Australian Consensus Statements for the Assessment and Management of Non-radiographic Axial Spondyloarthritis

Background

The understanding of non-radiographic axial spondyloarthritis (nr-axSpA) has accelerated over the last decade, producing a number of practice-changing developments. Diagnosis is challenging. No diagnostic criteria exist, no single finding is diagnostic, and other causes of back pain may act as confounders.

Aim

To update and expand the 2014 consensus statement on the investigation and management of non‐radiographic axial spondyloarthritis (nr-axSpA).

Methods

We created search questions based on our previous statements and four new topics then searched the MEDLINE and Cochrane databases. We assessed relevant publications by full-text review and rated their level of evidence using the GRADE system. We compiled a GRADE evidence summary then produced and voted on consensus statements.

Results

We identified 5145 relevant publications, full-text reviewed 504, and included 176 in the evidence summary. We developed and voted on 22 consensus statements. All had high agreement. Diagnosis of nr-axSpA should be made by experienced clinicians, considering clinical features of spondyloarthritis, blood tests, and imaging. History and examination should also assess alternative causes of back pain and related conditions including non-specific back pain and fibromyalgia. Initial investigations should include CRP, HLA-B27, and AP pelvic radiography. Further imaging by T1 and STIR MRI of the sacroiliac joints is useful if radiography does not show definite changes. MRI provides moderate-to-high sensitivity and high specificity for nr-axSpA. Acute signs of sacroiliitis on MRI are not specific and have been observed in the absence of spondyloarthritis. Initial management should involve NSAIDs and a regular exercise program, while TNF and IL-17 inhibitors can be used for high disease activity unresponsive to these interventions. Goals of treatment include improving the frequent impairment of social and occupational function that occurs in nr-axSpA.

Conclusions

We provide 22 evidence-based consensus statements to provide practical guidance in the assessment and management of nr-axSpA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00416-7.

Patient Perceptions of Psoriatic Arthritis Management and Communication with Physicians in Australia: Results from a Patient Survey

Introduction

The objective of this report was to evaluate perceptions of psoriatic arthritis (PsA) treatment and satisfaction with healthcare professional (HCP) communication among patients with PsA in Australia, compared with overall global perceptions.

Methods

Data were collected via a global and country-specific survey (The Harris Poll; November 2, 2017–March 12, 2018). Eligible patients were ≥ 18 years old, had been diagnosed with PsA > 1 year prior, had seen a rheumatologist or dermatologist within the past 12 months, and had previously received ≥ 1 conventional synthetic or biologic disease-modifying antirheumatic drug. Data reported by patients included baseline demographics, overall health, time since PsA diagnosis, PsA severity, satisfaction with current PsA medication and management, and experiences regarding communication with their HCP. Descriptive statistics were obtained.

Results

Most patients in Australia were very or somewhat satisfied with their PsA medication, and reported always or often taking their medication exactly as directed by their HCP. However, the majority still experienced symptoms, reported their overall health as poor or fair, and would change something about their PsA medication. While the majority of patients in Australia were satisfied with the communication with their HCP, most would prefer increased communication but some felt that asking too many questions would affect the quality of their care. Perceptions in Australia were similar to global perceptions.

Conclusions

Although most patients with PsA in Australia were satisfied with their disease management and communication with their HCP, many still experienced symptoms, would change something about their PsA medication, and would prefer increased communication with their HCP.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00297-w.

Psoriatic arthritis (PsA) can cause tender and swollen joints. If not treated properly, the joint damage can get worse, until patients struggle to cope with everyday tasks. Patients and their doctors need to communicate well to successfully manage PsA. We used an online survey to ask patients in Australia how they feel about their PsA medication and the way they communicate with their doctor. These patients were adults who had had PsA for more than 1 year, had seen a specialist doctor in the past year, and had taken one or more prescription PsA medications. A total of 152 patients in Australia completed the survey. Most patients were very or somewhat satisfied with the PsA medication they were taking, and most always or often took it exactly as their doctor told them to. However, almost all patients still had symptoms, most said their overall health was poor or fair, and most would like to change something about their medication. While most patients were satisfied with the communication with their doctor about PsA, most wished they talked more with their doctor about their PsA and treatment goals, but some felt that asking too many questions would harm their quality of care. Patients in Australia had similar answers to patients who answered the survey in other countries. Although the survey was limited by the number of patients who responded, and whether patients answered questions properly, it suggests that patients and doctors need to communicate more closely to improve PsA management.

