Clinical evaluation of multimodal environmental modification (MEMO) in the management of cats with idiopathic cystitis

This prospective observational study evaluated client-reported recurrence of lower urinary tract signs (LUTS) and other signs of abnormalities in cats with idiopathic cystitis after institution of multimodal environmental modification (MEMO). Forty-six client-owned indoor-housed cats with idiopathic cystitis, diagnosed based on a history of recurrent LUTS and evidence of absence of urolithiasis or bacterial urinary tract infection were studied. In addition to their usual care, clients were offered recommendations for MEMO based on a detailed environmental history. Cases were followed for 10 months by client contact to determine the effect of MEMO on LUTS and other signs. Significant ( P<0.05) reductions in LUTS, fearfulness, nervousness, signs referable to the respiratory tract, and a trend ( P<0.1) toward reduced aggressive behavior and signs referable to the lower intestinal tract were identified. These results suggest that MEMO is a promising adjunctive therapy for indoor-housed cats with LUTS, and should be followed up with prospective controlled clinical trials.

Novel restraint system for neuroendocrine studies of socially living common marmoset monkeys

We describe a novel soft jacket and sling-harness restraint that permits species-typical postures for small-bodied primates, such as the common marmoset ( Callithrix jacchus), during long-term (>6 h), continuous restraint. The restraint system is straightforward to use and manipulate, it is easily repaired, and the materials used are readily available. The soft jacket allows for increased versatility and longevity, and the sling-harness provides for greater movement and much longer duration of continuous restraint (up to 3 days) compared to a previously described, more conventional chair restraint for small-bodied primates. The new restraint system prevents the normal diurnal decrease in plasma cortisol levels across the daylight hours; however, it does not disrupt ovulatory cycles. Unlike the previously available techniques, therefore, this new restraint system is applicable to many neurobiological and neuroendocrine studies involving small-bodied, non-human primates and is especially suited to investigations requiring the maintenance of relationships within social groups.

A minimal stress model for the assessment of electroacupuncture analgesia in rats under halothane

The use of anesthetics in acupuncture analgesia is controversial. We evaluate a steady-state light anesthesia model to test whether minimal stress manipulation and reliable measurement of analgesia could be simultaneously achieved during electroacupuncture (EA) in animals. A series of experiments were performed. Firstly, EA compliance and tail-flick latencies (TFL) were compared in rats under 0.1%, 0.3%, 0.5%, 0.7%, or 1.1% halothane for 120min. Under 0.5% halothane, TFL were then measured in groups receiving EA at intensity of 3, 10 or 20 volt (V), 1 or 2mg/kg morphine, 20V EA plus naloxone, or control. Subsequently, the effect of EA on formalin-induced hyperalgesia was tested and c-fos expression in the spinal dorsal horn was analyzed. Rats exhibited profound irritable behaviors and highly variable TFL under 0.1% or 0.3% halothane, as well as a time-dependent increase of TFL under 0.7% or 1.1% halothane. TFL remained constant at 0.5% halothane, and needle insertion and electrical stimulation were well tolerated. Under 0.5% halothane, EA increased TFL and suppressed formalin-induced hyperalgesia in an intensity-dependent and naloxone-reversible manner. EA of 20V prolonged TFL by 74%, suppressed formalin-induced hyperalgesia by 32.6% and decreased c-fos expression by 29.7% at the superficial and deep dorsal horn with statistically significant difference. In conclusion, 0.5% halothane provides a steady-state anesthetic level which enables the humane application of EA stimulus with the least interference on analgesic assessment. This condition serves as a minimal stress EA model in animals devoid of stress-induced analgesia while maintaining physiological and biochemical response in the experiment.

[Fast track surgery]

Fast track (FT) surgery is a multimodal concept aiming to reduce postoperative pain and stress-induced organ dysfunction. Key elements are perioperative fluid restriction, epidural analgesia, early oral nutrition and early mobilization. Therefore, multidisciplinary teamwork is required in order to obtain the optimal outcome of reduced postoperative complications and a hospital stay of only three or four days after open colectomy. Most of the patients undergoing colorectal surgery qualify for FT surgery. Meanwhile, FT principles are applied in a variety of open and laparoscopic procedures. The aim of this review is to highlight the principles of FT and to answer the question why FT surgery should nowadays be considered as standard care.

How do humans control physiological strain during strenuous endurance exercise?

BACKGROUND

Distance running performance is a viable model of human locomotion.

METHODOLOGY/PRINCIPAL FINDINGS

To evaluate the physiologic strain during competitions ranging from 5-100 km, we evaluated heart rate (HR) records of competitive runners (n = 211). We found evidence that: 1) physiologic strain (% of maximum HR (%HRmax)) increased in proportional manner relative to distance completed, and was regulated by variations in running pace; 2) the %HRmax achieved decreased with relative distance; 3) slower runners had similar %HRmax response within a racing distance compared to faster runners, and despite differences in pace, the profile of %HRmax during a race was very similar in runners of differing ability; and 4) in cases where there was a discontinuity in the running performance, there was evidence that physiologic effort was maintained for some time even after the pace had decreased.

CONCLUSIONS/SIGNIFICANCE

The overall results suggest that athletes are actively regulating their relative physiologic strain during competition, although there is evidence of poor regulation in the case of competitive failures.

[Peri-operative stress response and peri-operative analgesia in children]

Peri-operative surgical stress (SS) is characterized by increased secretion of pituitary hormones and sympathetic activation and is correlated with changed blood levels of stress hormones and metabolites. Adverse effects of perioperative stress include mortality and morbidity and a negative nitrogen balance. Although peri-operative analgesia and stress response-free period are commonly considered as synonyms, pain seems not to be the only factor determining the hormonal-metabolic response to surgery. Other factors playing a role in the creation of SS in newborns include blood loss, site of surgery, superficial and visceral trauma, surgery duration, hypothermia, infection, prematurity and factors related to cardiac surgery. Potent semi-synthetic opioids attenuate the SS better than morphine. However, supplementation of general anesthesia (GA) with local anesthetics either by way of regional or local anesthesia seems to decrease SS more effectively than GA with IV opioids. Hemodynamic monitoring may not suffice for SS or analgesia quality estimation. The most accessible laboratory measure for the monitoring of the stress response for non-cardiac surgery and pre-bypass phase of cardiac surgery may be blood glucose. Blood glucose increases with stress and when analgesia is inadequate; it is easily measured and treated almost immediately once an excessive response is identified. This individualized approach and real-time feedback may be far better than using either excessive opioid doses (hoping to ablate stress response) or minimal opioid dosages.

