Preoperative metoprolol improves cardiovascular stability and reduces oxygen consumption after thoracotomy

Background : Increased sympathetic activity perioperatively and associated cardiovascular effects play a central role in cardiovascular complications. High thoracic epidural blockade attenuates the sympathetic response, but even with complete pain relief, haemodynamic and endocrine responses are still present. Beta–adrenoceptor blockade is effective in situations with increased sympathetic activity. This study was designed to evaluate the perioperative haemodynamic effect of preoperative βblockade and its influence on the haemodynamic aspects of the surgical stress response.
Methods : Thirty–six otherwise healthy patients undergoing elective thoracotomy for lung resection were randomised doubleblinded to receive either 100 mg metoprolol or placebo preoperatively. Anaesthesia was combined high thoracic epidural block and general anaesthesia. The epidural analgesia was continued during recovery. Patients were monitored with ECG, pulse oximetry, invasive haemodynamic monitoring, arterial blood gases and electrolytes.
Results : After induction of anaesthesia the mean arterial pressure (MAP) decreased in both groups, and decreased further in the placebo group after initiation of the epidural block. The heart rate (HR) was slightly less throughout the observation period after metoprolol. Peroperatively, the only difference in measured haemodynamics was a marginally higher MAP after metoprolol. Postoperative cardiac index (CI) was lower with a lower variability and cardiac filling pressures were slightly higher in the metoprolol group. The oxygen consumption index was higher after placebo throughout the observation period, with no difference in the oxygen delivery.
Conclusion. We found that preoperative β–blockade during combined general anaesthesia and high thoracic epidural blockade stabilised perioperative HR and CI and decreased total oxygen consumption.     

FACTORS ASSOCIATED WITH MET AND UNMET REHABILITATION NEEDS AFTER STROKE: A MULTICENTRE COHORT STUDY IN DENMARK AND NORWAY

ObjectivesTo examine patient-reported needs for care and rehabilitation in a cohort following different subacute pathways of rehabilitation, and to explore factors underpinning met and unmet needs.DesignObservational multicentre cohort study.Patients and methodsA total of 318 Norwegian and 155 Danish patients with first-ever stroke were included. Participants answered questions from the Norwegian Stroke Registry about perceived met, unmet or lack of need for help and training during the first 3 months post stroke. The term “training” in this context was used for all rehabilitative therapy offered by physiotherapists, occupational or speech therapists. The term “help” was used for care and support in daily activities provided by nurses or health assistants.ResultsNeed for training: 15% reported unmet need, 52% reported met need, and 33% reported no need. Need for help: 10% reported unmet need, 58% reported met, and 31% reported no need. Participants from both Norway and Denmark had similar patterns of unmet/met need for help or training. Unmet need for training was associated with lower functioning, (odds ratio (OR) = 0.32, p < 0.05) and more anxiety (OR = 0.36, p < 0.05). Patients reporting unmet needs for help more often lived alone (OR = 0.40, p < 0.05) and were more often depressed (OR = 0.31, p < 0.05).ConclusionSimilar levels of met and unmet needs for training and help at 3 months after stroke were reported despite differences in the organization of the rehabilitation services. Functioning and psychological factors were associated with unmet rehabilitation needs.LAY ABSTRACTThe aim of this study was to examine patient-reported needs for care and rehabilitation among selected patients with stroke in Norway and Denmark. A total of 318 Norwegian and 155 Danish patients with first-ever stroke were included. Participants answered the following 2 questions from the Norwegian Stroke Registry: Have you received enough help after the stroke? Have you received as much training as you wanted after the stroke? The term “training” in this context was used for all rehabilitative therapy offered by physio-, occupational or speech therapists. The term «help» was used for care and support in daily activities provided by nurses or health assistants. Levels of anxiety and depression were investigated. With regard to training needs, 15% of all participants reported unmet needs, 52% reported that their needs had been met, and 33% reported that they had no need for training. Regarding the need for help, 10%, 58% and 31% reported unmet needs, that needs had been met, and that they had no need for care, respectively. Participants in the 2 countries had similar patterns of unmet/met needs for help or training. Unmet need for training was associated with low function and anxiety. Patients reporting an unmet need for help more often lived alone and were more often depressed. There was no difference in met or unmet needs between Norwegian and Danish participants.Different rehabilitative follow-up after stroke did not affect levels of met and unmet rehabilitation needs. Health services should pay special attention to patients at risk, including those who are anxious or depressed, live alone or have functional deficits after stroke.Key words: stroke, rehabilitation, unmet needs, rehabilitation pathways

