Systematic review: Need for high-quality research on occupational therapy for children with intellectual disability

BACKGROUND

Enabling participation in everyday life and supporting development are essential goals in occupational therapy of children and young people with intellectual disabilities (ID).

OBJECTIVE

To gather and evaluate evidence of the effectiveness of occupational therapy interventions for children with ID in terms of participation in everyday life.

MATERIAL AND METHODS

A literature search conducted using electronic databases (CINAHL, Cochrane Library, PubMed and EMBASE) from January 2000 to May 2020. Methodological quality was assessed using the Joanna Briggs Institute critical appraisal tools. Quality of evidence was critically appraised with the GRADE.

RESULTS

The search yielded 4741 records, of which 15 studies met the inclusion criteria: 3 randomized controlled trials, 3 case-control studies, 2 case series and 7 case reports. The studies were diverse in quality. The evidence is inconclusive because of the limited amount of methodologically robust studies.

CONCLUSIONS AND SIGNIFICANCE

Results support the notion that occupational therapy in daily environments for children with ID may enhances participation in everyday activities. Further research with appropriate study designs and outcome measurements is needed. Although the research evidence was limited, the results encourage focussing on occupational therapy for children with ID to enhance participation in school and home environments.

Worse health‐related quality of life, impaired functioning and psychiatric comorbidities are associated with excess mortality in patients with severe chronic pain

Background

Severe chronic pain that interferes with daily activities is associated with an increased risk of mortality. We assessed the overall mortality of tertiary chronic pain patients in comparison with the general population, with a special aim to analyse the association of health‐related quality of life (HRQoL) and its dimensions with the risk of death.

Methods

In this prospective observational follow‐up study, patients with non‐cancer chronic pain attended an outpatient multidisciplinary pain management (MPM) episode in a tertiary pain clinic in 2004–2012 and were followed until May 2019. Mortality between the patients and the general population was compared with standardized mortality ratios (SMR) in different age groups. Causes of death and comorbidities were compared among the deceased. Association of mortality and HRQoL and its dimensions, measured with the 15D instrument, was studied with Cox proportional hazards model.

Results

During a mean of 10.4‐year follow‐up of 1498 patients, 296 died. The SMR in the youngest age group (18–49 years) was significantly higher than that of the general population: 2.6 for males and 2.9 for females. Even elderly females (60–69 years) had elevated mortality (SMR 2.3). Low baseline HRQoL at the time of MPM, as well as poor ratings in the psychosocial dimensions of HRQoL, was associated with an increased risk of death.

Conclusions

Our results support the role of HRQoL measurement by a validated instrument such as the 15D in capturing both the physical and the psychological symptom burden, and consequently, an elevated risk of death, in patients with chronic pain.

Significance

Severe chronic pain is associated with elevated mortality. In patients in chronic pain under 50 years old, the mortality was 2.5–3 times higher than in the general population. Psychological distress appears to contribute to the increased mortality. Regular follow‐up by health‐related quality of life (HRQoL) measurement could be useful in identifying patients in chronic pain who are in need of intensive symptom management and to prevent early death.

ICF Personal Factors Strengthen Commitment to Person-Centered Rehabilitation – A Scoping Review

Background: The International Classification of Functioning, Disability and Health (ICF) classification is a biopsychosocial frame of reference that contributes to a holistic understanding of the functioning of a client and the factors involved. Personal factors (PFs) are not currently classified in the ICF due to large societal and cultural diversity and lack of clarity in the scope of such factors.

Aims: To ascertain which factors in the ICF classification have been defined as PFs in different studies and what conclusions have been drawn on their role in the ICF classification.

Methods: The study was a scoping review. A systematic search for articles published in 2010–2020 was performed on the Cinahl, Pubmed, ScienceDirect, and Sport Discus databases. The PFs specified in the articles were classified according to the seven categories proposed by Geyh et al. socio-demographic factors; position in the immediate social and physical context; personal history and biography; feelings; thoughts and beliefs; motives; and general patterns of experience and behavior.

Results: The search yielded 1,988 studies, of which 226 met the inclusion criteria. The studies had addressed a wide variety of PFs that were linked to all seven categories defined by Geyh et al. Some studies had also defined PFs that were linkable to other components of the ICF or that did not describe functioning. Approximately 22% (51) of the studies discussed the role of PFs in rehabilitation.