Alzheimer's disease, amnestic mild cognitive impairment, and age-associated memory impairment: current understanding and progress toward integrative prevention

Alzheimer's disease, AD, is the most common form of dementia. AD initially targets memory and progressively destroys the mind. The brain atrophies as the neocortex suffers neuronal, synaptic, and dendritic losses, and the hallmark amyloid plaques and neurofibrillary tangles proliferate. Pharmacological management, at best, is palliative and transiently effective, with marked adverse effects. Certain nutrients intrinsic to human biochemistry (orthomolecules) match or exceed pharmacological drug benefits in double-blind, randomized, controlled trials, with superior safety. Early intervention is feasible because its heritability is typically minimal and pathological deterioration is detectable years prior to diagnosis. The syndrome amnestic mild cognitive impairment exhibits AD pathology and to date has frustrated attempts at intervention. The condition age-associated memory impairment is a nonpathological extreme of normal brain aging, but with less severe cognitive impairment than amnestic mild cognitive impairment. Age-associated memory impairment is a feasible target for early intervention against AD, beginning with the modifiable AD risk factors - smoking, hypertension, homocysteine, type 2 diabetes, insulin resistance, and obesity. Stress reduction, avoidance of toxins, and mental and physical exercise are important aspects of prevention. The diet should emphasize omega-3 fatty acids docosahexaenoic acid and eicosapentaenoic acid; flavonoids and other antioxidant nutrients; and B vitamins, especially folate, B6 and B12. Dietary supplementation is best focused on those proven from randomized, controlled trials: the phospholipids phosphatidylserine and glycerophosphocholine, the energy nutrient acetyl-L-carnitine, vitamins C and E, and other antioxidants. A comprehensive integrative strategy initiated early in cognitive decline is the most pragmatic approach to controlling progression to Alzheimer's disease.

Effects of redecoration of a hospital isolation room with natural materials on stress levels of denizens in cold season

We investigated the effects of redecoration of a hospital isolation room with natural materials on thermoregulatory, cardiovascular and hormonal parameters of healthy subjects staying in the room. Two isolation rooms with almost bilaterally-symmetrical arrangements were used. One room (RD) was redecorated with wood paneling and Japanese paper, while the other (CN) was unchanged (with concrete walls). Seven healthy male subjects stayed in each room for over 24 h in the cold season. Their rectal temperature (T(re)) and heart rate, and the room temperature (T(a)) and relative humidity were continuously measured. Arterial blood pressures, arterial vascular compliance, thermal sensation and thermal comfort were measured every 4 h except during sleeping. Blood was sampled after the stay in the rooms. In RD, T(a) was significantly higher by about 0.4 degrees C and relative humidity was lower by about 5% than in CN. Diurnal T(re) levels of subjects in RD significantly differed from those in CN, i.e., T(re)s were significantly higher in RD than in CN especially in the evening. In RD, the subjects felt more thermally-comfortable than in CN. Redecoration had minimal effects on cardiovascular parameters. Plasma levels of catecholamines and antidiuretic hormone did not differ, while plasma cortisol level was significantly lower after staying in RD than in CN by nearly 20%. The results indicate that, in the cold season, redecoration with natural materials improves the thermal environment of the room and contributes to maintaining core temperature of denizens at preferable levels. It also seems that redecoration of room could attenuate stress levels of isolated subjects.

Building physician resilience

OBJECTIVE

To explore the dimensions of family physician resilience.

DESIGN

Qualitative study using in-depth interviews with family physician peers.

SETTING

Hamilton, Ont.

PARTICIPANTS

Purposive sample of 17 family physicians.

METHOD

An iterative process of face-to-face, in-depth interviews that were audiotaped and transcribed. The research team independently reviewed each interview for emergent themes with consensus reached through discussion and comparison. Themes were grouped into conceptual categories.

MAIN FINDINGS

Four main aspects of physician resilience were identified: 1) attitudes and perspectives, which include valuing the physician role, maintaining interest, developing self-awareness, and accepting personal limitations; 2) balance and prioritization, which include setting limits, taking effective approaches to continuing professional development, and honouring the self;3) practice management style, which includes sound business management, having good staff, and using effective practice arrangements; and 4) supportive relations, which include positive personal relationships, effective professional relationships, and good communication.

CONCLUSION

Resilience is a dynamic, evolving process of positive attitudes and effective strategies.

Effect of floor space during transport of market-weight pigs on the incidence of transport losses at the packing plant and the relationships between transport conditions and losses

Data on 74 trailer loads of finishing pigs (mean BW = 129.0, SEM = 0.63 kg) from wean-to-finish buildings on 2 farms within 1 production system were collected to investigate the effect of amount of floor space on the trailer (0.39 or 0.48 m2/pig) during transport on the incidence of losses (dead and nonambulatory pigs) at the packing plant and to study the relationships between transport conditions and losses. Pigs were loaded using standard commercial procedures for pig handling and transportation. Two designs of flat-deck trailers with 2 decks were used. Floor space treatments were compared in 2 similarly sized compartments on each deck of each trailer type. Differences in floor space were created by varying the number of pigs in each compartment. The incidence of nonambulatory pigs at the farm during loading and at the plant after unloading, average load weight, load number within each day, event times, and temperature and relative humidity in the trailer from loading to unloading were recorded. Of the 12,511 pigs transported, 0.26% were non-ambulatory at the farm, 0.23% were dead on arrival, and 0.85% were nonambulatory at the plant. Increasing transport floor space from 0.39 to 0.48 m2/pig reduced the percentage of total nonambulatory pigs (0.62 vs. 0.27 +/- 0.13%, respectively; P < 0.05), nonambulatory, noninjured pigs (0.52 vs. 0.15 +/- 0.11%, respectively; P < 0.01), and total losses (dead and nonambulatory pigs) at the plant (0.88 vs. 0.36 +/- 0.16%, respectively; P < 0.05) and tended to reduce dead pigs (0.27 vs. 0.08 +/- 0.08%, respectively; P = 0.06). However, transport floor space did not affect the percentage of nonambulatory, injured pigs at the plant. Nonambulatory pigs at the farm were positively correlated with relative humidity during loading and load number within the day (r = 0.46 and 0.25, respectively; P < 0.05). The percentage of total losses at the plant was positively correlated to waiting time at the plant, unloading time, and total time from loading to unloading (r = 0.24, 0.51, and 0.36, respectively; P < 0.05). Average temperature during loading, waiting at the farm, transport, waiting at the plant, unloading, and average pig weight on the trailer were not correlated to losses. These results suggest that floor space per pig on the trailer and transport conditions can affect transport losses.