Results of a global, patient-based survey assessing the impact of psoriatic arthritis discussed in the context of the Psoriatic Arthritis Impact of Disease (PsAID) questionnaire

Background

Psoriatic arthritis (PsA) is a chronic immune-mediated inflammatory musculoskeletal disease, manifesting as peripheral arthritis, enthesitis, dactylitis, spondylitis, and skin and nail psoriasis. A core set of domains for measuring the impact of PsA has been developed, including pain, patient global assessment, physical function, health-related quality of life (HRQoL), and fatigue. To understand the impact of PsA on health domains from a patient’s perspective, a global survey was developed and results reported in the context of the 12-item Psoriatic Arthritis Impact of Disease (PsAID-12) questionnaire.

Methods

An online patient-based global survey was conducted by The Harris Poll in Australia, Brazil, Canada, France, Spain, Taiwan, the UK, and the US between November 2, 2017 and March 12, 2018. Eligible patients were ≥ 18 years old with a diagnosis of PsA for > 1 year, had visited a rheumatologist/dermatologist in the past 12 months and reported using ≥ 1 synthetic/biologic disease-modifying antirheumatic drug for PsA. Patients reported on PsA severity and symptoms, and the impact of PsA on HRQoL. After survey completion, responses were aligned with PsAID health domains. Descriptive statistics and chi-square tests were conducted.

Results

This analysis included 1286 patients from eight countries. Most patients (97%) reported musculoskeletal symptoms relating to PsA in the past year. Common moderate/major impacts of PsA were on physical activity (78%), ability to perform certain activities (76%), work productivity (62%), and career path (57%). Skin/nail symptoms occurred in 80% of patients. Overall, 69% of patients reported that PsA had a moderate/major impact on emotional/mental wellbeing, 56% on romantic relationships/intimacy, and 44% on relationships with family and friends. Social impacts included emotional distress (58%), social shame or disapproval (32%), and ceased participation in social activities (45%). Over half of all patients experienced unusual fatigue over the past 12 months (52%). The health domains that patients reported as being impacted by PsA aligned with life impact domains of the patient-derived PsAID health domains.

Conclusion

These results highlight the impact of PsA on multiple health domains from a patient perspective that should be considered during shared decision-making processes between healthcare providers and patients.

Effects of external rhythmical cueing on gait in patients with Parkinson's disease: a systematic review

Objective: To critically review studies evaluating the effects of external rhythmical cueing on gait in patients with Parkinson's disease.

Methods: Articles published from 1966 to January 2005 were searched by two physiotherapists in MEDLINE, PiCarta, PEDRo, Cochrane, DocOnline, CINAHL and SUMSEARCH. To be included, articles had to investigate the effects of external rhythmical cueing (i.e., auditory, visual or tactile cueing) on gait parameters in patients with idiopathic Parkinson's disease. Both controlled and noncontrolled studies were included. Based on the type of design and methodological quality a meta-analysis or best-evidence synthesis was applied.

Results: Twenty-four studies (total number of patients = 626) out of the 159 screened studies were evaluated in this systematic review. Two out of 24 were randomized controlled trails (RCT), both of high methodological quality. One RCT did not focus specifically on external rhythmical cueing of individual patients with Parkinson's disease, but on group exercises in general, including walking with cues. All other studies were pre-experimental studies. Best-evidence synthesis showed strong evidence for improving walking speed with the help of auditory cues. Insufficient evidence was found for the effectiveness of visual and somatosensory cueing.

Conclusion: Only one high-quality study, specifically focused on the effects of auditory rhythmical cueing, suggesting that the walking speed of patients with Parkinson's disease can be positively influenced. However, it is unclear whether positive effects identified in the laboratory can be generalized to improved activities of daily living (ADLs) and reduced frequency of falls in the community. In addition, the sustainability of a cueing training programme remains uncertain.

Consensus statement on the investigation and management of non-radiographic axial spondyloarthritis (nr-axSpA)

AIM

Non-radiographic axial spondyloarthritis (nr-axSpA) is axial inflammatory arthritis where plain radiographic damage is not evident. An unknown proportion of these patients will progress to ankylosing spondylitis (AS). The increasing recognition of nr-axSpA has been greatly assisted by the widespread use of magnetic resonance imaging. The aim of this article was to construct a set of consensus statements based on a literature review to guide investigation and promote best management of nr-axSpA.

