The patient with a tracheostomy

For the treatment of certain specific diseases, a tracheostomy is a required procedure in order to keep the patient's air passageways open. The nurse's care must ensure this permeability is maintained and infections avoided while serving to aid both the patient and his/her family to adapt as best as possible to the conditions caused by the intervention. Treatment Plan details will be drawn up based on each individual patient's diagnosis.     

Hemoptysis due to MDI therapy in a patient with permanent tracheostomy: treatment with mask AeroChamber

Persistent minor hemoptysis resulted from extensive granulation tissue on the main carina and adjacent bronchi due to frequent spraying of metered-dose inhaler (MDI)-generated aerosol medications directly into a permanent tracheostomy. Salbutamol, containing oleic acid, was considered the most likely cause. After an AeroChamber equipped with an infant mask was interposed between the MDI and the tracheal stoma, hemoptysis and the pathologic changes gradually resolved.     

Imagery mnemonic training in a patient with primary degenerative dementia.

A visual-imagery mnemonic was used as a memory training aid for a 66-year-old patient with primary degenerative dementia. Length of retention time was used as the primary outcome measure. The application of the mnemonic procedure extended the length of retention time for name-face recall from baseline. Performance gains were sustained at one month. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Malignant hypertension in a patient with primary aldosteronism with elevated active renin concentration

A 40-year-old male, with a past history of hypertension but receiving no medical treatment, was referred. He manifested malignant hypertension (190/130 mmHg; Keith-Wagener III), renal dysfunction (serum creatinine, 3.8 mg/dl), and elevated plasma aldosterone (450 pg/ml) and active renin concentration (ARC, 104 pg/ml). His blood pressure was controlled with multiple antihypertensive agents and ARC thus decreased (4.3 pg/ml), but aldosterone remained elevated. Abdominal magnetic resonance imaging (MRI) revealed a right adrenal adenoma, and aldosterone-producing adenoma was confirmed by adrenal venous sampling. Primary aldosteronism very rarely develops to malignant hypertension, and even in that case ARC is suppressed. Therefore this is a rare case of primary aldosteronism complicated with malignant hypertension and high ARC.     

Long-term inhalation of nitric oxide for a patient with primary pulmonary hypertension

Primary pulmonary hypertension is a disease with a high mortality rate and for which there is no satisfactory medical treatment. The safety of long-term inhalation of nitric oxide (NO) as a treatment is described. A 9-year-old girl inhaled NO for 32 weeks, accompanied with oral administration of beraprost sodium. Although NO did not improve her long-term prognosis, it eased the patient's dyspnea and increased her blood oxygenation. At doses of 20 ppm or more, attempts to withdraw from inhaled NO seemed to lead to an immediate elevation of the pulmonary artery pressure. This rebound phenomenon did not happen at doses under 5 ppm. This case study suggests that long-term inhalation of NO is safe and effective, but that pulmonary hypertension may rebound following withdrawal at higher doses of NO.     

Liver transplantation in a 29-year-old patient with gallbladder carcinoma complicating primary sclerosing cholangitis

Patients with primary sclerosing cholangitis (PSC) are at increased risk for cholangiocarcinoma. This tumor usually is a fatal complication, median survival after diagnosis is less than six months. In an asymptomatic 29-year-old patient with long-standing PSC and ulcerative colitis, routine abdominal ultrasound demonstrated an irregular mass, 11 x 13 mm, in the gallbladder. Cholecystectomy was performed, and histological examination demonstrated a moderately differentiated adenocarcinoma with infiltration of all layers of the gallbladder and invasion of local lymphatic vessels. Extensive diagnostic work-up failed to consistently demonstrate metastatic disease, and the patient was offered a liver transplantation. 24 months after the operation, the patient feels well and there is no indication of tumor recurrence. In carefully selected patients with gallbladder carcinoma complicating PSC, liver transplantation may be a therapeutic option.     

Pregnancy following thyroid hormone treatment in a patient with amenorrhea-galactorrhea due to primary hypothyroidism

A 32-year-old female with amenorrhea-galactorrhea due to primary hypothyroidism was treated with thyroid hormones, and serum levels of thyrotropin (TSH), prolactin (PRL), triiodothyronine (T3), thyroxin (T4), and T3 resin sponge uptake (RT3U) were measured throughout the course of treatment. The elevated serum levels of TSH and PRL fell into the normal range following T3 treatment. Subsequently, the menstrual cycle was restored within 1 month, and galactorrhea completely ceased and conception was achieved within 3 months. Desiccated thyroid was administered during pregnancy, and the patient gave birth to a female infant. Impaired secretion of PRL during pregnancy and poor milk secretion with blunted response of PRL to the suckling stimulus during the puerperium were noted.     