[Changes in the concentration of noradrenaline and adrenaline before and after castration of piglets with and without isoflurane anesthesia]

Since the amendment of the animal welfare law in Germany in April 2006, castration of piglets without anesthesia is only allowed in the first seven days of life. However, neonates are capable of feeling pain and react more sensitive to pain than adults. Accordingly we expect that castration without anesthesia will be unaccepted in Germany in the future as castration without anesthesia will be forbidden in Switzerland from 2009 on. Denmark and The Netherlands strive for an embargo of the castration without anesthesia and Norway is already asking for an elimination of pain during castration. In Switzerland castration under isoflurane-anesthesia is considered to be a good alternative for the castration without anesthesia. Whether isoflurane-anesthesia is able to reduce stress caused by castration adequately or anesthesia, especially anesthetization that often provokes defensive reaction, is stress for the animal itself was tested in the following investigation. To get an objective statement about the stress of the animals, concentrations of epinephrine and norepinephrine were detected before and immediately after castration/fixation with or without anesthesia. Five day old, healthy animals were divided into four groups. Animals of group A (n = 10) were only fixed without anesthesia, animals of group B (n = 10) were fixed and castrated without anesthesia. In group C (n = 10) the animals were only fixed under anesthesia and the animals of group D (n = 11) were fixed and castrated under anesthesia. Norepinephrine-concentrations and epinephrine-concentrations did rise significantly in all piglets handled without anesthesia (group A and B) independently if castrated or only handled. The values of these animals were significantly higher than the values of the anesthetized animals after fixation/castration (group C and D). In contrast the norepinephrine-concentrations and the epinephrine-concentrations of all anesthetized animals (group C and D) were significantly lower after castration than the concentrations before castration. The catecholamine peak did not differ significantly between the groups of anesthetized animals. The significant increase of the catecholamines of the non-anesthetized animals can be explained by the stress caused by fixation and/or castration without anesthesia. Because of the anesthesia the catecholamine-concentration was reduced considerably during the fixation and/or castration. The results show that fixation and/or castration under anesthesia causes no stress for the piglets.

Stress responses in adult cattle due to surgical dehorning using three different types of anaesthesia

Dehorning adult cattle is a surgical procedure causing distress of varying intensities that can be reflected in behavioural changes and alterations in plasma cortisol levels. Stress responses during the dehorning process were evaluated in 18 Red Pied cows. The cows were divided into 3 groups of six and kept in tie-stall housing. Those in the first group were dehorned under general anaesthesia (GA) induced by intravenous administration of xylazine and ketamine. The second group was dehorned under sedation and local anaesthesia (SLA) induced by intramuscular administration of xylazine and local anaesthesia with lidocaine. The third group was dehorned under local anaesthesia (LA) with lidocaine. Dehorning was performed with a foetotomy wire. Blood samples were taken 0.5 h before dehorning to determine cortisol levels, and, by means of a central venous catheter inserted into the jugular vein, during surgery at 0, 0.5, 1, 1.5, 2, 2.5, 3, 3.5, 4, 5, 6, 7 and 8 h post-surgery. Concurrently, occurrence of stress behaviours was assessed. Cortisol levels were measured by enzyme immunoassay (EIA). The lowest mean peak levels of plasma cortisol (82.53 +/- 6.04 nmol l(-1)), the most rapid return of plasma cortisol levels to baseline values (1.92 +/- 1.11 h), and the lowest occurrence of stress behaviours (2.38 +/- 5.83%) were noted in the SLA group. The highest mean peak levels plasma cortisol (113.86 +/- 25.65 nmol l(-1)), the slowest return of plasma cortisol levels to baseline values (3.83 +/- 2.18 h) and the most frequent occurrence of stress behaviours (65.48 +/- 28.72%) were observed in the LA group. There were significant differences between the SLA and LA groups in peak plasma cortisol levels (p = 0.011) and in occurrence of stress behaviours (p = 0.003). Sedation induced by intramuscular administration of xylazine in conjunction with local anaesthesia with lidocaine is considered the most suitable method of anaesthesia when dehorning adult cattle. Local anaesthesia with lidocaine alone was least suitable.

Effects of a concentrated lidocaine solution on the acute phase stress response to dehorning in dairy calves

The objective of this study was to more fully define the surgical stress response to dehorning by heat cauterization in dairy calves by measuring behavioral, hormonal, inflammatory, and immunological markers of stress and to determine whether a nerve block of the surgical site with a concentrated solution of lidocaine (5%) reduces the degree of stress. Thirty-two 10- to 12-wk-old female Holstein calves were randomly allotted to 1 of 4 treatments: 5% lidocaine followed by dehorning, 2% lidocaine followed by dehorning, saline followed by dehorning, or 5% lidocaine followed by sham dehorning. Plasma cortisol concentration was measured in blood samples collected via a jugular catheter at -0.5, 0, 0.5, 1, 1.5, 2, 2.5, 3, 3.5, 4, 6, 9, 12, 24, 48, and 72 h. Various other blood constituents were measured in samples collected at -0.5, 12, 24, 48, and 72 h. Feeding, drinking, scratching, grooming, rubbing, licking, and inactivity behaviors were observed in the standing and recumbent positions using a 10-min scan sampling method analyzed on a time period and daily basis for 72 h following the dehorning procedure. The frequency of vocalization, kicking, and lying in the chute during the dehorning procedure were also assessed. The overall plasma cortisol concentrations were higher in calves subjected to dehorning than in control calves. Compared with the control group, the saline-treated calves had a higher cortisol concentration at 30 and 60 min postdehorning. Plasma cortisol concentrations were higher in all groups at 30 min postdehorning than at other sampling times. The percentage of circulating neutrophils and the neutrophil:lymphocyte ratio were increased in the saline and 2% lidocaine group. Total plasma protein, fibrinogen, and alpha1-acid glycoprotein concentrations were similar among treatments. The behavioral response to dehorning, as manifested by kicking while in the chute, was greater in the saline and 2% lidocaine group than in the control or 5% lidocaine treatment groups. In the postdehorning period, the percentage of time calves spent performing various maintenance behaviors did not differ among treatments. Thus, injection of 5% lidocaine may not provide any added comfort after the dehorning but may decrease the overall stress response during the procedure.