METHODS

A literature review using Medline was conducted covering the major investigation modalities and treatment options available. A group of rheumatologists and a radiologist with expertise in investigation and management of SpA reviewed the literature and formulated a set of consensus statements. The Grade system encompassing the level of evidence and strength of recommendation was used. The opinion of a patient with nr-axSpA and a nurse experienced in the care of SpA patients was also sought and included.

RESULTS

The literature review found few studies specifically addressing nr-axSpA, or if these patients were included, their results were often not separately reported. Fourteen consensus statements covering investigation and management of nr-axSpA were formulated. The level of agreement was high and ranged from 8.1 to 9.8. Treatment recommendations vary little with established AS, but this is primarily due to the lack of available evidence on the specific treatment of nr-axSpA.

CONCLUSION

The consensus statements aim to improve the diagnosis and management of nr-axSpA. We aim to raise awareness of this condition by the public and doctors and promote appropriate investigation and management.

Telerheumatology: an idea whose time has come

Australia is a vast country with one-third of the population living outside capital cities. Providing specialist rheumatologist services to regional, rural and remote Australians has generally required expensive and time-consuming travel for the patient and/or specialist. As a result, access to specialist care for remote Australians is poor. Rheumatoid arthritis is a common disease, but like many rheumatic diseases, it is complex to treat. Time-dependent joint damage and disability occur unless best evidence care is implemented. The relatively poor access to rheumatologist care allotted to nonmetropolitan Australians therefore represents a significant cause of potentially preventable disability in Australia. Telehealth has the potential to improve access to specialist rheumatologists for patients with rheumatoid arthritis and other rheumatic diseases, thereby decreasing the burden of disability caused by these diseases. Advances in videoconferencing technology, the national broadband rollout and recent Federal government financial incentives have led to a heightened interest in exploring the use of this technology in Australian rheumatology practice. This review summarises the current evidence base, outlines telehealth's strengths and weaknesses in managing rheumatic disease, and discusses the technological, medicolegal and financial aspects of this model of care. A mixed model offering both face-to-face and virtual consultations appears to be the best option, as it can overcome the barriers to accessing care posed by distance while also mitigating the risks of virtual consultation.

Virtual histology: a window to the heart of atherosclerosis

Intravascular ultrasound has done much to improve our understanding of atherosclerosis and the impact of percutaneous intervention on the coronary artery. However, subjectivity in interpreting the acoustic reflection of the ultrasound signal has spawned the development of other progressive technologies. Virtual histology intravascular ultrasound (VHIVUS) utilises the ultrasound backscatter signal in order to colour code plaque into four pre-specified subtypes based on their histological composition. We review the background behind traditional grey scale intravascular ultrasound (IVUS) and examine the current evidence for VHIVUS and its potential for use in clinical interventional practice.

Expression of Ca2+ -activated K+ channels in human dermal fibroblasts and their roles in apoptosis

BACKGROUNDS/AIMS

Cell proliferation and apoptosis are responsible for maintaining normal tissue homeostasis, and K(+) currents play important roles in regulating the physiological balance between them. This function of Ca(2+)-activated K(+) (K(Ca)) channels has been demonstrated in many types of tissues, but not in dermal fibroblasts. We investigated the expression of K(Ca) channels and their effects on proliferation and apoptosis in human dermal fibroblasts.

METHODS

We used discoidin domain receptor 2 immunostaining to identify human dermal fibroblasts, and reverse transcription polymerase chain reaction, Western blot analysis and electrophysiological patch clamp recordings to evaluate the expression and characteristics of 3 members of the K(Ca) channel family, large-conductance K(Ca) (BK), intermediate-conductance K(Ca) (IK) and small-conductance K(Ca) channels. We also used the 3-(4,5-dimethyl-2-yl)-2,5-diphenyltetrazolium bromide assay, flow cytometry, Hoechst 33258 staining and Depsipher staining to investigate the effects of K(Ca) channels on cell proliferation and the mechanisms involved.

