Simultaneous inhibition of DNA-PK and Polϴ improves integration efficiency and precision of genome editing

Genome editing, specifically CRISPR/Cas9 technology, has revolutionized biomedical research and offers potential cures for genetic diseases. Despite rapid progress, low efficiency of targeted DNA integration and generation of unintended mutations represent major limitations for genome editing applications caused by the interplay with DNA double-strand break repair pathways. To address this, we conduct a large-scale compound library screen to identify targets for enhancing targeted genome insertions. Our study reveals DNA-dependent protein kinase (DNA-PK) as the most effective target to improve CRISPR/Cas9-mediated insertions, confirming previous findings. We extensively characterize AZD7648, a selective DNA-PK inhibitor, and find it to significantly enhance precise gene editing. We further improve integration efficiency and precision by inhibiting DNA polymerase theta (Polϴ). The combined treatment, named 2iHDR, boosts templated insertions to 80% efficiency with minimal unintended insertions and deletions. Notably, 2iHDR also reduces off-target effects of Cas9, greatly enhancing the fidelity and performance of CRISPR/Cas9 gene editing.

G Protein-Coupled Receptor GPR35 Suppresses Lipid Accumulation in Hepatocytes

Although prevalent, nonalcoholic fatty liver disease is not currently treated effectively with medicines. Initially, using wild-type and genome-edited clones of the human hepatocyte cell line HepG2, we show that activation of the orphan G protein-coupled receptor GPR35 is both able and sufficient to block liver X-receptor-mediated lipid accumulation. Studies on hepatocytes isolated from both wild-type and GPR35 knock-out mice were consistent with a similar effect of GPR35 agonists in these cells, but because of marked differences in the pharmacology of GPR35 agonists and antagonists at the mouse and human orthologues, as well as elevated basal lipid levels in hepatocytes from the GPR35 knock-out mice, no definitive conclusion could be reached. To overcome this, we generated and characterized a transgenic knock-in mouse line in which the corresponding human GPR35 splice variant replaced the mouse orthologue. In hepatocytes from these humanized GPR35 mice, activation of this receptor was shown conclusively to prevent, and also reverse, lipid accumulation induced by liver X-receptor stimulation. These studies highlight the potential to target GPR35 in the context of fatty liver diseases.

Correction of a urea cycle defect after ex vivo gene editing of human hepatocytes

Ornithine transcarbamylase deficiency (OTCD) is a monogenic disease of ammonia metabolism in hepatocytes. Severe disease is frequently treated by orthotopic liver transplantation. An attractive approach is the correction of a patient’s own cells to regenerate the liver with gene-repaired hepatocytes. This study investigates the efficacy and safety of ex vivo correction of primary human hepatocytes. Hepatocytes isolated from an OTCD patient were genetically corrected ex vivo, through the deletion of a mutant intronic splicing site achieving editing efficiencies >60% and the restoration of the urea cycle in vitro. The corrected hepatocytes were transplanted into the liver of FRGN mice and repopulated to high levels (>80%). Animals transplanted and liver repopulated with genetically edited patient hepatocytes displayed normal ammonia, enhanced clearance of an ammonia challenge and OTC enzyme activity, as well as lower urinary orotic acid when compared to mice repopulated with unedited patient hepatocytes. Gene expression was shown to be similar between mice transplanted with unedited or edited patient hepatocytes. Finally, a genome-wide screening by performing CIRCLE-seq and deep sequencing of >70 potential off-targets revealed no unspecific editing. Overall analysis of disease phenotype, gene expression, and possible off-target editing indicated that the gene editing of a severe genetic liver disease was safe and effective.

Incidence and predictors of recurrent and other new diabetic foot ulcers: a retrospective cohort study

AIMS

To estimate progression rates, evaluate risk factors for progression, and study rate ratios for progression among people with a healed diabetic foot ulcer according to whether the healed ulcer was neuropathic, neuro-ischaemic or critically ischaemic.

METHODS

We conducted a retrospective cohort study in all individuals with a healed diabetic foot ulcer treated at the Steno Diabetes Centre Copenhagen foot clinic in the period 2010 to 2016. The outcome of interest was recurrent/other new diabetic foot ulcers.