Conclusions: The range of PFs in the ICF classification addressed in the reviewed studies is wide. PFs play an important role in rehabilitation. However, according to the reviewed studies, a more precise coding of PFs is not yet warranted.

Uptake of Tele-Rehabilitation in Finland amongst Rehabilitation Professionals during the COVID-19 Pandemic

The COVID-19 pandemic has challenged rehabilitation professionals to provide therapy through telepractice. The aims of this study were to investigate and compare the uptake of tele-rehabilitation (TR) in Finland amongst different rehabilitation professions during the COVID-19 pandemic as well as potential differences between professions in carrying out TR. In addition, the goal was to explore in more depth therapists’ views about the features that work and challenges of TR. A total of 850 therapists in the physio-, occupational-, speech and language-, and psychotherapy professions participated in the survey that included both quantitative and open-ended questions. The results show that 52% of all the therapists who participated in this study did take up TR with all or most of their clients during the first wave of the COVID-19 pandemic. Of all professionals who have carried out tele-rehabilitation during the pandemic, 46% planned to use TR regularly or probably also after the pandemic. There were also clear differences between the professions. Psychotherapists carried out TR during the pandemic and planned to use it also after the pandemic more often than the other professional groups. The qualitative analysis revealed that therapists identified several beneficial but also multiple challenging features of TR. Psychotherapists reported less challenges than other professions. The pandemic has clearly sped up the use of TR in rehabilitation.

A Multiform, Group-Based Rehabilitation Program for Visually Impaired Young People to Promote Activity and Participation. A Pilot Study

Young people with visual impairment (YPWVI) face several challenges in their everyday lives. However, little is known about interventions that focus on promoting their participation that contributes to health and well-being and is considered the most relevant outcome in rehabilitation. Objectives: This study investigated the clinical outcomes and acceptability of a new one-year, multiform, group-based rehabilitation program for YPWVI. The aim of the pilot program was to support them becoming more independent and to promote their participation. Rehabilitation consisted of group-meetings in an institutional setting, online group meetings, individually tailored one-on-one guidance, individual online discussions and parents’ group meetings. Fifteen young persons with visual impairment were recruited and 14 completed the intervention, six of whom were blind or had severe visual impairment and eight had mild visual loss. Methodology: The study utilized a mixed methods triangulation design. Clinical outcome measures were goal attainment scaling (GAS) and occupational performance (COPM) completed with qualitative interview data. Focus group interviews with participants and parents were used to evaluate the acceptability of the program. Results: GAS-rated personal goals were widely achieved and the scores of both performance and satisfaction scales of COPM improved. Overall, the rehabilitation program proved to be acceptable. Group-based rehabilitation was deemed very important and it enabled peer support. However, two-day periods of inpatient rehabilitation, proved to be too short, whereas five-day periods were considered to disturb schoolwork. Conclusions: Group-based multi-form rehabilitation for YPWVI can have a positive impact on activity and participation of the participants. The program can support independence and the achievement of rehabilitation goals. The group format was applauded for providing social support and company. The program required some structural modifications.

Why does the impact of multidisciplinary pain management on quality of life differ so much between chronic pain patients?

Aims

To assess the change in quality of life and factors predicting this change in 1425 chronic pain patients treated in a multidisciplinary pain clinic.

Methods

This is an observational follow-up study using the 15D generic health-related quality of life (HRQoL) instrument. Patients filled in the HRQoL questionnaire at baseline, and 6 and 12 months after discharge. To assess if mental factors predicted treatment success, the changes in the overall 15D score were compared and related to the baseline variables of depression and distress. The group of patients, who scored 4 or 5 on the 1–5 scale for the depression and distress dimensions of the 15D instrument, were considered mentally distressed (N =199). They were compared with the non-distressed patients (i.e. those who scored 1; N = 401).

Results

Pain was associated to depression and distress: 85.4% of mentally distressed patients scored 4 or 5 also on the discomfort and symptoms dimension, vs. 51.4% of the non-distressed (p < 0.001). The mean 15D score of the mentally distressed patients improved statistically significantly more (from 0.572 to 0.636, N =141) during the first six months after treatment compared with the 15D of those who were not mentally distressed, who improved only marginally (0.790–0.803, N = 294; p < 0.001).

Conclusions

Patients with more severe depression or distress at baseline appear to gain more from the treatment than those who have less mental distress. In our ongoing study more baseline factors will be evaluated to assess their effect on the success of treatment.

Association of depressive symptoms and metabolic syndrome in men

OBJECTIVE

To explore the relationship between several indicators of depression and metabolic syndrome (MetS).

