Experiences and needs concerning health related information for newly arrived refugees in Sweden

BACKGROUND

Owing to communication challenges and a lack of knowledge about the health care system, refugees may be at risk of having limited health literacy, meaning that they will have problems in achieving, understanding, appraising and using health information or navigating in the health care system. The aim of this study was to explore experiences and needs concerning health related information for newly arrived refugees in Sweden.

METHODS

A qualitative design with a focus group methodology was used. The qualitative content analysis was based on seven focus group discussions, including 28 Arabic and Somali speaking refugees.

RESULTS

Four categories emerged. 'Concrete instructions and explanations' includes appreciation of knowledge about how to act when facing health problems. 'Contextual knowledge' comprises experienced needs of information about the health care system, about specific health risks and about rights in health issues. 'A variation of sources' describes suggestions as to where and how information should be given. 'Enabling communication' includes the wish for more awareness among professionals from a language and cultural point of view.

CONCLUSION

Concrete instructions and explanations are experienced as valuable and applicable. Additional information about health issues and the health care system is needed. Information concerning health should be spread by a variety of sources. Health literate health organizations are needed to meet the health challenges of refugees, including professionals that emphasize health literacy.

Filter-based treatment of leachate from an industrial landfill containing shredder residues of end-of-life vehicles and white goods

A pilot plant was set up to treat leachate from an industrial landfill containing shredder residues of end-of-life vehicles and white goods. The treatment plant consisted of aeration and sedimentation steps for pre-treatment, and a filter. The plant was designed to simultaneously remove various types of pollutants. The efficiencies of pre-treatment and of the main treatment step were investigated over a period of 3 years at the landfill site. By continuous aeration of the leachate the concentrations of Fe and Mn were reduced by 55% and 49%, respectively. By prolonged sedimentation suspended solid content was noticeably reduced (72%). In the filter, consisting of a mixture of peat and carbon-containing ash as a treatment medium, very high reduction of polar organic compounds, e.g. phenol (74%), o-and p-cresol (91%), and 2,4-dimethylphenol (73%), high average reduction of metals, e.g. Pb (78%), Fe (74%), Cu (73%), Mn (56%), Sn (55%), and Zn (47%), and good average reduction of DOC (26%), Tot-N (23%) and NH4-N (46%) were achieved. Sixty non-polar compounds in the leachate, identified by GC-MS screening, occurred at trace level. Most of them were considerably reduced in the filter.

The Conceptions of Pain and Rehabilitation Questionnaire (CPRQ): development and test of face validity and stability over time

The heterogeneity of diagnoses included in the concept of chronic pain, as well as differences in adaptation to the situation involving chronic illness, imply the need for a variety of rehabilitation forms. Despite evidence concerning the success of multidisciplinary behaviour-orientated rehabilitation programmes, not all participants experience the expected change. The aim of the present study was to develop and test the face validity and the stability over time of a Swedish self-administered questionnaire: the Conceptions of Pain and Rehabilitation Questionnaire (CPRQ) for persons with chronic pain. The questionnaire is to be used as a guiding tool in planning for rehabilitation. Its purpose is to distinguish between individuals with expectations of and motivation for active rehabilitation and those with expectations of more supportive forms of therapy. The face validity was mainly obtained by target-group discussions including persons with chronic pain and rehabilitation staff with experience in the rehabilitation of persons with chronic pain. The test-retest stability analysis was performed using a model for identifying occasional and systematic disagreement. The questionnaire in its final form showed face validity and reliability in terms of stability over time. Further steps in the development process will include laying down the guiding principles for the questionnaire, based on new focus-group discussions, and completing work on the manual by including information about the origin of the questionnaire and instructions for its administration. Thereafter, the next step in the development process will be a test of responsiveness, i.e. to examine the degree to which the questionnaire really serves its purpose.

Artemia salina as test organism for assessment of acute toxicity of leachate water from landfills

Artemia salina has, for the first time, been used as test organism for acute toxicity of leachate water from three landfills (the municipal landfills at Kristianstad, Sweden and Siauliai, Lithuania, and an industrial landfill at Stena fragmenting AB, Halmstad, as well as for leachate from Kristianstad treated in different ways in a pilot plan). Artemia can tolerate the high concentrations of chloride ions found in such waters. Large differences in toxicities were found, the leachate from Siauliai being the most toxic one. To increase the selectivity in the measurements, a fractionation was done by using ion exchange to separate ammonium/ammonia and metal ions from the leachate, and activated carbon adsorbents for organic pollutants. The influence of some metals and phenol compounds on the toxicity was investigated separately. It was found that most of the toxicity emanated from the ammonium/ammonia components in the leachate. However, there was also a significant contribution n from organic pollutants, other than phenol compounds, since separate experiments had in this latter case indicated negligible impact. The concentrations of metals were at a level, shown by separate experiments, where only small contribution to the toxicity could be expected.

Cardiotocography only versus cardiotocography plus ST analysis of fetal electrocardiogram for intrapartum fetal monitoring: a Swedish randomised controlled trial

BACKGROUND

Previous studies indicate that analysis of the ST waveform of the fetal electrocardiogram provides information on the fetal response to hypoxia. We did a multicentre randomised controlled trial to test the hypothesis that intrapartum monitoring with cardiotocography combined with automatic ST-waveform analysis results in an improved perinatal outcome compared with cardiotocography alone.

METHODS

At three Swedish labour wards, 4966 women with term fetuses in the cephalic presentation entered the trial during labour after a clinical decision had been made to apply a fetal scalp electrode for internal cardiotocography. They were randomly assigned monitoring with cardiotocography plus ST analysis (CTG+ST group) or cardiotocography only (CTG group). The main outcome measure was rate of umbilical-artery metabolic acidosis (pH <7.05 and base deficit >12 mmol/L). Secondary outcomes included operative delivery for fetal distress. Results were first analysed according to intention to treat, and secondly after exclusion of cases with severe malformations or with inadequate monitoring.

