The challenge of racial difference: skills for clinical practice

Just as racial injustice negatively affects the plight of minorities in society, racial tensions impede professional helping. Often, the racially dissimilar social worker and client approach each other with little understanding of each other's social realities and with unfounded assumptions. Unfortunately, professionals find it difficult to acknowledge such differences or their effect on their relationships. Yet the fruitfulness of the helping encounter often depends on the ability to develop and invest in a trusting relationship. This article identifies the societal roots of the stresses associated with cross-racial relationships. Three concerns commonly experienced by clients whose workers are racially different are identified: (1) Is the helper a person of goodwill? (2) Is the helper trained and skilled? (3) Is the help offered valid and meaningful for me and my social reality? Case vignettes are used to illustrate how each concern is typically mishandled. The importance of successfully managing each concern is stressed, and skills for successful management are illustrated.

Effect of atrial natriuretic peptide on vascular permeation in the ovine fetus

To study the effect of atrial natriuretic peptide (ANP) on vascular permeation of albumin in the fetus, ANP (167-600 ng/min) was infused into eight ovine fetuses and saline vehicle was infused into eight twin controls (gestational age 127 +/- 3 d) over a 50-min period. Using two different radiolabeled albumin markers, we determined the tissue to blood isotope ratio (TBIR), an index of albumin permeation, and the albumin clearance. Although ANP had no hemodynamic effect, a marked increase in the hematocrit was observed in ANP-infused fetuses compared with initial values (0.37 +/- 0.04 vs 0.42 +/- 0.04, p < 0.005) but was unchanged in the twin fetuses receiving saline vehicle (0.35 +/- 0.03 versus 0.35 +/- 0.02). TBIR and albumin permeation were increased in combined tissues of ANP-infused fetuses compared with saline controls (TBIR: 1.49 +/- 0.58 versus 1.29 +/- 0.3, p < 0.001; albumin clearance: 1091 +/- 1279 versus 827 +/- 1464 nL/g/min, p < 0.01). In individual tissues, TBIR was significantly increased in skin (2.88 +/- 0.67 versus 1.55 +/- 0.35, p < 0.02), muscle (1.6 +/- 0.27 versus 1.24 +/- 0.26, p < 0.02), adrenal (1.33 +/- 0.10 versus 1.13 +/- 0.15, p < 0.02), bone (1.67 +/- 0.45 versus 1.20 +/- 0.40, p < 0.02), kidney (1.52 +/- 0.25 versus 1.24 +/- 0.26, p < 0.03), and gut (1.69 +/- 0.20 versus 1.39 +/- 0.34, p < 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

An assessment of practitioner cross-racial treatment experiences

This study sought to determine differences in the cross-racial practice experiences of white and minority social services practitioners. Fifty-three counselors in a Veterans Administration outreach center evaluated various aspects of their cross-racial practice experiences. Both white and minority counselors perceived themselves to work equally well with white clients, but white counselors perceived themselves to be less effective when working with minority clients. The majority of white and minority counselors reported identifying the source of white clients' problems as being internal and that of minority clients' problems as being external. This finding was interpreted as being a possible bias against white clients on the part of both white and minority practitioners. White counselors reported experiencing less client credibility, and minority counselors reported more incidents of racism. Implications for social work are discussed.

Cortical organization in adulthood is modified by neonatal infarct: a case study

PURPOSE

To assess anomalous cortical organization of somatosensory function in a 23-year-old man who had had a neonatal infarct involving the left middle cerebral artery.

MATERIALS AND METHODS

The infarct destroyed the primary and secondary somatosensory areas of the subject's left hemisphere but caused only mild perturbation of somatosensation on the right side of his body. With magnetic source imaging, the authors integrated magnetoencephalographic data with magnetic resonance imaging data to create magnetic source localization images that showed the mapping between brain function and structure.