METHOD

A population-based sample with high (HMS group) or low (LMS group) levels of mental symptoms, including those of depression, in three follow-ups participated in a clinical examination in 2005 (n = 223). MetS was determined according to the NCEP criteria.

RESULTS

The prevalence of MetS was 49% in men and 21% in women. Men with MetS had higher rates of major depressive disorder than other men. They also displayed higher Hamilton Rating Scale for Depression (HDRS) scores and more often signs of suicidality. In logistic regression analyses, higher HDRS scores (OR 1.31, 95% CI 1.04-1.64) and belonging to the HMS group (OR 10.1, 95% CI 1.98-51.3) were independent associates for MetS but only in men.

CONCLUSION

The results highlight that there is an association between long-term depressive symptoms and the emergence of MetS, especially in men.

Itraconazole, a potent inhibitor of P-glycoprotein, moderately increases plasma concentrations of oral morphine

BACKGROUND

Individual variation in opioid response is considerable, partly due to pharmacokinetic factors. Transporter proteins are becoming increasingly interesting also in the pharmacokinetics of opioids. The efflux transporter P-glycoprotein can affect gastrointestinal absorption and tissue distribution, particularly brain access of many opioids. The aim of this study was to evaluate whether itraconazole, which is a potent inhibitor of P-glycoprotein and CYP3A4, would change the pharmacokinetics or the pharmacodynamics of oral morphine.

METHODS

Twelve healthy male volunteers ingested, in a randomized crossover study, once daily 200 mg itraconazole or placebo for 4 days. On day 4, 1 h after the last pre-treatment dose, the subjects ingested 0.3 mg/kg morphine. Blood samples for the determination of plasma morphine, morphine-3-glucuronide (M3G), morphine-6-glucuronide (M6G) and itraconazole concentrations were drawn up to 48 h after morphine ingestion. Pharmacodynamic effects were evaluated using a questionnaire, visual analogue scales, a reaction time test, the Digit Symbol Substitution Test and the Critical Flicker Fusion Test.

RESULTS

Itraconazole increased the mean area under the plasma concentration-time curve [AUC (0-9)] of morphine by 29% (P=0.002), its AUC (0-48) by 22% (P=0.013) and its peak plasma concentration by 28% (P=0.035). Itraconazole did not significantly affect the pharmacokinetic variables of M3G or M6G or the pharmacodynamic effects of morphine.

CONCLUSIONS

Itraconazole moderately increases plasma concentrations of oral morphine, probably by enhancing its absorption by inhibiting intestinal wall P-glycoprotein. A possible improvement of morphine penetration to the brain could not be observed.

Breakthrough pain characteristics and syndromes in patients with cancer pain. An international survey

Breakthrough pain (BKP) is a transitory flare of pain that occurs on a background of relatively well controlled baseline pain. Previous surveys have found that BKP is highly prevalent among patients with cancer pain and predicts more severe pain, pain-related distress and functional impairment, and relatively poor quality of life. An international group of investigators assembled by a task force of the International Association for the Study of Pain (IASP) evaluated the prevalence and characteristics of BKP as part of a prospective, cross-sectional survey of cancer pain. Fifty-eight clinicians in 24 countries evaluated a total of 1095 patients with cancer pain using patient-rated items from the Brief Pain Inventory (BPI) and observer-rated measures. The observer-rated information included demographic and tumor-related data, the occurrence of BKP, and responses on checklists of pain syndromes and pathophysiologies. The clinicians reported BKP in 64.8% of patients. Physicians from English-speaking countries were significantly more likely to report BKP than other physicians. BKP was associated with higher pain scores and functional interference on the BPI. Multivariate analysis showed an independent association of BKP with the presence of more than one pain, a vertebral pain syndrome, pain due to plexopathy, and English-speaking country. These data confirm the high prevalence of BKP, its association with more severe pain and functional impairment, and its relationship to specific cancer pain syndromes. Further studies are needed to characterize subtypes of BKP. The uneven distribution of BKP reporting across pain specialists from different countries suggests that more standardized methods for diagnosing BKP are needed.