Influence of supplemental magnesium, tryptophan, vitamin C, and vitamin E on stress responses of pigs to vibration

Our objectives were to investigate and compare the effects of supplemental Mg, Trp, vitamin E (vit E), and vitamin C (vit C) on stress responses of pigs undergoing transport simulation. In this study, 126 pigs (25.1 +/- 4.4 kg BW) were allocated to one of the six following treatments: 1) negative control (no supplementation); 2) positive control (i.m. injection with 0.5 mg of carazolol/20 kg BW 12 h before vibration, beta-blocker); 3) Trp (additional amount of 6 g/kg of feed for 5 d, as-fed basis); 4) Mg (3 g/L drinking water for 2 d); 5) vit E (additional amount of 150 mg/kg of feed for 21 d, as-fed basis); 6) or vit C (additional amount of 300 mg/kg of feed for 21 d, as-fed basis). Pigs were treated in groups of three, and each treatment was replicated seven times. Feed and water intake were not different among treatments. Heart rate variables (mean, peak, and minimum heart rate, ventricular ectopic beats, and ST elevation of Channels A and B) and heart rate variability were registered from the night before vibration. Pigs were subjected to vibration in a transport simulator (8 Hz, 3 m/s) for 2 h and allowed to recover for 2 h. Generally, the positive control pigs had the lowest heart rate values (mean, peak, minimum heart rate, ST elevation of Channel A; P < 0.05), whereas Mg and Trp decreased ventricular ectopic beats and ST elevation of Channel B, respectively. The effect of vit C and E as vagal stimulators was clearly visible, whereas carazolol and Mg clearly blocked the sympathetic pathways of the autonomic nervous system. During vibration, the negative control pigs lay the least, and Mg pigs the most (P < 0.05). Salivary cortisol concentrations (taken before and after vibration and after recovery) showed that vit E pigs produced the least cortisol during stress periods. Intermediary metabolites (glucose, lactate, creatine kinase, and NEFA) were analyzed in plasma from blood taken before and after vibration. At the two sampling points, the vit E and Mg pigs had the lowest NEFA concentrations (P < 0.05), and the vit E pigs also had the lowest lactate concentrations before vibration. Urine samples were collected before and after vibration to determine catecholamine concentrations; only negative control pigs had an increase (P = 0.04) in epinephrine concentration, despite large individual variation. In general, these results indicate that the supplementation of Trp, Mg, vit E, or vit C improved coping ability of pigs during vibration comparison with the negative control treatment. A muscular injection of carazolol influenced only the heart rate variables.

Changes in a surgical stress index in response to standardized pain stimuli during propofol–remifentanil infusion

BACKGROUND

The surgical stress index (SSI) is based on a sum of the normalized pulse beat interval (PBI) and the pulse wave amplitude (PPGA) time series of the photoplethysmography. As a measure of the nociception-anti-nociception balance in response to a standardized pain stimulus, SSI was compared with EEG changes in state and response entropy (SE and RE), PPGA, and heart rate (HR) during various targeted pseudo-steady-state concentrations of propofol and remifentanil.

METHODS

Forty ASA I patients were allocated to one of the four groups to receive a remifentanil step-up/-down effect-compartment target-controlled infusion (Ce(remi)) of 0, 2, 6, 2, 0 ng ml(-1), or 6, 2, 0, 2, 6 ng ml(-1), and an effect-compartment target-controlled propofol infusion (Ce(prop)) to keep the SE between 30 and 50 or 15 and 30, respectively. At each steady-state Ce(remi), maximum change in SSI, SE, RE, PPGA, and HR after a noxious stimulus was compared with the baseline value. A correlation and prediction probability (P(K)) with Ce(prop) and Ce(remi) was measured.

RESULTS

Static and dynamic values of SSI correlated to Ce(remi) better than SE, RE, HR, and PPGA. SSI was independent of Ce(prop), in contrast to SE and RE. The P(K) for Ce(remi) both before and during a noxious stimulus was better with SSI.

CONCLUSIONS

SSI appeared to be a better measure of nociception-anti-nociception balance than SE, RE, HR, or PPGA.

Methylphenidate administration to juvenile rats alters brain areas involved in cognition, motivated behaviors, appetite, and stress

Thousands of children receive methylphenidate (MPH; Ritalin) for attention deficit/hyperactivity disorder (ADHD), yet the long-term neurochemical consequences of MPH treatment are unknown. To mimic clinical Ritalin treatment in children, male rats were injected with MPH (5 mg/kg) or vehicle twice daily from postnatal day 7 (PND7)-PND35. At the end of administration (PND35) or in adulthood (PND135), brain sections from littermate pairs were immunocytochemically labeled for neurotransmitters and cytological markers in 16 regions implicated in MPH effects and/or ADHD etiology. At PND35, the medial prefrontal cortex (mPFC) of rats given MPH showed 55% greater immunoreactivity (-ir) for the catecholamine marker tyrosine hydroxylase (TH), 60% more Nissl-stained cells, and 40% less norepinephrine transporter (NET)-ir density. In hippocampal dentate gyrus, MPH-receiving rats showed a 51% decrease in NET-ir density and a 61% expanded distribution of the new-cell marker PSA-NCAM (polysialylated form of neural cell adhesion molecule). In medial striatum, TH-ir decreased by 21%, and in hypothalamus neuropeptide Y-ir increased by 10% in MPH-exposed rats. At PND135, MPH-exposed rats exhibited decreased anxiety in the elevated plus-maze and a trend for decreased TH-ir in the mPFC. Neither PND35 nor PND135 rats showed major structural differences with MPH exposure. These findings suggest that developmental exposure to high therapeutic doses of MPH has short-term effects on select neurotransmitters in brain regions involved in motivated behaviors, cognition, appetite, and stress. Although the observed neuroanatomical changes largely resolve with time, chronic modulation of young brains with MPH may exert effects on brain neurochemistry that modify some behaviors even in adulthood.

