Transplanted children's experiences of daily living: children's narratives about their lives following transplantation.

Transplantation is often an appropriate choice of treatment for children with end-stage renal, liver, heart or lung disease. Over the last decade, mortality and morbidity figures have been relatively stable and quality of life fairly good in children who have undergone organ transplantation. Few studies however, have focused on the experiences of transplantation from the child's perspective. The child's view is an important factor when evaluating the 'true' outcome and quality of life after transplantation. The aim of the present study was to illuminate the meaning of transplanted children's experiences of daily living. Unstructured interviews were carried out with 18 children and adolescents, aged 4-18 yr, who had undergone organ transplantation. Their narratives were transcribed and interpreted using a phenomenologic-hermeneutic method inspired by the philosophy of Ricoeur. Two main themes emerged: Being satisfied with life, with the themes: being able to live a normal life; someone who cares; coping with one's new life; and being dissatisfied with life, with the themes: not being able to live a normal life; lacking someone who cares; not being respected; existential thoughts. Most of the children and adolescents were of the opinion that they lived a normal life while the rest strived to achieve a normal life. Social support and mental support were of great importance and, when lacking, had negative consequences. Multi-disciplinary co-operation between healthcare professionals and between the healthcare system, the school and the family is crucial in order to optimize the outcome and quality of life after organ transplantation in children.

Pain threshold changes following acupuncture, measured with cutaneous argon laser and electrical tooth pulp stimulation, a comparative study.

1. The present study compared the argon laser technique for pain threshold measurements with the previously often used threshold measurements with electrical tooth pulp (TP) stimulation. 2. Conditioning stimuli with acupuncture was given since it previously has been shown to induce pain threshold changes. Acupuncture needles were inserted in the hands and arms and electrically stimulated. 3. The experiments were performed in a single blind fashion comparing pain threshold effects after either acupuncture or placebo. Pain threshold measurements with a method of limits were used with both electrical TP and the argon laser method. 4. In comparison to placebo the pain thresholds increased after acupuncture, both on the face and on the hand, with the argon laser method, while the TP thresholds were not influenced. No significant pain threshold change was detected with either the argon laser or the TP method following placebo treatment. 5. The results indicate that the argon laser used for sensory testing with a method of limits is a useful method for pain threshold measurements. The difference in pain threshold effects induced by acupuncture measured with the argon laser and the TP stimulation, are discussed and related to mechanisms that may differ between the two types of pain threshold measurements.

Pain threshold measurements with cutaneous argon laser, comparing a forced choice and a method of limits.

1. With the argon laser technique cutaneous nociceptors can be activated with high specificity and reproducibility making it a useful tool in psychophysical pain studies. This study was designed to examine and compare two different psychophysical methods combined with the argon laser technique. 2. Pain thresholds on different locations of the body and on different skin types were measured with (i) the method of limits and (ii) the forced choice method. 3. A significant correlation between the pain thresholds measured with the two different methods was detected on feet and hands. The method of limits yielded significantly higher pain thresholds in glabrous skin than hairy skin. Higher pain thresholds were also detected on the right side of the body. No statistically significant difference between sexes was found. A high reproducibility over time as well as in-between investigators was found for the method of limits. 4. Its concluded that the argon laser for pain threshold measurement with the method of limits is useful and preferred to the forced choice, since the method of limits is easier to perform and also less time consuming.

Does sympathetic nerve discharge affect the firing of polymodal C-fibre afferents in humans?