RESULTS

Electrical stimulation of the right median nerve evoked activity in two nontraditional areas: (a) an intact region of the left inferior temporal gyrus and (b) the ipsilateral right medial parietal cortex.

CONCLUSION

These data suggest that bilateral neural reorganization can be induced by unilateral neonatal damage.

The effect of dietary protein depletion on hepatic 5-fluorouracil metabolism

BACKGROUND

Protein calorie malnutrition, which is highly prevalent in tumor-bearing hosts, increases toxicity to 5-fluorouracil (5-FU), but the mechanisms are unclear. This study investigated the effects of protein depletion on 5-FU in vivo hepatic metabolism using F19-nuclear magnetic resonance spectroscopy (19F-NMRS).

METHODS

Rats received normal (21.5%) or low (2.5%) protein diet for 25 days. 5-FU was injected intraperitoneally, and hepatic fluorine spectra were obtained. Parallel experiments were conducted to determine serum 5-FU pharmacokinetics using high-performance liquid chromatography (HPLC) and to measure hepatic dihydropyrimidine dehydrogenase (DPD) activity.

RESULTS

The mean time of initial detection of fluoro-beta-alanine and the mean duration of the 5-FU signal in the liver were significantly prolonged in the low-protein group. 5-FU clearance and hepatic DPD activity were significantly lower in the low-protein group. Low-protein animals demonstrated increased toxicity, with diarrhea, weight loss, leukopenia (P < 0.001), and an 85% mortality, compared with regular diet animals, who had mild diarrhea and weight loss but no leukopenia and a 12% mortality.

CONCLUSION

Protein depletion results in increased toxicity to 5-FU, which is associated with a significantly decreased rate of hepatic metabolism and clearance of 5-FU and a significant decrease in hepatic DPD activity. 19F-NMRS can noninvasively identify these alterations of 5-FU metabolism in vivo and may serve as a useful guide to determining chemotherapy dosage adjustments to reduce toxicity.

Tuberculous meningitis in the southwest United States: a community-based study

This community-based study analyzed 54 patients with definite or probable tuberculous meningitis (TBM) in New Mexico from 1970 through 1990. Patients ranged in age from 4 months to 86 years. The highest age-specific incidence occurred in the elderly, but 22% of patients were less than 10 years old. Native American patients were overrepresented. Patients were as likely to live in small towns as in large urban cities. Symptoms were present for a median of 13 days before admission. The majority of patients had fevers, headache, stiff neck, and mental changes, such as confusion or lethargy. No patient was admitted comatose. Focal neurologic signs were present in 33%. Laboratory testing found hyponatremia in 79%, pulmonary infiltrates on chest x-ray in 40%, ventricular dilatation on CT or MRI in 52%, and tuberculomas in 16%. PPD skin tests were positive in 64%. CSF cultures grew Mycobacterium tuberculosis in 50%, but colony counts were always lower than 10(2)/ml. As a consequence, acid-fast stains of CSF sediment were reported as positive in only 4%. Six patients were not diagnosed during the hospitalization and died of complications. Twenty-three percent of patients who were appropriately treated also died of complications during the initial hospitalization. Tuberculous meningitis continues to be an important disease in small communities, and affects all ages and ethnic and socioeconomic backgrounds.

Devic's neuromyelitis optica: a clinicopathological study of 8 patients

We report the clinical, imaging, and laboratory features of 8 patients with Devic's neuromyelitis optica. All patients had severe myelopathy and optic neuritis. In no patient was the brain, the brainstem, or the cerebellum affected, even after several years of disease. Various immunosuppressive treatments failed to benefit the patients, 5 of whom died. Autopsies of these 5 patients demonstrated a severe necrotizing myelopathy with thickening of blood vessel walls and no lymphocyte infiltrates. In the appropriate clinical setting, the lack of white matter abnormalities demonstrated by magnetic resonance imaging of the head facilitates the recognition of Devic's syndrome during life. Inasmuch as Devic's myelopathy is necrotizing, rather than demyelinating, the prognosis of this syndrome is poor.

