Sense of coherence among elderly somatic patients: predictive power regarding future needs of care

The main aim was to study the predictive power of sense of coherence regarding future needs of care among elderly patients evaluated as medically ready for discharge from somatic emergency care. A secondary aim was to study the consistency of sense of coherence over time among patients with this kind of experience. The sample consisted of 53 Swedish patients (mean age 82.8 years, SD = 6.6 years) who had completed their medical treatment at surgical or orthopaedic departments. The predominant diagnosis was lower limb fractures. Sense of coherence was assessed twice, on the day the patient was evaluated as medically ready for discharge and 1 month later. On the second assessment occasion, 28 patients had returned to their homes, 17 were staying at institutions, and eight had died. Patients who returned to their homes reported the strongest sense of coherence while still in hospital. Patients who were staying at institutions scored lowest on the overall sense of coherence scale and on the comprehensibility subscale. Patients who died before the second measurement occasion scored lowest on the meaningfulness subscale. A correlation of 0.51 was noted between the two assessments of sense of coherence, indicating a moderate temporal consistency.     

Detection of Cell-Mediated Lympholysis Determinants Encoded by the I-A and I-E Genes on Ultraviolet-Irradiated Spleen Cells

We have analysed the effects of ultraviolet (UV) irradiation on the expression, by normal splenic cell populations, of cell-mediated lympholysis determinants encoded by the I-A and I-E genes of the H-2 complex. Cytotoxic T lymphocytes specific for class II antigens could be generated from unprimed responder mice when stimulated with UV-treated cells from I-A-and/or I-E-congenic mice in the presence of interleukin 2-containing medium. A cytotoxic T-cell line specific for I-Ek antigens was obtained and maintained upon stimulation with UV-irradiated spleen cells. Secondary Ia-specific responses were obtained with UV-irradiated stimulators in the absence of added soluble factors. The results show that the failure of UV-irradiated cells to stimulate primary cytotoxic T-cell responses is not due to a selective destruction of class II antigens but rather to the inactivation of a still undefined function of Ia-positive cells, other than interleukin-1 production, involved in the establishment of high-affinity interactions between the responding T helper cells and the stimulator cells.     

Regulation of Effector Functions of Human K-Cells and Monocytes by Antigen Density of the Target Cells

Antibody-dependent cytolysis and phagocytosis mediated by human K-cells or monocytes against chicken erythrocytes (ChRBC) were studied. The antigen density of the target cells was varied by coating the cells with different amounts of 3H-labelled dinitrophenyl (DNP) hapten. The degree of antigenicity thus acquired by the target cells was assessed on the basis of their uptake of the isotope. Anti-DNP serum was used to induce lysis or phagocytosis. Below 500 antigenic determinants per ChRBC the target cells were not affected. However, at the density, lysis and/or phagocytosis was seen when the antibody concentration was high (2 X 10(-9) M). With less antibody present (2 X 10(-11) M) only monocyte-mediated phagocytosis was induced. The estimated lowest number of target-cell-bound antibodies required for K-cell-mediated lysis was approximately 50. The corresponding number for monocyte-mediated phagocytosis was approximately 20 IgG per ChRBC. The result suggests that interaction of several Fc receptors on the effector cells with IgG molecules bound to adjacent sites on the target cell membrane is an important factor in the regulation of these antibody-dependent cell-mediated effector functions.     

VARIATIONS IN LUNG VOLUME AND COMPLIANCE DURING PULMONARY SURGERY

Functional residual capacity (FRC) and breath-by-breath complianceof the ventilatory system (C₁₅) were measured in 10 mechanicallyventilated patients during anaesthesia for lung surgery (pneumonectomy,lobectomy, lung or pleural resections or exploratory thoracotomy).In eight patients not requiring pneumonectomy, FRC of the lowerlung decreased by 8±9% (mean± 1 SD) (P < 0.05)while that of the upper lung increased by 75±24% (P <0.001) when the patient was turned to the lateral position.When the pleura was opened, FRC of the lower lung decreasedby a further 10±10% (P <0.01). One-lung ventilation(OLV), however, increased FRC of the lower lung back to thevalue found in the supine position before surgery. When two-lungventilation was re-established, FRC of the lower lung was aboutthe same as during corresponding stages before OLV. In the twopatients who underwent pneumonectomy, FRC of the remaining lungwas about 30% greater after OLV than at corresponding stagesbefore surgery. In the patients not requiring pneumonectomy,C₁₅ decreased from 29±6ml/cm H₂O to 23±6ml/cmH₂O (P < 0.05) on the lower side when the patient was turnedon his side. The corresponding figures on the upper side were24±8 ml/cm H₂O and 30±5ml/cm H₂O respectively(P < 0.05). There was no further significant change whenthe pleura was opened. After surgery when the patient was turnedto the supine position, C₁₅ of the lung not operated on wasalmost the same as before surgery.     