The effect on ecological systems of remediation to protect human health

Environmental remediation of contaminated eco-systems reduces stresses to these ecosystems, including stresses caused by the production, use, and storage of weapons of mass destruction. The effects of these various stressors on humans can be reduced by remediation or by blocking the exposure of humans, but blocking the exposure of resident biota is almost impossible. Remediation may involve trade-offs between reducing a minor risk to public health and increasing risks to workers and ecosystems. Remediation practices such as soil removal disrupt ecosystems, which take decades to recover. Without further human disturbances, and with low levels of exposure to stress-ors, ecosystems can recover from physical disruptions and spills. Remediation to remove negligible risk to humans can destroy delicate ecosystems for very little gain in public health.

Chronic stress: implications for neuronal morphology, function and neurogenesis

In normal life, organisms are repeatedly exposed to brief periods of stress, most of which can be controlled and adequately dealt with. The presently available data indicate that such brief periods of stress have little influence on the shape of neurons or adult neurogenesis, yet change the physiological function of cells in two time-domains. Shortly after stress excitability in limbic areas is rapidly enhanced, but also in brainstem neurons which produce catecholamines; collectively, during this phase the stress hormones promote focused attention, alertness, vigilance and the initial steps in encoding of information linked to the event. Later on, when the hormone concentrations are back to their pre-stress level, gene-mediated actions by corticosteroids reverse and normalize the enhanced excitability, an adaptive response meant to curtail defense reactions against stressors and to enable further storage of relevant information. When stress is experienced repetitively in an uncontrollable and unpredictable manner, a cascade of processes in brain is started which eventually leads to profound, region-specific alterations in dendrite and spine morphology, to suppression of adult neurogenesis and to inappropriate functional responses to a brief stress exposure including a sensitized activation phase and inadequate normalization of brain activity. Although various compounds can effectively prevent these cellular changes by chronic stress, the exact mechanism by which the effects are accomplished is poorly understood. One of the challenges for future research is to link the cellular changes seen in animal models for chronic stress to behavioral effects and to understand the risks they can impose on humans for the precipitation of stress-related disorders.

Surgery as a risk factor for breast cancer recurrence and metastasis: mediating mechanisms and clinical prophylactic approaches

Surgical resection of the primary tumor is a necessary and effective treatment for breast cancer patients. For various reasons discussed, we believe that the short postoperative period is critical for eliminating minimal residual disease (MRD), thus markedly impacting long term survival. Unfortunately, both animal and human studies have shown that surgery induces suppression of anti-metastatic cell-mediated immunity (CMI) at this critical period, which is suggested to worsen patients' prognosis. In this review we examine different aspects of the surgical procedure that cause immunosuppression (e.g., anesthesia and tissue damage), discuss their mediating humoral and cellular mechanisms, and suggest prophylactic interventions feasible in cancer patients to avoid postoperative suppression of CMI. The use of the suggested interventions has been shown to significantly reduce postoperative metastasis in animal models, including mammary adenocarcinoma, and initial data suggest similar efficacy in breast cancer patients. We believe that our recommended prophylactic interventions can easily be applied by health-care practitioners and hold promise in reducing long-term recurrence and metastasis in cancer patients.

Examination of KNK437- and quercetin-mediated inhibition of heat shock-induced heat shock protein gene expression in Xenopus laevis cultured cells

We examined the effect of quercetin (3,3',4',5,7-pentahydroxyflavon) and KNK437 (N-formyl-3,4-methylenedioxy-benzylidene-gamma-butyrolactam), a benzylidene lactam compound, on heat-induced heat shock protein (hsp) gene expression in Xenopus laevis A6 kidney epithelial cells. In previous studies, both quercetin and KNK437 inhibited heat shock factor activity resulting in a repression of hsp mRNA and protein accumulation in human cultured cells. In this first study of the effect of these hsp gene expression inhibitors in a non-mammalian cell line, we report that both quercetin and KNK437 reduced the heat shock-induced accumulation of hsp30, hsp47 and hsp70 mRNA in X. laevis cultured cells. However, these inhibitors had no effect on the relative level of a non-heat shock protein mRNA, ef1alpha, in either control or heat shocked cells. Western blot and immunocytochemical analyses revealed that quercetin partially inhibited HSP30 protein accumulation. In contrast, HSP30 protein was not detectable in KNK437-treated cells. Finally, treatment of A6 cells with KNK437 inhibited the heat shock-induced acquisition of thermotolerance, as determined by preservation of actin filaments and cellular morphology using immunocytochemistry and laser scanning confocal microscopy.

Postconflict third-party affiliation in rooks, Corvus frugilegus

Conflict features in the lives of many animal species and induces social stress mediated by glucocorticoid hormones [1]. Postconflict affiliation, between former opponents (reconciliation) or between former opponents and a bystander (third-party affiliation), has been suggested as a behavioral mechanism for reducing such stress [2], but has been studied almost exclusively in primates [3]. As with many primates, several bird species live in social groups and form affiliative relationships [4]. Do these distantly related animals also use affiliative behavior to offset the costs of conflict? We studied postconflict affiliation in a captive group of rooks. Unlike polygamous primates, monogamous rooks did not reconcile with former opponents. However, we found clear evidence of third-party affiliation after conflicts. Both initiators and targets of aggression engaged in third-party affiliation with a social partner and employed a specific behavior, bill twining, during the postconflict period. Both former aggressors and uninvolved third parties initiated affiliative contacts. Despite the long history of evolutionary divergence, the pattern of third-party affiliation in rooks is strikingly similar to that observed in tolerant primate species. Furthermore, the absence of reconciliation in rooks makes sense in light of the species differences in social systems.

Cardiovascular consequences of high-performance aircraft maneuvers: implications for effective countermeasures and laboratory-based simulations

The gravitational stress encountered by pilots of high-performance aircraft can cause dramatic shifts in blood volume and circulatory pressure, thus placing the cardiovascular system under significant stress, sometimes resulting in loss of consciousness due to cerebral under-perfusion. Since pilots experience both increased and decreased gravitational stress in high-risk environments, it is important not only to examine the cardiovascular effects of altered gravitational exposure, but also to create effective countermeasures that will increase pilot safety. In this review, we discuss the cardiovascular consequences of rapid changes in gravitational forces. We also examine the effectiveness of the countermeasures that have been developed to combat gravity-induced loss of consciousness. Finally, we examine those current laboratory-based techniques that simulate hyper-gravity and the "push-pull effect"; making it possible to investigate the cardiovascular mechanisms responsible for maintaining cerebral perfusion and consciousness.

