Formulation of the purified fusion protein of respiratory syncytial virus with the saponin QS-21 induces protective immune responses in Balb/c mice that are similar to those generated by experimental infection.

The feasibility of employing a vaccine composed of the purified fraction 21 of Quillaja saponaria (QS-21) and the fusion (F) protein of respiratory syncytial virus (RSV) to induce protective immune responses in the lower respiratory tract of Balb/c mice was examined. Our goal was to compare local and systemic immune responses with those induced following immunization with the protein adsorbed to aluminium hydroxide (F/ALOH) adjuvant or by experimental infection. Sera from mice vaccinated with the QS-21 formulation (F/QS-21) contained elevated anti-F protein IgG antibody titres that were dependent on the dose of QS-21 employed. Similar to the immune responses generated by experimental infection, the sera from mice vaccinated with F/QS-21 possessed greater capacity to neutralize virus infectivity that was associated with the generation of heightened complement-fixing IgG2a antibody titres. In contrast, vaccination with F/ALOH elicited systemic immune responses that were characterized by a predominance of protein-specific antibodies of the IgG1 subclass and lower neutralizing antibody titres. The capacity of F/QS-21 to facilitate local pulmonary immune responses was also examined and found to be similar to those induced by experimental infection. After virus challenge, a 90-fold increase in the number of F protein-specific antibody-secreting cells was observed and associated with the clearance of virus from the infected lungs. Moreover, elevated levels of antigen-dependent killer cell activity were detected and appeared to be mediated by class I major histocompatibility complex restricted CD8+ T cells. Additional characterization of the pulmonary immune response was performed on the cellular infiltrates obtained after bronchoalveolar lavage and on formalin-fixed lung tissue. The local protective immune responses induced after challenge of the groups immunized with F/QS-21 or infectious virus were significantly different from those elicited in naive control mice injected with adjuvant alone, or in mice immunized with F/ALOH. The cellularity of the lavage fluids from the former groups was characterized by a significantly greater percentage of lymphocytes and less neutrophils. In similar fashion histological evaluation of the lungs from mice immunized with F/QS-21 or infectious virus revealed significantly elevated local immune responses after challenge. In conclusion, the results suggest that formulation with F/QS-21 alters the qualitative and quantitative nature of the immune response to the F glycoprotein when compared with the traditional aluminium-based adjuvants.

Acute/critical care nurses' knowledge of physical restraints--implications for staff development.

The use of physical restraints in acute care facilities has become a routine practice. Although nursing home settings have been federally mandated to reduce reliance on restraints, there has been no indication of a reduction in hospital settings. Staff development educators can provide guidance in the proper use of restraints. A total of 235 acute/critical care nurses from 17 states were asked to complete an 18-item knowledge questionnaire about the proper use and application of restraints. A majority (n = 142; 60.4%) had 13 of the 18 questions correct. The results suggest variability in knowledge about restraints due most likely from lack of information rather than misinformation. One hundred fifty-four nurses (65.6%) stated they were unsure about caring for a restrained patient. The authors describe implications of the study findings for nursing staff development and offer an outline for an inservice program on restraint use.

Growth factors alter neonatal type II alveolar epithelial cell proliferation.

The type II alveolar epithelial cell plays a critical role in the repair of lung injury by repopulating the entire damaged alveolar epithelium. We report our studies of the effects of known growth factors on the in vitro proliferation of isolated neonatal rabbit type II cells. Transforming growth factor-alpha (TGF-alpha) and epidermal growth factor (EGF) increased [3H]thymidine incorporation, cell number, and labeling index above control. Transforming growth factor-beta (TGF-beta) decreased [3H]thymidine incorporation, cell number, and labeling index compared with control. When added simultaneously, TGF-beta blocked the stimulatory effect of TGF-alpha or EGF. If TGF-alpha is added before TGF-beta, the ability of TGF-beta to block the mitogenic effect of TGF-alpha was diminished the later in time TGF-beta was added. If TGF-beta was added first, later addition of TGF-alpha had no effect. The current work demonstrates that specific growth factors, including some known to be produced by other lung cells, alter the proliferation in vitro of isolated neonatal rabbit type II alveolar epithelial cells.

