Developing and testing a consensus-based core set of outcome measures for rehabilitation in musculoskeletal diseases.

OBJECTIVES: Rehabilitation is important for people with musculoskeletal diseases (MSDs), and evaluating the effect of rehabilitation on both an individual and group level is advocated. A consensus concerning use of outcome measures will improve collaboration between healthcare providers, and increase the possibility of conducting meta-analyses in future research. The aim of this study was to develop a consensus-based core set of outcome measures for rehabilitation in MSDs, and to test the feasibility and responsiveness of the set. METHOD: The core set was developed through a stepwise process comprising a Delphi consensus procedure, systematic literature searches, and a pilot study, including 386 patients, to test the feasibility and responsiveness of the set. RESULTS: The following aspects and outcome measures were selected: pain [numeric rating scale (NRS)], fatigue (NRS), physical fitness (the 30-second Sit to Stand test), mental health (Hopkins Symptom Checklist 5), daily activities (Hannover Functional Questionnaire), goal attainment (Patient-Specific Functional Scale including motivation score for baseline assessment), quality of life (5-level EuroQol 5 Dimensions), social participation (the social participation item from COOP/WONCA) and coping (Effective Musculoskeletal Consumer Scale-17). All tested outcome measures were found to be feasible, with high completion rates and acceptable score distribution. Standard response means varied from 0.3 to 0.9. CONCLUSIONS: A consensus-based core set of patient reported outcome measures is presented for evaluating rehabilitation in MSDs. The core set is feasible and responsive for use in Norway, but needs further testing in other countries.

An observational study of community-acquired severe sepsis comparing intensive care and non-intensive care patients.

BACKGROUND: Most studies of sepsis are from intensive care units (ICUs). We aimed to investigate community-acquired severe sepsis in a broader population, in order to compare patients treated in or outside an ICU . METHODS: We performed a 1-year prospective observational study with enrollment of patients from three units; a general ICU, a combined ICU/non-ICU and a medical ward with limited surveillance facilities. Hospital survivors were followed up for 5 years. RESULTS: Overall, 220 patients were included, of which 107 received ICU treatment. The majority of abdominal (77%, P = 0.003) and genitourinary (81%, P < 0.001) infections were found in ICU and non-ICU patients, respectively. Time to first antibiotic administration was longer in ICU-patients (median 3.5 vs. 2.0 h in non-ICU patients, P = 0.011). ICU developed more organ dysfunctions than non-ICU patients (P < 0.001), nevertheless supportive therapy with vasoactive drugs and non-invasive ventilation was documented in 22% and 27% of the latter. Median hospital length of stay was 15 vs. 9 days (P = 0.001), and hospital and 5-year mortality rates 35% vs. 16% (P = 0.002) and 57% vs. 58% (P = 0.892) among ICU and non-ICU patients, respectively. Increasing age (HR 1.06 (1.04, 1.07) per year, P < 0.001), not care level during hospitalization (HR 1.19 (0.70, 2.02), P = 0.514), influenced long-term survival. CONCLUSION: Half of the subjects with community-acquired severe sepsis never received ICU treatment. Still, use of organ supportive therapy outside the ICU was considerable. Hospital mortality was higher, whereas 5-year survival was similar when comparing ICU with non-ICU patients.

Lack of pro-inflammatory cytokine mobilization predicts poor prognosis in patients with acute heart failure.

AIMS: The aim of this study was to gain insight in the inflammatory response in acute heart failure (AHF) by assessing (1) plasma cytokine profiles and (2) prognostic value of circulating cytokines in AHF patients. METHODS AND RESULTS: Plasma levels of 26 cytokines were quantified by multiplex protein arrays in 36 patients with congestive AHF, characterized by echocardiographic, radiologic, and clinical examinations on admission, during hospitalization and at discharge. Recurrent AHF leading to death or readmission constituted the combined end point, and all patients were followed for 120 days after discharge. Levels of 15 of the measured cytokines were higher in AHF than in healthy subjects (n=22) on admission. Low levels of MCP-1, IL-1ß and a low IL-1ß/IL-1ra ratio predicted fatal and non-fatal AHF within 120 days. Patients with low circulating levels of IL-1ß had lower left ventricular ejection fraction and higher levels of N-terminal pro-B-type natriuretic peptide, while patients with low levels of MCP-1 had higher E/E' and inferior caval vein diameter, than patients with high levels. CONCLUSION: Immune activation, reflected in increased cytokine levels, is present in AHF patients. Interestingly, failure to increase secretion of IL-1ß and MCP-1 during AHF is associated with poor outcome.