Sexual motivation in relation to social rank in pair-housed sows

The influence of social subordination on sexual motivation during oestrus was studied using 36 sows of which 24 treatment sows were housed in pairs and 12 control sows were housed individually in 12 and 6 m(2) pens, respectively. Video recordings were made from 07:00 h to 19:00 h during the first 2 days after grouping, which took place 3 days after weaning of the piglets. Based on the aggressive interactions between the pair-housed sows, their rank was determined. From day 4 after weaning, a test for sexual proceptive behaviour was carried out twice daily and back-pressure test was carried out four times daily in order to detect standing oestrus. When standing oestrus had occurred, transrectal ultrasonographical scans were also carried out in order to determine if ovulation took place. The proceptivity test took place in a T-maze with a 2 m x 10 m runway ending in two 1.5 m x 1.5 m goal boxes each adjacent to a stimulus compartment. One compartment contained an adult sexually experienced boar and the other was empty. Latency to and duration of time spent close to the boar and time spent presenting were recorded during the 10-min test period. On the first day that standing oestrus had been detected, a test for sexual receptivity was also carried out by introducing the sow to a mature boar in his home pen (9 m(2)). Sexual- and fear-related behaviour of sow and boar were recorded until mating was terminated or the sow had spent 5 min in the pen without mating being initiated. During oestrus the proceptivity test showed a significant increase (P < 0.05) in the time spent standing close to the boar and in presenting for single-housed sows and for pair-housed dominant sows, but not for subordinate sows. During oestrus subordinate sows spent significantly less time standing close to the boar than the dominant sows (P = 0.01) and the same tended to be the case for presenting (P = 0.07). In the receptivity test more subordinate sows than dominant sows fled (40% versus 0%, P = 0.001) and more subordinate sows than dominant sows squealed (58% versus 15%, P = 0.02) as a response to boar stimulation. In both tests, the single-housed sows differed neither from the dominant nor the subordinate sows. There was however no difference between the groups in the weaning to oestrous interval, duration of oestrus and number of piglet born. In addition, all the sows ovulated. The results indicate that social subordination can have significant consequences for sexual motivation in sows. Subordinate sows showed fear-related behaviour in response to boar stimulation even when they were in standing oestrus. Thus, both heat detection and mating may be impaired in subordinate sows. The results emphasise the importance to alleviate the social stress experienced by subordinates as well as the need for stock people to pay special attention to these animals when they are to be mated or inseminated.

EPEC, EAEC and STEC in stool specimens: prevalence and molecular epidemiology of isolates

Stool specimens of Finns (n = 695) with (n = 603) and without (n = 92) diarrhea were studied for enteropathogenic (EPEC), enteroaggregative (EAEC) and Shiga toxin-producing (STEC) Escherichia coli by PCR. The specific isolates were subsequently investigated for their O:H serotypes and were genotyped by pulsed-field gel electrophoresis (PFGE). A subset (n = 506) of the diarrheal and all non-diarrheal specimens were also searched for conventional enteric bacterial pathogens by standard methods. Diarrheagenic E. coli were found in 5.5% and other enteric pathogens in 6.7% of the patients with and in 2.2% and 1.1% of the subjects without diarrhea, respectively. Campylobacter (3.8%), EPEC (3.2%) and Salmonella (2.0%) were the most common findings, and were detected in diarrheal patients only. STEC were associated with bloody diarrhea (8/9 isolates), whereas EAEC were equally common (1%) in diarrheal and non-diarrheal subjects. Great genomial heterogeneity was seen among diarrheagenic E. coli, and only one EPEC isolate belonged to the "classic" EPEC serogroup (O55).

Which displaced spiral tibial shaft fractures can be managed conservatively?

The aim of the present study was to establish a threshold for the initial displacement of a spiral tibial shaft fracture beyond which its retention in an acceptable position cannot be guaranteed by plaster immobilization. We reviewed the records and radiographs of 131 plaster cast-treated patients with spiral tibial shaft fracture, initially displaced 50% or less, for patients whose fracture had either lost its acceptable retention or consolidated in an unacceptable position. The fractures were classified, according to the true initial displacement as measured on the first radiographs, into four pairs of categories using cut-off points of 10, 20, 30 and 40% of the diameter of the tibial diaphysis. Comparison was then made of the proportions of failed treatments between each of these pairs. Plaster cast treatments failed in 28% when the true initial displacement was 30% or less, and in 46% when the true initial displacement was more than 30%. The risk of failed plaster cast treatment increased when true initial displacement exceeded 30%. In all patients whose plaster cast treatment was interrupted the true initial displacement was more than 30%. We therefore conclude that diaphyseal fractures of the tibia for which the initial displacement exceeds 30% are not suitable for plaster cast treatment.

