Planning for psychiatric emergencies.

Hospital emergency services have been used increasingly in recent years. This has resulted in questions as to the true nature of patients'' complaints and the appropriateness of this type of care. Since the increase in the number of psychiatric emergency patients has paralleled that for patients at other types of emergency clinics a study was conducted at the Clarke Institute of Psychiatry, Toronto, to examine the situation prior to the inception in 1977 of a crisis intervention unit. It was found that most patients had both psychiatric and social difficulties, and it was considered that planning should concentrate on strategies for efficient management of the clinical problems.     

Infant feeding practices: 1984-85 versus 1977-78.

In 1979 and 1980 the Canadian Paediatric Society''s Nutrition Committee published guidelines for professionals counselling mothers of infants on feeding practices. The practices in 1984-85 of mothers in Toronto were determined for comparison with the practices identified in a similar study conducted in Toronto and Montreal in 1977-78 to ascertain if practices had changed in favour of the recommendations. Between July 1984 and February 1985, 404 metropolitan Toronto mothers of infants were interviewed. Compared with the 1977-78 group of mothers, more of the 1984-85 mothers had chosen to breast-feed and fewer had stopped breast-feeding in the first month. As well, fewer of the 1984-85 infants had been fed unmodified cow''s milk in the first 6 months of life and introduced to solid foods before 4 months of age. We conclude that major changes in infant feeding practices had occurred since 1977-78 and that the 1984-85 practices corresponded closely to the infant feeding guidelines.     

Selective effect of low protein diets in chronic renal diseases.

It has recently been established that the rate of progression of chronic renal failure in man can be slowed by restricting dietary protein. Consequently, the short term and long term effects of a low protein diet on the course of different chronic nephropathies were studied in an attempt to delineate the factors that determine the response to such a diet. When a low protein diet was given for six months renal function improved significantly in nine patients with chronic tubulointerstitial nephritis (p less than 0.025); the diet had a marginally beneficial effect in 12 patients with chronic glomerulonephritis (p less than 0.05) and no effect in nine with hypertensive nephrosclerosis. The heterogeneous functional response in the patients with chronic glomerulonephritis correlated closely with the effect of the diet on these patients'' proteinuria (r = 0.76, p less than 0.01). In a short term study (four weeks) of 12 patients with chronic renal failure changes in renal plasma flow were proportional to dietary protein intake. Renal vascular resistance fell during a high protein diet and increased when dietary protein was restricted. The changes in renal plasma flow during the low protein diet correlated well with the patients'' long term functional response to the diet (r = 0.76, p less than 0.01). It is concluded that the response to a low protein diet in chronic renal failure is determined, firstly, by the nature of the underlying nephropathy, with maximal benefit being observed in non-glomerular disorders; secondly, by the effect of the diet on the proteinuria in chronic glomerulonephritis; and, thirdly, by the haemodynamic response to the diet, with patients with a reactive renal vascular bed improving with a low protein diet.     

Goodpasture's Syndrome: Pulmonary Hemosiderosis with Glomerulonephritis

Three cases of Goodpasture''s syndrome (pulmonary hemosiderosis and glomerulonephritis) are described. Each presented with unexplained hemoptysis and subsequently developed glomerulonephritis which caused uremia. These cases include the youngest and the oldest individuals yet reported with the condition. Steroid therapy was administered to one patient but apparently did not influence the course of the disease. The variations in the clinical course and the pathology of the disease are discussed.     

Hospitals' response to the buckle-up baby legislation in Ontario.

Drivers in Ontario are legally responsible to ensure that infants and toddlers are restrained in a child safety seat or by a lap belt. In 1982 the minister of health sent a memorandum to all medical officers of health and the administrators and medical directors of all public hospitals in Ontario, urging them to encourage and assist parents in protecting their newborn children with safety seats. In 1983 the Toronto General Hospital established the Cooperative Hospital Infant Restraint Program (CHIRP) to study the feasibility of a "loaner" program for hospitals in metropolitan Toronto. The authors describe CHIRP and its objectives. They also report the results of a questionnaire they sent in 1984 to all Ontario hospitals that had a newborn or pediatric service to assess their response to the minister''s memorandum.     

