoscopic therapeutic effects on gastric varices in 8 patients. Three patients had F₃ type gastric varices and eleven had F₂. The ECDUS was performed with a PENTAX FG-32UA (7.5MHz, convex type) and a HITACHI EUB 565 was used as a display machine. The intramural blood flow in the gastric varices and inflows from the extra-gastric wall were clearly observed with the ECDUS in all 14 patients. The extramural blood flow (gastro or spleno-renal shunts) was detected in 9 of 14 patients. The velocity of the intramural flow in tumorous type varices (F₃) was higher than in the nodular or flat elevated type (Fa). Next, we evaluated the therapeutic effects on gastric varices of the ECDUS. The successful disappearance of intramural blood flow was observed in 6 of 8 patients who had this endoscopic therapy. In two of the 8 patients, there was not enough therapeutic effect on the intramural blood flow. The extramural blood flow, however, did not change before or after endoscopic therapy with the ECDUS. Therefore, we concluded that ECDUS is a very useful modality for the diagnosis of hemodynamics and to evaluate the therapeutic effects on gastric varices.     

Pyramidal tract degeneration in sporadic Creutzfeldt‐Jakob disease

We investigated the neuropathologic features of pyramidal tract degeneration in 27 cases of sporadic Creutzfeldt‐Jakob disease (sCJD). The present study included 13 cases of subacute spongiform encephalopathy (SSE), 13 cases of panencephalopathic‐type (PE‐type) sCJD and one case of thalamic‐type sCJD. Pyramidal tract degeneration was observed in PE‐type sCJD cases with disease duration of more than 13 months. Cases of SSE, PE‐type sCJD of relatively short duration and thalamic‐type sCJD showed no pyramidal tract degeneration. All cases with pyramidal tract degeneration showed severe cerebral neocortical involvement with widespread cerebral white matter degeneration. The loss of myelin and axons and macrophage infiltration and fibrillary gliosis seen in these pyramidal tract lesions is consistent with secondary tract degeneration due to cerebral neocortical involvement. Interestingly, some cases with pyramidal tract degeneration showed a distal‐dominant pathology that we believe indicates retrograde degeneration or a “dying‐back” phenomenon of the pyramidal tract. Our results indicate that pyramidal tract degeneration is a late pathologic event in sCJD. Investigation of pyramidal tract degeneration may help clarify the mechanisms underlying the development of sCJD white matter pathology, particularly that of PE‐type sCJD.     

Low-dose combination therapy with temocapril and losartan reduces proteinuria in normotensive patients with immunoglobulin a nephropathy.

This study investigates the ability of low doses of angiotensin-converting-enzyme inhibitors, in combination with angiotensin II receptor blockers, to exert antiproteinuric effects in normotensive and proteinuric outpatients with immunoglobulin A (IgA) nephropathy confirmed by biopsy. We performed a prospective, randomized, 6-month study of the effects of temocapril 1 mg (n=10), losartan 12.5 mg (n=10), and both (n=11) on mild-to-moderate proteinuria 0.76+/-0.35 g/day (range, 0.4 to 1.6 g/day) and renal function. The study subjects comprised 31 normotensive and proteinuric outpatients with IgA nephropathy accompanied by normal, or mild-to-moderately reduced but stable renal function (glomerular filtration rate>50 ml/min) without steroid or immunosuppressive therapy. We prospectively evaluated blood pressure, proteinuria, renal function and biochemical parameters before and after 6 months of therapy. The combination therapy significantly reduced proteinuria (63.2%) compared with either temocapril or losartan alone (41.3% and 36.6%, respectively, p=0.04 and 0.01, respectively). Blood pressure was most decreased in the group that received combination therapy. The reduced proteinuria did not correlate with reduced systolic or diastolic blood pressure or mean arterial pressure in any of the groups. The glomerular filtration rate fell during the first 3 months of combined therapy, but became reversible after a further 3 months of therapy. The combination significantly decreased angiotensin II (p <0.01), and this decrease was greater than that by either drug alone. In conclusion, the effectiveness of the combined therapy may have been at least partly due to the greater inhibition of the action of angiotensin II in patients with IgA nephropathy. This strategy apparently reduced mild-to-moderate proteinuria in patients with normotensive IgA nephropathy.     

