Long-term home oxygen therapy

Trichomonas vaginalis was diagnosed in 42 (19%) of 227 adult males with urethral discharge. In 27 men (15%) T. vaginalis was isolated together with Neisseria gonorrhoeae. Non-gonococcal urethritis was diagnosed in 15 patients and T. vaginalis was isolated from 47% of such patients. Stained smear preparations, i.e. RapiDiff and acridine orange of modified Diamond's media, were superior to wet smear microscopy for the identification of T. vaginalis. RapiDiff stain was the most sensitive and identified 41 of 42 (98%) positive cultures. It is recommended that all turbid culture media should be stained for the optimal diagnosis of trichomoniasis.     

Intravenous theophylline therapy: nomogram guidelines

We evolved a nomogram for guiding and standardizing intravenous theophylline therapy in hospitalized patients. It provides rapid calculation of a loading dose based on body weight and previous therapy and a maintenance infusion rate related to three categories of expected metabolic activity. The guidelines were prospectively used in the treatment of 72 patients, mainly in a respiratory care unit. The nomogram was successfully used to attain near-steady-state serum concentrations in the therapeutic range of 8 to 20 mg/litre in 72% of patients, with only two patients outside of the range of 5 to 25 mg/litre. These guidelines facilitate initial theophylline dosage in older patients with liver and cardiac disease and provide a rational basis for interpreting serum concentration measurements and adjustment of drug therapy.     

Starting home nebulizer therapy: patients' expectations and subsequent outcome at 2 months

Twenty-six patients with severe COPD or asthma completed standard questionnaires before, and 2 months after, starting home nebulized bronchodilator therapy. Patients' perceived illness severity and their expectations of treatment with regard to symptoms were examined in the first questionnaire, and outcome was assessed in the second. Before treatment started patients expected a definite improvement in all symptoms studied. After treatment the group showed only a marginal subjective improvement in all symptoms. The improvement attained with regard to breathlessness, ability to get out and about, and general quality of life was significantly lower than had been expected. While home nebulized bronchodilator therapy is well tolerated and confers some subjective benefit in selected individuals, patients appear to have unrealistically high expectations of treatment.     

Hospital care at home

Red cell aggregation has been studied by photometry in 47 children with insulin-dependent diabetes mellitus. The disease was associated with boosting of reversible red cell aggregation, which was most of all expressed during metabolic decompensation with ketoacidosis. When metabolic subcompensation was attained, this parameter did not completely normalize and still had to be corrected.     

Technology-dependent children at home

Many children cared for at home are dependent on medical technology. Stressors for the family caring for technology dependent children include: finances and adaptation to new roles. Good discharge planning is the key to successful adaptation by the family as discharge home is often delayed by financial wrangles between purchasers and providers.     

Intravenous immune globulin therapy for neurologic diseases

High-dose intravenous immune globulin (IVIg) has emerged as an important therapy for various neurologic diseases. Different interpretations of clinical trial results; the expected benefit of IVIg compared with that of alternate therapies; and issues about IVIg's safety, cost, and mechanisms of action have raised concern and uncertainty among practitioners. To clarify these areas, this paper examines the clinical, serologic, and immunologic data on more than 110 patients with various autoimmune neurologic diseases who received IVIg during the past 6 years at the National Institute of Neurological Disorders and Stroke. It also reviews work by other investigators on the efficacy, risks, benefits, and mechanisms of the action of IVIg in these diseases. In controlled clinical trials, IVIg has been effective in treating the Guillain-Barré syndrome, multifocal motor neuropathy, chronic inflammatory demyelinating polyneuropathy, and dermatomyositis. In other controlled or open-label trials and case reports, IVIg produced improvement in several patients with the Lambert-Eaton myasthenic syndrome and myasthenia gravis but had a variable, mild, or unsubstantiated benefit in some patients with inclusion-body myositis, paraproteinemic IgM demyelinating polyneuropathy, certain intractable childhood epilepsies, polymyositis, multiple sclerosis, optic neuritis, and the stiff-man syndrome. The primary adverse reaction was headache; aseptic meningitis, skin reactions, thromboembolic events, and renal tubular necrosis occurred rarely. The most relevant immunomodulatory actions of IVIg, operating alone or in combination, are inhibition of complement deposition, neutralization of cytokines, modulation of Fc-receptor-mediated phagocytosis, and down-regulation of autoantibody production. Therapy with IVIg is effective for certain autoimmune neurologic diseases, but its spectrum of efficacy has not been fully established. Additional controlled clinical trials are needed.     

