Reemergence of Positive Symptoms after Initial Response to Risperidone

Risperidone was effective in successfully treating a patient's negative symptoms of schizophrenia as well as reducing adverse effects from typical antipsychotic drugs. Auditory hallucinations reemerged after 8 months, however, and again after 24 months of risperidone therapy. Reemergence of psychotic symptoms after initial response might be explained by inadequate dosage, by the natural course of the patient's schizophrenia independent of drug therapy, or by the possibility that, for this patient, risperidone was less effective than chlorpromazine for the positive symptom of auditory hallucinations.     

Causes of Alcoholism: A Qualitative Study of Traditional Muscogee (Creek) Indians

Abstract Traditional Native American people are experiencing serious health, economic, and social problems resulting from alcoholism. Native Americans maintain a worldview of health and illness that conflicts with the dominant culture's approach to treatment. The purposes of this study were to describe the health beliefs of traditional Muscogee (Creek) Indians concerning the causes of illness and learn how these beliefs relate to alcoholism. The researchers conducted in-depth interviews of 55 traditional Muscogee (Creek) participants to learn traditional beliefs about illness and alcoholism. Data were analyzed using content analysis. Results indicate that both illness and alcoholism are perceived as having natural and unnatural (supernatural) causes. A challenge facing nurses is how to provide culturally sensitive care when clients' and nurses' beliefs about the cause of alcoholism may be in conflict. The authors discuss preservation, accommodation, and repatterning of health care beliefs as a basis for planning culturally sensitive nursing care.     

Clinical Acumen: Brief Report: Therapeutic Manipulations in Severe Nocturnal Asthma. A Nonconventional Approach in a Severe High-Risk Asthmatic

A patient with severe nocturnal asthma of multifactorial pathogenesis with high-risk features leading to several episodes of nocturnal respiratory arrests is described. Despite aggressive conventional therapy with broncho-dilators and glucocorticoid agents, the patient had progressive worsening within the year prior to admission. After a nonconventional approach consisting of: high-dose inhaled steroids, afternoon dose of prednisone, addition of troleandomycin therapy, high-dose inhaled ipratropium at bedtime, maximizing serum theophylline concentrations in the early morning, and nasal CPAP through the night; the patient's pulmonary functions were optimized with minimal or no reduction in morning FEV₁, and decreased airways hyperresponsiveness to methacholine.     

Identifying incident cases of parkinsonism among veterans using a tertiary medical center.

To better understand the impact of incident Parkinson's disease (PD) on the Veteran's Health Administration (VHA) and to develop methods applicable to future epidemiological research, we performed a medical record review study at a tertiary referral VHA medical center. Searching the local data base, we identified 782 veterans with diagnostic codes for PD or secondary parkinsonism (SP) between 1998 and 2000. Based on structured medical record review, a movement disorders specialist confirmed diagnoses for incident parkinsonism cases. Among the 782, 191 incident parkinsonism cases were identified (100 PD, 75 SP, and 16 Parkinson's Plus). Incident PD cases were older at diagnosis (74.5 vs. 70.4 yr; P < 0.05) and more likely to be white (81% vs. 62; P < 0.07) than incident SP cases. Diagnostic codes were insufficient to distinguish between incident PD and SP (positive predictive value, 57% and 39%, respectively), and VHA sources failed to identify 21% of confirmed deaths among the incident PD cohort by November 2004. Although the large number of incident cases identified suggests PD is an important cause of disability among elderly VHA users, observed limitations of VHA sources for identifying incident PD cases and determining their vital status should be considered when designing future studies.     

Extreme bradycardia during sleep apnea caused by myxedema

A 52-year-old man with myxedema was evaluated for anterior chest pain that was considered to be compatible with myocardial ischemia. The night after admission he developed extreme bradycardia, hypotension, and apneic episodes lasting up to 25 s. Continuous positive airway pressure and administration of medroxyprogesterone acetate prevented further episodes and relieved much of the somnolence and lethargy that had contributed to the evidence for myxedema. Alveolar hypoventilation caused by decreased sensitivity to carbon dioxide, inadequate central neural drive, peripheral muscle force, and obesity all may have contributed to the apnea. Chest pain has not recurred, and results of electrocardiography have remained normal following full thyroid hormone replacement. The early recognition of myxedema causing sleep apnea will allow specific treatment to avoid the cardiovascular risks related to prolonged apnea and will help avoid confusion with other etiologies of cardiovascular abnormalities.     

Alternative Treatments for Asthma: Assessing the Need

Alternative treatments such as troleandomycin methotrexate, gold, and intravenous gamma globulin are sometimes considered for severe asthmatics to minimize the need for systemic corticosteroids and reduce adverse effects. These alternative therapies may also be associated with significant toxicity and expense. The ability to reduce corticosteroid use and the need for alternative treatment interventions in 125 pediatric patients at our institution were reviewed. Because corticosteroid requirements were reduced significantly, only 23 of 125 children evaluated were considered for treatment alternatives with only 10 receiving such therapy. This study emphasizes the importance of a thorough and comprehensive review of corticosteroid requirements and usage prior to initiating alternative approaches to treatment in moderate to severe asthmatics as well as in patients thought to be “steroid-dependent.”