Physician-patient privilege: the legal assault continues.

The confidentiality of patient records, particularly in cases where sexual assault is alleged, has been called into question by two recent Supreme Court decisions. Toronto lawyer Marilou McPhedran discusses the recent Beharriell and O''Connor decisions and how they affect physicians.     

Towards a more rapid diagnosis of rapidly progressive glomerulonephritis.

An attempt was made to provide simple practical guidelines to alert general practitioners to the diagnosis of rapidly progressive glomerulonephritis and lead to early referral to hospital. The duration of illness before referral to this hospital and its effect on outcome in patients with crescentic nephritis were assessed retrospectively from the case notes of 24 patients referred over two years. Four patients had Goodpasture''s syndrome, 11 Wegener''s granulomatosis, seven microscopic polyarteritis, and two idiopathic progressive glomerulonephritis. The duration of symptoms before referral to the local hospital was similar in the four groups of patients and varied from one week to 28 months (mean 10 months). The duration of stay in the local hospital was two, nine, 11, and 180 days in the patients with Goodpasture''s syndrome and a mean of four days (range one to eight) in those with Wegener''s granulomatosis and 10 days (one to 18 days) in those with microscopic polyarteritis. In the local hospital the diagnosis was based on the results of renal biopsy and detection of antibodies to glomerular basement membrane in two patients with Goodpasture''s syndrome and on the results of renal biopsy in seven of the other patients aided by the detection of antibodies to the cytoplasm of neutrophils (ANCA) in 10. Three of the 24 patients died and four required maintenance haemodialysis. Patients who present to their general practitioners with persistent non-specific symptoms should have a urine dipstick test and then blood tests and emergency referral to hospital if necessary. Hospital physicians should be aware of the speed and accuracy with which current assays can confirm a diagnosis of rapidly progressive glomerulonephritis.     

Diagnosis and management of hypertension: the stated practices of family physicians.

Hypertension is an important and common problem in family practice, but there is no general agreement on the systolic and diastolic pressures at which it should be diagnosed and treated. Responses from 273 family physicians surveyed by mail in Metropolitan Toronto showed a wide variation in the pressures used as cut-off points. The probability that in a given patient hypertension would be diagnosed or treated at different systolic and diastolic pressures varied considerably among the physicians, the variation increasing with the age of the patient. There was also wide variation in opinion among the surveyed physicians about how often patients should be screened for hypertension; depending on the patient''s age, up to 35% of the physicians stated that the blood pressure should be measured at every visit. Only one third reported using any one or more methods to ensure that patients with hypertension were not lost to follow-up. The family physicians with an academic appointment used higher cut-off points for diagnosis and treatment, and they screened and scheduled follow-up visits less frequently than those without an academic appointment.     

Differential ConA-enriched urinary proteome in rat experimental glomerular diseases

Glomerular diseases are leading causes of end-stage renal diseases worldwide. They are considered to be consequences of injury primarily to the three types of glomerular cells. Differential diagnosis typically relies on invasive biopsy findings. We expected that injuries of different glomerular cells would cause different changes in urinary proteome. The goal of this study was to identify differential urinary proteins distinguishing between injuries of different glomerular cells before significant histopathologic changes. Adriamycin nephropathy and Thy1.1 glomerulonephritis were employed as models with different primary impaired cells. ConA-enriched urinary glycoproteome on day3 were profiled by gel-free shotgun tandem mass spectrometry, and compared with self-healthy controls to identify differential urinary proteins for each model. By comparing the changes of the differential proteins between these two models, we identified 39 proteins with different directions of changes, which may potentially be useful in differentiation; and 7 proteins with the same direction of changes, which may be potential indicators of early renal damage. These differential proteins were of several origins: plasma proteins, proteins with urine or kidney specificity, proteins without tissue-specificity (mainly inflammatory mediators) etc. Our results may help better understand the effects of injuries of different glomerular cells at the initial stage, and lead to the discovery of novel early diagnostic markers for human focal segmental glomerulosclerosis (FSGS) and mesangioproliferative glomerulonephritis (MsPGN) which have the same primary impaired cells with adriamycin nephropathy and Thy1.1 glomerulonephritis, respectively.     