RESULTS AND CONCLUSIONS

All 3 members of the K(Ca) channel family were found in fibroblasts. 1,3-Dihydro-1-[2-hydroxy-5-(trifluoromethyl)phenyl]-5-(trifluoromethyl)-2H-benzimidazol-2-one (NS1619, a BK channel activator) or 1-ethyl-2-benzimidazolinone (EBIO, an IK channel activator) decreased the proliferation of fibroblasts and induced apoptotic changes by mitochondrial membrane potential disruption. However, a pan-caspase inhibitor (Z-VAD-fmk) failed to prevent the apoptotic changes. Our findings indicate that 3 types of functional K(Ca) channels are expressed in human dermal fibroblasts and are involved in apoptosis of the cells through the mitochondrial apoptotic pathway, but seemingly in a caspase-independent manner.

The attentional cost of external rhythmical cues and their impact on gait in Parkinson's disease: effect of cue modality and task complexity

Changes in gait performance in 153 subjects with PD using three rhythmical cues (auditory, visual and somatosensory) were measured during a simple walking task and a dual walking task in the home. Subjects were 'on' medication and were cued at preferred step frequency. Accelerometers recorded gait and walking speed, step amplitude and step frequency were determined from raw data. Data were analysed with SAS using linear regression models. Gait performance during a single task reduced with cues in contrast to a dual task where PD subjects appeared to benefit from rhythmical cues (increased speed and step length). Effects were dependent on cue modality with significant improvements for auditory cues compared to others. A significant short-term carry-over effect of cues reduced 3 weeks later. Cues may reduce attentional demands by facilitating attentional allocation, accounting for differences of cue seen during single and dual task. Furthermore cue modality may influence attentional demand which is an important consideration for rehabilitation.

Cueing training in the home improves gait-related mobility in Parkinson's disease: the RESCUE trial

OBJECTIVES

Gait and mobility problems are difficult to treat in people with Parkinson's disease. The Rehabilitation in Parkinson's Disease: Strategies for Cueing (RESCUE) trial investigated the effects of a home physiotherapy programme based on rhythmical cueing on gait and gait-related activity.

METHODS

A single-blind randomised crossover trial was set up, including 153 patients with Parkinson's disease aged between 41 and 80 years and in Hoehn and Yahr stage II-IV. Subjects allocated to early intervention (n = 76) received a 3-week home cueing programme using a prototype cueing device, followed by 3 weeks without training. Patients allocated to late intervention (n = 77) underwent the same intervention and control period in reverse order. After the initial 6 weeks, both groups had a 6-week follow-up without training. Posture and gait scores (PG scores) measured at 3, 6 and 12 weeks by blinded testers were the primary outcome measure. Secondary outcomes included specific measures on gait, freezing and balance, functional activities, quality of life and carer strain.

RESULTS

Small but significant improvements were found after intervention of 4.2% on the PG scores (p = 0.005). Severity of freezing was reduced by 5.5% in freezers only (p = 0.007). Gait speed (p = 0.005), step length (p<0.001) and timed balance tests (p = 0.003) improved in the full cohort. Other than a greater confidence to carry out functional activities (Falls Efficacy Scale, p = 0.04), no carry-over effects were observed in functional and quality of life domains. Effects of intervention had reduced considerably at 6-week follow-up.

CONCLUSIONS

Cueing training in the home has specific effects on gait, freezing and balance. The decline in effectiveness of intervention effects underscores the need for permanent cueing devices and follow-up treatment. Cueing training may be a useful therapeutic adjunct to the overall management of gait disturbance in Parkinson's disease.

Species dependent expression of intestinal smooth muscle mechanosensitive sodium channels

A mechanosensitive Na(+) current carried by Na(v)1.5 is present in human intestinal circular smooth muscle and contributes to regulation of intestinal motor function. Expression of this channel in different species is unknown. Our aim was to determine if Na(+) currents and message for the alpha subunit of the Na(+) channel (SCN5A) are found in circular smooth muscle cells of human, dog, pig, mouse and guinea pig jejunum. Currents were recorded using patch clamp techniques. Message for SCN5A was investigated using laser capture microdissection and reverse transcription polymerase chain reaction (RT-PCR). Na(+) currents were identified consistently in human and dog smooth muscle cells; however, Na(+) current was not found in pig (0/20) or guinea pig smooth muscle cells (0/21) and found only one mouse cell (1/21). SCN5A mRNA was found in circular muscle of human, dog, and mouse, but not in pig or guinea pig, and not in mouse longitudinal or mucosal layers. In summary, SCN5A message is expressed in, and Na(+) current recorded from, circular muscle layer of human and dog but not from pig and guinea pig. These data show that there are species differences in expression of the SCN5A-encoded Na(v)1.5 channel, suggesting species-specific differences in the electrophysiological response to mechanical and depolarizing stimuli.

