Chemical impairment in colleagues: perceptions of Western New York nurses.

The purpose of this study was to determine nurses' perceptions about substance abuse in professional colleagues, opinions about strategies for dealing with substance abuse, and knowledge about resources available for dealing with the problem of chemical impairment. Subjects included a convenience sample of 161 nurses from Western New York. Data were gathered by a questionnaire that included "The Perceptions of Nursing Impairment Inventory" and items regarding respondents' background characteristics, suspicions about alcohol and drug abuse in nurse colleagues, and knowledge about and use of peer assistance services available through District I of the New York State Nurses Association. The major outcome of the study was identification of a knowledge deficit on the extent of the substance abuse problem in nursing, ability to recognize an impaired colleague, and awareness of services available. These data substantiate the need for implementing educational programs to increase nurses' basic knowledge of, and sensitivity to, the problem of chemical dependency.     

Longitudinal neurological follow-up of a group of HIV-seropositive and HIV-seronegative hemophiliacs: results from the hemophilia growth and development study

BACKGROUND: Boys and young men with hemophilia treated with factor infusions before 1985 had a substantial risk of acquiring the human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome. This study was designed to assess the effects of HIV and hemophilia per se on neurological function in a large cohort of subjects with hemophilia, and to investigate the relationships between neurological disease and death during follow-up. METHODS: Three hundred thirty-three boys and young men (207 HIV seropositive and 126 HIV seronegative) were evaluated longitudinally in a multicenter, multidisciplinary study. Neurological history and examination were conducted at baseline and annually for 4 years. The relationship between neurological variables, HIV serostatus, CD4+ cell counts, and vital status at the conclusion of the study was examined using logistic regression models. RESULTS: The risks of nonhemophilia-associated muscle atrophy, behavior change, and gait disturbance increased with time in immune compromised HIV-seropositive subjects compared with HIV seronegative or immunologically stable HIV-seropositive subjects. The risk of behavior change in immune compromised HIV-seropositive hemophiliacs, for example, rose to 60% by year 4 versus 10% to 17% for the other study groups. Forty-five subjects (13.5%), all of whom were HIV seropositive, died by year 4. Subjects who died had had increased risks of hyperreflexia, nonhemophilia-associated muscle atrophy, and behavior change. CONCLUSIONS: These results indicate that immune compromised, HIV-seropositive hemophiliacs have high rates of neurological abnormalities over time and that neurological abnormalities were common among subjects who later died. By contrast, immunologically stable HIV-seropositive subjects did not differ from the HIV-seronegative participants. Hemophilia per se was associated with progressive abnormalities of gait, coordination, and motor function.     

Influence of magnesium ion on human ventricular defibrillation after aortocoronary bypass surgery

The administration of magnesium ion (Mg++) has been reported to defibrillate the ventricles and to decrease the incidence of arrhythmias after cardiopulmonary bypass. In a prospective study of 76 randomly selected patients undergoing coronary artery bypass grafting, patients received either no Mg++, 0.25 mEq/kg of Mg++ during cardiopulmonary bypass with the aorta clamped, or 0.375 mEq/kg of Mg++ before cardiopulmonary bypass. Spontaneous resumption of a cardiac rhythm or spontaneous defibrillation during reperfusion was not significantly affected by Mg++ administration. However, the number of shocks to initial and to sustained defibrillation and the energy required for the last direct-current shock was greatest in patients who received Mg++ before bypass and in those whose plasma Mg++ was greater than 2.26 mg/dl. Thus, the administration of Mg++ may have adverse effects on the heart if intraoperative plasma Mg++ exceeds 2.26 mg/dl.     

The epidural blood patch. Resolving the controversies

PURPOSE: To review the literature regarding epidural blood patch (EBP) to generate conclusions relating to the controversial issues surrounding its application. SOURCE: A Medline search was made for relevant publications using keywords epidural blood patch, prophylactic epidural blood patch, dural puncture, and postdural puncture headache. Bibliographies of retrieved articles were hand-searched for relevant articles. Case series and comparative trials were emphasized in the analyses. These were culled and those deemed relevant were reviewed. PRINCIPAL FINDINGS: The majority of the literature consists of observational reports: there are few comparative studies. Headache most likely results from cerebrospinal fluid (CSF) loss leading to intracranial content shift and traction on pain sensitive structures; cerebrovascular alterations may be implicated. An EBP with 10-15 ml blood is indicated and effective therapy for severe headache after dural puncture. There is conflicting evidence regarding larger volume blood injections or delaying EBP for 24 hr or more after the diagnosis of postdural puncture headache (PDPH). Efficacy of EBP is related to a "patch effect" as well as transmission of increased epidural space pressure to the CSF space. Previous estimates of EBP efficacy were overgenerous; persistent symptomatic relief can be expected in 61-75% of patients with initial EBP. Patching with non-blood solutions, although initially effective, is associated with a high incidence of headache recurrence. Prophylactic injection of saline or blood decreases the incidence of severe headache after dural puncture. CONCLUSION: Blood-patching is an effective treatment of PDPH but further research is required regarding its mechanisms and prophylaxis.     

Abnormal renal vasodilation to an amino acid infusion in congestive heart failure: normalization by enalapril

In congestive heart failure (CHF), the neurohormonal mechanisms that cause renal vasoconstriction, particularly those depending on the renin-angiotensin system, could interfere with renal vasodilating mechanisms. To elucidate this issue, we studied the kidney response to an amino acid infusion (known to cause renal vasodilation in healthy individuals) in eight patients with CHF. We found that the amino acid infusion (0.7 mL/kg/h of a 10% solution) elicited no renal hemodynamic response, in marked contrast to healthy subjects. We next hypothesized that the renin-angiotensin system (known to be activated in heart failure) has a role in the lack of response to the amino acid infusion. To test this hypothesis, we repeated the study after two 5-mg doses of enalapril, an inhibitor of the angiotensin-converting enzyme, administered 12 hours apart. After enalapril treatment, the amino acid infusion caused a 45% increase in mean renal blood flow (RBF) from 383 +/- 55 to 557 +/- 51 mL/min at the fifth hour (P < 0.05). This normalization of the renal response to the amino acid infusion occurred without changes in cardiac output or in systemic vascular resistance. Hence, the renal fraction of the cardiac output increased during the amino acid infusion. The recovery of the renal vascular response was not accompanied by an increase in glomerular filtration rate (GFR; filtration fraction decreased), suggesting a predominant efferent arteriole dilatation. Our study shows that, in heart failure, the kidney loses its ability to increase RBF in response to an amino acid load. This lack of renal vascular response can be restored by inhibiting the renin-angiotensin system and is unrelated to changes in systemic hemodynamics.