Extensively hydrolysed infant formulas: Need for aligned definition of peptide size characteristics and standardisation of analytical methods.

Letter by Nutten et al. on article by Levin et al. (Levin ME, Blackhurst DM, Kirstein F, Kok D, van der Watt GF, Marais AD. Residual allergenicity of amino acid-based and extensively hydrolysed cow's milk formulas. S Afr Med J 2017;107(9):763-767. S Afr Med J 2017;107(3):258-263. https://doi.org/10.7196/SAMJ.2017.v107i9.12137); and response by Levin et al.

Peptides obtained by tryptic hydrolysis of bovine beta-lactoglobulin induce specific oral tolerance in mice.

BACKGROUND: Oral tolerance against food proteins has been achieved in different animal models with use of native or moderately hydrolyzed proteins as inducers. However, native proteins remain highly allergenic, although it has been demonstrated that protein hydrolyzates and resulting peptides can lose their allergenicity. OBJECTIVE: This study was designed to evaluate the ability of beta-lactoglobulin hydrolyzate and peptides to induce oral tolerance to native beta-lactoglobulin and to identify tolerogenic beta-lactoglobulin peptides with low allergenicity. METHODS: beta-Lactoglobulin was hydrolyzed by trypsin and fractionated by ion exchange chromatography. Peptide enrichment of fractions was evaluated. Balb/c mice were fed beta-lactoglobulin hydrolyzate or fractions by single gavage at day 1. Five days later animals were challenged intraperitoneally with native beta-lactoglobulin. At day 27 delayed-type hypersensitivity was performed. Twenty-four hours later mice were bled, and intestinal contents and spleens were collected. Oral tolerance was measured by titrating specific IgE in sera and intestinal samples. Specific T-cell responses were analyzed by splenocyte proliferation. Antigenicity of hydrolyzate and fractions was evaluated by specific ELISA inhibition. RESULTS: Mice fed either beta-lactoglobulin hydrolyzate or 2 fractions of the hydrolyzate were tolerized against beta-lactoglobulin. Specific serum and intestinal IgE were suppressed. Delayed-type hypersensitivity and proliferative responses were inhibited. One tolerogenic fraction was found to be 50 times less antigenic than the total beta-lactoglobulin hydrolyzate was. CONCLUSION: These findings support the strategy of inducing oral tolerance in "at-risk" patients by means of tolerogenic cow's milk peptides or hydrolyzate.

Neurologic recovery after traumatic spinal cord injury: data from the Model Spinal Cord Injury Systems.

OBJECTIVE: To present data on neurologic recovery gathered by the Model Spinal Cord Injury (SCI) Systems over a 10-year period. DESIGN: Case series. SETTING: Twenty-one Model SCI Systems. PATIENTS: A total of 3,585 individuals with traumatic SCI admitted between January 1, 1988 and December 31, 1997. MAIN OUTCOME MEASURES: Neurologic impairment category; Frankel grade; American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade; motor score. RESULTS: SCI caused by violence is more likely than SCI from nonviolent etiologies to result in a complete injury. Changes in severity of injury were similar using the older Frankel scale and the newer ASIA Impairment Scale. Individuals who were motor-complete with extended zones of sensory preservation but without sacral sparing were less likely to convert to motor-incomplete status than those with sacral sparing (13.3% vs 53.6%; p < .001). Motor score improvements at 1 year were related to severity of injury, with greater increases for better AIS grades except grade D, because of ceiling effects. Individuals with AIS grade B injuries have a mixed prognosis. CONCLUSION: Neurologic recovery after SCI is influenced by etiology and severity of injury. Multicenter studies on prognostic features such as preserved pin sensation in grade B injuries may identify subgroups with similar recovery patterns. Identification of such groups would facilitate clinical trials for neurologic recovery in acute SCI.

Employment after spinal cord injury: an analysis of cases from the Model Spinal Cord Injury Systems.