A field test of a web-based workplace health promotion program to improve dietary practices, reduce stress, and increase physical activity: randomized controlled trial

BACKGROUND

Most work sites engage in some form of health promotion programming designed to improve worker health and reduce health care costs. Although these programs have typically been delivered through combinations of seminars and print materials, workplace health promotion programs are increasingly being delivered through the Internet.

OBJECTIVE

The purpose of this research was to evaluate the effectiveness of a Web-based multimedia health promotion program for the workplace, designed to improve dietary practices, reduce stress, and increase physical activity.

METHODS

Using a randomized controlled trial design with pretest-posttest comparisons within each group, 419 employees of a human resources company were randomly assigned to the Web-based condition or to a condition that provided print materials on the same topics. All subjects were assessed at pretest and posttest through an online questionnaire containing multiple measures of health behavior and attitudes. The test period was 3 months. Questionnaire data were analyzed mainly by analysis of covariance and t tests.

RESULTS

Retention rates were good for both groups-85% for the Web-based group and 87% for the print group. Subjects using the Web-based program performed significantly better than the print group on Attitudes Toward a Healthful Diet (F(1,415) = 7.104, P = .008) and Dietary Stage of Change (F(1,408) = 6.487, P = .01), but there were no significant group differences on the five other dietary measures. Both groups also showed improvement from pretest to posttest on most dietary measures, as indicated by significant t tests. Within the Web-based group, dosage analyses showed significant effects of the number of times the subject accessed the program on measures of Dietary Self-Efficacy (F(2,203) = 5.270, P = .003), Attitudes Toward a Healthful Diet (F(2,204) = 2.585, P = .045), and Dietary Stage of Change (F(2,200) = 4.627, P = .005). No significant differences were found between the two groups on measures of stress or physical activity, although t tests of pretest-posttest changes indicated that both groups improved on several of these measures. The Web-based group gave significantly higher ratings to the program materials than the print group on all health topics and in their overall evaluation (F(1,410) = 9.808, P = .002).

CONCLUSIONS

The Web-based program was more effective than print materials in producing improvements in the areas of diet and nutrition but was not more effective in reducing stress or increasing physical activity. The higher ratings given to the Web-based program suggest that workers preferred it to the print materials. Both groups showed numerous pretest-posttest improvements in all health topics, although such improvements might be attributable in part to a Hawthorne effect. Results suggest that a multimedia Web-based program can be a promising means of delivering health promotion material to the workforce, particularly in the area of diet and nutrition.

[Gender and stress]

Stress is an independent risk factor for developing e.g. heart diseases and depression. There are marked gender differences which need to be examined in depth. Some of the explanation seems to be related to the traditional pattern of gender roles--men as breadwinners and women with responsibility for the family as well as paid work in addition to housework. But gender differences in biological factors also seem to play an important role in chronic stress and stress-related diseases. We need to know more about gender differences, but we can already incorporate the known ones in the prevention of stress-related disorders.

[Endoplasmic reticulum stress and metallothionein]

Much attention has been paid to lifestyle-related diseases including type 2 diabetes mellitus, cardiovascular disease, hypertension, and hyperlipidemia because the incidence rates of these diseases are increasing in developed countries. Elucidation of factors contributing to the development of obesity and insulin resistance is needed. Metallothionein (MT), a ubiquitous metal-binding protein, is induced not only by heavy metals but also by various kinds of stresses. Endoplasmic reticulum (ER) stress is caused by accumulation of misfolded proteins in ER. Recently, increased ER stress by obesity and impairment of insulin action by ER stress have been reported. Exposure to ER stress increased induction of MT synthesis, and an enhanced response to ER stress evaluated as expression of Bip/GRP78mRNA was observed in the liver of MT-null mice, suggesting that MT attenuates expression of ER stress. MT may prevent ER stress and thereby modulate the development of obesity and insulin resistance. A possible role of metallothionein in response reaction for ER stress is discussed.

A Pilot Study to Test the Effects of Art-Making Classes for Family Caregivers of Patients With Cancer

PURPOSE/OBJECTIVES

To test the effects of an art-making class (AMC) on reducing anxiety and stress among family caregivers of patients with cancer.

DESIGN

A pretest and post-test quasi-experimental design.

SETTING

A residential care facility near tertiary treatment centers in the southeastern United States.

SAMPLE

The convenience sample of 69 family caregivers was aged 18-81 years (X = 48 years) and predominantly Catholic. Most had at least a high school education. Two-thirds were daughters, wives, or mothers of patients with cancer.

METHODS

Participants completed a demographic data survey and a Beck Anxiety Inventory (BAI). Researchers collected a saliva sample from each participant to measure salivary cortisol, which indicates stress levels. Following pretesting, a two-hour AMC was delivered. Post-tests included a repeat BAI and a second saliva sample.

MAIN RESEARCH VARIABLES

Anxiety and stress.

FINDINGS

Anxiety was significantly reduced after AMC. Stress was reduced.

CONCLUSIONS

The AMC appeared to reduce anxiety and stress. The addition of a control group and replication with larger numbers are suggested. The physiologic cortisol measure corroborated BAI findings but was difficult to obtain from some cultural groups and was expensive to analyze.

IMPLICATIONS FOR NURSING

Family caregivers may benefit from participation in art-making interventions. Nurses should continue to investigate the use of creative approaches to promote holistic care.

[Effect of different doses of sufentanil on stress responses to tracheal intubation in patients undergoing heart valve replacement surgery]

OBJECTIVE

To determine the effect of different doses of sufentanil on stress responses to tracheal intubation in patients undergoing heart valve replacement surgery.

METHODS

Sixty patients undergoing heart valve replacement surgery were randomly divided into 4 groups (n=15). Before the tracheal intubation, patients received 10microg/kg fentanyl (Group A), 1microg/kg sufentanil (Group B ), 1.5micro/kg sufentanil (Group C), and 1.5microg/kg sufentanil (Group D), respectively, with midazolum and vecuronium intravenous injection. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (HR) were recorded before the induction of anesthesia(T(0)), after the induction of anesthesia(T(1)), and at 1(T(2)), 3(T(3)), 5(T(4)), and 10 min after the tracheal intubation(T(5)). Rate-pressure product was derived from SBP and HR. Blood sugar was monitored at T(0), T(2) and T5.