Temporal bone histopathology 14 years after cytomegalic inclusion disease: a case study

Temporal bones were examined from a 14-year-old male who died of sequelae of congenital cytomegalic inclusion disease (CID). Cytomegalovirus (CMV) was not isolated from inner ear fluid or multiple systemic tissues at the time of death. Examination of temporal bones revealed chronic pathology of both cochlear and vestibular sensory and nonsensory tissues. Endolymphatic hydrops was observed in the basal turn of the cochlear duct, while Reissner's membrane was collapsed in the more apical turns. Strial atrophy and a loss of cochlear hair cells were observed along the entire length of the basilar membrane. Vestibular neuroepithelial regions were degenerated and fibrosis was seen within the vestibular perilymphatic tissue spaces, suggesting prior labyrinthitis within the perilymph compartment in addition to the more typical pattern of endolabyrinthitis associated with human CMV infection. Distention of the saccular membrane was evident. In both cochlear and vestibular tissues, there were isolated regions of calcifications that appeared characteristic to that reported in other organ systems of individuals with CID. Collectively, these chronic, pathological findings in this case of CID demonstrate more extensive injury than has been identified in the previously reported acute temporal bone pathology of CID.

Positive end-expiratory pressure lowers the risk of laser-induced polyvinylchloride tracheal-tube fires

BACKGROUND

The possibility of ignition of polyvinylchloride (PVC) tracheal tubes by a CO2 laser is of concern in patients undergoing CO2 laser surgery of the airway. The authors analyzed the ignition of PVC tracheal tubes by a CO2 laser beam to determine what variables were involved, and then designed a study to determine how they affect the incidence of such fires.

METHODS

For the analysis, PVC tracheal tubes were enclosed in a clear plexiglass enclosure and a laser beam was focused on the tubes. The enclosure contained one of three different gas combinations. A high-speed camera photographed the tubes during the analysis and showed that tracheal tube perforation always preceded ignition in all three gas combinations. These results led to the hypothesis that intraluminal gauge pressure (IGP) may be an important variable, because it would affect the flow of O2 across the perforation. This hypothesis was tested by aiming a CO2 laser beam at PVC tracheal tubes and varying IGP in 0.25-cm H2O increments, from 0.25 to 28 cm H2O, while nitrogen or helium containing O2 at 40, 50, or 60% flowed through the tubes. To simulate the clinical effect of IGP on PVC tracheal tube ignition, we used a mechanical lung model connected to an anesthesia breathing circuit with a standing bellows ventilator in which 60% He and 40% O2 flowed through a PVC tracheal tube. Laser beam exposure was started at three different times during the respiratory cycle: at the start of inspiration, at the end of inspiration, or at the end of expiration. Also, for each condition, trials were made at baseline circuit pressure (2.5 cm H2O) and at 5.0 cm H2O by the addition of 2.5 cm H2O positive end-expiratory pressure (PEEP) applied to the circuit.

RESULTS

The incidence of tracheal tube ignition decreased as IGP increased. The IGP at which ignition did not occur (which increased as O2 concentration increased) did not differ between N2 and He at 40% O2, but was twice as high with N2 as with He at O2 of 50% and 60%. Fires never occurred when PEEP was added to the system and, when PEEP was not added, always started during the last 2 s of end expiration (when airway pressure is lowest), regardless of when the laser beam was activated.

CONCLUSIONS

It is recommended that, in addition to other safety practices, PEEP be added to the breathing circuit during CO2 laser operations on the airway in which PVC tracheal tubes or laser-resistant tracheal tubes with PVC components are used.