OBJECTIVE: To describe the relationship of multiple biographic, injury-related, and educational factors with employment outcomes after spinal cord injury (SCI). DESIGN: Cross-sectional. SETTING: Data were collected through 18 model SCI systems, a nationwide network of hospitals that treat approximately 14% of all SCIs in the United States. PARTICIPANTS: A total of 3,756 persons with traumatic SCI who completed the Form II data collection during their annual follow-up at years 1, 2, 5, 10, 15, 20, or 25 years (the most recent Form II was accepted). MAIN OUTCOME MEASURES: The Model Systems Forms I and II were used to identify biographic, injury-related status, employment at injury, and productivity status upon follow-up (Form I is used to elicit basic demographic and discharge information, whereas Form II is used to track multiple outcomes during annual follow-ups). The Craig Handicap Assessment Reporting Technique (CHART) was used to assess hours spent in gainful employment and other productive activities. RESULTS: CHART data revealed only a modestly higher Employment rate (24.8%) than that of the traditional single Form II item (22%). Being Caucasian, younger at injury, having lived more years with SCI, having a less severe injury, and having more years of education were all predictive of being employed. Violence at injury was associated with lower employment rates (only 12.9% employed), especially among Caucasians (only 24% employed). Being employed at injury was associated with a greater probability of postinjury employment, but only in the first few years after injury. Among employed participants, women and those who had been injured fewer years averaged fewer hours spent at work. CONCLUSIONS: Findings were consistent with those in previous studies. Interventions to improve employability should focus on education and the needs of individuals from minority backgrounds.

A test of the 1992 International Standards for Neurological and Functional Classification of Spinal Cord Injury.

This study was designed to test the 1992 International Standards for Neurological and Functional Classification of Spinal Cord Injury. One hundred and six professionals in the field of spinal cord injury attending an instructional course at the 1994 ASIA Meeting participated in the test. Participants completed a pretest and posttest in which they classified two patients who had a spinal cord injury (one with complete tetraplegia and one with incomplete paraplegia) by sensory and motor levels, zone of partial preservation (ZPP), ASIA Impairment Scale and completeness of injury. Between tests, three members of the ASIA Standards Executive Committee gave presentations on the neurological assessment, scoring, scaling and classification of spinal cord injury and a video of the actual examinations of the two cases was viewed. Percent 'correct' (as defined by the ASIA Standards Committee) was calculated for sensory and motor levels, ZPP, ASIA Impairment and completeness. Overall, the analyses showed that participants had very little difficulty in correctly classifying the patient with complete tetraplegia. Pretests scores ranged from 72% (left motor level) to 96% (complete injury), posttest scores from 73% (left motor level) to 100% correct (complete injury). For the patient with incomplete paraplegia (Case 2), scores were considerably lower. Pretest scores ranged from 16% (right motor level) to 95% correct (incomplete injury); posttest scores from 21% (right motor level) to 97% correct (incomplete injury). The results showed that further revisions of the 1992 Standards and more training is needed to ensure accurate classification of spinal cord injury.

Human IgE binding capacity of tryptic peptides from bovine alpha-lactalbumin.

The specific IgE binding capacity of native bovine alpha-lactalbumin (alpha-La), a globular whey protein, and tryptic peptides was investigated using 19 sera from patients with cow's milk protein allergy. The specific anti-bovine alpha-La IgE titers ranged from 0.6 to 125 IU/ml. Highly purified tryptic peptides from native and disulfide-bond-reduced alpha-La were obtained by reverse phase chromatography. By ELISA technique using immobilized native protein or peptides, 11 of the 19 sera reacted exclusively with intact protein while 8 of them also presented a specific IgE response to different tryptic peptides. Polyclonal IgE population specificity was not related to anti-bovine alpha-La IgE levels. Sequence (17G-K58) and larger peptides sharing this sequence were most strongly and frequently recognized. Competitive ELISA inhibition tests confirmed this IgE-specific response and gave also clear evidence for IgE binding to smaller peptides corresponding to sequences (6C-R10):S-S:(115L-L123) and (109A-L123). IgE binding to native alpha-La and large peptides confirmed the importance of conformational epitope(s). However, in some sera reduced and S-alkylated peptide (59I-K94) exhibited a similar or higher IgE binding capacity than the native corresponding fragment, suggesting the existence of sequential epitope(s) exposed through protein denaturation. Moreover, IgE binding sequences were also located within hydrophobic regions of alpha-La and/or within parts with high sequence homology to human alpha-La.

Moderator-variable effect on the Brief Symptom Inventory test-item endorsements of spinal cord injury patients.