Stroke is a major cause of death, with an increasing number of patients affected worldwide (1). Stroke survivors often have varying degrees of physical, psychosocial and cognitive disabilities, which may substantially affect their functional ability in daily and working life (2). Treatment offered by specialized stroke units (3), inpatient multidisciplinary rehabilitation teams (4) and community-based rehabilitation services adapted to patients’ home environment (5) are key elements to successful rehabilitation. At all intervention levels, the identification of patients’ individual needs is crucial for the optimization of rehabilitation outcomes. The definition of a need is, however, not unambiguous (6). A pragmatic approach is to adopt the most commonly used definition of healthcare needs and define rehabilitation needs as the needs that can be fulfilled by rehabilitation interventions and services (7). From the patient’s perspective, a need represents the perception of a situation in which help or support is desired. If adequate help is not offered, the provision of services does not fit the needs, gaps occur and needs become unmet (8).A perceived need for therapy, comprehensive care, pscyhological support or information are examples of commonly reported unmet needs post-stroke (9).Unmet rehabilitation needs may persist for years after stroke (10). According to a UK study, they are more often reported by people with disabilities, those belonging to ethnic minorities, and those living in the most deprived areas (10). According to a recent systematic review of 19 studies, mostly cross-sectional in design, 74% of stroke survivors experienced at least one unmet need. The studies revealed heterogeneous levels of unmet needs, ranging between 5% and 40% for care and between 2% and 36% for therapy (9). In most studies, unmet needs were assessed by using different multi-item questionnaires, such as the Longer-term Unmet Need after Stroke (11) and the Greater Manchester Stroke Assessment Tool (12), or by the self-report of long-term needs after stroke (10).In a Swedish registry study evaluating perceived unmet or partly met rehabilitation needs with a single question, 21.5% of patients reported unmet needs one year after stroke. Important underpinning factors were older age, dependency on others, pain and depressive/ affective symptoms (13).Rehabilitation practices are formulated and enacted in a cultural and historical context aligned to the development of healthcare services (14). Specialized stroke rehabilitation is integrated in the public healthcare systems in Nordic countries (15), but, whereas the Norwegian study region mainly emphasizes inpatient rehabilitation, the Danish region has developed an additional and more specialized, community-based rehabilitation programme (16). Although some studies have reported different rehabilitation pathways in the early subacute phase of stroke (17), no previous studies have, to our knowledge, compared unmet needs post stroke in participants with different subacute rehabilitation pathways.The primary aim of this study was to examine patient-reported needs for healthcare and rehabilitation services in a cohort with different rehabilitation pathways recruited from 2 Nordic country-regions. Secondary aims were to assess to what extent these needs were met or unmet 3 months post stroke and to explore factors associated with met and unmet needs.     

Adrenal Function in Asthmatic Children Treated with Inhaled Budesonide

Bisgaard, H., Pedersen S., Damkjær Nielsen M and Østerballe O. (Department of Paediatrics, University Hospital of Copenhagen, County of Gentofte, Copenhagen; Department of Paediatrics, County Hospital of Kolding; Department of Clinical Physiology, University Hospital of Copenhagen, County of Glostrup, Copenhagen; Department of Paediatrics, County Hospital of Viborg, Denmark). Adrenal function in asthmatic children treated with inhaled budesonide. Acta Paediatr Scand 80: 213, 1991
The effect of the inhaled topical steroid budesonide on adrenal function was evaluated in 33 children (aged 7–15 years) with moderate bronchial asthma. The trial was designed as a prospective single-blind study of the effect of budesonide in daily doses of 200 μg through 400 μg to 800 μg in three randomized consecutive periods of 8 weeks. The unstimulated diurnal production of cortisol was assessed by measurement of free cortisol in 24-hour urine samples at the end of each period. No significant dose-related suppression was found. The cortisol production did not differ significantly during treatment with 800 μg budesonide as compared to treatment with 200 μg budesonide (95% confidence interval: 74%–112%). It is concluded, that budesonide is a topical steroid with a favourable ratio between topical and systemic effects in asthmatic children.     

Recurrent otitis media as a presenting symptom in children with special references to cholesteatoma

Ten children with histiocytosis X and recurrent otitis media as a presenting symptom were compared to children with otitis media complicating cholesteatoma. When radiography and biopsy findings were not diagnostic a low age (<3 years) and a remaining elevated ESR were characters that most effectively separated the histiocytosis X group from the cholesteatoma group.     

The Acute Effects of FK-506 on Renal Haemodynamics,Water and Sodium Excretion and Plasma Levels of Angiotensin II,Aldosterone, Atrial Natriuretic Peptide and Vasopressin in Pigs

FK-506 has been shown to be an effective immunosuppressive drug with possible nephrotoxic side effects. In this study we have investigated the acute effects of FK-506 on renal haemodynamics, water, sodium and lithium excretion rates and plasma levels of angiotensin II, aldosterone, atrial natriuretic peptide (ANP) and vasopressin in 29 anaesthetized Lancaster/Yorkshire female pigs. A continuous intravenous infusion was given over a 2-h period to 4 groups: A: 0.075 mg kg^?1 (n = 7), B: 0.15 mg kg^?1 (n = 8), C: 0.3 mg kg^?1 (n = 6) and P: placebo vehicle (n = 8). Glomerular filtration rate (GFR) and renal plasma flow (RPF) were measured by the constant infusion clearance technique using 125-I-iothalamate and 131-I-hippuran as reference substances. Hormonal parameters were measured by radioimmunoassay. In all three FK-506 groups, fractional lithium excretion was significantly decreased 2 h after FK506 infusion (P: + 0.4%, A: ? 8.8% (P < 0.05), B: ?12.9% and C: ?11.2% (P < 001 for both). Mean arterial blood pressure (MBP) was significantly increased in the two highest dosage groups (B,C) at 2 h of infusion: (MBP; P: +2.9%, A: +3.5%, B: +12.0%, C: + 15.3% (P < 0.01 for both). GFR and RPF showed minor and inconsistent changes while all other parameters measured showed similar or no changes. In conclusion, acute infusion of FK-506 to pigs does not change overall renal function significantly, but increases mean arterial blood pressure and decreases fractional excretion of lithium.     

FAILURE OF PNEUMOCOCCAL VACCINATION IN A SPLENECTOMIZED CHILD

ABSTRACT. Recurrent Streptococcus pneumoniae septicaemia occurred in a splenectomized child with idiopathic thrombocytopenic purpura. Fatal infection took place 1 year after pneumococcal vaccination and was caused by sero-type 18C which was included in the vaccine. The efficacy of pneumococcal vaccination is discussed in relation to specific pneumococcal polysaccharide antibody titers, and it is concluded that vaccination alone is insufflcient in preventing overwehlming infections in splenectomized Individuals.