Predicting survival from microarray data--a comparative study.

MOTIVATION: Survival prediction from gene expression data and other high-dimensional genomic data has been subject to much research during the last years. These kinds of data are associated with the methodological problem of having many more gene expression values than individuals. In addition, the responses are censored survival times. Most of the proposed methods handle this by using Cox's proportional hazards model and obtain parameter estimates by some dimension reduction or parameter shrinkage estimation technique. Using three well-known microarray gene expression data sets, we compare the prediction performance of seven such methods: univariate selection, forward stepwise selection, principal components regression (PCR), supervised principal components regression, partial least squares regression (PLS), ridge regression and the lasso. RESULTS: Statistical learning from subsets should be repeated several times in order to get a fair comparison between methods. Methods using coefficient shrinkage or linear combinations of the gene expression values have much better performance than the simple variable selection methods. For our data sets, ridge regression has the overall best performance. AVAILABILITY: Matlab and R code for the prediction methods are available at http://www.med.uio.no/imb/stat/bmms/software/microsurv/.

Serological markers of extracellular matrix remodeling predict transplant-free survival in primary sclerosing cholangitis.

BACKGROUND: Primary sclerosing cholangitis is a progressive liver disease with a remarkably variable course. Biomarkers of disease activity or prognostic models predicting outcome at an individual level are currently not established. AIM: To evaluate the prognostic utility of four biomarkers of basement membrane and interstitial extracellular matrix remodeling in patients with primary sclerosing cholangitis. METHODS: Serum samples were available from 138 large-duct primary sclerosing cholangitis patients (of which 102 [74%] with IBD) recruited 2008-2012 and 52 ulcerative colitis patients (controls). The median follow-up time was 2.2 (range 0-4.3) years. Specific biomarkers of type III and V collagen formation (PRO-C3 and PRO-C5, respectively) and type III and IV collagen degradation (C3M and C4M, respectively) were assessed. The Enhanced Liver Fibrosis test, including procollagen type III N-terminal peptide, tissue inhibitor of metalloproteinase-1 and hyaluronic acid was assessed for comparison. RESULTS: All markers were elevated in primary sclerosing cholangitis compared to ulcerative colitis patients (P < 0.001). PRO-C3 showed the largest difference between the two groups with a threefold increase in primary sclerosing cholangitis compared to ulcerative colitis patients. Patients with high baseline serum levels of all markers, except C3M, had shorter survival compared to patients with low baseline serum levels (P < 0.001). Combining PRO-C3 and PRO-C5 the odds ratio for predicting transplant-free survival was 47 compared to the Enhanced Liver Fibrosis test's odds ratio of 11. CONCLUSIONS: Extracellular matrix remodeling is elevated in primary sclerosing cholangitis patients compared to ulcerative colitis patients. Furthermore, the interstitial matrix marker PRO-C3 was identified as a potent prognostic marker and an independent predictor of transplant-free survival in primary sclerosing cholangitis.

Vaccine-associated systemic Rhodococcus erythropolis infection in farmed atlantic salmon Salmo salar.

In 7 instances between 2000 and 2003, clinical investigation of populations of fresh- and seawater-reared, vaccinated, Atlantic salmon Salmo salar suffering total losses of between 0.1 and 35 % revealed infection with a Gram-positive rod-shaped bacterium. The isolations were geographically widespread, occurring in both Norway and Scotland. In all cases, a Gram-positive bacterium, subsequently identified as Rhodococcus erythropolis, was isolated in pure culture. Infections, although systemic, were focused within the peritoneal cavity. While initial attempts to reproduce the disease by intraperitoneal injection of unvaccinated Atlantic salmon failed, Koch's postulates were subsequently fulfilled in fish vaccinated with a commercially available oil-adjuvanted vaccine.