FINDINGS

The CTG+ST group showed significantly lower rates of umbilical-artery metabolic acidosis than the cardiotocography group (15 of 2159 [0.7%] vs 31 of 2079 [2%], relative risk 0.47 [95% CI 0.25-0.86], p=0.02) and of operative delivery for fetal distress (193 of 2519 [8%] vs 227 of 2447 [9%], 0.83 [0.69-0.99], p=0.047) when all cases were included according to intention to treat. The differences were more pronounced after exclusion of 291 in the CTG+ST group and 283 in the CTG group with malformations or inadequate recording.

INTERPRETATION

Intrapartum monitoring with cardiotocography combined with automatic ST-waveform analysis increases the ability of obstetricians to identify fetal hypoxia and to intervene more appropriately, resulting in an improved perinatal outcome.

Brånemark Novum: prosthodontic and dental laboratory procedures for fabrication of a fixed prosthesis on the day of surgery

PURPOSE

The purpose of this report is to describe a new technique to fabricate and deliver an implant-supported fixed prosthesis to the patient on the day of surgery, and to propose a protocol for the prosthodontic and dental laboratory procedures.

MATERIALS AND METHODS

The development of the Brånemark Novum prosthodontic protocol is reviewed, and clinical and dental laboratory assessments and methods are described.

RESULTS

The total treatment time to fabricate a permanent implant-supported fixed prosthesis in the mandible can be reduced to 1 day with the Brånemark Novum technique. The new method includes a precise surgical technique using drilling templates for predetermined implant positions, a rigid splinting of the implants immediately after placement, the use of a prefabricated titanium framework, and elimination of implant impression procedures.

CONCLUSION

With the technique described in this report, it is possible to provide patients with a permanent implant-supported fixed prosthesis in the mandible on the day of implant surgery. Patient benefits are obvious, with drastically reduced total treatment time, lower cost, and fewer clinical visits.

Subcutaneous versus intracutaneous injections of sterile water for labour analgesia: a comparison of perceived pain during administration

OBJECTIVE

To investigate whether, during injections of sterile water, there is any difference in perceived pain between intracutaneous and subcutaneous injections.

DESIGN

Blind controlled trial with cross-over design.

SETTING

Göteborg and Skövde, Sweden.

PARTICIPANTS

One hundred healthy female volunteers.

METHODS

The women were randomised into two groups and subjected to two trials, within one week of each other. During the first trial one group (n = 50) received the intracutaneous injection first, followed by the subcutaneous injection. The second group (n = 50) was given the subcutaneous injection first, followed by intracutaneous injection. In both groups all the injections were given in reverse order during the second trial.

MAIN OUTCOME MEASURES

Experienced pain during the administration of sterile water injections, measured by visual analogue scale.

RESULTS

The analysis showed intracutaneous injections to be significantly more painful than subcutaneous injections, even after adjusting for injection day and for left/right site of injection (mean 60.8 vs 41.3, P < 0.001).

CONCLUSIONS

The findings suggest that the less painful subcutaneous injection technique should be used.

Labour pain treated with cutaneous injections of sterile water: a randomised controlled trial

OBJECTIVE

To evaluate the relief of pain in labour with subcutaneous and intracutaneous injections of sterile water, compared with placebo.

DESIGN

Randomised controlled trial.

SETTING

Labour ward with approximately 3000 deliveries annually in a suburban area near Gothenburg, Sweden.

PARTICIPANTS

Ninety-nine pregnant women at term, requiring pain relief for severe lower back pain during the first stage of labour. The women were randomised to receive four injections of 0.1 mL sterile water (without salt) intracutaneously (n = 33), four injections of 0.5 mL sterile water subcutaneously (n = 33) or placebo treatment (n = 33).

MAIN OUTCOME MEASURES

Reduction of labour pain measured by visual analogue scale.

RESULTS

The median visual analogue scale pain score for labour pain was significantly lower compared with initial values in the two study groups and compared with placebo at 10 and 45 minutes after treatment. The median reductions in visual analogue scores after 10 minutes were 5.0 cm and 4.5 cm in the intracutaneous and subcutaneous injection groups, respectively; women in the placebo group scored a median reduction of 1.7 cm. After 45 minutes the median reductions in the visual analogue scores were 4.9 cm and 4.0 cm in the intracutaneous and subcutaneous injection groups, respectively, compared with 1.0 cm for women in the placebo group. No significant differences in analgesic effect or pain experienced during administration were found between the two study groups.

CONCLUSION

The new subcutaneous method of administering sterile water, as well as the earlier described intracutaneous injection method, were effective for the relief of pain in labour.

Intestinal and hepatic perfusion and metabolism in hypodynamic endotoxic shock. Effects of nitric oxide synthase inhibition

BACKGROUND

Inhibition of nitric oxide synthase (NOS) has been claimed to be beneficial in septic shock. We investigated the overall and regional effects of a NOS-inhibitor on perfusion and metabolism during severe endotoxic shock.

METHODS

Nineteen anaesthetised pigs were catheterised and ultrasonic flow-probes were placed around the portal vein, the hepatic artery, and the superior mesenteric artery. Thirteen animals were given a 3-h infusion of endotoxin; in 6 of these an infusion of NG-nitro-L-arginine-methyl-ester (L-NAME) was started an hour after the start of endotoxin while 7 animals served as controls and received endotoxin only. Six animals were sham operated with no further intervention.

RESULTS

Endotoxin produced a hypodynamic shock with pulmonary hypertension. L-NAME did not increase arterial blood pressure, but deepened the fall in cardiac output and enhanced the increase in systemic and pulmonary vascular resistance. The infusion of endotoxin caused a decrease in flows in all regions. The addition of L-NAME induced a further decrease in the mesenteric artery flow only. L-NAME had no additional effect on hepatic artery flow ratio, while a transient decrease was seen in mesenteric flow ratio. Portal flow ratio decreased in the control group only. Global as well as regional oxygen extraction increased in both groups, more so in the L-NAME group. Lactate levels increased with no differences between the groups.