The effect of rhythmic somatosensory cueing on gait in patients with Parkinson's disease

BACKGROUND AND AIMS

Gait and gait related activities in patients with Parkinson's disease (PD) can be improved with rhythmic auditory cueing (e.g. a metronome). In the context of a large European study, a portable prototype cueing device was developed to provide an alternative for rhythmic auditory cueing: rhythmic somatosensory cueing (RSC, a miniature vibrating cylinder attached to the wrist). We investigated whether PD patients could adapt their walking pattern using RSC under conditions of changing walking speed and the presence of potentially distracting visual flow while walking on a treadmill.

METHODS

A total of 17 patients with PD participated (mean age 63.4+/-10.3 years; Hoehn-Yahr score 2.5+/-0.9, mean Unified Parkinson's Disease Rating Scale score 49.8+/-13.7, mean disease duration 7.7+/-5.1 years). They performed systematic walking speed manipulations under 4 conditions in a random order: (1) no cue, no visual flow, (2) no cue, visual flow, (3) cue, no visual flow and (4) cue, visual flow. Visual flow in the form of a virtual corridor that moved at the current walking speed was projected on a 2 x 2 m rear-projection screen. The cueing rhythm was set at -10% of preferred stride frequency at each speed. Stride frequency was assessed using peaks in the trajectories of thigh sagittal plane segmental angles.

RESULTS

Walking with RSC resulted in lower stride frequencies, and thus larger step lengths (p-values <0.05), regardless of walking speed. The presence of visual flow did not impair the use of RSC, as evidenced by the lack of differences between conditions 3 and 4 (p>0.05).

CONCLUSION

Rhythmic somatosensory cueing may be a viable alternative for auditory cueing and is robust to changes in walking speed and visual distractors.

The effects of visual rhythms and optic flow on stride patterns of patients with Parkinson's disease

This study was aimed at determining the effects of rhythmic visual cueing under changing visual conditions on stride frequency in patients with Parkinson's disease (PD; n = 21) and healthy age matched controls (n = 7) while walking at different speeds on a treadmill. Stride frequency and stride length in patients with PD as well as controls were not rigidly coupled to walking speed and could be manipulated with walking speed as well as by using spatial and temporal rhythmic visual cues.

Nitric oxide stimulates a large-conductance Ca-activated K+ channel in human skin fibroblasts through protein kinase G pathway

In order to investigate the large-conductance Ca(2+)-activated K(+) (BK(Ca)) channel and determine the effects of nitric oxide (NO) on the channel in human skin fibroblasts, we performed electrophysiological patch clamp recordings on 5th-passage cells of human genital skin cultures. The whole-cell outward K(+) current was increased with depolarization, and proved to be sensitive to NS1619 (a selective BK(Ca) channel activator) and iberiotoxin (a specific BK(Ca )channel inhibitor). The single-channel currents showed 226 pS of mean conductance in symmetrical K(+). Sodium nitroprusside (SNP; an NO donor) significantly increased the K(+) current amplitude in the whole-cell mode, and open probability of the channel (NPo) in the cell-attached mode, but not in the inside-out mode. S-nitroso-N-acetylpenicillamine (an NO donor) and 8-Br-cGMP (a membrane-permeant cGMP analogue) also increased the BK(Ca )channel activity. The stimulatory effect of SNP on BK(Ca) channels was inhibited by pretreatment with 1H-[1,2,4]-oxadiazolo[4,3-a]quinoxalin-1-one (a soluble guanylyl cyclase inhibitor), or KT5823 [a specific protein kinase G (PKG) inhibitor]. Cytoplasmic PKG also increased the channel activity in inside-out patches. In conclusion, the present data indicate that BK(Ca) channels constitute a significant fraction of K(+) current in human skin fibroblasts, and that NO increases NPo of BK(Ca) channels, which are mediated via the cGMP/PKG pathway, without direct effects on the channel.