Death from asthma.

The factors associated with the deaths of 31 asthma patients were examined. The subjects, whose deaths occurred in the period 1967 through 1979, had all received some care at the Hospital for Sick Children in Toronto, but only nine died there. The greatest single cause of death was the inappropriate use of beta-agonists, with or without the concurrent use of epinephrine. In seven patients an asthma attack that occurred outside hospital progressed so rapidly that there was insufficient time for them to obtain adequate therapy. In five cases the assessment of the patient''s condition or the therapy recommended by the attending physician appeared to have been inadequate. Two patients suffered an acute attack in hopital and did not respond to treatment that appeared to have been adequate. In six cases the available information was insufficient to indicate the cause of death. Over half (18) of the deaths occurred in teenagers. Various ways of preventing death from asthma are discussed, including better education of physicians and patients, adequate management of factors that provoke bronchospasm, sufficient follow-up -- especially in teenagers -- and the use of approaches with teenagers that encourage better compliance.     

Recurrent Goodpasture's syndrome.

Goodpasture''s syndrome was diagnosed in a 17-year-old boy with glomerulonephritis and hemoptysis. He was successfully treated with cyclophosphamide, prednisone and courses of plasmapheresis. The syndrome recurred 3 1/2 years later and was again successfully treated.     

The first 10 years of the dialysis-transplantation program at The Hospital for Sick Children,Toronto. 1: Predialysis and dialysis.

Renal dialysis and transplantation have been used for many years for adults with kidney failure but only recently for children. In May 1967 a renal-dialysis-transplantation program was established at The Hospital for Sick Children, Toronto for patients aged 6 to 18 years living within 240 km of Toronto. In 1973, children aged 1 to 5 years began to be accepted into the program, and by August 1977, 90 children (mean age 11 years) from all parts of Canada had been admitted to the program. The creation of vascular access in very small patients is difficult; the most successful types of access have been central shunts (established above the knee or the elbow) and bovine grafts. Specially made dialysis equipment is necessary for young patients. Young children should only be accepted in a dialysis-transplantation program that has a medical staff expert in meeting the specific needs of such children.     

Cognitive rehabilitation advanced by multifaceted research,conference told

More than 400 researchers, physicians and therapists recently gathered in Toronto for an international conference on cognitive rehabilitation. Speakers said this field of study is still in its infancy, although research is progressing in varied areas such as plasticity of the brain, ways to improve the brain''s ability to recover from trauma, stroke or disease, motivation strategies and external memory aids. A Toronto psychologist described positive clinical experiences achieved through individual counselling, alleviation of the family''s anxiety and the teaching of behaviour-management techniques.     

Lepromatous leprosy presenting with polyarthritis,myositis, and immune-complex glomerulonephritis.

A Pakistani man aged 19 years was admitted to a rheumatological unit in the United Kingdom with acute widespread polyarthritis accompanied by night sweats and fever. Preliminary examination suggested Reiter''s disease, but further investigation showed acute glomerulonephritis with uraemia. The possibility of periarteritis nodosa, and the prominence of muscle tenderness in the legs, led to biopsies of striated muscle and skin, in both of which were changes typical of lepromatous leprosy, with many Mycobacterium leprae on Ziehl-Neelsen staining. Serum showed IgG-IgM cryoglobulinaemia without antiglobulin activity, and in the recovery phase renal biopsy showed a resolving proliferative glomerulonephritis with linear IgG and IgM immunofluorescence and granular deposits of C3. Clinical signs subsided rapidly under steroid treatment and subsequent progress on anti-leprosy drugs was uneventful. The term erythema nodosum leprosum is inadequate and misleading as a title for a common and important immune-complex reaction of lepromatous leprosy, in which numerous body systems may be involved.     

Hypercoagulation in glomerulonephritis.