Experimental and clinical studies in animals and humans have indicated that nociceptive nerve fibres can acquire sensitivity to norepinephrine after injury or chemical sensitization. To evaluate the functional relevance of such sensitization, we recorded the activity of single polymodal C-fibre afferents in healthy human volunteers and investigated whether intense physiological sympatho-excitation could affect their firing properties. This was studied before and after chemical sensitization of receptive fields by topical application of mustard oil. All afferent C fibres investigated (11 units in 10 subjects) were mechano-heat-sensitive, and four of seven fibres subjected to mustard oil were also chemosensitive. Putative sensitivity to sympathetic stimulation was investigated during low-frequency (0.25 Hz) electrical stimulation of the unit receptive field at a threshold intensity sufficient to evoke an action potential in the afferent fibre after every second to third stimulus. Following a prolonged period of silent rest, sympathoexcitation was elicited by forced mental arithmetic for 60 s, again followed by a long silent rest period. During stress, sympathetic nerve traffic increased to 625 +/- 146% of the control level, while firing of the afferent units remained unchanged. There was no sign of sympathetically mediated direct activation of afferent units and no change in the relative amounts of afferent activations caused by the background electrical stimulation. Results were similar for all units, both before (seven units in six subjects) and after (seven units in seven subjects) chemical sensitization of their cutaneous receptive field. The results suggest that if chemical sensitization of nociceptive C afferent neurons with mustard oil does induce sensitivity to noradrenaline in humans, it is not sufficient to make C nociceptive fibres respond to short-lasting physiological variations in sympathetic outflow.

Materials emission of chemicals--PVC flooring materials.

Data of chemical emissions from flooring materials have been collected and investigated in a database known as METS. The emission tests are performed using the Field and Laboratory Emission Cell (FLEC). The emission rates of total volatile organic compounds (TVOC) in the boiling point range of hexane to octadecane varies from around 4,000 micrograms/(m2.h) to less than 10 micrograms/(m2.h). Results obtained 1994/95 are presented and compared with the results obtained in 1992 for similar materials. The tests are performed 4 weeks and 26 weeks after the manufacturing of the material. The emission rates of TVOC decrease on the average approximately 60% from 4 to 26 weeks. The differences and trends in emission rates of individual chemicals and their use are discussed. For many VOCs emission rates decrease rapidly and become near to or below 2 micrograms/(m2.h) (the detection limit) after 26 weeks. For a small number of individual compounds the emission rate decrease little over 26 weeks. A small number of chemicals are singled out for particular interest in a health and comfort evaluation based on the emission results.

Determinations of PCB within a project to develop cleanup methods for PCB-containing elastic sealant used in outdoor joints between concrete blocks in buildings.

Determinations of PCB were carried out as part of a project aimed at developing cleanup methods for PCB-containing elastic sealant used in outdoor joints between concrete blocks. The goals of the project were to develop methods, which minimise the spread of PCB to the outdoor environment and to indoor air, and which keep the PCB levels as low as reasonably possible in the workplace environment whilst removing the elastic sealant. The following PCB determinations were carried out: (1) concentration in the elastic sealant; (2) concentration in the concrete close to the sealant; (3) concentration in soil; (4) concentration in the indoor air; and (5) concentration in the air in the workplace environment. The cleanup process consisted of a number of different steps: (1) cutting the elastic sealant with an oscillating knife; (2) grinding the concrete with a mechanical machine; (3) sawing the concrete with a mechanical saw and (4) cutting the concrete with a mechanical chisel. In all these different steps a high capacity vacuum cleaner connected to the machines was used. The elastic sealant contained 4.7 to 8.1% total PCB of a technical product with a composition most similar to Clophene A40. The concrete close to the sealant (first 2 mm) contained 0.12 and 1.7% total PCB at two different places. The pattern of the PCB in the concrete resembled that of the sealant. PCB concentrations in the soil from the ground close to the building were 0.1 and 0.3 ppm at two different places before the remedial action. The source of the PCB in the soil is most likely the sealant as the PCB pattern is similar for the two materials. The PCB levels in the workplace air at the beginning of the project, when the techniques were not fully developed, were generally above the occupational exposure limit of 10 micrograms m-3 (up to 120 micrograms m-3). Later when the techniques were optimised to better take care of dust and gases produced during the cutting and grinding etc., the levels were below or close to 10 micrograms m-3. The pattern of the PCB in the workplace air was different from that of the sealant and contained higher levels of lighter components. The PCB concentrations in the indoor air were measured before and during the remedial process. The levels were around 600 ng m-3 and there was no significant increase during the removal of the sealant. The PCB level after the remedial action will be measured later. The pattern of the PCB in the indoor air was different from that of the sealant as well as from that of the workplace air. Higher levels of the lighter PCB were present indoors compared to the composition in both workplace air and in sealant. Extracts of PCB were analysed by GC-MS with a SIM method (selected ion monitoring). Standard procedures were used for extraction of solid materials. For the air samples an OVS tube was used with XAD-2 as adsorbent. The filter and adsorbent were extracted with toluene. This work shows that it is important to perform remedial action of PCB-containing elastic sealant as: (1) there is a spread of PCB to the indoor air giving high enough concentrations to make this the main PCB load on humans living in the apartments studied in this project; (2) large amounts are spread to the soil from these sealants; and (3) many of the PCB-containing elastic sealants used need to be changed from a functional perspective.