RESULTS

A total of 780 people had a healed diabetic foot ulcer in the study period (2010-2016). The participants were followed for 1249 person-years [median (Q1-Q3) 1.04 (0.38-2.46) person-years] in total. One-third (33.1%) developed a recurrent/other new diabetic foot ulcer per year. Male gender, people with Type 2 diabetes and smokers had a statistically significantly higher risk of progression to a recurrent/other new diabetic foot ulcer compared to participants without these risk factors. Participants with neuro-ischaemic or critically ischaemic diabetic foot ulcers had statistically significantly higher progression rates than participants with neuropathic diabetic foot ulcers.

CONCLUSIONS

Focus should be on preventing future recurrent/other new diabetic foot ulcers especially in people with ischaemia.

Enabling 1536-Well High-Throughput Cell-Based Screening through the Application of Novel Centrifugal Plate Washing

Cell-based assays have long been important within hit discovery paradigms; however, improving the disease relevance of the assay system can positively affect the translation of small-molecule drug discovery, especially if adopted in the initial hit identification assay. Consequently, there is an increasing need for disease-relevant assay systems capable of running at large scale, including the use of induced pluripotent stem cells and donor-derived primary cells. Major hurdles to adopting these assays for high-throughput screening are the cost, availability of cells, and complex protocols. Miniaturization of such assays to 1536-well format is an approach that can reduce costs and increase throughput. Adaptation of these complex cell assays to 1536-well format brings major challenges in liquid handling for high-content assays requiring washing steps and coating of plates. In addition, problematic edge effects and reduced assay quality are frequently encountered. In this study, we describe the novel application of a centrifugal plate washer to facilitate miniaturization of a range of 1536-well cell assays and techniques to reduce edge effects, all of which improved throughput and data quality. Cell assays currently limited in throughput because of cost and complex protocols may be enabled by the techniques presented in this study.

Synthesis of ligand-free CZTS nanoparticles via a facile hot injection route

Single-phase, ligand-free Cu2ZnSnS4 (CZTS) nanoparticles that can be dispersed in polar solvents are desirable for thin film solar cell fabrication, since water can be used as the solvent for the nanoparticle ink. In this work, ligand-free nanoparticles were synthesized using a simple hot injection method and the precursor concentration in the reaction medium was tuned to control the final product. The as-synthesized nanoparticles were characterized using various techniques, and were found to have a near-stoichiometric composition and a phase-pure kesterite crystal structure. No secondary phases were detected with Raman spectroscopy or scanning transmission electron microscopy energy dispersive x-ray spectroscopy. Furthermore, high resolution transmission electron microscopy showed large-sized nanoparticles with an average diameter of 23 nm ± 11 nm. This approach avoids all organic materials and toxic solvents that otherwise could hinder grain growth and limit the deposition techniques. In addition the synthesis route presented here results in nanoparticles of a large size compared to other ligand-free CZTS nanoparticles, due to the high boiling point of the solvents selected. Large particle size in CZTS nanoparticle solar cells may lead to a promising device performance. The results obtained demonstrate the suitability of the synthesized nanoparticles for application in low cost thin film solar cells.

Succinate receptor GPR91, a Gα(i) coupled receptor that increases intracellular calcium concentrations through PLCβ

Succinate has been reported as the endogenous ligand for GPR91. In this study, succinate was confirmed to activate GPR91 resulting in both 3'-5'-cyclic adenosine monophosphate (cAMP) inhibition and inositol phosphate formation in a pertussis toxin (PTX)-sensitive manner. GPR91 agonist-mediated effects detected using dynamic mass redistribution (DMR) were inhibited with PTX, edelfosine and U73122 demonstrating the importance of not only the Gαi pathway but also PLCβ. These results show that GPR91 when expressed in HEK293s cells couples exclusively through the Gαi pathway and acts through Gαi not only to inhibit cAMP production but also to increase intracellular Ca(2+) in an inositol phosphate dependent mechanism via PLCβ activation.

Contextual factors associated with pain response of preterm infants to heel-stick procedures

BACKGROUND

Evidence indicates that medical and demographic contextual factors (cFs) impact pain responses in preterm neonates, but the existing evidence is very heterogeneous.

AIM

To explore the effect of cFs on pain responses to heel-stick procedures of preterm infants.