The clotting values of 50 patients with glomerulonephritis were examined. Three different coagulation groups were recognised: those with normal clotting values (group 1); those with high concentrations of factor VIII but otherwise normal clotting results (group 2); and patients who showed the presence of an activator of the intrinsic coagulation pathway, indicated by the presence of a short activated partial thromboplastin time or the ability of patients'' plasma to shorten control clotting time in mixing studies (group 3). Patients in group 2 either had a uniform rise in all three components of the factor VIII molecule or a disproportionately higher concentration of factor-VIII-related antigen. In contrast, the level of VIII clotting activity in patients in group 3 was always higher than concentrations of either VIIIAg or VIIIWF. A significantly high incidence of thrombotic complications was observed in patients with group 3 but in none of the patients in either group 1 or group 2. Impaired renal function was more common in patients in groups 2 and 3, with higher mean serum creatinine concentrations in those with group 3. Patients with glomerulonephritis who have a short partial thromboplastin time with kaolin or who shorten control clotting time form a subgroup in whom hypercoagulation could adversely affect the course of their disease. The value of antiplatelet or anticoagulant treatment in these patients needs to be explored.     

Factors associated with outcome of renal transplantation.

To explore the associations between a number of preoperative risk factors and the failure of renal grafts 99 consecutive patients were followed for up to 7 years after transplantation. The patients had all received their grafts from nonliving donors; the operations were performed at one hospital. Statistical analysis in relation to several outcomes showed that rapidly progressive glomerulonephritis, pre-existing cardiovascular disease, the degree of presensitization to histocompatibility antigens and the donor''s being of blood group B were associated with an increased risk of graft rejection or death after transplantation. The risks of acute and accelerated rejection were associated with different factors, which suggests that distinct pathogenetic processes may be involved. The risk of technical failure was associated with immunologic factors, which suggests the possibility that this outcome was not caused by surgical difficulties alone.     

Issues in determining financial competence in the elderly.

With the ever-increasing numbers and relative proportion of elderly in the population, physicians are now frequently facing the difficult task of determining the financial competence of vulnerable individuals. The determination of financial competence in the elderly is still a very poorly defined issue. In this paper an attempt is made to clarify the existing law and the physician''s legal obligations. The Mental Health Act, Powers of Attorney Act and Mental Incompetency Act, as they relate to a patient''s financial competence, are reviewed. The difficulties in the clinical application of these laws are illustrated by two reports of patients referred to the geriatric psychiatry service of Sunnybrook Medical Centre, University of Toronto. Some general principles and practical guidelines are proposed to help physicians deal more effectively with this issue.     

血管紧张素受体阻断剂联合冬虫夏草对肾小球肾炎临床疗效观察

目的:探讨血管紧张素受体阻断剂联合冬虫夏草对肾小球肾炎的临床疗效。方法:选取2011年1月至2015年3月期间我院收治的340名尿检符合蛋白尿或血尿的患者作为研究资料,按治疗方式将研究对象分为A组(单纯百令组)、B组(奥美沙坦组)、C组(除去奥美沙坦外的其他ARB组)、D组(所有ARB组)、E组(奥美沙坦联合百令组)、F组(除去奥美沙坦外的其他ARB联合百令组)、G组(所有ARB联合百令组),于服药1、2、3个月跟踪随访尿微量白蛋白、尿a1微量球蛋白、血尿、血生化等指标的变化。结果:与单纯百令组相比,单独应用ARB组或ARB联合百令胶囊组在降低肾小球性蛋白尿方面显示出了良好的疗效(P0.05);在降低肾小管蛋白尿方面,单独应用ARB仅在1月组显示出明显效果,而ARB联合百令治疗则在1-3个月均显示出持续的缓解(P0.05);无论单用ARB还是ARB联合百令对于血生化指标的显著影响仅体现在治疗1个月内(P0.05)。结论:常规应用ARB类药物治疗同时,加用冬虫夏草治疗,可以更加有效的降低蛋白尿,保护肾小管功能,对于改善患者病情及延缓疾病发展具有重要意义。