Phage-displayed peptides mimicking the discontinuous neutralization sites of puumala Hantavirus envelope glycoproteins

We selected peptide ligands mimicking the surface structure of discontinuous binding sites of Puumala hantavirus-neutralizing monoclonal antibodies from a random 18-amino acid peptide library containing a disulfide bridge in a fixed position and displayed on a filamentous phage. The varying of selection conditions, either by shortening of the association time or by competitive elution with antigen, was crucial for the selection of peptide inserts that could be aligned with the primary sequences of the envelope glycoproteins G1 and G2. Correspondingly, when the envelope glycoprotein sequences were synthesized as overlapping peptides as spots on membrane, the same site in primary structure was found as with phage display, which corroborates the use of the two methods in mapping of conformational epitopes. Also, epitopes reactive with early-phase sera from Puumala virus infection were defined with the pepspot assay in the amino-terminal region of G1. Similarities of the selected phage clones to a monoclonal antibody-escape mutant site and to a linear early-phase epitope were found.

Shiga toxin-producing Escherichia coli in finland from 1990 through 1997: prevalence and characteristics of isolates

During the past 10 years Shiga toxin-producing Escherichia coli (STEC) has emerged as one of the most important causes of food-borne infections in industrialized countries. In Finland, with a population of 5.1 million, however, only four STEC O157:H7 infections were identified from 1990 through 1995; the occurrence of non-O157 STEC infections was unknown. In 1996, we established a national prospective study to determine the prevalence of STEC serotypes in feces of Finns with bloody diarrhea. During this enhanced 1-year study period eight sporadic cases of STEC infection were found; of them, only two were indigenously acquired O157:H7 infections. In 1997, O157 infections increased dramatically, with O157 strains causing 51 of all 61 STEC infections. Altogether 14 non-O157:H7 STEC strains were found in Finland in the 1990s: O26:H11 (four strains), O26:HNM (HNM indicates nonmotile), O2:H29, O91:H21, O91:H40, O101:HNM, O107:H27, O157:HNM, O165:H25, OX3:H21, and Rough:H49. All O157:H7 and O26:H11 isolates produced enterohemolysin, but seven of the other STEC strains did not. Most (n = 63) of the 71 STEC strains isolated carried the stx2 gene only, five carried the stx1 gene only, and three carried both genes. The eaeA gene was detected in all other isolates except five non-O157 strains. There were seven distinct pulsed-field gel electrophoresis (PFGE) genotypes among 57 O157 strains and three distinct PFGE types among four O26:H11 strains. The main PFGE type was found among 65% of all O157 isolates.

Effects of blocking CYP2D6 on the pharmacokinetics and pharmacodynamics of oxycodone

BACKGROUND

Oxycodone is metabolized in the liver by means of O-demethylation to form oxymorphone in a reaction catalyzed by the enzyme cytochrome P450 2D6 (CYP2D6). This enzyme is expressed as 2 phenotypes (extensive and poor metabolizers). Several drugs are metabolized by CYP2D6, and clinically relevant drug interactions may occur. The aim of this study was to evaluate the role of oxymorphone in mediating the opioid effects of oxycodone by means of blocking CYP2D6 with quinidine.

METHODS

Ten healthy extensive metabolizers were administered 20 mg controlled-release oxycodone after premedication with placebo or 200 mg quinidine in this randomized, double-blind crossover study. A dose of 100 mg quinidine was administered 6 hours later. Plasma opioid concentrations, subjective pharmacodynamic ratings, and psychomotor function were assessed for 24 hours after drug administration.

RESULTS

No oxymorphone was detected at any time after quinidine premedication in 8 of 10 subjects. Plasma oxycodone (difference not significant) and noroxycodone (P < .01) concentrations were greater after quinidine pretreatment. Prevention of the production of oxymorphone by quinidine did not affect the psychomotor or subjective drug effects of oxycodone. No difference in number of adverse effects was observed after the 2 pretreatments.

CONCLUSIONS

A significant reduction in plasma oxymorphone levels did not substantially alter the pharmacodynamic effects of oxycodone. Analgesia was not evaluated because pain was not present.