Neuromagnetic mapping of brain function

Magnetic source imaging, a technique that combines magnetoencephalography (MEG) and magnetic resonance (MR) imaging, was used to localize the somatosensory and auditory cortex in seven healthy subjects. Functional neuromagnetic data were obtained with a 37-channel biomagnetometer. Structural MR imaging data were obtained with a 1.5-T superconducting imager. Coordinates used in defining MEG and MR imaging space were reconciled to produce magnetic source images that displayed the putative locations of somatosensory and auditory activity in relation to brain anatomy. Sources of somatosensory activity were typically localized to the postcentral gyrus; sources of auditory activity were localized to the superior temporal plane. Extension of these results to patients with tumors (or other disorders) that distort normal brain anatomy has the potential to make noninvasive magnetic source imaging examinations clinically useful in guiding neurosurgical interventional procedures.

The influenza B virus mouse model of Reye's syndrome: pathogenesis of the hypoglycaemia

Up to 40% of children with Reye's syndrome have hypoglycaemia that could contribute to the patient's encephalopathy. We developed a mouse model in which intravenous inoculation of influenza B/Lee virus produced a non-permissive infection of hepatocytes and cerebral endothelial cells and caused many clinical, biochemical and pathologic features of Reye's syndrome. We used this model to study the pathogenesis of the hypoglycaemia. Beginning 6 hours after virus inoculation and persisting to death 18-30 hours later, blood glucose levels fell by 40% and glycogen disappeared from the liver. Gluconeogenesis in liver slices from a pyruvate substrate was significantly impaired. Pyruvate carboxylase, normally present in hepatocyte mitochondria, was largely displaced into the cytosol, rendering that enzyme fraction relatively useless in the gluconeogenesis pathway. Brain glucose levels fell proportionately to the depressed blood glucose level to a mean of 44 mg/100 g compared to 108 mg/100 g in control brains. We conclude that hypoglycaemia in the mouse model developed largely as a result of a non-permissive influenza viral infection of hepatocytes which impaired the mitochondrial phase of gluconeogenesis. The hypoglycaemia may have contributed to, but did not solely account for, the encephalopathy. A similar non-permissive influenza B infection may cause hypoglycaemia in Reye's syndrome.

Transverse myelitis. Retrospective analysis of 33 cases, with differentiation of cases associated with multiple sclerosis and parainfectious events

OBJECTIVE

A study was undertaken to determine whether cases of parainfectious-associated transverse myelitis (TM) and multiple sclerosis-associated TM could be distinguished on the basis of clinical criteria, radiologic features, or cerebrospinal fluid examination. A secondary objective was to determine the incidence of TM in a US population.

DESIGN

A retrospective analysis of 33 cases was conducted. Cases were classified as being related to parainfectious multiple sclerosis, or spinal cord ischemia, or idiopathic.

SETTING

All cases occurring in the Albuquerque, NM, area from 1960 through 1990 were reviewed. The population base was 500,000.

OUTCOME MEASURES

Clinical presentation, radiologic features, cerebrospinal fluid, recovery of ambulation and bladder function, and recurrence rates were compared.

RESULTS

Thirty-three patients satisfied study criteria, corresponding to an incidence of 4.6 per million per year. Forty-five percent of these cases were categorized as parainfectious, 21% as associated with multiple sclerosis, 12% as associated with spinal cord ischemia, and 21% as idiopathic. Patients with parainfectious TM suffered from spinal shock more frequently than did those with multiple sclerosis-associated TM. Patients with parainfectious TM showed evidence of spinal cord swelling, whereas patients with multiple sclerosis-associated TM had spinal cord plaques on magnetic resonance images but none showed swelling. Oligoclonal bands were absent in patients with parainfectious TM and present in three of five patients with multiple sclerosis-associated TM.

CONCLUSIONS

Parainfectious TM may be distinguishable from that associated with multiple sclerosis on the basis of presentation, findings on imaging, and the presence of cerebrospinal fluid oligoclonal bands.