Efficacy of home cervical traction therapy

Cervical traction is administered by various techniques ranging from supine mechanical motorized cervical traction to seated cervical traction using an over-the-door pulley support with attached weights. Duration of cervical traction can range from a few minutes to 20 to 30 min, once or twice weekly to several times per day. Anecdotal evidence suggests efficacy and safety, but there is no documentation of efficacy of cervical traction beyond short-term pain reduction. Because of a clinical impression that a simplified, inexpensive, over-the-door home cervical traction method of treatment requiring 5 min of cervical traction twice daily was efficacious for both cervical pain and radiculopathic syndromes, we undertook a retrospective study of 58 outpatients treated between 1994 and 1996. Age range was 29 to 84 (mean, 56) yr. Twenty-three males and 35 females were classified as Grade 1 to Grade 3 according to the Quebec Task Force of Whiplash-Associated Disorders Cohort Study. Outcomes were as follows: Grade 1 (mild)--4 of 4 (100%) patients improved; Grade 2 (moderate)--34 of 44 (77%) patients improved (P < 0.01), 5 were unchanged, and 5 felt their symptoms were aggravated by cervical traction; Grade 3 (patients with radiculopathy)--9 of 10 (90%) patients improved (P < 0.01). In a retrospective study, a brief (3-5 min), over-the-door home cervical traction modality provided symptomatic relief in 81% of the patients with mild to moderately severe (Grade 3) cervical spondylosis syndromes. Prospective, randomized assessment of cervical traction for this and other methods is needed.     

Physical therapy in the home setting

"Physical therapy service in the home is a changing landscape for both patients and providers," notes Linda H. Krulish, MHS, PT, who owns a home care contracting and consulting agency, Home Therapy Services, in Columbus, Ohio. Regrettably, physical therapy often has been defined by what it is not.     

Intravenous therapy: current practice and nursing concerns

The field of intravenous (i.v.) therapy has been subject to major change, with increasing numbers of nurses taking on the high profile, technical aspects of care. The transfer of previously medicalized tasks such as cannulation has been welcomed by nurses who are keen to develop practical skills in order to embrace the concept of holistic patient care. This literature review aims to clarify the role of the nurse in i.v. therapy, exploring cannulation as a specific issue. Legal and professional aspects are discussed in terms of extended/expanded practice and practical aspects in terms of i.v. access and maintenance. Discussion focuses on a team approach to the management of i.v. therapy. Finally, the nursing process is applied to an i.v. therapy scenario. Exploration of the nursing issues enables practitioners to justify the expansion of individual practice in order to deliver holistic care and improve standards of service. The review concludes that nurses cannot afford to lose sight of the caring component of their role as a result of immersion in the culture of technical skill acquisition.     

Intravenous immunoglobulin as sole therapy for systemic vasculitis

High-dose, pooled, i.v. immunoglobulin (IVIg) is a potential, alternative treatment for Wegener's granulomatosis (WG) and microscopic polyangiitis (MPA) which has shown promise in the treatment of refractory disease when administered with continuing immunosuppression. This study of six new patients with antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis and early disease, without threatened vital organ function, examined the therapeutic response to treatment with IVIg alone. IVIg was well tolerated and all six patients had early reductions in disease activity. Four entered full, clinical remission which lasted for at least 1 yr, while in two the responses were partial and transient, and they subsequently required conventional treatment. After 16-48 months of follow-up, two of the four patients in full remission relapsed, but the other two have remained well.     

Intravenous gentamicin therapy in bilateral Menière disease

BACKGROUND: The treatment of severe forms of bilateral Menière's disease remains an especially challenging task. Similar problems also occur in debilitating Menière's disease in the only hearing ear. The intramuscular titration therapy with streptomycin has been the means of choice since 1984 to minimize the risk of total hearing loss in cases of severe bilateral disease. METHOD: Since 1989 we have treated six out of 21 cases of bilateral Menière's disease by intravenous application of 2 x 120 mg gentamicin in Ringer's solution for several days. Additionally we reported on two cases in 1988. Only minor amounts of gentamicin were applied to sedate the function of both vestibular organs while avoiding damage to the cochlea. RESULTS: In two cases hearing approved approximately about 10 dB, in two cases hearing remained stable, and in two cases hearing worsened about 10 dB. Five of six patients showed minor excitability in caloric tests on both sides, they did not complain of vertigo attacks one to five years after therapy. CONCLUSION: Given that only very small amounts of gentamicin are applied to sedate the function of the vestibular organ while causing almost no damage to the cochlea, this method seems to be an excellent means for treatment of bilateral Menière's disease. Patients do not experience severe problems with equilibrium afterwards, and the treatment can be repeated as often as necessary.