CONCLUSION

In hypodynamic endotoxic shock, L-NAME infusion enhanced pulmonary vasoconstriction and increased left ventricular afterload. The resulting hypoperfusion caused an increase in mortality. The effects of L-NAME on global and mesenteric blood flow and metabolism were similar, while L-NAME had no additional effects on hepatic hypoperfusion or oxygen extraction. Thus, nitric oxide does not seem to be a major factor in the preservation of hepatic perfusion during unresuscitated endotoxic shock.

Differential effects of nitric oxide synthase modulation on porcine systemic and pulmonary circulation in vivo

OBJECTIVE

To study and compare the effects of inhibiting endothelial nitric oxide synthase on systemic and pulmonary circulation in an in vivo model.

DESIGN

Prospective, randomized, controlled study.

SETTING

Laboratory for experimental surgery at a university medical center.

SUBJECTS

Seventeen anesthetized, mechanically ventilated pigs.

INTERVENTIONS

To produce a stable and continuous stimulation of endothelial nitric oxide synthase, an infusion of acetylcholine was given to one group of animals (n = 5) in a dose that decreased mean arterial pressure by 15%. After 45 mins, N(G)-monomethyl-L-arginine (L-NMMA) was given in a dose of 3 mg/kg for 5 mins in order to inhibit the enzyme. A second dose of 10 mg/kg was given 30 mins later. L-arginine was then given in a dose of 100 mg/kg to reverse the inhibition. One group of animals (n = 6) received a single dose of indomethacin (2.5 mg/kg) 15 mins after the start of acetylcholine infusion. L-NMMA and L-arginine were then given. In a control group (n = 5), the effects of L-NMMA and L-arginine were studied without acetylcholine. Circulatory parameters were monitored and resistance indices were calculated via arterial, central venous, and pulmonary artery catheters.

MEASUREMENTS AND MAIN RESULTS

In control animals, 3 and 10 mg/kg of L-NMMA induced an increase in mean arterial pressure of 14% and 25%, respectively, with similar increases in systemic vascular resistance. Mean pulmonary arterial pressure increased by 22% and 48%, respectively. Acetylcholine lowered mean arterial pressure by 15% and did not affect the relative changes induced by L-NMMA. Acetylcholine had no effect on pulmonary resting tone but enhanced the pulmonary hypertension and increase in resistance induced by L-NMMA. This enhancement was abolished by indomethacin, which produced systemic hypertension while no effect on pulmonary pressure was seen.

CONCLUSIONS

A basal release of nitric oxide contributes to the maintenance of normal vascular tone in the anesthetized pig. Stimulation of endothelial nitric oxide synthase by acetylcholine did not result in any further pulmonary vasodilation as was seen in the systemic circulation. Inhibition of nitric oxide synthase had a greater effect on pulmonary pressure than on systemic pressure. However, this difference was abolished by the administration of indomethacin. Increased nitric oxide release or acetylcholine itself seems to stimulate the production of a vasoconstricting prostanoid in the pulmonary circulation.

Generation of nitrate during dialysis as a measure of nitric oxide synthesis

Nitric oxide (NO) is a recently identified messenger, which influences the local regulation of blood flow and platelets as well as neuronal and inflammatory pathways. Disturbed NO information might be involved in the uremic syndrome and might also cause hypotension during dialysis. To clarify these issues, we analyzed plasma and dialysis fluid concentrations of nitrate, the stable NO metabolite, in 9 patients during hemodialysis. Plasma nitrate was raised at the onset of dialysis as compared with healthy subjects (83 +/- 9 versus 26 +/- 2 mumol/L). The plasma concentration decreased to 20 +/- 2 mumol/L (p < 0.01) during the dialysis. The relative decrease was more pronounced than the relative reduction in creatinine, phosphate, and urea concentrations. A parallel decrease in nitrate was seen in effluent dialysis fluid (32 +/- 4 to 14 +/- 1 mumol/L; p < 0.01). Calculations of the amount of nitrate coming to and from the dialyzer were performed in 7 of the 9 patients, and in 5 of the 7 patients, generation of nitrate within the dialyzer could be postulated. This might explain the paradoxical venodilation noted during hemodialysis.

A case of foodborne listeriosis in Sweden

A 70-year-old woman fell seriously ill overnight with meningitis and was admitted to hospital. Cerebrospinal fluid culture yielded Listeria monocytogenes. One of the first problems in solving a human case of listeriosis suspected to be foodborne is to find the foods likely to have been transmitting L. monocytogenes. Two enrichment procedures and a direct plating procedure were used for isolation of the bacteria from different food items collected from the patient's refrigerator, local retail store and producer. Samples of vacuum-packed products of sliced pork brawn, sliced cooked medwurst and berliner wurst of the same brand harboured L. monocytogenes. Serotyping and restriction enzyme analysis (REA) with pulsed-field gel electrophoresis (PFGE) were used to characterize and compare 41 isolates, including the human strain. At least three clones were present in the foods investigated, and one of these was identical to the human clone. This clone was present in samples of medwurst from the patient's refrigerator and the local retail store. This is, to our knowledge, the first proven foodborne case of listeriosis reported in Sweden.