Recordings of polymodal single c-fiber nociceptive afferents following mechanical and argon-laser heat stimulation of human skin.

Recordings were made in the peroneal nerve of healthy volunteer subjects from C-mechano-heat (CMH) nociceptors (n=25) with their receptive fields in the skin on the dorsum of the foot. The investigation focused on afferent single C-fiber activity induced by short (200 ms) high-intensity argon-laser light pulses projected to localized spots of the skin. Cutaneous heat stimulation with the argon laser, 2-3 times the activation threshold, induced inter-burst spike frequencies in the nerve, reaching 50 Hz, while mechanical stimulation 10-20 times threshold only evoked frequencies reaching 10 Hz. The decrease in conduction velocity of action potentials in the C-fiber afferents following mechanical and heat stimulation was closely related to the degree of activation. Following a laser pulse of 200 ms, a spike pattern with highly reproducible inter-spike intervals was evoked with a fast saturation. On the contrary, a high variability in the number of action potentials evoked by both heat and mechanical stimuli was found, depending on the location of stimuli within the receptive field. A relation between the conduction velocity and the peak firing within the spike train following laser stimulation was detected. Heat and mechanical stimulation activated single C-fibers in matching spots within the same skin areas, in line with the assumption that the two modalities in the CMH-fibers share matching morphological cutaneous substrates. No correlation was found in thresholds or excitability to mechanical and heat stimulation, respectively. This suggests that subsets of receptors exist within nerve endings of the cutaneous receptive fields, with the ability to generate action potentials independent of heat and mechanical stimuli. Unexpectedly, no signs of sensitization or other inflammatory responses were observed after repeated laser pulses; on the contrary, a rapidly developing fatigue was observed when single spots were repeatedly stimulated. However, no fatigue was observed if neighboring spots were stimulated, indicating a localized generator of the fatigue. In each subject, a good correlation was observed between the reported pain sensation and the activity evoked in the afferent C-fibers by the laser. However, the magnitude of the reported pain sensation to comparable degrees of C-fiber activation showed a high variability between different subjects. A fairly good subjective estimate of the afferent-fiber activation was observed when skin spots from 3- down to 1-mm diameter were stimulated. In a few individuals, no painful sensation was reported when the stimulated spots were reduced to 1-mm diameter, despite the occurrence of multiple spikes in single C-fiber afferents, amplifying the importance of spatial summation in the perception of pain.

Recordings of human polymodal single C-fiber afferents following mechanical and argon-laser heat stimulation of inflamed skin.

Activity in single C-fiber afferents, whose cutaneous receptive fields were on the dorsal side of the foot (n=10), were recorded in the peroneal nerve of healthy voluntary subjects. Characterization of the fibers with respect to thresholds and field areas were made before and after cutaneous inflammation, which was induced with mustard oil. To test the nociceptive heat modality, a high-intensity argon laser was used and single 200-ms light pulses were focused onto the skin. The mechanical properties were tested with von Frey-type filaments. In the uninflamed skin, heat and mechanical stimulation activated single C-fibers in matching skin areas. The areas were all within the receptive field borders defined by electrical cutaneous stimulation. The mustard-oil-induced cutaneous inflammation was subjectively reported by the subjects as being moderately painful. In six of the units, a spontaneous activity was induced in the sample of ten previously non-active units. Before the inflammation, the 200-ms argon-laser pulse evoked a highly reproducible pattern of spike-trains. Following inflammation, this pattern was reproducible, but appeared with a significantly reduced activation rate despite the same energy being delivered to the skin both before and after the inflammation. A reduction in slope of the stimulus-response relationship was also observed after inflammation. Following inflammation, changes occurred with expansion both of the mechanical- and heat-receptive fields. The expansion was delineated by the areas defined by electrical stimulation. Following inflammation, the threshold to heat was decreased, but that to mechanical stimuli was not. No relation was detected between the threshold change and the degree of receptive-field expansion. The subjective pain reported changed following inflammation with an increase in the perceived pain in relation to the recorded action potentials, which emphasizes the importance of either an increase in sensitivity in the central nervous system or an increase in peripheral spatial summation after inflammation.