Hepatocellular uptake of 3H-dihydromicrocystin-LR, a cyclic peptide toxin.

The cellular uptake of microcystin-LR, a cyclic heptapeptide hepatotoxin from the cyanobacterium Microcystis aeruginosa, was studied by means of a radiolabelled derivative of the toxin. 3H-dihydromicrocystin-LR. The uptake of 3H-dihydromicrocystin-LR was shown to be specific for freshly isolated rat hepatocytes whereas the uptake in the human hepatocarcinoma cell line Hep G2 as well as the mouse fibroblast cell line NIH-3T3, and the human neuroblastoma cell line SH-SY5Y, was negligible. By means of a surface barostat technique it was shown that the membrane penetrating capacity (surface activity) of microcystin-LR was low, indicating that the toxin requires an active uptake mechanism. The hepatocellular uptake of microcystin-LR could be inhibited in the presence of bile acid transport inhibitors such as antamanide (5 microM), sulfobromophthalein (50 microM) and rifampicin (30 microM). The uptake was also reduced in a concentration dependent manner when the hepatocytes were incubated in the presence the bile salts cholate and taurocholate. A complete inhibition of the hepatocellular uptake was achieved by 100 microM of either bile salt. The overall results indicate that the uptake of microcystin-LR is through the multispecific transport system for bile acids. This mechanism of cell entry would explain the previously observed cell specificity and organotropism of microcystin-LR.

Region and context-specific intracellular responses associated with cocaine-induced conditioned place preference expression.

The development and maintenance of cocaine addiction depend heavily on learned reward-environment associations that can induce drug-seeking behavior and relapse. Understanding the mechanisms underlying these cue-induced conditioned responses is important for relapse prevention. To test whether intracellular responses measured after cocaine conditioned place preference (CPP) expression are context-dependent, we re-exposed cocaine-treated rats (drug-free) to an environment previously paired with cocaine or saline, 24h after the CPP test. After 8 days of cocaine CPP training with one of two cocaine doses (5mg/kg or 20mg/kg, i.p.), CPP was expressed only after conditioning with the higher cocaine dose. In CPP expressing rats, locomotor responses after re-exposure to the cocaine-chamber were greater than in rats re-exposed to the saline-paired chamber. Nucleus Accumbens (NAc) phosphorylated ERK (pERK) levels were increased after re-exposure to the cocaine-paired, but not the saline-paired chamber, regardless of whether or not CPP behavior was expressed. Caudate Putamen (CPu) pERK and FosB protein levels increased after re-exposure to the cocaine chamber only after conditioning with the higher cocaine dose. Conversely, the higher cocaine dose, independent of environment, resulted in increased NAc FosB, ΔFosB and phosphorylated CREB (pCREB) protein levels compared to those conditioned with 5mg/kg cocaine (non-CPP-expressing). Our results suggest that NAc ERK phosphorylation may be involved with retrieving the contextual information of a cocaine-association, without necessarily motivating the expression of CPP behavior. Additionally, we show distinct patterns of intracellular responses in the NAc and CPu indicating a region-specific role for pERK/pCREB/FosB intracellular signaling in the retrieval of cocaine-context associations.

IL-18 neutralization during alveolar hypoxia improves left ventricular diastolic function in mice.

AIM: In patients, an association exists between pulmonary diseases and diastolic dysfunction of the left ventricle (LV). We have previously shown that alveolar hypoxia in mice induces LV diastolic dysfunction and that mice exposed to hypoxia have increased levels of circulating interleukin-18 (IL-18), suggesting involvement of IL-18 in development of diastolic dysfunction. IL-18 binding protein (IL-18BP) is a natural inhibitor of IL-18. In this study, we hypothesized that neutralization of IL-18 during alveolar hypoxia would improve LV diastolic function. METHODS: Mice were exposed to 10% oxygen for 2 weeks while treated with IL-18BP or vehicle. Cardiac function and morphology were measured using echocardiography, intraventricular pressure measurements and magnetic resonance imaging (MRI). For characterization of molecular changes in the heart, both real-time PCR and Western blotting were performed. ELISA technique was used to measure levels of circulating cytokines. RESULTS: As expected, exposure to hypoxia-induced LV diastolic dysfunction, as shown by prolonged time constant of isovolumic relaxation (τ). Improved relaxation with IL-18BP treatment was demonstrated by a significant reduction towards control τ values. Decreased levels of phosphorylated phospholamban (P-PLB) in hypoxia, but normalization by IL-18BP treatment suggest a role for IL-18 in regulation of calcium-handling proteins in hypoxia-induced diastolic dysfunction. In addition, MRI showed less increase in right ventricular (RV) wall thickness in IL-18BP-treated animals exposed to hypoxia, indicating an effect on RV hypertrophy. CONCLUSION: Neutralization of IL-18 during alveolar hypoxia improves LV diastolic function and partly prevents RV hypertrophy.