RESULTS

The SBP,DBP,MAP, HR and RPP at T(0) were not significantly different among the 4 groups (P>0.05). These parameters at T(1) were significantly lower than those at T(0) (P<0.01), but there was not significant difference among the 4 groups. The SBP, DBP, MAP in Group A increased significantly at T(2) and T(3) than those at T(1)(P<0.01 approximately 0.05), but were not significantly different than those at T(0)(P>0.05). The SBP,MAP in Group B,C,D at T(2) and T(3) were significantly lower than those in Group A (P<0.01 approximately 0.05 ). The SBP and MAP in Group D at T(4) were still lower than those in Group A (P<0.05). The HR at T(2) in Group A increased compared with that at T(1)(P<0.05),but was still lower than that at T(0). The HR at T(2) in Group B, C, and D was not significantly changed. The HR decreased significantly at T(2) in Group D compared with that in Group A(P<0.05), and the HR at T5 in Group A and D significantly decreased compared with that in Group B(P<0.05). The RPP at T(1) to T5 in Group B, C, and D significantly decreased compared with that at T(0)(P<0.01). The RPP at T(2) in Group A increased significantly compared with those in Group B, C, and D(P<0.01). The cases of using atropine during the induction and intubation in Group A,B,C, and D were 5(33.3%),0(0%),4(26.7%),5(33.3%),respectively, and the cases in Group B were significantly different compared with those in Group A and D(P<0.05). The change of blood sugar in Group A,B,C, and D was not significantly different(P>0.05).

CONCLUSION

Three doses of sufentanil may effectively control the stress responses to the tracheal intubation in patients undergoing heart valve replacement surgery, and the hemodynamics during the intubation at 1microg/kg is much more stable.

Hypertension Intervention Nurse Telemedicine Study (HINTS): testing a multifactorial tailored behavioral/educational and a medication management intervention for blood pressure control

BACKGROUND

Only 31% of Americans with hypertension have their blood pressure (BP) under effective control. We describe a study that tests 3 different interventions in a randomized controlled trial using home BP telemedicine monitoring.

METHODS

A sample of hypertensive patients with poor BP control at baseline (N = 600) are randomized to 1 of 4 arms: (1) control group--a group of hypertensive patients who receive usual care; (2) nurse-administered tailored behavioral intervention; (3) nurse-administered medication management according to a hypertension decision support system; (4) combination of the 2 interventions. The interventions are triggered based on home BP values transmitted via telemonitoring devices over standard telephone lines. The tailored behavioral intervention involves promoting adherence with medication and health behaviors. Patients randomized to the medication management or the combined arm have their hypertension regimen changed by the study team using a validated hypertension decision support system based on evidence-based hypertension treatment guidelines and individualized to patients' comorbid illnesses. The primary outcome is BP control: < or = 140/90 mm Hg (nondiabetic) and < or = 130/80 mm Hg (diabetics) measured at 6-month intervals over 18 months (4 total measurements).

CONCLUSIONS

Given the increasing prevalence of hypertension and our inability to achieve adequate BP control using traditional models of care, testing novel interventions in patients' homes may improve access, quality, and outcomes.

Vaticanol B, a resveratrol tetramer, regulates endoplasmic reticulum stress and inflammation

Enhanced endoplasmic reticulum (ER) stress has been implicated in various pathological situations including inflammation. During a search for compounds that regulate ER stress, we identified vaticanol B, a tetramer of resveratrol, as an agent that protects against ER stress-induced cell death. Vaticanol B suppressed the induction of unfolded protein response-targeted genes such as glucose-regulated protein 78 (GRP78) and C/EBP-homologous protein (CHOP) after cells were treated with ER stressors. Analysis in the mouse macrophage cell line RAW 264.7 revealed that vaticanol B also possesses a strong anti-inflammatory activity. Production of a variety of inflammatory modulators such as tumor necrosis factor-alpha, nitric oxide, and prostaglandin E(2) was inhibited by vaticanol B to a much greater extent than by monomeric or dimeric resveratrol after exposure of cells to lipopolysaccharide. Further investigations to determine the common mechanisms underlying the regulation of ER stress and inflammation by vaticanol B disclosed an important role for vaticanol B in regulation of basic gene expression and in prevention of the protein leakage from the ER into the cytosol in both conditions. These results suggest that vaticanol B is a novel anti-inflammatory agent that improves the ER environment by reducing the protein load on the ER and by maintaining the membrane integrity of the ER.

Use of a low-concentration heparin solution to extend the life of central venous catheters in African green monkeys (Chlorocebus aethiops)

Normal hematologic values for African green monkeys have been reported, but these results are confounded by the effect of chemical restraint (for example, ketamine), physical restraint, and capture stress. The dual-lumen central venous catheter, jacket, and tether combination we describe here allows intravenous fluid administration and repeated blood sampling without the use of anesthesia or inducing capture-related stress. The use of a low-concentration heparin solution for catheter maintenance significantly increased the mean patency time, compared with a saline-only catheter flush solution. Adding a low-concentration heparin solution creates a suitable system for serial blood collection in the African green monkey for as long as 25 d.

A comparison of paracetamol, ibuprofen or their combination for pain relief following extractions in children under general anaesthesia: a randomized controlled trial

OBJECTIVE

This study was designed to compare the effectiveness of different oral analgesics for relieving pain and distress in children following the extraction of teeth under general anaesthesia (GA). The analgesics included paracetamol alone, ibuprofen alone, and paracetamol and ibuprofen in combination.

METHODS

Two hundred and one subjects were randomly allocated to one of four groups. Forty-seven children were included in the ibuprofen alone (5 mg kg(-1)) group, 51 in the paracetamol/ibuprofen combination (15/5 mg kg(-1)) group, 48 in the high-dose paracetamol (20 mg kg(-1)) group, and 55 children were included in the usual-dose paracetamol (15 mg kg(-1)) group (control group). Evaluation of distress for children was made immediately pre-operatively, on recovery from anaesthesia and again after 15 min by using a five-point face scale. Furthermore, each child was observed immediately postoperatively and 15 min postoperatively for signs of pain using the Children's Hospital of Eastern Ontario Pain Scale.

RESULTS

There were significant decreases in the mean pain and distress scores for both the ibuprofen alone and paracetamol/ibuprofen combination groups compared to the control group (usual-dose paracetamol) at 15 min postoperatively.

CONCLUSIONS

This study provides evidence to support the oral administration of ibuprofen alone or in combination with paracetamol for postoperative analgesia in children who are having teeth extracted under GA.