Molecular epidemiology of two international sprout-borne Salmonella outbreaks

Sprout-borne Salmonella outbreaks in Finland have increased during the last 10 years. The latest two were caused by Salmonella enterica serovar Bovismorbificans (antigenic structure 6,8:r:1,5) in 1994 and S. enterica serovar Stanley (4,5, 12:d:1,2) in 1995. In this study, the restriction fragment length polymorphism of genomic DNA after pulsed-field gel electrophoresis (PFGE) and antimicrobial resistance profiles of the outbreak and nonoutbreak strains were compared. In each separate outbreak, the PFGE patterns of the outbreak strains (40 strains of S. enterica serovar Bovismorbificans and 28 strains of S. enterica serovar Stanley) after digestion of genomic DNA with restriction enzyme XbaI were indistinguishable from each other but differed clearly from those of the nonoutbreak strains (26 strains of S. enterica serovar Bovismorbificans and 40 strains of S. enterica serovar Stanley). The restriction enzyme XhoI did not differentiate the outbreak and nonoutbreak strains. The S. enterica serovar Stanley strains associated with the outbreak also had a unique antimicrobial resistance pattern, whereas all S. enterica serovar Bovismorbificans strains, both outbreak and nonoutbreak strains, were sensitive to all antimicrobial agents tested. Thus, the molecular typing confirmed that the S. enterica serovar Bovismorbificans outbreak isolates from humans and sprout salad were identical and strongly supported the epidemiological finding that S. enterica serovar Stanley outbreak isolates also originated from contaminated alfalfa seeds. It also confirmed that the sources of similar outbreaks in Sweden in 1994 caused by S. enterica serovar Bovismorbificans and in the United States in 1995 caused by S. enterica serovar Stanley and the source of the Finnish outbreaks were common.

Controlled-release oxycodone and morphine in cancer related pain

Controlled-release (CR) formulations of oxycodone and morphine were compared in 45 patients with chronic cancer pain. The study was started with an open-label, randomised titration phase to achieve stable pain control for at least 48 h, followed by a double-blind, randomised, crossover phase in two periods, 3-6 days each. To blind the study using available tablet strengths, the dose ratio of oxycodone to morphine was set at 2:3. A daily telephone contact was maintained between the patient and the investigator. The patients were asked to assess pain intensity four times a day and acceptability of therapy twice daily, and to record possible adverse effects. Pharmacodynamic evaluations were performed at the end of each double-blind period. The patients were allowed to use escape analgesic (respective opioid as oral solution) as needed. Twenty-seven patients were evaluable for both safety and efficacy. Pain was well-controlled during both stable phases. When the period effect was taken into account the two opioids provided comparable analgesia. If the results of the two periods were combined, the patients consumed significantly more escape doses and the mean pain intensities were significantly greater with CR oxycodone. The total opioid consumption ratio of oxycodone to morphine was 2:3 when oxycodone was administered first, and 3:4 when oxycodone was administered after morphine. The total incidence of adverse experiences reported by the patients was similar, but significantly more vomiting occurred with morphine, whereas constipation was more common with oxycodone.

Phage-displayed peptide targeting on the Puumala hantavirus neutralization site

We have selected ligands for Puumala hantavirus, the causative agent of nephropathia epidemica, from a seven-amino-acid peptide library flanked by cysteines and displayed on a filamentous phage. To direct the selection to areas on the virus particle which are essential for infection, phages were competitively eluted with neutralizing monoclonal antibodies specific for the viral glycoproteins. The selected phage populations were specific for the same sites as the antibodies and mimicked their functions. The peptide insert, CHWMFSPWC, when displayed on the phages, completely inhibited Puumala virus infection in cell culture at the same effective concentration as the eluting antibody specific for envelope glycoprotein G2. The binding of the phage clones to the virus and inhibition of infection were not necessarily coincident; Pro-6 was critical for virus inhibition, while consensus residues Trp-2 and Phe-4 were essential for binding. The strategy described can be applied to any virus for production of molecules mimicking the effect of neutralizing antibodies.

Epidural and subcutaneous morphine in the management of cancer pain: a double-blind cross-over study

Ten patients who suffered from severe cancer-related pain participated in a randomised, double-blind and cross-over study to compare the effectiveness and acceptability of epidural and subcutaneous administration of morphine. The patients titrated themselves pain-free in 48 h using a patient controlled analgesia system. The median daily doses calculated from the consumption of the last 4-h study period were 372 mg for subcutaneous and 106 mg for epidural administration. The two modes of morphine administration turned out to be comparable in terms of both effectiveness and acceptability. Both treatments provided better pain relief with less adverse effects compared with the prestudy oral morphine treatment.