Beneficial effect of cold dialysate for the prevention of hemodialysis-induced hypoxia

Hypoxia occurs frequently during routine hemodialysis (HD). In this study the effect of dialysate temperature on arterial blood gas parameters was investigated. Ten stable HD patients (2 smokers) were dialyzed for 240 min with each of three different dialysate temperatures: 36.5 degrees C (normal temperature HD; NHD), 38.5 degrees C (warm HD; WHD) and 34.5 degrees C (cold HD; CHD). A cuprophane plate dialyzer was used. The ultrafiltration volume was identical in each patient. Arterial blood gas samples were frequently (approximately 10 times/treatment) taken during the dialysis and immediately analyzed. The dialysate temperature significantly affected PaO2 (p < 0.001) but not PaCO2. We also compared the effect of NHD with that of WHD and CHD, respectively, as regards PaO2. NHD and WHD differed significantly p < 0.01), whereas NHD and CHD were not significantly different. However, the relative PaO2 value (% of the baseline value) at the end of CHD (105 +/- 5%) was significantly higher than after both NHD (96 +/- 4%, p < 0.01) and WHD (91 +/- 3%, p < 0.01). In the case of NHD and WHD the fraction of time during which the patients had a PaO2 value below 80 mm Hg was 62 and 64%, respectively. The corresponding figure for CHD was 44%. Arterial oxygen saturation (SaO2) increased during CHD from 95.2 +/- 0.6 to 96.7 +/- 0.6% (p < 0.05), while SaO2 was unchanged during NHD and WHD. The positive effect of CHD was evident in 7 patients. In 1 patient PaO2 was not affected by the dialysate temperature, while in the remaining 2 patients (smokers) a decrease in PaO2 was induced by WHD as well as CHD. A separate statistical analysis with the 2 smokers excluded was performed, which showed that the dialysate temperature significantly affected PaO2 (p < 0.001). A comparison between NHD and CHD showed a significant difference (p < 0.001), whereas NHD and WHD did not differ significantly. When the 2 smokers were excluded from the analysis the fraction of time with a PaO2 value below 80 mm Hg was 60% during NHD and 56% during WHD, but it was reduced to 31% during CHD. In conclusion, despite the existence of interindividual variations most patients seemed to benefit from cold dialysate for the prevention of dialysis-induced hypoxia.

Nitric oxide inhalation decreases pulmonary platelet and neutrophil sequestration during extracorporeal circulation in the pig

OBJECTIVE

The inhibiting effect of nitric oxide on the aggregation and adhesion of neutrophils and platelets has been well documented in vitro. In vivo evidence, however, is more scant. In this study, we studied the effects of inhaled nitric oxide on pulmonary cellular sequestration in our sham hemodialysis model. Accumulation of neutrophils and platelets in the lungs has been shown to be an early event in this model.

DESIGN

Prospective, randomized, controlled study.

SETTING

Animal laboratory at a university medical center.

SUBJECTS

Twenty-six anesthetized, mechanically ventilated pigs.

INTERVENTIONS

111Indium-oxine was used to selectively label neutrophils or platelets and the activity over the lungs was followed dynamically with a gamma camera. Sham hemodialysis, using a cuprophan hollow-fiber dialyzer, was instituted via catheters in the femoral vessels. The animals were divided into two main groups: a) the nitric oxide recipient group (n = 12, with platelets labeled in seven animals and neutrophils labeled in five animals); and b) the control group (n = 14, with platelets labeled in seven animals and neutrophils labeled in seven animals). The animals in the former group were given 50 parts per million of nitric oxide in the inspiratory gas from the beginning of dialysis and for 30 mins onward.

MEASUREMENTS AND MAIN RESULTS

Inhalation of nitric oxide attenuated the increase in activity over the lungs in both the neutrophil and platelet groups during sham hemodialysis. In addition, an inhibiting effect on the increase in pulmonary pressure was noted.

CONCLUSION

Apart from the effects of nitric oxide on central hemodynamics in this model, the scintigraphic findings indicate an in vivo effect of nitric oxide on the accumulation of platelets and neutrophils in the lungs, probably due to inhibition of the adhesion and/or aggregation of these cells.

Fetal pulse oximetry. A methodogical study

BACKGROUND

During recent years fetal pulse oximetry has been under development for use in monitoring fetal oxygenation during labor. In a methodological study we have tested the practical applicability of one type of sensor (FS-10 Oxisensor, Nellcor). Both obstetricians and midwives took active part in sensor placement. The readings of fetal arterial oxygen saturation (SpO2) were not taken into account when managing the patients.

METHODS

Oxygenation was monitored during labor in 96 singleton pregnancies. Mean SpO2 levels were calculated when cervical dilatation was 4-7 cm and 8-10 cm, and in the second stage of labor. Student's t-test was used for paired comparisons. A p-value<0.05 was considered significant.

RESULTS

Of the 96 oxisensors, 91 (95%) were successfully placed. One mother felt pain which disappeared when the sensor was removed. Two of the newborns manifested an impression mark caused by the sensor, which disappeared completely within a day. No infection or increased bleeding was noted. The mean recording time was 134 minutes. SpO2-values were obtainable during 69% of the recording time. A significant fall of mean SpO2 occurred between the first and second stages of labor.

CONCLUSIONS

The method seems to be harmless for mother and child, and allows SpO2-values to be obtained during two thirds of the recording period. Further research is needed to evaluate the possible clinical value of the method.

Dynamic accumulation of neutrophils in lungs and visceral organs during early abdominal sepsis in the pig

Activation and accumulation of polymorphonuclear leukocytes (PMNs, neutrophils) in the lungs is considered an important mechanism in the pathogenesis of pulmonary dysfunction in association with sepsis. It probably constitutes only part of a general cellular response; and a corresponding reaction has been implicated in other organs during sepsis (e.g., the liver). In this experiment a model was developed that allows study of the dynamic PMN reaction in the lungs and visceral organs during early abdominal sepsis. The animals were divided into two groups. In the septic group (n = 8) a bacterial challenge was attempted through the intraperitoneal administration of Escherichia coli (1 x 10(11)/kg). Five animals served as controls. All animals in the septic group developed bacteremia, leukopenia, and a hypodynamic circulatory response. PMNs were selectively labeled with 111In-oxine. The activity over the organs was followed dynamically with a gamma camera. The animals subjected to peritonitis exhibited a significant increase in 111In-oxine activity (i.e., neutrophil trapping) in the lungs, compared to the controls at 40 minutes and onward during the observation period. A similar picture was seen over the liver and abdomen, with significance after 70 minutes. The findings in this study indicate that accumulation of PMNs is an early phenomenon not only in the lungs but also in the liver during the development of sepsis. The present model offers possibilities for further studies of the cellular reactions during sepsis.