Estrogen-induced left ventricular chamber enlargement in ewes

We studied the chronic effect of administration of a single large intramuscular dose of 17 beta-estradiol on left ventricular chamber size and output in the ewe. Fourteen oophorectomized ewes were successfully instrumented and studied, with measurements made of left ventricular, aortic, right and left atrial pressures, left ventricular stroke volume, and left ventricular minor axis dimension. Unanesthetized ewes were studied before and 1, 2, and 3 wk after intramuscular administration of 0.6 mg/kg 17 beta-estradiol (7 ewes) or 1.5 ml sesame oil placebo (7 ewes). Left ventricular end-diastolic pressure-end-diastolic dimension (LVEDP-EDD) and left ventricular end-diastolic pressure-stroke volume (LVEDP-SV) relationships were quantified during graded inferior vena caval occlusion and volume infusion. Left ventricular end-diastolic diameter was larger after estrogen but not after placebo administration. The LVEDP-EDD relationship shifted progressively rightward, indicating left ventricular chamber enlargement in the estrogen group but was unchanged in the placebo group. The plateau limb of the LVEDP-SV relationship in the estrogen group shifted up from a mean stroke volume of 77.1-89.5 ml/beat and did not change in the placebo group. We conclude that administration of a single large intramuscular dose of 17 beta-estradiol resulted in left ventricular chamber enlargement and increased stroke volume in the ewe.

Botulinum toxin. From poison to medicine

Although thousands of people in the world each year continue to be poisoned with botulinum toxin-food-borne, infantile, or wound botulism-the neurotoxin is now sufficiently understood to allow it to be used as a medicinal agent to paralyze specific muscles, giving temporary symptomatic relief from a variety of dystonic neurologic disorders. I review some of the epidemiologic, clinical, and pathophysiologic aspects of botulinum toxin and how the neurotoxin may act as a poison or a medicine.

Viruses and vestibular neuritis: review of human and animal studies

There is increasing evidence in man and animals that several human viruses can damage the vestibular labyrinth. Clinical and serologic studies of patients with vestibular neuritis suggest that the viruses may play a role in the pathogenesis of this disease. Temporal bone studies of patients dying after vestibular neuritis have found maximal damage in the distal branches of the vestibular nerve. These changes are felt to be consistent with a viral etiology. No satisfactory animal viral model of vestibular neuritis currently exists. However, animal studies have demonstrated that several human viruses including rubeola, herpes simplex, reovirus, mouse and guinea pig cytomegalovirus, and neurotropic strains of influenza A and mumps virus, can infect the vestibular nerve and the vestibular membranous labyrinth.

Hepatitis A post-viral encephalitis

We report a seven-year-old girl who developed a hepatitis A viral infection and encephalitis. The patient developed fever, abdominal pains and jaundice. Five days later she became delirious, combative, and did not respond to verbal commands. Laboratory studies showed elevated liver enzymes and elevated serum immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies to hepatitis A virus. Cerebrospinal fluid contained IgG antibodies to hepatitis A virus but not IgM antibodies. Polymerase chain reaction, which amplifies a portion of the hepatitis A virus genome, did not demonstrate viral nucleic acid in cerebrospinal fluid. These studies suggest that the patient may have suffered from a post-viral hepatitis A encephalitis from which she fully recovered.

Role of angiotensin II and alpha-adrenergic receptors during estrogen-induced vasodilation in ewes