Effects of acupuncture treatment on daily life activities and quality of life: a controlled, prospective, and randomized study of acute stroke patients.

BACKGROUND AND PURPOSE: A number of studies have indicated that acupuncture might improve the functional recovery of stroke patients. These studies vary in inclusion criteria, sample size, and evaluation methods. The present study was designed to investigate whether electroacupuncture treatment favorably affects stroke patients' ability to perform daily life activities, their health-related quality of life, and their use of health care and social services. METHODS: One hundred four consecutive patients >40 years of age admitted to hospital because of an acute stroke were randomized to 3 groups: deep, superficial, and no acupuncture treatment. The acupuncture treatment given by 4 physiotherapists started 4 to 10 days after randomization and was given twice a week for 10 weeks. All patients underwent conventional stroke rehabilitation as well. Two occupational therapists, blinded regarding the patients' allocation, evaluated the treatment effects. The assessments were performed 4 times during the first year after randomization by means of interviews and observations. RESULTS: There were no differences between the groups with reference to changes in the neurological score and the Barthel and Sunnaas activities of daily living index scores after 3 and 12 months. Regarding the Nottingham Health Profile, the no acupuncture group had somewhat fewer mobility problems. No differences in health care and social services were found between the groups. CONCLUSIONS: The present study does not give support to the previous studies, which indicates that acupuncture treatment may have a beneficial effect on acute stroke patients' ability to perform daily life activities, their health-related quality of life, and their use of health care and social services.

Antispastic effects of L-dopa.

Antispastic effects of the noradrenaline and dopamine precursor l-3,4-dihydroxyphelanine (L-dopa) were investigated in 11 subjects in which exaggerated stretch reflexes developed after spinal cord injuries. The effects were evaluated from changes in the electromyographic (EMG) response of the quadriceps muscle during tendon jerks evoked by standardized taps over the patellar tendon, in clonus and in resistance to passive movements of the limb. After administration of L-dopa, EMG responses occurring 30-150 ms after the tendon tap decreased to about 50% of control, and clinical tests revealed a marked decrease in the resistance to muscle stretches and in the degree of clonus. The effects were maximal within about 1 h. The depressive actions of L-dopa are interpreted as being exerted primarily at the spinal level, since they were evoked in paraplegics and tetraplegics. The results support the previous hypothesis that group II muscle afferents contribute to.the exaggerated stretch reflex in spastic patients because L-dopa depresses transmission from group II but not from group I muscle afferents. They also indicate the possibility of using L-dopa in the treatment of spastic patients.

Convergence of afferents from superior sagittal sinus and tooth pulp on cells in the thalamus of the cat.

We have previously shown convergence of craniovascular and tooth pulp afferents in the cervical spinal cord of cats. This study looked for similar convergence in the thalamus. Fifty-four thalamic cells with input from tooth pulp, superior sagittal sinus, or both, were identified. Twenty-nine cells with tooth pulp and superior sagittal sinus input were located in the ventrobasal complex of the intralaminar nuclei. Most of these 29 cells were also excited by cooling the contralateral tooth pulp, and 21 had receptive fields on the contralateral face or forelimb. Twenty cells excited by stimulation of superior sagittal sinus, and not tooth pulp, were found in several nuclei. The 5 cells excited by stimulation of tooth pulp, but not sagittal sinus, were restricted to the ventrobasal complex. The data confirm convergence from sagittal sinus, tooth pulp, and skin in the thalamus of anaesthetized cats.

Convergence of afferents from superior sagittal sinus and tooth pulp on cells in the upper cervical spinal cord of the cat.