Circulatory and ventilatory effects of intermittent nitric oxide inhalation during porcine endotoxemia

The effects of intermittent inhalation of 57 ppm nitric oxide (NO) were studied in eight anesthetized, ventilated pigs given a continuous infusion of Escherichia coli endotoxin. Seven animals served as controls. By administering NO synchronized with inspiration and close to the orotracheal tube, measurable amounts of the toxic metabolite, NO2, in the inspiratory gas mixture were avoided. No direct systemic effects of NO inhalation were seen, but through counteracting pulmonary vasoconstriction, a fall in cardiac output was delayed. Nitric oxide effectively attenuated the initial peak rise in mean pulmonary artery pressure and resistance, both returning to control levels after cessation of NO. These effects were reproduced during later phases of endotoxemia, giving further proof to the role of gaseous NO as a selective pulmonary vasodilator. Nitric oxide diminished pulmonary shunting, but unimpaired oxygenation was preserved only during the first inhalation period. Leukocyte counts decreased drastically and platelet aggregation was enhanced, but after 1.5 hours of endotoxin infusion, platelet hyperaggregation was maintained in the NO group while it decreased in the control group.

Iloprost attenuates trauma-related pulmonary sequestration of leucocytes and platelets

The purpose of this study was to investigate the effects of iloprost, a synthetic prostacyclin analogue, on the pulmonary cellular trapping after a standardized soft tissue trauma. In two groups 1 and 2 iloprost was given in doses of 100 ng/kg/min commencing 30 and 20 min respectively prior to trauma and ceasing 10 min after trauma. 111Indium-oxine was used to label neutrophils in 6 animals from each group. Platelets were labelled in 6 and 7 animals respectively. A third group of 11 pigs served as a control and did not receive iloprost. The pulmonary sequestration of platelets and neutrophils was studied dynamically with a gamma camera and directly after trauma was significantly less in group 1 when compared to the control group. A rise in pulmonary vascular resistance and pulmonary arterial pressure was seen in the control group immediately after trauma but this was not evident in the iloprost groups. PaO2 decreased significantly in group 1 and 2 during the iloprost infusion. The results indicate that iloprost attenuates the pulmonary cellular sequestration and changes in central hemodynamics during trauma in this model.

Changes in plasma levels of vasoactive substances during routine acetate and bicarbonate hemodialysis

Hemodynamic stability is better preserved during bicarbonate hemodialysis compared to acetate. We have studied the effects of bicarbonate (HDB) and acetate hemodialysis (HDA) on plasma levels of vasoactive substances. The treatments were performed for 270 min. A cuprophan plate dialyzer was used. The ultrafiltration volume and the ultrafiltration rate were identical in the individual patients during the two treatments. In the case of vasoconstrictors there was an increase in neuropeptide Y (NPY) (20%, p < 0.01) during HDB and arginine vasopressin (AVP) was unchanged. Unlike this was the response during HDA when there was no change in NPY and a decrease in AVP (38%, p < 0.01). An increase in noradrenaline (NA) (41%, p < 0.05) occurred during HDA different from what was the case during HDB. There was a gradual increase in renin (PRA) during both HDB (141%, p < 0.05) and HDA (148%, p < 0.01). With respect to vasodilators there were no differences between the two regimes regarding calcitonin gene-related peptide (CGRP) and motilin (MOT). The change in substance P (SP) during the treatments was also similar but somewhat more pronounced during HDB. Thus, an initial rise occurred (HDB, 81%, p < 0.01; HDA, 36%, p < 0.05) followed by a decrease (HDB, 26%, p < 0.05) or a tendency to decrease (HDA, 12%, p = 0.058) during the remaining part of the treatment. A rise in beta-endorphin (beta-END) occurred during HDB (10%, p < 0.05) but not during HDA. An increase in vasoactive intestinal peptide (VIP) occurred during HDB (27%, p < 0.05) different from the decrease during HDA (11%, p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Delayed decrease in plasma levels of atrial natriuretic peptide during cold hemodialysis

The high plasma levels of the vasodilating hormone atrial natriuretic peptide (alpha-ANP), observed in patients with chronic renal failure, decrease substantially during hemodialysis (HD), probably owing to volume reduction. Cardiovascular stability is better maintained by the use of cold dialysate although underlying mechanisms are unknown. In order to investigate the effects of different dialysate temperatures on hemodynamic stability and plasma levels of immunoreactive ANP (p-irANP), 10 stable HD patients were dialyzed with bicarbonate dialysis fluid for 240 min with each of 3 different dialysate temperatures: 36.5 degrees C (normal HD; NHD), 38.5 degrees C (warm HD; WHD) and 34.5 degrees C (cold HD; CHD). A Cuprophan plate dialyzer was used. The ultrafiltration volume and ultrafiltration rate were identical in each patient during the treatments. p-irANP was determined by radioimmunoassay, using 2 antisera which different cross-reactivity to ANP-related peptides. During NHD a nonsignificant decrease in mean arterial blood pressure from 111 +/- 5 to 103 +/- 8 mm Hg was observed. A significant (p < 0.05) decrease in mean arterial blood pressure from 109 +/- 4 to 96 +/- 6 mm Hg occurred during WHD, while during CHD it remained stable (111 +/- 4 before, 112 +/- 5 mm Hg after). Irrespective of the dialysate temperature or the antiserum used, p-irANP decreased significantly (p < 0.05) during the treatment. The reduction in p-irANP was delayed during CHD, the decrease being significantly (p < 0.05) less pronounced after 120 min. At the end of the treatment no significant difference was observed between the regimes.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in plasma levels of vasoactive peptides during standard bicarbonate hemodialysis