Gamma-Interferon-Mediated Down-Regulation of Electrolyte Secretion by Intestinal Epithelial Cells: A Local Immune Mechanism?

Active chloride (Cl-) secretion by intestinal crypt enterocytes is the central pathophysiological disturbance in most cases of acute diarrhoea. We examined monolayers of the human intestinal cell line T84 mounted in Ussing chambers to see whether the T-cell lymphokine gamma interferon (IFN-gamma) might affect the Cl- secretory properties of these cells, which morphologically and functionally resemble native crypt enterocytes. Pretreatment of T84 cell layers with IFN-gamma for 24 h (but not for 3 h) markedly decreased the Cl- secretory response to vaso-active intestinal polypeptide (VIP) and to cholera toxin and carbachol without appreciably affecting the overall morphology, electrical resistance, or cyclic AMP response of the T84 cell monolayer. The IFN-gamma treatment, however, did induce subtle changes in the T84 cell membrane protein composition which might have affected ion channels regulating Cl- secretion. Our results may indicate a possible novel 'cell-mediated' immune mechanism through which activated gut T cells could modulate the extent of intestinal electrolyte and fluid secretion in, for example, enteric infections.     

Automated pre-ejection period variation indexed to tidal volume predicts fluid responsiveness after cardiac surgery

Background: Reliable continuous monitoring of fluid responsiveness is an unsolved issue in patients ventilated with low tidal volume. We hypothesised that variations in the pre-ejection period (PEP) defined as the time interval between electrocardiogram (ECG) R-wave and onset of systolic upstroke in arterial blood pressure could reliably predict fluid responsiveness in patients ventilated with moderately low tidal volume. Furthermore, we hypothesised that indexing dynamic parameters to tidal volume would improve their prediction. The aim was to refine and automate a previously suggested algorithm for PEP variation (ΔPEP) and to test this new parameter indexed to tidal volume (PEPV), as a marker of fluid responsiveness along with central venous pressure (CVP), pulse pressure variation (PPV) and ΔPEP. Additionally, the aim was to evaluate the concept of indexing dynamic parameters to tidal volume.
Methods: Arterial pressure, CVP, ECG and cardiac index (CI) were acquired from 23 mechanically ventilated post-cardiac surgery patients scheduled for volume expansion. PEPV, PPV and ΔPEP were extracted.
Results: Using responder/non-responder classification (response=change in CI>+15%), sensitivity and specificity were 100% and 83%, respectively, for PEPV, 94% and 83% for ΔPEP, and 94% and 83% for PPV. CVP offered no relevant information. Tidal volume indexing improved sensitivity for ΔPEP to 100%.
Conclusion: In this study in post-cardiac surgery patients, a refined parameter, PEPV, predicted fluid responsiveness better than PPV and ΔPEP. Our results suggest that dynamic parameters using variations in PEP should be indexed to tidal volume.     

Body Temperature in General Population Samples

ABSTRACT Oral body temperature was measured in 816 men, 57 and 67 years old, sampled from the general population of Göteborg, Sweden, and 22 physically highly active men, sampled on clinical grounds. The measurements were taken in the morning for 14 months. After adding 0.3°C to the readings to make them comparable with rectal readings, the mean body temperature was 36.8±0.4°C. There was a seasonal variation with a peak during the winter and a trough during the summer. Body temperature was inversely correlated with height and positively correlated with weight and body fat but not with lean body mass. High physical activity and sensitivity to heat were associated with a higher than average body temperature. Sensitivity to cold was associated with a lower than average body temperature. Smoking prior to the measurements did not appear to affect body temperature.     

The place of premedication in pediatric practice

Behind the multiple arguments for and against the use of premedication, sedative drugs in children is a noble principle that of minimizing psychological trauma related to anesthesia and surgery. However, several confounding factors make it very difficult to reach didactic evidence-based conclusions. One of the key confounding issues is that the nature of expectations and responses for both parent and child vary greatly in different environments around the world. Studies applicable to one culture and to one hospital system (albeit multicultural) may not apply elsewhere. Moreover, the study of hospital-related distress begins at the start of the patient's journey and ends long after hospital discharge; it cannot be focused completely on just the moment of anesthetic induction. Taking an example from actual practice experience, the trauma caused by the actual giving of a premedication to a child who absolutely does not want it and may struggle may not be recorded in a study but could form a significant component of overall effect and later psychological pathology. Clearly, attitudes by health professionals and parents to the practice of routine pediatric premedication, vary considerably, often provoking strong opinions. In this pro–con article we highlight two very different approaches to premedication. It is hoped that this helps the reader to critically re-evaluate a practice, which was universal historically and now in many centers is more selective.