Units in the dorsolateral area of the upper cervical cord respond to craniovascular stimulation. This study examined tooth pulp responses in this area in cats. Eleven of 21 units tested in the dorsolateral area had convergent inputs from superior sagittal sinus and tooth pulp; while 10 units had sagittal sinus, but not tooth pulp, input. Mean response latency to tooth pulp stimulation (25.8 ms) was significantly longer than to superior sagittal sinus stimulation (9.8 ms). Half of the units had cutaneous receptive fields; and in five units, action potentials could be evoked by electrical stimulation in the posterior complex of the thalamus.

Dorsal column inhibition of nociceptive thalamic cells mediated by gamma-aminobutyric acid mechanisms in the cat.

Cells in posterior parts of the cat thalamus were investigated. Responses in single units excited by electrical stimulation in the lateral funiculus (LF), the dorsal column nucleus (DCN) or the canine tooth pulp (TP) were analysed. All cells had a spontaneous resting activity which could be increased by extracellular iontophoretic application of DL-homocysteic acid (DLH) and decreased by gamma-aminobutyric acid (GABA). No effect on the spontaneous firing rate was observed following iontophoresis of the selective GABA-antagonists, picrotoxin (GABA-A receptor antagonist) or saclofen (GABA-B receptor antagonist). However, the decreased firing following GABA application was partially blocked by picrotoxin but not by saclofen. A phasic inhibition induced by DCN stimulation in nociceptive thalamic cells is indicated since simultaneous administration of picrotoxin increased the evoked response. This type of inhibitory mechanism could not be detected following LF or TP stimulation. The extracellular activity evoked by electrical stimulation of LF or TP was significantly depressed by preceding electrical stimulation in the DCN. This inhibition was reversed by simultaneous administration of picrotoxin, indicating an involvement of GABA-A receptors. The reversal of the DCN-induced depression of the late responses following LF stimulation occurred after application of saclofen. It is suggested that this effect is partly mediated via GABA-B receptors. Results from the present study indicate an interaction in the thalamus between presumed low-threshold (DCN) and presumed nociceptive afferents (LF and TP) similar to that previously described in the spinal cord.

Thalamic nociceptive mechanisms in cats, influenced by central conditioning stimuli.

Field potentials and single cell activity evoked by tooth pulp (TP) stimulation were studied in the ventrobasal (VB) complex of the cat. The experiments were performed using a conditioning-test paradigm. Evoked cell activity or field potentials following TP stimulation was used as a test. Conditioning stimulus was given to different regions of the thalamic central lateral nucleus (CL). Conditioning electrical stimulation in medial (ML 2.8-3.6 mm) parts of CL induced a depression of the TP evoked response in 10 cells. Stimulation sites in lateral CL (ML 3.6-4.2 mm) induced facilitation in eight cells and decreased activity in seven cells. Tooth pulp evoked field potentials in thalamus were facilitated by a preceding stimulation in lateral CL. Cells in the lateral parts of CL are suggested to induce an increased activity in cells in the VB complex which mediate nociceptive information. This effect is suggested to be mediated via a CL induced disinhibition at a reticular thalamic (RE) or at a VB complex level. The medial parts of CL seem to give a traditional feedback inhibition on VB cells. Such an effect is also suggested to be mediated via the RE complex. The importance of these findings are discussed with relation to changes in the thalamus that may occur following long lasting nociceptive stimulation.

Craniovascular nociceptive pathways relay in the upper cervical spinal cord in the cat.

Units in the dorsolateral area of the upper cervical cord and the ventroposteromedial nucleus of the thalamus respond to stimulation of cranial vessels. To study the physiological role of the upper cervical cord in craniovascular transmission, we used a cryoprobe to interrupt reversibly neural transmission through the cord while recording in the thalamus. Twenty-one of 47 thalamic units tested showed reversible diminution in their response to superior sagittal sinus stimulation during cervical cord cooling. In contrast, receptive field responses and spontaneous thalamic activity were unaffected. These data suggest offt the cervical cord relays craniovascular nociceptive afferents.

Properties of single neurons in the cat midsuprasylvian gyrus.