During bicarbonate hemodialysis, there is an increase in peripheral vascular resistance of nonadrenergic origin, counteracting the hypotensive effect of fluid removal during the course of the dialysis. In this study, the plasma levels of vasoactive regulatory peptides, noradrenaline and renin, were investigated in 11 patients with chronic renal failure during standard bicarbonate hemodialysis (STHD) for 270 min. As regards vasoconstrictors, an increase in gamma 2-melanocyte-stimulating hormone (gamma 2-MSH), neuropeptide Y (NPY) and plasma renin activity (PRA) occurred. However, arginine vasopressin and noradrenaline were unchanged. With respect to vasodilators, calcitonin gene-related peptide was not changed. An initial increase in beta-endorphin (beta-END) occurred, followed by a decrease during the remaining part of the treatment. Motilin decreased during the first part of the treatment but increased to the baseline level during the latter part. An increase in substance P was observed while vasoactive intestinal peptide decreased. We conclude that an increase in vasoconstricting substances (gamma 2-MSH, NPY, PRA) occurs during STHD, probably owing to the decrease in plasma volume. With the exception of beta-END, the changes in vasodilators were fairly small. The data suggest that vasoactive substances might participate in the hemodynamic response to hemodialysis.

Increased pulmonary platelet sequestration due to infusion of cold saline during extracorporeal circulation

We have previously documented that neutrophils (polymorphonuclear leukocytes) aggregate in the lungs 10-15 min after the start of dialysis. The aim of the present study was to investigate the corresponding platelet reaction and evaluate the effect of prewarmed priming solution on this reaction. The animals were divided into two groups, each consisting of 6 pigs. In group 1 the priming solution was prewarmed to 36-38 degrees C whereas it was maintained at room temperature in group 2. Platelets were selectively labelled with 111In-oxine. The activity over the lung was followed dynamically with a gamma camera and already after 2 min a significant difference in platelet sequestration showed between the groups. A significant increase in pulmonary vascular resistance was noted in group 2, but not in group 1. In conclusion, platelet aggregation occurs early on during dialysis in this model. The results also indicate that prewarming the priming solution attenuates the pulmonary platelet sequestration and also seems to decrease the changes in central hemodynamics.

Changes in plasma levels of vasoactive peptides during sequential bicarbonate hemodialysis

The hemodynamic response to isolated ultrafiltration (IUF) is characterized by a vasoconstriction, while there is no significant change in peripheral vascular resistance during isovolemic bicarbonate hemodialysis (IVHD). The present investigation was designed to study the plasma levels of vasoactive regulatory peptides together with noradrenaline (NA) and plasma renin activity (PRA) in 11 patients during sequential hemodialysis (SQHD) - IUF for 60 min, followed by IVHD for 210 min. During IUF, the vasoconstrictors arginine vasopressin (AVP), gamma 2-melanocyte-stimulating hormone (gamma 2-MSH), neuropeptide Y (NPY), NA and PRA increased. During IVHD, NPY and PRA remained unchanged on a higher level. A decrease in AVP below the baseline and in gamma 2-MSH and NA to the baseline levels occurred during IVHD. In the case of vasodilators, there were no changes in calcitonin gene-related peptide or motilin during SQHD. An increase in beta-endorphin (beta-END) occurred during IUF, followed by a decrease during IVHD. Substance P and vasoactive intestinal peptide were unchanged during IUF but decreased during IVHD. We conclude that SQHD is characterized by an increase in all the measured vasoconstrictors during IUF in response to loss of fluid, and by a decrease in some vasoconstrictors (AVP, gamma 2-MSH, NA) during IVHD. With the exception of beta-END, there were no changes or only minor ones in vasodilators during SQHD. There are changes in plasma levels of vasoactive substances during SQHD but the importance of these changes for the hemodynamic adaptation to ultrafiltration and dialysis needs to be studied further.

Effects of sham hemodialysis on plasma levels of vasoactive peptides in patients with uremia

Changes in plasma levels of vasoactive peptides during hemodialysis have mainly been attributed to changes in plasma volume and osmolality. This study investigated the effect of the extracorporeal circulation on plasma levels of vasoactive peptides, noradrenaline, and renin. Eleven stable hemodialysis patients were studied during sham dialysis for 60 min using a Cuprophan dialyzer (Alwall GFE11, Gambro AB, Lund, Sweden). With regard to vasoconstrictors, there was an increase in noradrenaline (NA) (13%, p < 0.05) and renin (PRA) (32%, p < 0.05), while arginine vasopressin and neuropeptide Y remained unaltered. Concerning vasodilators, an increase in substance P (SP) (23%, p < 0.05) and vasoactive intestinal peptide (VIP) (15%, p < 0.01) was observed, while a decrease in atrial natriuretic peptide (ANP) (17%, p < 0.05) and motilin (MOT) (24%, p < 0.01) occurred. Calcitonin gene related peptide and beta endorphin were unaltered. A decrease in blood pressure was observed, while heart rate remained unchanged. The authors conclude that the extracorporeal circulation, per se, affects plasma levels of vasoactive substances and influences vascular stability. The decrease in ANP and MOT might be due to adsorption to the dialysis membrane. The increase in some vasoconstrictors (NA, PRA) and vasodilators (SP, VIP) might be induced by the blood-artificial surface contact, or by other factors, e.g., heparin or cooling of the blood during the procedure.