Synthesis, organotropism and hepatocellular uptake of two tritium-labeled epimers of dihydromicrocystin-LR, a cyanobacterial peptide toxin analog.

Two tritium-labeled epimers of dihydromicrocystin-LR, a derivative of the cyanobacterial peptide hepatotoxin microcystin-LR, were synthesized by reduction with sodium boro[3H]hydride and purified with reversed-phase liquid chromatography. The epimers were hepatotoxic in mice; the i.p. LD50 was 120-135 micrograms/kg. They were concentrated in the liver and to some extent in the intestine and the kidney after an i.v. injection. Freshly isolated rat hepatocytes showed a rapid uptake of both epimers. The cellular uptake of the epimers was almost complete within 5 min at concentrations 1 microM (0.5 microM dihydromicrocystin-LR + 0.5 microM microcystin-LR) and 4 microM (0.5 microM + 3.5 microM). The uptake of the earlier eluting epimer was about three times higher than that of the later eluting epimer.

Accuracy of predictions of survival at admission to the intensive care unit.

PURPOSE: The purpose of this study was to compare the accuracy of outcome predictions made on the day of intensive care unit (ICU) admission by critical care physicians, critical care fellows, and primary team physicians. PATIENTS AND METHODS: Fifty-nine consecutive patients admitted to a Medical-Surgical ICU were included in the study. Two ICU attending physicians and two critical care fellows, not involved in medical management, evaluated each new ICU patient at admission and after 48 to 72 hours. Altogether six ICU attendings and six fellows were involved in the study. Each investigator separately assigned probability to each patient of being discharged alive from the ICU and the hospital. On the day of admission the primary service was also asked to estimate the likelihood of successful outcome. All values are expressed in percentiles. Statistical analysis was performed by a logistic regression procedure with a binary outcome. Data are presented as mean +/- SD. RESULTS: Fifty-nine patients were surveyed. Twenty-six (44%) patients died in the ICU, 3 (5%) died in the hospital wards, and 30 (51%) were discharged alive from the hospital. ICU attendings most reliably and accurately estimated patient outcome on admission compared with critical care fellows and primary team physicians. ICU attendings were more consistent than ICU fellows at predicting outcome at 48 and 72 hours. Clinical predictions were better for patients at the extremes of disease severity, and the accuracy of predictions in these patients was highest. Accuracy was diminished in patients with moderate compromise of clinical status. CONCLUSION: ICU attendings predicted most accurately and consistently the final outcome of patients, and ICU fellows estimated outcome more reliably than the primary service. For the most part, the primary service tended to overestimate the probability of favorable outcome of patients for whom ICU admission had been requested. Additionally, clinical accuracy of survival or mortality was best for those patients at the extremes of clinical compromise: this point seems to confirm the validity of using clinical judgement as a guide to restricting ICU resources for those severely compromised or mildly compromised.This study also indicates that predictions of outcome in critically ill patients made within days of admission are statistically valid but not sufficiently reliable to justify irrevocable clinical decisions at present.

Outcome of direct percutaneous endoscopic jejunostomy tube placement for nutritional support in critically ill, mechanically ventilated patients.