Recurrence of urinary tract infection in a primary care setting: analysis of a 1-year follow-up of 179 women

In a prospective study, 179 adult women (age range, 17-82 years) were followed up for 12 months after an index episode of community-acquired cystitis caused by Escherichia coli. Episodes of symptomatic urinary tract infection (UTI) were recorded, and urinary isolates were compared with the index episode isolate; 147 UTI episodes were detected during the follow-up. Of these episodes, 131 were classified as recurrences occurring at least 1 month after the index episode; 44% of the patients had recurrences. A history of UTI increased the risk of recurrence; only 11.8% of the 17 patients without previous episodes of UTI had at least one recurrence, while 47.5% of those with previous episodes had at least one recurrence (OR, 6.8; univariate logistic regression). E. coli caused 78% of the recurrent episodes. Phenotypic and genotypic analysis of E. coli strains showed that one-third of the recurrences were caused by the index episode strain, which could persist and cause recurrences throughout the 1-year follow-up period. The prevalence of adhesins or other identified virulence factors for UTI among the recurrence strains was identical to that among the index episode strains. The presence of these factors did not affect the risk of recurrence but did increase the likelihood that the index episode strain would persist and cause recurrent episodes of UTI.

Human leucocyte glycosylasparaginase is an alpha/beta-heterodimer of 19 kDa alpha-subunit and 17 and 18 kDa beta-subunit

Human lysosomal glycosylasparaginase (AGA; EC 3.5.1.26) consists of two glycosylated subunits, alpha and beta. Treatment with 3% SDS at 45 degrees C as part of a new purification scheme did not affect enzyme activity, but the alpha-subunit migrated an apparent 19 kDa peptide on SDS/PAGE instead of as a 24 kDa peptide, as observed without this SDS treatment. The N-terminal sequence was similar to that of the 24 kDa form, and, after reversed-phase h.p.l.c., the 19 kDa form was transformed to an apparent 24 kDa peptide on SDS/PAGE, indicating that their primary structures were identical. As the molecular mass of the alpha-subunit deduced from its cDNA was 19.5 kDa, the variation might be due to incomplete SDS coating of the 24 kDa form. This was confirmed by the tendency of the 24 kDa variant to polymerize even in the presence of SDS. The molecular mass of the beta-subunit was 17 and 18 kDa in accordance with previous reports. Chemical cross-linking with 1-ethyl-3-(3-dimethylaminopropyl)carbodi-imide resulted in the appearance of a 38 kDa peptide on SDS/PAGE which reacted with both the subunit-specific antisera on Western-blot analysis. On SDS/PAGE at pH 10.2 the active enzyme migrated as an apparent 43 kDa peptide. These results indicate that native human glycosylasparaginase is a heterodimer.

Concentration and molecular weight distribution of hyaluronate in synovial fluid from clinically normal horses and horses with diseased joints

High molecular weight (MW) hyaluronate (HA) is an integral part of synovial fluid (SF), regulating many important physiologic and pathophysiologic mechanisms. Many of its effects depend on, or are reflected in, the concentration and MW of HA. High-performance liquid chromatography was used to assess simultaneously the concentration and MW of HA in SF obtained from horses with various arthritides: acute traumatic arthritis; chronic traumatic arthritis, including degenerative joint disease (DJD); and infectious arthritis. The size-exclusion column was calibrated, using appropriate HA concentration and MW standards, before the high-performance liquid chromatographic assays of the SF samples. Calibration of the column disclosed that the maximal limit for MW estimation of HA was around 3 million. In control joints, MW of HA ranged from 2 to 3 x 10(6) (mean 2.5 x 10(6)) and did not differ significantly from MW of HA in SF from horses with acute or chronic traumatic arthritis (mean 2 x 10(6); range 1.5 to 3 x 10(6)). Interestingly, a small amount of HA of moderately high MW (approx 1 to 1.5 x 10(6)) was detected in chromatograms of SF from infected joints. This degree of polymerization of SF HA was significantly (P < 0.01) lower, compared with that for control joints. There was no difference in mean (+/- SD) concentration of HA between control joints and joints with acute or chronic traumatic arthritis (0.33 +/- 0.12 g/L vs 0.18 +/- 0.03 g/L or 0.23 +/- 0.12 g/L), indicating that SF HA concentration probably should not be used as a diagnostic marker for the condition.(ABSTRACT TRUNCATED AT 250 WORDS)

Large-scale purification of human aspartylglucosaminidase: utilization of exceptional sodium dodecyl sulfate resistance