Absence of lung reactions after complement depletion during dialysis: an experimental study in pigs

Sequestration of 111In-labeled neutrophils (polymorphonuclear leukocytes--PMNs) in the lungs during sham dialysis was studied dynamically using a gamma camera. Five animals were pretreated with cobra venom factor, naja naja (CVF), to achieve depletion of the complement system, mainly C5a. Seven animals were studied without pretreatment with CVF. Central hemodynamics and gas exchange were studied as well as neutrophil function using luminescence and aggregation. In the control group there was a significant sequestration of neutrophils in the lungs, which reached a maximum between 15 and 17 min after the start of hemodialysis. The peripheral neutrophil count decreased concomitantly. These changes were virtually absent in the CVF-treated group. PMN aggregation and luminescence were abolished in CVF-treated animals. Both pulmonary artery pressure and pulmonary vascular resistance increased significantly in the control group, whereas in the CVF group these parameters remained unchanged. There were no differences in blood gases, platelet count, or hematocrit between the groups. The results clearly indicate that the activation of neutrophils within minutes after the start of hemodialysis is greatly dependent on C5a activation because it can be abolished by C5a depletion. This activation is accompanied by changes in the pulmonary circulation with increases in pressure and resistance.

Oleic acid-induced injuries in the guinea-pig. Effects of allopurinol on cell dynamics, erythrocyte-catalase and uric acid plasma levels

1. Oleic acid was used to produce adult respiratory distress syndrome-like pulmonary microvascular injuries. The resulting injuries have previously indicated involvement of accumulating neutrophils (Hultkvist et al. 1988). Activated neutrophils release oxygen free radicals that may be possible to detect in the plasma. 2. The dynamics of neutrophils and platelets were studied in the guinea-pig after oleic acid-induced injury (0.03 ml/kg per 10 min). 3. As an indication of oxygen free radical activity, plasma levels of uric acid and red blood cell (RBC)-catalase, were analysed. 4. Allopurinol (10 mg/kg, i.p.) was given prior to oleic acid infusion to block the production of uric acid. 5. The neutropenia, in contrast to the thrombocytopenia seen at 15 min, was significantly inhibited in the allopurinol pretreated group compared with oleic acid and vehicle alone. 6. The blood plasma concentration of uric acid was significantly elevated after 15 min from start of experiment. Allopurinol pretreatment significantly reduced the uric acid plasma level. 7. The RBC catalase activity did not change with time within or between any groups. 8. The results indicate that sequestration of activated neutrophils in the microvasculature are to some extent oxygen free radical dependent.

External detection of pulmonary accumulation of indium-113m labelled transferrin in the guinea pig

Accumulation of radioisotope labelled transferrin in the lungs of guinea pigs was determined with an external detection system. The method is based on the intravascular and extravascular distribution of indium-113m labelled transferrin compared with the intravascular distribution of technetium-99m labelled red blood cells. Guinea pigs were given iloprost, a prostacyclin analogue and potent pulmonary vasodilator, and noradrenaline, a pulmonary vasoconstrictor, in an attempt to increase and decrease respectively the blood volume in the lungs. Neither agent altered transferrin accumulation in the lung by comparison with a saline infusion. Iloprost infused before and after oleic acid infusion reduced macro-molecular leakage when compared with oleic acid alone. These data suggest that the double isotope method can distinguish between hydrostatic and injury induced pulmonary oedema.

Portable closed loop feedback system for control of the blood glucose level in the pig

To establish the difference in glucose consumption of healthy compared to diabetic pigs, a transportable system for the feedback control of insulin and glucose was used in conscious pigs. The system for controlling glucose levels, as well as glucose consumption, was easy to use and adjusted smoothly to rapid changes in insulin level. Five days prior to the first day of experiment, healthy animals were prepared with intravenous jugular catheters tunnelled subcutaneously to the neck. On the first day of experiment, measurements of glucose were continuously taken before and after food ingestion. The animals were rendered diabetic after 2 days using Alloxan and streptozotocin. The measurements were then repeated. To be able to obtain constant glucose levels of approximately 3 mmol during both fasting and postprandial periods requires only small glucose adjustment infusion in the diabetic pigs, as opposed to healthy ones. Using the described system, it would be possible to evaluate subclinical diabetes and control unstable diabetics with different therapeutic regimes.

Dynamic pulmonary accumulation of labelled neutrophils by blood membrane contact in the pig

Nine anesthetized pigs were subjected to short (90 min) sham dialysis with blood membrane contact with the aim to select effects of the artificial surface during dialysis. The importance of the neutrophil (PMN) was investigated by the selective isotope labelling, dynamically followed by gamma-camera imaging and biochemical assays specifically oriented for PMN function. These assays included cell count, PMN aggregation, PMN luminescence, fibronectin and catalase activity. Additionally, pulmonary and systemic hemodynamics and acid base balance were monitored. Sham dialysis induced an accumulation of labelled PMN attaining a maximum between 15 and 17 min. This was coupled with a time-related neutropenia, pulmonary vasoconstriction, increased in vitro PMN aggregation and luminescence response. The neutrophil response abated by the end of dialysis. Cardiac output and arterial blood pressure declined to a steady level after 30 min of sham dialysis. There was an insignificant decrease in catalase activity. All other parameters remained unaltered. The results indicate that PMN accumulates in the pulmonary vessels, in association with neutropenia and activation. The transience of the event points to a protective mechanisms of humoral and/or cellular character.

Polymorphonuclear leucocyte sequestration in the lungs and liver following soft-tissue trauma: an in vivo study

Neutrophils are thought to sequestrate in the lungs and the liver in association with shock. Indications for this have previously been demonstrated in different in vitro studies. In this experiment an in vivo technique for dynamic studies of pulmonary and liver neutrophil sequestration (PNT and LNT, respectively) is described. Autologous neutrophils from ten pigs were labelled with 111Indium-oxine. The pigs were placed under a scintillation camera for continuous recording of the activity distribution in the pigs during 105 minutes. Following a steady-state period of 15 minutes seven pigs were subjected to a standardized soft-tissue trauma. Three pigs were used as controls and not traumatized. Within 1-3 minutes after trauma the radioactivity over the lungs increased dramatically, indicating PNT. This was followed by a fast decrease but 90 minutes after trauma PNT levels were still significantly elevated. LNT showed a similar pattern, although the immediate increase was less dramatic. This study shows that PNT and LNT occur immediately after soft-tissue trauma and can be studied dynamically in vivo.