Restrained patients: an important issue for critical care nursing.

OBJECTIVE: To determine practice and attitudes of acute-critical care nurses toward the use of physical restraints. DESIGN: Survey with a self-administered anonymous questionnaire. SUBJECTS: A self-selected sample of 235 acute-critical care nurses from 17 states who were enrolled in critical care review classes. MEASUREMENTS: Data were gathered by use of a questionnaire developed by the researchers. The questionnaire was designed to elicit information regarding demographic and professional characteristics, nursing practice, and attitudes toward the use of restraints. Nurses responded to the practice items on a three-point Likert Scale as to whether they "always," "sometimes," or "never" carried out the procedure. To obtain information on attitudes, nurses were asked to respond on a three-point Likert Scale as to whether they "agreed," were "undecided," or "disagreed" with the statement. RESULTS: Responses indicated 78% of the sample "always" try alternative nursing measures before restraining the patient. However, when units were believed to be understaffed there was more reliance on restraints. Thirty-eight percent of the sample would "always" rather sedate patients than physically restrain them. The overall score on the attitude component of the questionnaire reflected positive or acceptable attitudes toward the use of restraints. Most (62%) "agreed" that a patient suffers a loss of dignity when placed in restraints. Significant relationships did exist between select demographic and professional characteristics and practice and attitudes regarding the use of restraints. The longer the respondents had worked in critical care the more appropriate (positive) their attitudes toward the use of restraints (r = -.211, p < .01). CONCLUSIONS: In general, nursing practice and attitudes regarding the use of physical restraints indicated that respondents were using restraints in accordance with accepted practice. There is a need for additional research in this area, especially regarding the use of alternative measures to physical restraints.

Colloids vs crystalloids.

The choice of colloid or crystalloid solutions for resuscitation of a patient in shock remains controversial. Colloids quickly restore plasma volume along with stabilizing hemodynamics. Almost the entire volume is retained within the vascular space after 1 hour. However, only 8 percent of infused water and less than 25 percent of infused saline are retained in intravascular fluid compartments after 1 hour. When using crystalloids for resuscitation, two to four times as much fluid is required for fluid repletion. The very young or old or persons with cardiac or renal dysfunction may have an increased risk of developing pulmonary edema when crystalloids are administered.

Nutritional support for the shock patient.

In the past, patients were indescriminately fed until they began to gain weight; however, this should not be the philosophy today. With the specialized solutions and laboratory tests available today, precise tailoring of a patient's nutritional needs can be achieved. Nutritional support has been devised to maintain the energy, vitamins, and minerals necessary to supply amino acids for protein synthesis and to reduce the loss of amino acids from the periphery. Providing patients with early nutritional supplementation either by the parenteral or enteral route decreases the incidence of septic complications by improving overall nutritional status and maintaining immune competence and wound healing. Careful determination of the patient's nutritional needs and close monitoring during therapy are important nursing interventions. As the patient recovers from the shock state, the catabolic phase gradually gives way to an anabolic phase. There is a decrease in urinary nitrogen excretion that reflects a decrease in protein catabolism. The stress hormones of catabolism change to the growth hormones of anabolism. The state of convalescence can continue for weeks to months depending on the body protein and fat lost during the stressed state. As the nurse prepares to administer enteral or parenteral nutrition, a thorough assessment is obtained, including history of current illness, recent weight changes, and food allergies or intolerances. Solutions are administered according to institutional policies. Patients are evaluated to ensure that nutritional support is effective. Visceral protein status and fluid and electrolyte balances should improve. Nutritional support is not static, but requires ongoing assessment and reevaluation. The route, composition, and quantity of the formula are adjusted to meet the changing requirements of the patient.