Estradiol-17 beta (E2 beta) produces uterine and systemic vasodilation in nonpregnant ewes without altering mean arterial pressure (MAP). Mechanisms responsible for maintaining MAP and thus uterine blood flow (UBF) may include activation of the renin-angiotensin and/or adrenergic systems. We therefore investigated the effects of systemic blockade of angiotensin II (ANG II) and/or alpha-adrenergic receptors in nonpregnant, castrated ewes, using saralasin (Sar) and/or phentolamine (Phen) in the presence or absence of intravenous E2 beta (1.0 microgram/kg). In nonestrogenized ewes neither antagonist alone had substantial cardiovascular effects; however, Sar + Phen decreased systemic vascular resistance (SVR) 20 +/- 7.4% (SE) and increased heart rate (HR) 50 +/- 19% (P < 0.01); MAP and UBF were unaffected. Following E2 beta treatment SVR fell 17 +/- 2.4% (P < 0.01), UBF increased more than fourfold, and MAP was unchanged. Compared with E2 beta alone, Phen + E2 beta decreased SVR 42 +/- 4.7%, and MAP fell 11 +/- 1.8% (P < 0.05) despite 40-50% increases in HR and cardiac output (P < 0.05). Responses to Sar + E2 beta were similar to E2 beta alone, except for a fall in MAP, whereas responses to Sar + Phen + E2 beta resembled those of Phen + E2 beta. E2 beta-induced uterine vasodilation was unaltered by Sar and/or Phen. During E2 beta-induced vasodilation, MAP is maintained by enhanced activation of the alpha-adrenergic and renin-angiotensin systems; however, uterine vascular responses to E2 beta are independent of both systems and perfusion pressure.

Quinolinic acid and kynurenine pathway metabolism in inflammatory and non-inflammatory neurological disease

Neurological dysfunction, seizures and brain atrophy occur in a broad spectrum of acute and chronic neurological diseases. In certain instances, over-stimulation of N-methyl-D-aspartate receptors has been implicated. Quinolinic acid (QUIN) is an endogenous N-methyl-D-aspartate receptor agonist synthesized from L-tryptophan via the kynurenine pathway and thereby has the potential of mediating N-methyl-D-aspartate neuronal damage and dysfunction. Conversely, the related metabolite, kynurenic acid, is an antagonist of N-methyl-D-aspartate receptors and could modulate the neurotoxic effects of QUIN as well as disrupt excitatory amino acid neurotransmission. In the present study, markedly increased concentrations of QUIN were found in both lumbar cerebrospinal fluid (CSF) and post-mortem brain tissue of patients with inflammatory diseases (bacterial, viral, fungal and parasitic infections, meningitis, autoimmune diseases and septicaemia) independent of breakdown of the blood-brain barrier. The concentrations of kynurenic acid were also increased, but generally to a lesser degree than the increases in QUIN. In contrast, no increases in CSF QUIN were found in chronic neurodegenerative disorders, depression or myoclonic seizure disorders, while CSF kynurenic acid concentrations were significantly lower in Huntington's disease and Alzheimer's disease. In inflammatory disease patients, proportional increases in CSF L-kynurenine and reduced L-tryptophan accompanied the increases in CSF QUIN and kynurenic acid. These responses are consistent with induction of indoleamine-2,3-dioxygenase, the first enzyme of the kynurenine pathway which converts L-tryptophan to kynurenic acid and QUIN. Indeed, increases in both indoleamine-2,3-dioxygenase activity and QUIN concentrations were observed in the cerebral cortex of macaques infected with retrovirus, particularly those with local inflammatory lesions. Correlations between CSF QUIN, kynurenic acid and L-kynurenine with markers of immune stimulation (neopterin, white blood cell counts and IgG levels) indicate a relationship between accelerated kynurenine pathway metabolism and the degree of intracerebral immune stimulation. We conclude that inflammatory diseases are associated with accumulation of QUIN, kynurenic acid and L-kynurenine within the central nervous system, but that the available data do not support a role for QUIN in the aetiology of Huntington's disease or Alzheimer's disease. In conjunction with our previous reports that CSF QUIN concentrations are correlated to objective measures of neuropsychological deficits in HIV-1-infected patients, we hypothesize that QUIN and kynurenic acid are mediators of neuronal dysfunction and nerve cell death in inflammatory diseases. Therefore, strategies to attenuate the neurological effects of kynurenine pathway metabolites or attenuate the rate of their synthesis offer new approaches to therapy.

No-scalpel vasectomy: a technique for family physicians

Family physicians frequently perform outpatient vasectomies. A new approach to exposing the vas deferens, called the no-scalpel vasectomy, results in fewer complications and, the authors believe, improved patient acceptance. This technique, which calls for two specialized instruments, is described, along with patient selection and education issues, vasal occlusion techniques and post-vasectomy follow-up.

