Organising pneumonia - the experience of an outpatient clinic of a central hospital.

AIM: to characterise outpatients of a Portuguese central hospital diagnosed with organising pneumonia (OP) and compare results with current literature. METHODS: medical processes with diagnosis of OP were retrospectively studied as to demographics, aetiology, clinical and radiological features, average time until and date of diagnosis, laboratory and histological changes, treatment and relapse. Results - thirteen patients with a mean follow -up of 171.6 weeks (max 334 and min 28 weeks) were evaluated. Nine of these patients (70%) had cryptogenic OP (COP) while 30% had secondary OP (SOP), two with rheumatoid arthritis, one with dermatomyositis and another undergoing radiotherapy for breast cancer. Mean age was 55.6 (+ -15.3 years), 92% female, 77% were non -smokers. Average time until diagnosis was 77.2 weeks (min 3 and max 432 weeks). Symptoms at presentation were tiredness (92%), cough (85%), fever (65%), shortness of breath (54%), thoracic pain (23%) and weight loss (23%). At the time of diagnosis, the mean erythrocyte sedimentation rate was 70mm (max 170mm and min 16mm). C -reactive protein level was increased in eight patients. Significant leucocytosis was absent. Chest X -ray and chest CT scan showed bilateral distribution in 12 patients (92%). Consolidation with an air bronchogram was present in 12 patients and in four (31%), consolidation was migratory. Four patients (30%) underwent transbronchial pulmonary biopsy, all uncharacteristic and eight patients surgical pulmonary biopsy, four showed histological confirmation of SOP. Corticosteroids were started in 11 patients and average treatment was 61.6 weeks (16-288 weeks). 15% (2/13) had spontaneous resolution. Four patients (31%) relapsed, one of them five times. Two patients are dependent on a low dose of corticosteroids, one due to underlying disease and another due to multiple relapses. Therapy of relapse was corticosteroids alone in minimum effective dosage or associated to azathioprine or ciclosporin. DISCUSSION AND CONCLUSION: such a high incidence in females (92%) may be explained by the limited sample of patients. In 70% of the patients diagnosis were established by clinical and radiology criteria. Mean time to diagnosis was very variable which suggests that in some cases the disease was not diagnosed and treated as another interstitial lung disease or as recurrent pneumonia. Most patients (53.8%) had a favourable clinical course after treatment with corticosteroids with a very low number of relapses (30.8%), much lower than described by other authors (60%). Only in experienced centres should the diagnosis of OP established by clinical and radiological criteria.

Use of computer- and teacher-delivered prompts in discrimination training with individuals who have mental retardation.

Individuals with mental retardation received training on a series of 16 visual discrimination problems. Eleven subjects received computer-delivered instruction with a stimulus-fading procedure and 11 were trained with verbal and nonverbal prompts delivered by a human teacher. We found that (a) the teacher's prompts were effective with more subjects than was the computer-based fading procedure; (b) transfer to stimulus control to task stimuli was poor with the teacher's prompts but nearly perfect when fading was effective; and (c) subjects learned more discrimination problems with the computer-delivered fading procedure. These results suggest that the computer could be a useful tool to assist in discrimination training in special-education settings.

Chemical stability and adsorption of succinylcholine chloride injections in disposable plastic syringes.

The purpose of these investigations was to determine the stability and adsorption behaviour of succinylcholine chloride (SCC) when stored in plastic syringes. Drug degradation was monitored using the USP high-pressure liquid chromatography method. Solutions containing 20 mg/ml of SCC in 5% dextrose, and in normal saline, were studied at 5, 25 and 40 degrees C. The hydrolysis of SCC in i.v. fluids followed apparent zero-order kinetics. The manufacturer's recommended expiry period was found to be too conservative. If protected from light, storage at room temperature for up to 3 months can be safely recommended, without significant loss of chemical stability. However, microbiological quality assurance will need to be implemented and an appropriate shelf-life assigned on the basis of both microbiological and chemical stability data.

The legal danger of written protocols and standards of practice.

Nurse practitioners have historically developed protocols and standards of practice to guide and improve the quality of their patient care. Written protocols and standards of practice can, however, create a potential malpractice problem. Lawyers who bring malpractice cases on behalf of patients will use the protocols and standards to measure the practitioner's care. The practice standards are often too high to be reasonably met by practitioners at all times and in all settings. As a result, the practitioner's care may breach those standards. Nurse practitioners should develop protocols that are based on a minimum safe level and not the maximum level aimed at ideal care. Standards and protocols should be updated and realistic. Once developed, protocols and standards must be followed precisely to limit potential liability.

Reducing severe aggressive and self-injurious behaviors with functional communication training.

Functional communication training is a behavioral intervention that incorporates a comprehensive assessment of the communicative functions of maladaptive behavior with procedures to teach alternative and incompatible responses. In two studies severe aggressive and self-injurious behaviors exhibited by two adult men with mental retardation were reduced through the implementation of functional communication training. In both studies, these reductions came after years of less successful nonaversive and aversive interventions and generalized across staff, new environments, and increasing task demands. The role of this training as a refinement of the traditional differential reinforcement of other behavior and as an alternative to the use of aversive interventions was discussed.