Role of the nucleus of the optic tract in monkeys in relation to optokinetic nystagmus

Nine monkeys were used in order to clarify the role of the nucleus of the optic tract (NOT) in the generation of optokinetic nystagmus (OKN). In 3 monkeys whose NOTs were almost totally damaged, optokinetic stimulus toward the lesioned side failed to generate either eye deviation or OKN and revealed only voluntary saccades, whereas that toward the side contralateral to the lesion generated normal gain of OKN. The phenomenon was identical in either monocular or binocular stimulation. In two of 3 monkeys whose NOTs were partially destroyed, optokinetic stimulus toward the lesioned side produced OKN, but the gain of OKN, but the gain of OKN was at maximum less than 60% in both binocular and monocular stimulation. In the remaining one monkey whose NOT was injured, but superficially, OKN showed normal gain in both directions. In 3 other monkeys whose NOTs were spared, this OKN asymmetry was not observed. Pursuit and saccadic eye movements were normal in all NOT-lesioned monkeys. Visually induced eye movements in the vertical axis were likewise normal. The present experiment suggests that the NOT in monkeys may be the first relay station in the horizontal optokinetic path and that in primates as in non-primates both crossed and uncrossed fibers reach motor centers for OKN via the NOT.     

Anesthesia mortality and morbidity in Japan: A study of lawsuit cases

To date, there have been no systematic studies on anesthetic accidents in Japan. This study was conducted to clarify the present status of anesthetic accidents by sending a questionnaire to a group of plaintiff's lawyers specializing in medical malpractice. At present, because of manpower shortages, anesthesia is provided by either anesthesia specialists (anesthesiologists) or non-anesthesiologist physicians in Japan. Among 112 lawsuits which involved the use of anesthesia, 64 were analyzed as to the person primarily responsible for administering the anesthesia, the types of anesthesia, the details of major mishaps, and intraoperative monitoring. Of particular note was a large number of deaths from cardiac arrest and hypotension in spinal anesthesia administered by non-anesthesiologists. The results clearly showed that non-anesthesiologists had a substantial incidence of mortality cases among accidents compared with anesthesiologists. Human error was the most frequent cause, but a lack and/or a grave omission of intraoperative monitors was found in non-anesthesiologist-related cases.     

The review of seclusion and restraint in psychiatric practice]

In order to create the least restrictive setting in psychiatric practice, we investigated the effects of an assessment by a committee on seclusion and restraint. Using consistent procedures, the committees, which were established in 9 hospitals, reviewed seclusion and restraint maintained for periods of over 2 weeks during a 4-month period. Frequency and duration of seclusion and restraint, staff perceptions of and attitudes to the review system, and patient satisfaction were evaluated before and after the study period. As a result of this review process, the frequency of seclusion decreased slightly in 7 hospitals and 1 of the remaining 2 hospitals showed an increased frequency of seclusion days that were partially interrupted. Frequency of restraint decreased slightly in 5 hospitals, and of the remaining 3, 1 interrupted all periods of restraint, while the other 2 institutions showed an increase in interruption of restraint periods. As there were no common patients in 2 specialist psychiatric emergency hospitals between before and after the study periods, statistical analyses were performed. Only minor variables such as duration of partially interrupted periods of restraint, and duration of periods of restraint that were partially released showed a statistically significant increase. Although patient satisfaction showed a significant increase, staff attitudes to and perceptions of the review system became appreciably more negative. These findings suggest that although the review system had the potential to slightly reduce the use of seclusion and restraint, and to increase patient satisfaction, staff burnout was risked because staff effort was perceived to be disproportionately high in relation to the effect achieved. Furthermore, the possibility remains that the slight decrease of seclusion and restraint demonstrated did not necessarily reflect the appropriate use of these strategies, and were not necessarily lasting effects. However, as differences in opinion existed between the review system committee and treating clinicians regarding continuation of long term seclusion and restraint, the review system could have a role in monitoring the long term use of seclusion and restraint. Further investigation is needed into the long term effectiveness of procedures reviewing the use of seclusion and restraint in the psychiatric setting, taking into account both positive and negative outcomes.     

Reconsideration of normalization of Emax for heart size

Summary We previously proposedEmax Vd as a normalized form ofEmax for heart size relatively independent of wall volumeVm, whereEmax is the slope of the end-systolic pressure-volume line andVd is its volume axis intercept. WhenEmax Vd remains constant, average circumferential stress for a specified average circumferential strain in the ventricular wall also remains relatively constant, despite changes inVd/Vm around its normal value. Because accurate determination ofVd is difficult and stress for a givenEmax Vd changes slightly withVd/Vm, we investigated whetherVd could be replaced withVm in a normalizedEmax in this analysis. As the result, we obtained a function ofVd/Vm as the coefficient by which to multiplyEmax Vd orEmax Vm to yield stress for a specified strain. Using this coefficient, one can easily calculate stress for any strain fromEmax, Vd, andVm in order to compare myocardial contractility among left ventricles of different sizes. The present study confirms the importance ofVd as an indispensable reference volume for normalization ofEmax, as well as the low sensitivity ofEmax Vd as a normalizedEmax to changes inVd/Vm. Only whenVd/Vm remains constant isEmax Vm proportional toEmax Vd and can replaceEmax Vd.