Responses of cells in the midsuprasylvian gyrus (MSSG) of cats were investigated following electrical stimulation of the central lateral nucleus (CL) of the thalamus and tooth pulp, low-threshold cutaneous or visual afferents. Electrical stimulation in CL induced excitation in many cells located in cortical areas 5 and 7. Cells in these areas also received input from somato-sensory and visual afferents. Cells in MSSG showed a wide convergence from tooth pulp, low-threshold cutaneous afferents and from the CL. The majority of wide convergent cells in area 5 were found in layers IV and V, while cells excited by CL and tooth pulp were found in layers II and III. Similarities were found between CL and tooth pulp evoked responses with regard to the excitation-inhibition pattern. The excitation evoked from CL and tooth pulp was less often followed by a hyperpolarizing potential compared to that seen after low-threshold lip, paw and visual afferent stimulation. Stimulation sites in the lateral parts of CL-evoked responses with the shortest latencies in area 5. In this part of the cortex, short latency synaptic potentials were found in cells in superficial layers. In the same area, synaptic potentials of short latency were also evoked by electrical stimulation of tooth pulp, lip and paw. Light-flash stimulation evoked responses with the shortest latencies in area 7. The results of this study demonstrate that putative nociceptive information reaches the parietal association cortex and that part of this input may be relayed via CL. We suggest that the excitatory influences of nociceptive and CL stimulation is related to behavioral arousal and attention mechanisms.

Field potential analysis of the cortical projection of the central lateral nucleus in the cat.

A previous field potential study has indicated a monosynaptic projection of fibres from the central lateral nucleus (CL) to the mid-suprasylvian gyrus (MSSG). The present study, which is based on an analysis of current source density (CSD), aims to investigate further the sites of major localized synaptic activities in different layers of the MSSG after electrical stimulation in the CL. An initial positive surface potential was evoked in the MSSG with a latency of 3-5 ms and followed by a large negative potential with a peak latency of 8-15 ms. The initial positivity was only found in the rostral part of the MSSG, which corresponds to area 5. The positivity reversed in deeper layers. The CSD analysis showed a sink at a depth from 650 to 1050 microns. A corresponding source was found more superficially at 400-600 microns. This indicates that CL fibres have an excitatory synaptic termination on the soma or proximal dendrites of neurons in layers III and IV. The surface negative potential reversed at the border between layers II and III, suggesting a superficial CL projection. The CSD analysis of potentials in superficial layers showed a sink appearing between the pial surface and a depth of 350 microns, and a source lying in layers below. This indicates a depolarization of apical dendrites of cells in layers II and III. The superficial sink appeared in a large part of the MSSG. Application of a solution of 0.5% gamma-aminobutyric acid (GABA) on the surface of the cortex blocked the superficial sink and source and revealed a prominent sink current in layers III and IV in agreement with a deep termination of CL fibres. Application of a solution of 25 mM DL-2-amino-5-phosphono-valeric acid (APV) abolished CL-evoked cortical responses indicating that N-methyl-D-aspartate (NMDA) receptors are involved in the cortical activation. The CSD analysis confirms that CL has a wide superficial projection to the MSSG. It also confirms a deeper monosynaptic projection from CL to area 5.

Sympathetic and noradrenaline effects on C-fibre transmission: single-unit analysis.

Single afferent unmyelinated fibres were dissected from the otherwise intact sural nerve in anesthetized rabbits. The sympathetic trunk could be stimulated via electrodes implanted through the abdomen. The response in single C fibres was elicited by electrical stimulation in the cutaneous innervation area of the fibre. Sympathetic stimulation (8 Hz, 1 ms pulses, 5 mA for 60 s) increased the latency in all tested C fibres (2.0% +/- 0.8%, mean +/- SD, n = 17). In 48% of the units the amplitude of the action potential decreased (26.4% +/- 12.3%) during sympathetic stimulation. Infusion of noradrenaline (5 micrograms min-1) increased (7.7% +/- 4.1%) the latency in all units and increased (36.9% +/- 29.8%) the amplitude of 25% of the units. The effects of sympathetic stimulation and noradrenaline infusion were blocked by pre-treatment with phentolamine (3 mg kg-1 i.v.). The results suggest that catecholamines change the membrane properties of unmyelinated fibres.