Neuropeptide precursor processing detected by triple immunolabeling

Peptides that play critical physiological roles are often encoded in precursors that contain several gene products. Differential processing of a polypeptide precursor by cell-specific proteolytic enzymes can yield multiple messengers with diverse distributions and functions. We have isolated SDNFMRFamide, DPKQDFMRFamide, and TPAEDFMRFamide from Drosophila melanogaster. The peptides are encoded in the FMRFamide gene and have a common C-terminal FMRFamide but different N-terminal extensions. In order to investigate the regulation of expression of FMRFamide peptides, we generated antisera to distinguish between the structurally related neuropeptides. We established a triple-label immunofluorescence protocol using antisera raised in the same host species and mapped the neural distribution of SDNFMRFamide, DPKQDFMRFamide, and TPAEDFMRFamide. Each peptide has a unique, nonoverlapping cellular expression pattern, suggesting that the precursor is differentially processed. Thus, our data indicate that D. melanogaster contains cell-specific proteolytic enzymes to cleave a polypeptide protein precursor, resulting in unique expression patterns of neuropeptides.

Regulation of Drosophila FMRFamide neuropeptide gene expression

Physiologically important peptides are often encoded in precursors that contain several gene products; thus, regulation of expression of polypeptide proteins is crucial to transduction pathways. Differential processing of precursors by cell- or tissue-specific proteolytic enzymes can yield messengers with diverse distributions and dissimilar activities. FMRFamide-related peptides (FaRPs) are present throughout the animal kingdom and affect both neural and gastrointestinal functions. Organisms have several genes encoding numerous FaRPs with a common C-terminal structure but different N-terminal amino acid extensions. We have isolated SDNFMRFamide, DPKQDFMRFamide, and TPAEDFMRFamide contained in the Drosophila FMRFamide gene. To investigate the regulation of expression of FMRFamide peptides, we generated antisera to distinguish among the three neuropeptides. We have previously reported the distribution of SDNFMRFamide and DPKQDFMRFamide. In this article, we describe TPAEDFMRFamide expression. TPAEDFMRFamide antisera stain cells in embryonic, larval, pupal, and adult thoracic and abdominal ganglia. In addition, TPAEDFMRFamide-immunoreactive material is present in a lateral protocerebrum cell in adult. Thus, TPAEDFMRFamide antisera staining of neural tissue is different from SDNFMRFamide or DPKQDFMRFamide. In addition, TPAEDFMRFamide antisera stain larval, pupal, and adult gut, while SDNFMRFamide and DPKQDFMRFamide do not. TPAEDFMRFamide immunoreactivity is present in cells stained by FMRFamide antisera. Taken together, these data support the conclusion that TPAEDFMRFamide is differentially processed from the FMRFamide polypeptide protein precursor and may act in both neural and gastrointestinal tissue.

Antisera to multiple antigenic peptides detect neuropeptide processing

Peptides act as critical messengers of essential physiological function. Frequently, several peptides are encoded in the same precursor and, often, there is structure relatedness among the gene products. The complexity of protein precursors and presence of homologous peptides raises issues about regulation of gene expression and function of structurally-related peptides. We have determined the cellular location of DPKQDFMRFamide and SDNFMRFamide encoded in the Drosophila FMRFamide gene. We raised antisera that distinguish between the two peptides and conducted double label immunostaining utilizing antisera raised in the same host species. We found that DPKQDFMRFamide and SDNFMRFamide are present in distinct distribution patterns. We also established that the peptides are present in cells stained by FMRFamide antisera. Thus, our data are consistent with the conclusion that Drosophila contains cell-specific proteolytic processing enzymes capable of posttranslationally cleaving a polypeptide protein precursor to yield unique expression patterns of neuropeptides that may have diverse activities.

Dromyosuppressin and drosulfakinin, two structurally related Drosophila neuropeptides, are uniquely expressed in the adult central nervous system

Drosophila myosuppressin (TDVDHVFLRFamide; DMS) and sulfakinin (FDDYGHMRFamide; DSK) have similar C-terminal structures. To determine the neuronal expression patterns of these structurally related peptides, we have generated DMS- and DSK-specific antisera to multiple antigenic peptides and performed double-label immunochemistry with antisera raised on different animals of the same species host animal. Our data indicate that DMS and DSK staining patterns in the adult central nervous system are unique and nonoverlapping.