The effects of an intensive lifestyle modification program on sleep and stress disorders

BACKGROUND

To determine if a lifestyle change program can modify behavior to reduce sleep and stress disorders.

METHODS

Analyses are based on 2,624 individuals aged 30 to 80 years from the Rockford, Illinois metropolitan area who completed a lifestyle evaluation at baseline and again after four weeks, following participation in a 40-hour educational course given over a four-week period. Participants receive instruction on the importance of making better lifestyle choices related to making long-term improvements in nutrition and physical activity and they learn ways to improve sleep and reduce stress in their lives.

RESULTS

Significant percent decreases were observed in the number experiencing selected sleep or stress disorders from baseline to four weeks later for "sleeps restlessly" (-59%), "suffers from insomnia" (-64%), "feels under pressure" (-37%), "easily emotionally upset" (-52%), and "feels fearful or depressed" (-61%). Experiencing a selected sleep or stress disorder after four weeks among those who had the disorder at baseline was significantly more likely in those not physically active and/or not having lowered their BMI after four weeks. Changes in alcohol consumption and smoking did not significantly contribute to changes in the disorders. Those who failed to lower their coffee/tea use after four weeks were significantly more likely to have a sleep disorder and be easily emotionally upset.

CONCLUSIONS

Changes in lifestyle behaviors after attending an educational program significantly reduced sleep and stress disorders in as little as four weeks, primarily explained by decreasing BMI and/or increasing exercise.

Consumer perceptions of nutrition and health claims

The number of food products containing extra or reduced levels of specific ingredients (e.g. extra calcium) that bring particular health benefits (e.g. stronger bones) is still increasing. Nutrition- and health-related (NH) claims promoting these ingredient levels and their health benefit differ in terms of the (legal) strength with which the claim is brought forward and the specific wording of the claim, both of which may differ between countries. Using a large-scale cross-national internet-based survey in Italy (n=1566), Germany (n=1620), UK (n=1560) and US (n=1621), the purpose of the study described here is to investigate consumer perceptions of NH food product claims, across different countries. NH claims are systematically varied as a function of six health benefits (cardiovascular disease, stress, infections, fatigue, overweight and concentration) and five claim types (content, structure-function, product, disease-risk reduction and marketing claim). The general results indicate that consumer perceptions differ substantially by country and benefit being claimed but much less by the claim type. Implications of these findings are being discussed.

[Nitric oxide is involved in the protective effects of short-term adaptaion to hypoxia in the course of stress-induced disorders in Krushinsky-Molodkina rats]

A possible involvement of nitric oxide in the protective effect of short-term adaptation of Krushinsky-Molodkina rats to mild hypoxia simulating 5000 m above sea level was studied. Nitric oxide proved to have a considerable protective effect on stress-induced disorders in Krushinsky-Molodkina rats as demonstrated using NO-synthase inhibitors and NO monitoring by electron spin resonance under different experimental conditions.

Stress, mental health, and cognition: a brief review of relationships and countermeasures

Today's network-centric battlefield environment is highly stressful and cognitively demanding. Many warfighters are feeling overwhelmed and end up being medically evacuated from theater due to mental health problems [i.e., post traumatic stress disorder (PTSD) and depression]. Of a sample of troops evacuated for psychiatric reasons, 21% (106 out of 509) had psychiatric histories prior to deploying to the theater of operations. Most cases were either related to stress (i.e., PTSD, n - 33, 310%) or to depression (n = 72, 66%). Stress disorders and depression predominate among the psychiatric causes for medical evacuation. This review paper discusses stress theories as they pertain to warfighting, the types of stress and stress disorders most prevalent on modern battlefields, the relationships among stress, psychiatric disease, and cognitive performance, and potential methods to decrease some types of stress-related acute and chronic disorders (i.e., virtual-reality stress inoculation training).

Enteral resuscitation and early enteral feeding in children with major burns--effect on McFarlane response to stress

AIM

Early enteral feeding has become standard practice for burned patients. The aim of this study was to determine whether early enteral feeding could be used as an avenue for resuscitation and feeding and the effect it would have on the induction/amelioration of the hormonal stress response.

METHOD

Eighteen children with <20% TBSA were randomly assigned to either early enteral feeding and resuscitation, or intravenous resuscitation with the induction of enteral feeding delayed. The enteral fluid volume was incrementally increased every 3h with a simultaneous equal reduction in the intravenous volume until all the calculated intravenous fluid requirements for resuscitation and maintenance could be administered enterally. In the second group, intravenous resuscitation continued for 48 h when enteral feeding was introduced. Parameters measured were the clinical responses and outcome as well as the concentrations of insulin, insulin-like growth factor 1, glucagon, cortisone and growth hormone. The estimated and calculated energy expenditure was measured calorimetrically and bowel permeability was assessed using a dual sugar absorption test.

RESULTS

Three children were excluded from the study because of early death from organ failure or carbon monoxide poisoning. Early enteral resuscitation and feeding (ER/EEF) was initiated within a median of 10.7h post-burn in nine children and late enteral feeding introduced on an average 54 h post-burn. The ER/EEF group showed an anabolic response with significantly higher insulin concentrations (p=0.008) and insulin: glucagon ratios (p=0.043). Although blood glucose concentrations were initially slightly elevated (EEF: 10.3g/l, LEF: 8.1g/l), they rapidly returned to within the normal range. The cortisol and IGF1 concentrations did not differ significantly between the two treatment groups. Growth hormone concentrations were significantly higher in the late enteral feeding (LEF) group (p=0.03). The estimated energy expenditure was not different amongst the groups. Small bowel permeability [lactulose:rhamnose (L:R) ratios] decreased significantly over time (p=0.02) in both study groups. No pulmonary aspiration was found. Diarrhoea in the ER/EEF settled quickly (2-4 days), whereas in the LEF group it persisted for longer than a week. The LEF group lost a median of 7.75% (acceptable range=<or=5%) of admission body weight, whereas the ER/EEF group lost a median of 3.01%. Patients in the LEF group required antibiotic treatment for a longer period (p=0.08) and their hospital stay was longer, though not significant.

CONCLUSIONS

Enteral resuscitation and early enteral feeding is a safe and effective method and particularly suited for children in developing countries. It resulted in the amelioration of the hormonal stress response and improved outcome. Enteral resuscitation should not be introduced in a patient in shock or with existing gastrointestinal disease. Complications were minimal.