Aspiration of oral feedings in patients with tracheostomies

Oral feeding aspiration can be a threat to positive outcomes for patients with tracheostomy who require mechanical ventilation. A review of current literature reveals a high incidence of aspiration in this population. Silent aspiration is particularly common, meaning that beside evaluations of swallowing function often are unreliable. Advanced practice nurses who are aware of the risk factors for aspiration may be able to improve outcomes for this population. This article presents a review of the literature on oral feeding aspiration in patients with tracheostomies, suggests areas of additional research, and provides nursing implications for the safe care of these patients.     

Characterization of primary and metastatic cell lines established from a patient with renal cell carcinoma

Prolonged hypoxia induced transient drug resistance in Chinese hamster lung fibroblasts. Previously hypoxic cells were resistant to adriamycin and resistant to etoposide. Complete recovery of etoposide sensitivity was observed following reaeration for 24 hr. A change in P-glycoprotein expression was unlikely to contribute to the resistance caused by hypoxia, since adriamycin resistance was not reversed by verapamil. However, alteration in the plasma membrane structure may be involved, since previously hypoxic cells were resistant to extracellular superoxide radical generated by the addition of xanthine/xanthine oxidase. In contrast, adriamycin sensitivity was not altered by hypoxia in 3 human breast-cancer cell lines. MDA-468 and MCF-7/Adr differed in their response to EGF, independent of the presence of hypoxia. These results suggest that hypoxic-stress-induced drug resistance is not generalized.     

Mental nerve paresthesia associated with a non-vital tooth

Apical periodontitis is a common development associated with teeth with necrotic pulp. Although rare, some cases may present further complications, such as neuropathies in areas adjacent to the affected tooth. A case is described in which mental nerve paresthesia was associated with a non-vital mandibular premolar. Endodontic therapy resolved the paresthesia completely without further clinical complications.     

Controversies in the surgical options for the patient with primary breast cancer

We analysed the results of relapse free survivals for breast cancer patients treated with traditional mastectomy through 10 years of follow up. In the consecutive series of 162 patients with Stage III breast tumor, we noted that the mastectomy followed by radiation to axilla and adjacent area failed to confirm the efficacy to support the prevention for local and distant relapse in the past decade (1962-1974) (27.2%). The concepts of neoadjuvant and/or adjuvant chemotherapy were evolved primarily from clinical trials: these have been shown to influence favorably for the 228 patients with STAGE III in the next decade (1975-1985) (46.1%). Modified mastectomy, which involved removal of the breast, overlying skin and axillary contents but spares the pectoralis muscle, has recently been established as an entirely satisfactory approach for STAGE I (295 patients) and STAGE II (281 patients) breast carcinomas (1986-1991). Five-year relapse free survivals of these 2 categories calculated 93.7% and 86.8%, respectively. In recent studies, the many trials to breast conservation therapy reported, such as partial mastectomy plus nodes dissection with or without radiotherapy for selected patients with early cancer represent as effective results as modified mastectomy. Breast preservation has focused attention on the extent and distribution of cancer (multifocality, residual foci of surgical margin, etc) for clinicians.     

An autopsy case of renal failure as its cause of death in a patient with primary hyperparathyroidism associated with chronic pancreatitis

This paper presents a 59-year-old man who was admitted to our hospital because of abdominal pains in 1973. He had pancreatic calcification and showed high levels of serum amylase, Ca, and PTH. He was diagnosed as primary hyperparathyroidism with chronic pancreatitis. After excision of an ectopic parathyroid adenoma, serum Ca levels were decreased and normalized by dihydrotachysterol p.o. At the same time his symptoms disappeared. The exocrine and endocrine pancreatic functions, however, decreased gradually. Diabetes mellitus appeared in 1975 and he required insulin injection since 1983. In spite of the treatment, his diabetic control was poor. Seventeen years later in 1992, he showed hypertension and edema (nephrotic syndrome). Because of renal failure, he underwent hemodialysis and passed away due to myocardial infarction in 1993. Autopsy findings showed existence of diabetic nephropathy as the cause of renal failure. Clinical course of this patient suggests that severe complications occur even in pancreatic diabetes and that we have to control diabetes strictly in pancreatic diabetes as well as in primary diabetes.     

Changes in urinary kallikrein excretion and plasma natriuretic factor in a patient with primary aldosteronism with special reference to adrenal histology

High level of urinary kallikrein excretion was observed in a 23-year-old man with primary aldosteronism. Unilateral adrenalectomy improved the clinical symptoms and normalized the urinary concentration of this vasoactive substance. Although plasma atrial natriuretic factor was not elevated, adrenal surgery lowered its concentration. Coexistence of an adrenal adenoma and lesions of nodular hyperplasia were detected in the removed adrenal gland. We summarize the clinical data of this patient and review the literature.