Model of pulmonary extravasation as an effect of neutropenia in endotoxic shock in guinea pigs

A guinea pig model was developed to document the association of polymorphonuclear neutrophils (PMN) decrease with pulmonary leakage after a sublethal infusion of endotoxin (LPS Escherichia coli 0111:B4, 5 micrograms/min/kg). A control group was prepared in the same manner and given an infusion of vehicle alone. Severe leukopenia developed, mostly expressed in the neutrophil population. There was a decrease in RBC catalase and fibronectin. Plasma leakage in the lung followed the endotoxin infusion, which could indicate endothelial cell damage. The results from the present study suggest an activation of PMN in endotoxin-infused animals, degranulation and release of toxic oxygen species, resulting in pulmonary plasma extravasation.

Cystatin C: a new marker of biocompatibility or a good marker for the redistribution of LMW proteins during hemodialysis?

The mechanism(s) behind the larger relative increase of Plasma beta 2 microglobulin (P-beta 2m) than that of Plasma albumin (P-alb) during Cuprophan hemodialysis is disputed. To elucidate this phenomenon P-alb, P-beta 2m (MW 11,800) and Plasma cystatin (P-cC; MW 13,000) an inhibitor of cystein proteinases, were determined before and after a Cuprophan or polysulphone hemodialysis (4-7 hr, QB 200 ml/min) in 30 stable regular dialysis treatment (RDT) patients. Body weight (BW) decreased by 2.5 +/- 1.4% (mean +/- SD). P-alb, P-beta 2m and P-cC increased by 11.4 +/- 14.8%, 15.4 +/- 11.5%, and 22.1 +/- 14.3%, respectively, during Cuprophan dialysis. The relative increase of P-cC was larger than that of P-beta 2m (P less than 0.05) and that of P-alb (P less than 0.02). During polysulphone dialysis BW decreased by 4.1 +/- 1.8%. P-alb, P-beta 2m, and P-cC increased almost equally by 28.1 +/- 18, 26.5 +/- 19.2, and 26.8 +/- 14.4%, respectively. These results are hard to interpret. Is the increase in P-cC a new marker of biocompatibility or does it reflect the true shift of low molecular weight (LMW) proteins between the interstitial and the plasma volume during hemodialysis better than P-beta 2m? In vitro studies indicate that small amounts of both Serum beta 2m (S-beta 2m) and Serum cystatin C (S-cC) are adsorbed to or sieved through the Cuprophan membrane, findings which render the kinetics of LMW proteins during hemodialysis still more complex.

External 113Inm and 99Tcm radiation detection of lung edema induced by oleic acid in the guinea pig

The establishment of a small animal model for studies of lung injury is in great demand. Therefore, a double radioisotope labeling method was applied to study the dynamics of lung injury with protein-rich edema in the anesthetized guinea pig. One external scintillation detector was placed over the lung and another over the heart, where they continuously sampled the energy spectrum of 113Inm labeled transferrin, a macromolecular marker, and 99Tcm labeled red blood cells (RBC), a blood pool marker. Lung injury was induced by i.v. oleic acid in doses of 0.03 and 0.06 ml/kg b.wt. infused for 10 min. We calculated the rate of increase of accumulated 113Inm-transferrin in the lung corrected for blood pool changes. Macromolecular leakage showed a graded response in regression line-slope (RLS) to oleic acid. Both oleic acid groups showed significantly different RLSs as compared to the saline control (mean +/- SD x 10(-3) min-1; 0.03 ml: 3.86 +/- 1.01 (n = 7); 0.06 ml: 10.75 +/- 4.06 (n = 6), and control 1.12 +/- 1.19 (n = 6]. Assays of changes of acid-base balance, cell dynamics, and lung wet-dry weight were in accordance with the occurrence of lung edema. The RLS was well correlated with the lung wet-dry weight (r = 0.98). We conclude that measurements of pulmonary edema in guinea pigs can be performed quantitatively with the aid of external detection of radiolabeled transferrin and RBC:s. Thus, the method could be useful in further studies on mechanisms and/or treatment of protein-rich lung edema.

Movement of oxygen, glucose, and lactate across the uterus of the awake near-term guinea pig

In this study the uterine movement of oxygen, glucose, and lactate was quantitated in the awake late pregnant guinea pig. Mean uterine uptake of oxygen per kg of uterus with conceptus was 581 mumol min-1, which is comparable to the value reported for the awake near-term rabbit, but 30% higher than the value reported for the awake near-term sheep. Experiment-related anemia in some animals was associated with a reduced uterine oxygen uptake. The arteriovenous oxygen difference across the uterus correlated positively with the arterial oxygen content and the hemoglobin concentration and negatively with uteroplacental blood flow. Uterine oxygen uptake showed a positive correlation with both the arterial hemoglobin and the uteroplacental blood flow. Uterine lactate output accounted for 20% of uterine glucose uptake, assuming maternally derived glucose to be the only source for uterine lactate output. After correction for this lactate output, the uterine glucose uptake was 96.5 mumol min-1 X kg-1 of pregnant uterus. This value is 30% higher than in the awake near-term rabbit and more than twice as high as that in the awake near-term sheep. Nevertheless, because of the high uterine demand for substrates, this uterine glucose uptake could only cover 45% of the caloric requirements of the pregnant uterus. The late pregnant guinea pig fetus may derive as much as 55% of its caloric uptake for fat deposition and protein accretion. Therefore, it is likely that the nonglucose uterine caloric uptake in the late pregnant guinea pig consists predominantly of fat precursors and amino acids.