Nuzhet O. Atuk

Effect of Aminophylline on Urinary Excretion of Epinephrine and Norepinephrine in Man

The excretion of catecholamines and the changes in plasma concentration of free fatty acids during aminophylline administration were explored. The relationships between cardiac arrhythmia, cardiac rate, and change in blood pressure under the conditions of these experiments were defined. Eighteen experiments were performed on eight volunteers. Blood pressures and heart rates before and during aminophylline infusion were recorded at frequent intervals, and urine and blood were collected during the control and infusion periods and in some subjects after the infusion. Loading with ethanol, glucose, or placebo before administration of aminophylline was used.These studies demonstrated that intravenous infusion of aminophylline increases the urinary excretion of epinephrine and norepinephrine in man, the rate of excretion of epinephrine being greater than that of norepinephrine. This increase was accompanied by an increase in the concentration of free fatty acids in the plasma.

Therapy of the idiopathic nephrotic syndrome with alternate day steroids

Eighty-one adult patients with the idiopathic nephrotic syndrome were treated with prednisone, 60 to 120 mg, on alternate days. Treatment was continued with diminishing drug doses for up to 10 years. Biopsy specimens were categorized as showing lipoid nephrosis 36 per cent, focal sclerosis 12 per cent, diffuse proliferative 22 per cent and membranous nephropathy 30 per cent. Patients with systemic causes of the nephrotic syndrome were excluded. Proteinuria decreased to normal or to less than or equal to 3 g with a greater than or equal to 50 per cent decrease from base line in 83 per cent of the patients with lipoid nephrosis, 30 per cent of the patients with focal sclerosis, 50 per cent of the patients with diffuse proliferative nephritis and 71 per cent of the patients with membranous nephropathy. Improvement occurred in those with focal sclerosis, diffuse proliferative nephritis and membranous nephropathy only after prolonged treatment (14 to 15 months). Stable or improved renal function occurred in 97 per cent of those with lipoid nephrosis, 50 per cent of those with focal sclerosis, 73 per cent of those with diffuse proliferative nephritis and in 83 per cent of those with membranous nephropathy. Death or dialysis occurred in 12 per cent of the patients, and complications coincident with treatment occurred once every 12 patient years. Compared to other series of patients with the idiopathic nephrotic syndrome, therapy of our patients with prolonged alternate day steroids resulted in (1) decreased protein excretion, (2) maintenance of good renal function and (3) decreased number of complications of therapy.

Catecholamine Uptake, Accumulation, and Release in Acute Porphyria

Hypertension and tachycardia are well known features of acute porphyria and have been shown to be related to increased circulating catecholamines. The mechanism by which circulating catecholamines are increased was studied using the isolated perfused rat heart and human platelets as a model of adrenergic neuronal function. It was found that neither delta-aminolevulinate (ALA) nor porphobilinogen (PBG) blocked uptake or caused release in the isolated perfused rat heart. Platelets from six patients with acute prophyria, three in remission and three latent, with matching normal controls were studied with regard to their uptake of [(3)H]norepinephrine in the presence of ALA or PBG. It was found that ALA and PBG significantly reduced uptake and accumulation of [(3)H]-norepinephrine in patients with acute porphyria; however, no similar reduction in uptake and accumulation was observed in the platelets of normal controls. Therefore, it appears that there is a latent defect in the catecholamine uptake and (or) accumulation of platelets of patients with acute prophyria which only manifests itself in the presence of ALA or PBG. If platelet uptake serves as a model of adrenergic neuron uptake, this suggests that elevated circulating catecholamine levels during acute attacks of acute porphyria are caused at least partially by blockade of re-uptake into the sympathetic neurons.

Massive diflunisal overdosage with recovery.

To the Editor: -Both the original article by Zimmer et al,’ “Nursing Homes as Acute Care Providers: A Pilot Study of Incentives to Reduce Hospitalizations” and the response it prompted from Dr Katz2 overlook major and conspicuous problems in implementing effective management of acute medical problems within nursing homes. For Dr Katz, ”the h t and most obvious problem relates to the paucity of physicians.” For me, as a nursing supervisor in a nursing home, the first and most obvious problem is the paucity of qualified and interested nurses. The well publicized nursing shortage has hit the nursing homes especially hard. The salaries offered to our staff nurses is considerably less than that offered hospital staff nurses. Agencies are luring away an ever-increasing number of nurses with salaries twice that of staff. Many long-term care facilities in the urban areas are staffed daily by more than 50% agency nurses. This pattern leads inevitably to destroying continuity of care and allowing subtle physical, emotional, or mental changes to go unnoticed, sometimes for days. Further, the general attitude that geriatric care involves few nursing skills beyond the custodial encourages nursing applicants whose poor clinical skills prohibit them from taking hospital positions. Even nursing agencies seem to take this view, sending to the nursing homes nurses whom they would not consider for a hospital position. Combine these problems with the low regard for nurses’ aides. Theirs is truly a thankless job. They are regularly abused verbally by patients and families because whatever is needed was not done soon enough or well enough, and their supervisors rarely thank them for their good work, but are certain to criticize everything else. Their physically exhausting work has the added appeal of risking injury from confused or combative patients. They‘ve always got their hands in “it.” And for all this, they are paid little more than hamburger slappers. Is it any surprise that nursing homes are constantly understaffed? The problems are not limited to the medical or nursing professionals and staff. The reimbursement system is set up in such a way that allied health professionals are infrequently available. Our patients would benefit greatly from increased use of nutritionists, physical therapists, speech therapists, and occupational therapists. How about frequent dental check-ups; now there‘s a novel idea! Nursing homes could theoretically provide acute care but many things must change. Requisite for such care, we must recognize that (1) no single health profession works in a vacuum and the problems within each affect the others; (2) financial incentives to all those giving care to our chronically ill, dependent geriatric patients are essential; (3) providing care to these patients is intellectually and professionally challenging; and (4) all students of all the health professions should become acquainted with the challenges and satisfactions of providing high quality geriatric health care.