Multiple antigenic peptides designed to structurally related Drosophila peptides

We have isolated TDVDHVFLRFamide (DMS), FDDYGHMRFamide (DSK), and DPKQDFMRFamide from Drosophila melanogaster. These peptides, structurally related by a common C-terminus -XRFamide, where X = L or M, are encoded by three different genes. To determine cellular expression, we have generated antisera to multiple antigenic peptides and performed double-label immunofluorescence using antisera raised in the same species host animal. Our results indicate that DMS and DSK immunoreactive materials have unique, non-overlapping expression patterns, while DMS and DPKQDFMRFamide immunoreactive materials colocalize in two superior protocerebrum neurons, and DSK and DPKQDFMRFamide immunoreactive materials colocalize in one superior protocerebrum neuron, one subesophageal ganglion neuron, and three thoracic ganglia neurons.

Cellular expression of the Drosophila melanogaster FMRFamide neuropeptide gene product DPKQDFMRFamide. Evidence for differential processing of the FMRFamide polypeptide precursor

DPKQDFMRFamide is one of five different FMRFamide-containing peptides encoded in the Drosophila FMRFamide gene. To study the cellular expression of DPKQDFMRFamide, we have generated antisera to DPKQD, the N-terminal sequence of the peptide, to avoid crossreactivity with other -FMRFamide-containing peptides. The antisera were purified and the specificity characterized. DPKQDFMRFamide immunoreactive material is first observed in the embryonic central nervous system (CNS) in one cell of the subesophageal ganglion and one cell in each of the three thoracic ganglia. This pattern of expression is observed in larval, pupal, and adult neural tissue, albeit with increased signal intensity. In larva, pupa, and adult, additional cells in the superior protocerebrum, a thoracic ganglion, and an abdominal ganglion express DPKQDFMRFamide immunoreactive material. Immunoreactivity is observed in a cell in the lateral protocerebrum of pupa and adult and cells in the optic lobe of adult. No immunoreactive material was observed in gut tissue. DPKQDFMRFamide antisera stain a subset of cells previously identified by in situ hybridization and immunocytochemistry to express the FMRFamide transcript and polypeptide precursor. These data suggest that the Drosophila FMRFamide polypeptide precursor undergoes differential processing to produce DPKQDFMRFamide immunoreactive material in a limited number of cells expressing the FMRFamide precursor.

Rule based artificial intelligence expert system for determination of upper extremity impairment rating

Quantitative evaluation of upper extremity impairment, a percentage rating most often determined using a rule based procedure, has been implemented on a personal computer using an artificial intelligence, rule-based expert system (AI system). In this study, the rules given in Chapter 3 of the AMA Guides to the Evaluation of Permanent Impairment (Third Edition) were used to develop such an AI system for the Apple Macintosh. The program applies the rules from the Guides in a consistent and systematic fashion. It is faster and less error-prone than the manual method, and the results have a higher degree of precision, since intermediate values are not truncated.

Rapid prototyping of interactive software for automated instrumentation in rehabilitative therapy

Rapid prototyping is a quick, efficient way to evaluate new electrical instruments. A hardware interface between a computer and an instrument can be simulated in software. The authors demonstrate the technique of rapid prototyping by developing interfaces for two therapeutic strength-testing devices and an electromagnetic tracker/digitizer. The LabVIEW rapid prototyping software tool was used to create "virtual instruments," which combine to form interfaces. The functions and connections of each virtual instrument are described.

Comparative evaluation of nonradiometric BACTEC and improved oxoid signal blood culture systems in a clinical laboratory

The BACTEC NR660 blood culture system, which uses infrared spectroscopy to detect carbon dioxide generated by bacterial growth, was compared with the new medium formulation of the Oxoid Signal system. Two trials were conducted: a comparative study of 88 organisms in simulated blood cultures and a clinical trial of 3,321 paired patient blood culture samples. Both trials showed that overall the BACTEC system performed better in the recovery of organisms. The Oxoid system was unable to detect by signal the growth of the majority of yeasts, nonfermentative gram-negative bacilli, Neisseria meningitidis, Nocardia spp., and Corynebacterium jeikeium. There were no significant differences in the yield of Staphylococcus spp., members of the family Enterobacteriaceae, Streptococcus spp., or anaerobic organisms. BACTEC detected growth more quickly than did the Oxoid system; 61% of the isolates were detected by BACTEC at 24 h, while 49% of the isolates were detected by Oxoid. The Oxoid system had a high proportion (58.5%) of false-positives, compared with 7.7% for the BACTEC system. Despite the new medium formulation of the Oxoid system, its performance is still not equivalent to that of the BACTEC system.