Deficiency of human aspartylglucosaminidase (AGA, glycosylasparaginase, EC 3.5.1.26), a lysosomal amidase, results in the lysosomal storage disease aspartylglucosaminuria (AGU). This disorder is most prevalent in the genetically isolated Finnish population. To facilitate the detailed analysis of this important enzyme, which functions in the final degradation step of glycoproteins, we developed a novel purification method which makes possible a simple five-step 5000-fold purification to apparent homogeneity of human aspartylglucosaminidase from leukocytes. This purification procedure takes advantage of the remarkable SDS resistance of aspartylglucosaminidase as SDS-sensitive proteins aggregate preferentially at low (NH4)2SO4 concentrations in the presence of SDS. This new method should be applicable to the isolation of other SDS-resistant enzymes, e.g., superoxide dismutase. The homogeneous enzyme preparation exhibited a previously unreported fully denatured 19-kDa form of the alpha-subunit of aspartylglucosaminidase on SDS-polyacrylamide gel electrophoresis as a consequence of complete coating by SDS.

Community-acquired pyelonephritis in adults: characteristics of E. coli isolates in bacteremic and non-bacteremic patients

Escherichia coli strains isolated from the urine in 49 consecutive episodes of community-acquired pyelonephritis in adult women were characterized for adhesins and hemolysin production. The mean age of the patients was 56 years and 47% had at least 1 compromising condition. P fimbriae was found in 67% and hemolysin production in 35% of the strains; these figures were significantly (p < 0.001) higher than the corresponding figures (11% for each) among 287 strains isolated from stool of healthy adults (Siitonen A. J Infect Dis 1992; 166: 1058-1065). The prevalence of Non-P mannose-resistant adhesins and type 1C fimbriae was low (4 and 8%, respectively) and did not differ significantly from the corresponding prevalences (1 and 7%) in healthy adults. 74% fo the pyelonephritic (but only 22% of the stool) isolates had at least 1 of these 4 virulence factors (p < 0.001) and 37% and 7%, respectively, had at least 2 (p < 0.001). Nevertheless, the strains represented a wide variety of O:K serotypes without any indication of specially virulent clones. Of the 49 patients 15 had concomitant bacteremia, and in all except 2 compromised elderly patients the urinary and blood isolates were identical.

Human aspartylglucosaminidase. A biochemical and immunocytochemical characterization of the enzyme in normal and aspartylglucosaminuria fibroblasts

Aspartylglucosaminidase (AGA, EC 3.5.1.26) is an essential enzyme in the degradation of asparagine-linked glycoproteins. In man, deficient activity of this enzyme leads to aspartylglucosaminuria (AGU), a recessively inherited lysosomal storage disease. Here we used affinity-purified polyclonal antibodies against the native AGA and its denatured subunits to establish the molecular structure and intracellular location of the enzyme in normal and AGU fibroblasts. Inactivation of the enzyme was found to coincide with the dissociation of the heterodimeric enzyme complex into subunits. Although the subunits were not linked by covalent forces, the intrapolypeptide disulphide bridges were found to be essential for the normal function of AGA. AGA was localized into lysosomes in control fibroblasts by both immunofluorescence microscopy and immuno-electron microscopy, whereas in AGU cells the location of antigen was different, suggesting that, owing to the mutation, a missing disulphide bridge, most of the enzyme molecules get retarded in the cis-Golgi region and most probably face intracellular degradation.

Cardiovascular dimensions in patients with intracranial arteriovenous malformation

The hemodynamics of 29 adult subjects with a congenital intracranial arteriovenous malformation were studied by radiocardiography. The cardiac index, heart rate, stroke index, systemic arterial pulse pressure and radiographical heart volume did not differ significantly from the normal. However, the total blood volume (P < 0.001) and the plasma volume (P < 0.05) were greater than normal.

The radiocardiograms of 17 patients were analyzed by analogue computer. The right heart blood volume (P < 0.05) and the left heart blood volume (P < 0.02) were above normal, but of equal magnitude. The pulmonary blood volume did not differ from the normal. The same was true of the respective volumes as percentages of the total blood volume. The cardiopulmonary (P < 0.01) and the peripheral (P < 0.005) blood volumes were greater than normal.

The results indicate that the major circulatory consequence of a congenital intracranial arteriovenous malformation is an increased circulating blood volume.

The size or the location of the malformation did not correlate with the hemodynamic parameters.