PURPOSE: Gastrointestinal function is adversely affected in critically ill mechanically ventilated patients. The most common abnormality is delayed gastric emptying. Among the options for postpyloric feeds, direct percutaneous endoscopic jejunostomy (PEJ) provides a permanent, reliable, and direct access to the small bowel and can be used for full enteral feedings, thus eliminating the need for parenteral nutrition. PATIENTS AND METHODS: All patients who underwent direct PEJ tube placement while mechanically ventilated in the intensive care unit (ICU) were evaluated. For each patient the following factors were identified: age, indication for ICU admission and PEJ placement, nutritional support before and after PEJ placement, calories received, complications, and outcome. RESULTS: Seventeen patients underwent the procedure. All had successful placement of direct PEJ tube. There was a single complication. Within 24 hours of PEJ placement, 16 of 17 patients tolerated jejunal feedings. All patients progressed to their established nutritional goals. There were no cases of aspiration of enteral feedings. In the 16 patients, total parenteral nutrition (TPN) was not required once PEJ tubes were placed. Thirteen patients were discharged home or to a rehabilitation facility with jejunal feedings. CONCLUSIONS: Direct PEJ placement is a safe and reliable device that can be successfully placed in critically ill, mechanically ventilated patients. With this procedure, all patients can meet their nutritional requirements and eliminate the need for TPN.

The effect of varying inspiratory flow waveforms on pulmonary mechanics in critically ill patients.

PURPOSE: Ten mechanically ventilated patients were evaluated to determine the effect of three different inspiratory flow patterns on pulmonary mechanics. MATERIALS AND METHODS: Ten consecutive mechanically ventilated critically ill patients with acute respiratory failure admitted to the intensive care unit were evaluated to assess the effects of decelerating, square, and sine waveforms on pulmonary mechanics. The variables measured were peak airway pressure (PaW), pleural pressure (Ppl), change in peak airway pressure (dPaW), inspiration time/total ventilation cycle time (Vi/tot), dynamic compliance (Cdyn), respiratory rate (RR), minute ventilation (Ve), and work of breathing (WOB). RESULTS: The PaW, Ppl, and dPaW (cm H2O) were significantly lower using the decelerating inspiratory flow waveform (P<.05) compared with sine or square waveform patterns. Ti/Ttot was also lower with the decelerating waveform (P<.05) with better dynamic compliance compared with the other waveforms (P<.10). CONCLUSIONS: These results indicate that critically ill mechanically ventilated patients show improved respiratory mechanics with decelerating inspiratory waveform that may have beneficial clinical implication.

First cases of amoebic gill disease (AGD) in Norwegian seawater farmed Atlantic salmon, Salmo salar L., and phylogeny of the causative amoeba using 18S cDNA sequences.

Amoebic gill disease (AGD) was observed in seawater farmed Atlantic salmon at four geographically distant locations on the western coast of Norway. To the best of our knowledge, these are the first detected AGD outbreaks in Norway. The outbreaks lasted for 7-12 weeks in late autumn 2006 and were for the most part concurrent. The crude, cumulative mortality was in the range of 12-20% at three farms and 82% at a fourth. The histopathology showed uniform parasomal amoebae in lesions characteristic for AGD. Another gill disease, proliferative gill inflammation (PGI), was also present to a variable degree and the distinction between the two gill problems is discussed. Seawater temperatures were 3.5 degrees C higher than average before disease outbreaks, which subsided in early winter. The geographical and time pattern of these outbreaks strongly indicates simultaneous infection from the marine environment. Two contiguous 18S cDNA sequences, obtained by reverse transcriptase PCR from gill tissue with AGD-related lesions, showed highest similarity (99.2%) to a newly recognized species designated Neoparamoeba perurans and maximum likelihood analysis demonstrates that they represent Norwegian strains of this Neoparamoeba lineage.

Impact of involuntary outpatient commitment on the revolving-door syndrome in North Carolina.

Involuntary outpatient commitment has been used as a means of treating so-called revolving-door patients in the community and allowing them to experience the positive aspects of social and community life that stability can bring. To study the impact of North Carolina's revised outpatient commitment law on institutionalization rates, the authors measured state hospital admissions and days of hospitalization within a three-year period for all patients committed to outpatient treatment during that period. Statistically significant decreases occurred in both measures; the biggest percent reduction occurred in admission rates.