Stereoselective sulfoxidation of a series of alkyl p-tolyl sulfides by microsomal and purified flavin-containing monooxygenases

The enantioselective sulfoxidation of a series of alkyl p-tolyl sulfides was compared using purified rabbit lung and mini-pig liver flavin-containing monooxygenase (FMO). Analysis was performed by chiral-phase high pressure liquid chromatography, which afforded baseline resolution of each pair of enantiomers. The extent of enantioselective sulfoxidation was found to be a function of (a) the isozyme employed, (b) the steric bulk of the alkyl substituent, and (c) pH. At pH 8.5, rabbit lung FMO catalyzed the oxidation of methyl, ethyl, propyl, and isopropyl sulfides to products with greater than 99, 91, 85, and 63% (R)-(+)-stereochemistry, respectively. Corresponding values for the mini-pig liver form were 91, 82, 72, and 41% (R)-(+)-sulfoxide. The stereochemical profile obtained with the isolated rabbit lung form could be duplicated exactly in microsomal preparations if precautions were taken to abolish the contribution that P-450 makes to net stereochemistry. It was noted that increasing the reaction mixture pH from 8.5 to 10 led to a decrease in the stereochemical purity of products obtained from the lung form. In contrast, the stereochemical profile obtained with the isolated mini-pig liver form could not be exactly duplicated in suitably treated microsomal preparations. No evidence for multiple forms of mini-pig liver FMO was obtained, and it was concluded that discrepancies between microsomal and purified FMO metabolic profiles were most consistent with a minor modification to active site geometry occurring during purification of the mini-pig form. These data show that the active site chirality of rabbit lung and mini-pig liver FMO is largely retained following removal from microsomal membranes. Qualitative similarities in the structure-activity relationships exhibited by microsomal or purified FMO from rabbit lung and mini-pig liver suggest some conservation of active site geometry between these two otherwise distinct FMOs. Quantitative differences in the structure-activity relationships exhibited by the two FMO forms indicate that analysis of product stereochemistry may be a useful method for the discrimination of catalytically distinct FMO isozymes.

A prospective hospital study of the aetiology of community-acquired pneumonia

In a one-year prospective study of 106 adults (mean age, 60 years) who were admitted to hospital with community-acquired pneumonia, an aetiological diagnosis was made in 82 (77%) patients. Streptococcus pneumoniae was considered to be responsible for 44 (42%) and respiratory viruses for 19 (18%) infections. Other aetiological agents that were found in a smaller number of patients included Haemophilus influenzae (9% of patients), enteric Gram-negative bacilli (8% of patients), Staphylococcus aureus (3% of patients), Legionella spp. (3% of patients), Mycobacterium tuberculosis (3% of patients), Mycoplasma pneumoniae (8% of patients) and Chlamydia psittaci (5% of patients). The mortality was 10% and was related significantly to increasing age and to coexisting heart and lung disease. Antibiotic treatment that was commenced before admission to hospital and investigations were undertaken reduced significantly the isolation rate of susceptible bacterial pathogens. The Gram-stained smear of sputum was valuable in establishing a tentative diagnosis of bacterial pneumonia. The most-useful tests in making an early diagnosis proved to be those which detected pneumococcal and mycoplasmal antigens, blood cultures and culture of sputum for appropriate bacterial pathogens.

Legionella longbeachae pneumonia: report of two cases

Legionella longbeachae serogroup 1 was isolated from the respiratory secretions of two patients with community-acquired pneumonia. One patient had a mild infection without evidence of the involvement of other organs and recovered, in spite of inappropriate antibiotic therapy. The other patient was severely-ill on presentation with multisystem failure and died soon after admission to hospital. The organisms were identified by the immunofluorescence technique and by quantitative DNA-hybridization studies. The sources of the infection in these patients are unknown as the organism has never been isolated from the SA environment.

Extragenital Mycoplasma hominis infection: a report of two cases

Mycoplasma hominis was isolated from the surgical wounds of two patients. One of these patients developed a septicaemia-like illness after coronary artery vein-graft surgery. Mycopl. hominis was isolated from the sternotomy wound and pleural fluid of this patient but not from his blood. No other pathogens were isolated. The second patient developed a low-grade soft-tissue infection due to Mycopl. hominis in a craniotomy wound; his condition responded to tetracycline treatment. The source of infection in both cases presumably was mycoplasmaemia which was secondary to urethral catheterization. Infections due to Mycopl. hominis are overlooked easily unless appropriate steps are taken to isolate and to identify these organisms.