This study shows that results from the Brief Symptom Inventory (BSI), an instrument used in several US rehabilitation centers to assess psychological distress among patients, are significantly confounded by the somatic characteristics of physically disabled patients with a specific diagnosis: spinal cord injury. Our findings also illustrate the nature and the effect of this moderator variable of physical condition on BSI item endorsement and suggest a method for controlling the moderator's variable effect. The BSI item responses of 288 persons with spinal cord injury (SCI) were compared to a non-patient normative sample of 719 persons. Thirty-six items reliably differentiated the two groups (p < 0.001) and seven of these items were judged to be physical sequelae of SCI. Other highly endorsed items describe a frequent pattern of psychological response to SCI. This response pattern does not appear to reflect the latent variables which are claimed to underlie test items. Expected endorsement of these items by patients with SCI can lead to errors in test interpretation by rehabilitation professionals.

Predicting depression and psychological distress in persons with spinal cord injury based on indicators of handicap.

This study examined whether experiences of handicap influence levels of depression and distress among persons with spinal cord injury (SCI) during the years after initial discharge from rehabilitation. SCI outpatients (163), who had received inpatient treatment at one of two rehabilitation centers in Michigan and who were between 2 to 7 years since injury, participated in the study. Measures of depression, of psychological distress and of handicap were collected during 2 consecutive years utilizing the Zung Self-Rating Scale, the Brief Symptom Inventory and the Craig Handicap Assessment and Reporting Technique (CHART) in conjunction with the Perceived Handicap Questionnaire (PHQ), respectively. According to the study's findings, depressed/distressed SCI subjects reported spending more hours in bed (P < 0.01), fewer days out of the house (P < 0.03) and receiving more paid personal care assistance (P < 0.02) than did other subjects. They also expended more for general medical expenses (P < 0.001) and reported less access to readily available transportation (P < 0.003). CHART total scores, reflecting a simple objective measure of handicap as described by Whiteneck et al. (Whiteneck GG, Charlifue SW, Gerhart KA, Overholser JD, Richardson GN: Guide for Use of the CHART: Craig Handicap Assessment and Reporting Technique. Craig Hospital, CO, 1988) were significantly associated with both distress and depression as measured during the second year of data collection. Other significant predictors of depression and distress included subjects' self-perceived handicap (measured by the PHQ), gender, marital status and age.(ABSTRACT TRUNCATED AT 250 WORDS)

Determining differences in post discharge outcomes among catastrophically and noncatastrophically sponsored outpatients with spinal cord injury.

This study tested differences in functional independence status, level of psychologic distress and extent of handicap experienced after discharge from inpatient rehabilitation among a group of 125 outpatients with spinal cord injury (SCI) sponsored by one of three types of rehabilitation insurance payors: catastrophic (Michigan Automobile No-Fault and Workers' Disability Compensation), Medicaid and third-party privates. Outcome measures included the functional independence measure, the brief symptom inventory and the Craig handicap assessment reporting technique. Insurance data was obtained via medical chart reviews and interviews that were conducted either face-to-face or by telephone, using the benefits coverage inventory. No differences in terms of post discharge functional independence across subjects sponsored by the three payors was found when controlling for neurologic status. However, SCI subjects sponsored by different payors reported receiving different amounts of benefits. Subjects also differed on the extent of psychologic distress experienced after discharge and the extent of their handicaps. SCI subjects sponsored by Medicaid reported receiving fewer benefits, being more distressed and experiencing greater handicap in comparison to others. Third-party privately sponsored subjects, conversely, experienced less handicap and distress than did the study's other subjects.

Coping with the late effects: differences between depressed and nondepressed polio survivors.

This study examined differences between depressed and nondepressed individuals with a history of paralytic poliomyelitis in terms of demographics, health status and coping strategies. The prevalence of distress and depression in this group of 116 polio survivors was determined. Subjects completed the Brief Symptom Inventory, the Coping with Disability Inventory and a questionnaire concerning their polio histories and self-perceptions of health. Medical assessments were performed by physicians. Only 15.8% of the sample had scores indicating depression and elevated distress. Depressed/distressed polio survivors were more likely to: be living alone, be experiencing further health status deterioration, seek professional help, view their health as poor, report greater pain, be less satisfied with their occupational status and their lives in general and exhibit poorer coping outcome behaviors in relation to their disability. Three factors in coping with the late effects of polio were identified through a factor analysis of the Coping with Disability Inventory: positive self-acceptance, information seeking/sharing about the disability and social activism. Differences between depressed/distressed and other polio survivors were found across these three factors, with depressed/distressed subjects having significantly lower coping scores. These and other results are discussed.

Predictors of psychologic distress one year after spinal cord injury.