Early viral brain invasion in iatrogenic human immunodeficiency virus infection

We report a 68-year-old man who received an IV inoculation of WBCs for an indium radionuclide scan containing 600 to 700 tissue culture infectious doses of human immunodeficiency virus type 1 (HIV-1) from an HIV-1-infected individual. The recipient immediately received zidovudine, then was switched to dideoxyinosine and interferon-alpha, but died of hepatorenal syndrome and hepatic encephalopathy 15 days later. HIV-1 cultures were positive from the recipient's blood on day 14 but not days 0, 1, and 8. At autopsy, cultures of parietal lobe isolated HIV-1. HIV-1 nucleic acid was present in several brain areas, but not in several other organs, by two independent laboratories using the polymerase chain reaction. The brain showed mild perivascular cuffing and a mild lymphocytic meningitis, but there was no evidence of glial nodules, giant cells, or white matter abnormalities. HIV-1 pg41 viral antigen was seen by immunoperoxidase staining in rare infiltrating cells within perivascular and subpial spaces. Thus, HIV-1 was isolated from brain 15 days after mistaken HIV-1 inoculation and 1 day after virus was first recovered from blood.

Human type A botulism and treatment with 3,4-diaminopyridine

3,4-diaminopyridine was evaluated for its ability to improve muscle strength, respiratory function and electromyographic compound muscle action potentials in human botulism. In a double blind, placebo controlled study, 3,4-diaminopyridine failed to improve these parameters in a 31-year old patient with severe food-borne type A botulism. The addition of an anti-cholinesterase medication to the 3,4-diaminopyridine did not add any benefit. Lack of clinical improvement from 3,4-diaminopyridine in this patient differed from some reports of benefit in animals experimentally poisoned with type A botulinum toxin.

Noninvasive preoperative cortical localization by magnetic source imaging

The authors successfully used magnetoencephalography and MR data to localize the sensorimotor cortex in two patients prior to neurosurgery; preoperative localization influenced surgical management.

Hemodynamics and organ blood flow in fetal sheep subjected to chronic anemia

To investigate cardiovascular adaptation to chronic anemia we studied eight ovine fetuses made anemic by serial isovolemic hemorrhage and seven nonanemic controls. After 1 wk carotid arterial oxygen content was reduced to 1.6 +/- 0.2 ml/dl and hematocrit to 13.3 +/- 1.6% in anemic fetuses compared with 6.9 +/- 1.2 ml/dl and 32.4 +/- 3.9% in controls. Cardiac output was higher in the anemic group (753 +/- 102 vs. 490 +/- 66 ml.min-1.kg fetus-1) as stroke volume and heart rate both increased. Blood flow to the carcass, skin, kidneys, intestines, brain, and heart was increased. Vascular resistance fell in all tissues except the placenta. Central venous pressure, arterial pH, plasma total protein, and blood volume were not different although extravascular fluid accumulated in six of the anemic fetuses. The estimated capillary hydrostatic pressure was greater in anemic (7.6 +/- 1.8 mmHg) than control fetuses (5.0 +/- 1.5 mmHg) and the ratio of precapillary to postcapillary resistance was less. We conclude that reduction in the ratio of precapillary to postcapillary resistance in chronic fetal anemia increases blood flow, oxygen delivery, and capillary hydrostatic pressure.

Aiding the Alzheimer's dementia patient to live in safety and security

Alzheimer's is truly a "family" disease, affecting not only the patient but the entire family. The patient's emotional/psychological safety and security are as important as his or her physical condition, and therefore must be addressed. Families should be encouraged to use every resource that is available. The nurse/caregiver is in an excellent position to offer support and suggest resources. The key is understanding the course of the disease and measures that can be employed to maintain the patient in optimal safety and security.