The use of tetanus toxoid to elucidate the delayed-type hypersensitivity response in an older, immunized population.

Tuberculin reactivity decreases with age despite epidemiologic evidence that the elderly are more likely to have been infected. Whether this phenomenon is due to lack of antigenic stimulus or host inability to mount a delayed type hypersensitivity (DTH) response is unclear. In order to determine if the DTH response to tetanus toxoid in an exposed population is a useful tool to understand the phenomenon of lack of tuberculin reactivity in the remotely exposed elderly, a trial of skin testing was undertaken. Seventy-seven residents of a Veterans Affairs domiciliary were skin-tested using solutions of tetanus toxoid, candida and mumps skin test antigen. The 35 subjects who had negative reaction to the tetanus skin test were randomized into two groups: one which received tetanus vaccination before repeat skin testing and one which did not. Positive skin test reactions occurred in 42 patients to tetanus toxoid, 44 to mumps and 37 to candida. Of the 35 randomized, 27 were available for repeat skin tests. None reacted to the repeat tetanus skin test although 5 reacted to other antigens to which they had previously been nonreactive. Tetanus toxoid was equal to other antigens in its ability to elicit a DTH response originally; however antigenic stimulation with vaccination did not elicit positive skin test in nonreactors. Lack of DTH response to tetanus toxoid in recently vaccinated patients implies that nonresponse was secondary to host factors rather than lack of antigenic stimulation.

Update: Assessment of gastric pH in the critically ill.

The purpose of this manuscript is to update a review of the measurement of intraluminal gastric pH in the critically ill. Intraluminal gastric pH is readily measured by aspirates tested with litmus paper or a nasogastric tube with an antimony or glass electrode tip. Significant variations of intragastric pH have been shown in different stomach locations. Significant variations in the accuracy of pH readings have also been demonstrated. Prophylactic therapy in the critically ill is aimed at maintaining a gastric pH greater than 4.0 by drug therapy that 1) neutralizes acid, 2) interrupts the signal to produce acid, 3) reduces the amount of acid produced, or 4) enhances the mucosal barrier of the stomach lining. The critically ill patients at risk of respiratory failure or coagulopathy are the patients most at risk of gastrointestinal bleeding and are, therefore, the ones most likely to benefit from prophylactic therapy. Multiple pH readings are more reliable indicators of gastric pH than are individual readings. Continuous prophylaxis is more effective than intermittent.

Comparison of two methods of measuring gastric pH.

OBJECTIVE: To assess the agreement between two methods of measuring gastric pH in critically ill patients (multiple band litmus paper-tested aspirations versus a meter-read probe located in the tip of a nasogastric tube) and to compare nurse satisfaction with both methods of measuring pH. DESIGN: Prospective, correlational, nonprobability sample. SETTING: Mid-Atlantic, semirural Veterans Affairs Medical Center. SUBJECTS: 39 male, surgical, critical care patients, who were nasogastrically intubated in the operating room and received nothing by mouth. NURSES: Twenty-seven registered nurses on the medical-surgical intensive care staff. OUTCOME MEASURES: Differences in pH units as determined by two methods of measurement and nurse satisfaction scores. INSTRUMENTATION: Litmus paper-tested aspirations versus a meter-read probe located in the tip of the nasogastric tube, measured every 2 hours for 48 hours. A nurse satisfaction assessment form for both measurement methods at entry, 6 months, and 12 months. RESULTS: All measures of association, Pearson's r (0.79), the concordance coefficient (0.74), and eta (0.88), were high. The concordance coefficient measures indicated sufficient agreement between the two methods at the initial and 24 hour measurement times (Cb) = 0.97, 0.97, and 0.94), but not at 48 hours. The meter method indicated prophylaxis was needed when the paper did not, more often than did the paper method (9.3% vs 5.2%). A significant difference between methods was found only at the last reading at 48 hours (z = -2.24, p < .0249). MANOVA revealed that nurses' preference for the meter method was significant (F = 139.48, df = 1.18) and increased over time (F = 4.77, df = 2,36). CONCLUSIONS: The gastric probe method of measuring pH is an accurate substitution up to 48 hours for the litmus-paper aspiration method in the postoperative patient who is receiving nothing by mouth. Nurses prefer the gastric probe method of measuring pH over the litmus-paper method because they judge it to be safer, faster, and more accurate.