This study investigated predictors of psychologic distress at 1 year after injury. The brief symptom inventory, a symptom checklist that provides an overall index of distress, was administered to 119 spinal cord-injured patients. All patients had diagnoses of recent, traumatic SCI and had been admitted for initial inpatient rehabilitation between 1985 and 1990. Results showed levels of psychologic distress to be significantly higher 1 year after injury when compared with results obtained on admission and at discharge from the inpatient rehabilitation program. The prevalence rate for elevated distress after injury was 28%. Significant predictors of psychologic distress 1 year after injury included level of distress at admission, neurologic completeness of SCI, type of rehabilitation insurance payor (catastrophic v noncatastrophic), occupational status before SCI and participation status in an inpatient independent living program. A multiple regression model with nine independent variables was specified that explained 63% of the variance in psychologic distress measured after injury.

Prevalence and associated features of depression and psychological distress in polio survivors.

This cross-sectional study examines the prevalence of psychological distress and depression among 116 polio survivors. It investigates demographic, medical, and coping differences between subjects with (n = 17) and without (n = 99) these symptoms. Subjects were administered the Brief Symptom Inventory (BSI), the Coping with Disability Inventory (CDI), and a questionnaire about their polio histories. The BSI provided measures of psychological distress and depression that defined the subgroups. The CDI assessed coping behaviors. BSI scores for the overall sample were within the normal range indicating no major distress, depression, nor elevated somatic complaints. Several significant differences were found between the two subgroups. On average, depressed/distressed subjects reported an increase in pain (p < .01) and further deterioration of their medical status since the time of their physical best subsequent to the onset of polio (p < .01). They consistently rated their health as poorer than did nondepressed/nondistressed subjects (p < .001). They also reported less satisfaction with life and their occupational status (p < .001) and displayed poorer coping behaviors combined (p < .001). Selected variables such as life satisfaction, pain, decrease in activity, and current living situation accounted for 51% of the variance when predicting distress and depression among this group of polio survivors.

Incidence, characteristics, and outcome of spinal cord injury at trauma centers in North America.

Acute spinal cord injury occurred in 2.6% of the 114,510 patients entered into the Major Trauma Outcome Study from 1982 to 1989. The most common causes of spinal cord injury were motor vehicle accidents (40%), falls (20%), and gunshot wounds (13.6%). Almost 80% of patients with spinal cord injury had multiple injuries. Cervical cord injury was seen in 65% of patients with isolated spinal cord injury, but in only 52% of patients with multiple injuries. The hospital mortality rate was 17%, with patients with multiple injuries having a significantly higher mortality rate than patients with isolated spinal cord injury (19.8% vs 6.9%). The TRISS method overpredicted the mortality rate among patients with multiple injuries (450 vs 379), but not among those with isolated injury. A program for better national surveillance and prevention of spinal cord injury is warranted.

Insurance benefits coverage for persons with spinal cord injuries: determining differences across payors.

This investigation represents a preliminary step in determining differences in benefits coverage among three types of rehabilitation insurance payors (Catastrophic payors, which include Automobile No-Fault and Workers' Disability Compensation; Medicaid; and Third-party private payors). Subjects in this study were 122 spinal cord injury (SCI) outpatients who received their initial rehabilitation at the University of Michigan Medical Center and at the Rehabilitation Institute of Michigan. Insurance benefits received by them were examined across the following areas: accessible housing, transportation, personal attendant care services, professional outpatient services and adapted equipment. Results indicated differences across the three payors, with catastrophically-sponsored SCI outpatients receiving more benefits than SCI outpatients sponsored by public Medicaid or by private third-party insurance. Implications and recommendations for further studies are briefly discussed.

Osteoarthritis of the hand and wrist in the post poliomyelitis population.

People with a chronic motor disability of the legs become increasingly more dependent upon their upper limbs for mobility and self-care skills as they age. Many of them complain of hand and wrist pain. A cross-sectional study of 61 post-poliomyelitis survivors was done to determine the prevalence of osteoarthritis within this population and to determine any inherent risk factors. Each subject underwent a radiographic evaluation of both hands and wrist as well as a detailed physical examination. A questionnaire was used to ascertain a history of hand activity, use of canes/crutches, walkers and wheelchairs. The mean age of the population sample was 49 +/- 6 with a mean duration of disability of 35 +/- 4 years. The prevalence of moderate or severe osteoarthritis of either the hand or wrist was 13% whereas the prevalence was 68% when cases with mild arthritic changes were also included. The risk factors associated with hand and wrist osteoarthritis in this population included age, lower limb weakness, use of an assistive devices, and severity of disability.