METHODS

This study was a secondary analysis of data collected during a randomized controlled trial examining pain response to non-pharmacological interventions across repeated heel sticks. Five heel sticks across the first 14 days of life were videotaped. Pain response was rated with the Bernese Pain Scale for Neonates (BPSN) by four raters blinded to the heel-stick phases (baseline, heel stick, recovery). Demographic and medical cFs were extracted from medical charts. Mixed single and multiple regression analyses were performed controlling for the intervention group, site and heel-stick phase.

RESULTS

Apgar scores at 1 min were negatively associated with behavioural (p = 0.002) BPSN scores, while Apgar scores at 5 min after birth were positively associated with behavioural (p = 0.006) scores. Accumulated number of painful procedures (p = 0.002) and gender (p = 0.02) were positively associated with physiological scores while continuous positive airway pressure CPAP (p = 0.009) and mechanical ventilation (p = 0.005) were negatively associated.

CONCLUSION

Higher exposure to painful procedures, male infants and having CPAP or mechanical ventilation were cFs associated with physiological response. The only variables significantly associated with behavioural BPSN scores were Apgar scores but these relationships were inconsistent.

Nurse-reported patient safety climate in Swiss hospitals: a descriptive-explorative substudy of the Swiss RN4CAST study

QUESTIONS UNDER STUDY

Measuring the patient safety climate in the organisation of healthcare can help to identify problematic issues with a view to improving patient safety. We aimed (1) to describe the nurse-reported engagement in safety behaviours, (2) to describe the prevailing nurse-reported patient safety climate of general medical, surgical and mixed medical-surgical units in Swiss acute-care hospitals and (3) to explore differences between hospital type, unit type and language regions.

METHODS

This substudy utilised data from the nurse survey (N = 1,633) of the multicentre-cross sectional RN4CAST study. Patient safety climate was measured with the 9-item Safety Organizing Scale (SOS) which captured registered nurses' engagement in safety behaviours and practices at the unit level.

RESULTS

A total of 35 Swiss hospitals participated in the study. Of the 120 eligible units included in the analysis, only on 33 units (27.5%) did at least 60% of the nurses report a positive patient safety climate. A majority of nurses (51.2-63.4%, n = 1,564) reported that they were "consistently engaged" in only three of the nine measured patient safety behaviours. Our multilevel regression analyses revealed both significant between-unit and between-hospital variability. From our three variables of interest (hospital type, unit type and language regions) only language regions was consistently related to nurse-reported patient safety climate. Nurses in the German-speaking region reported a more positive patient safety climate than nurses in the French- and Italian-speaking language regions.

CONCLUSIONS

The findings of this study suggest a need to improve the patient safety climate on many units in Swiss hospitals. Leaders in hospitals should strengthen the patient safety climate at unit level by implementing methods, such as root cause analysis or patient safety leadership walk rounds, to improve individual and team skills and redesign work processes. The impact of these efforts should be measured by periodically assessing the patient safety climate with the SOS.

The unspoken disease: symptom experience in women with vulval neoplasia and surgical treatment: a qualitative study

Women with vulval neoplasia often experience severe post-surgical complications. This study focuses on symptom experience of women during the first 6 months following surgical treatment for vulval neoplasia considering their socio-cultural context. In this qualitative study using a critical hermeneutic approach, narrative interviews were conducted. A purposeful sample of 20 patients was recruited from one Swiss and two German university hospitals. Content analysis was employed to analyse the transcribed interviews considering women's experiences and social perceptions. Narratives showed eight interrelated themes: delayed diagnosis, disclosed disease, disturbed self-image, changed vulva care, experienced wound-related symptoms, evoked emotions, affected interpersonal interactions and feared illness progression. The women experienced a general lack of information pertaining to above themes and all described strategies used to handle their situation, which affected their distress. The communication, assessment and treatment of symptoms were hampered by the society's and the health system's tendency to overlook these symptoms and leave them in the realm of the unspeakable. Health professionals need new strategies to support these women to recognise, assess and evaluate the seriousness of symptoms, and to communicate their symptom experience so that timely medical treatment is sought. This support may minimise potentially preventable complications and symptom-related distress.

Facilitated tucking as a non-pharmacological intervention for neonatal pain relief: is it clinically feasible?

There is an impressive body of knowledge on pain management in infants hospitalized in neonatal intensive care units. However, deficits in the clinical management of pain in these infants remain. One reason is the gap between research evidence and translation of this knowledge into the clinical setting. This is particularly true for non-pharmacological pain-relieving methods. Effective performance of some of these methods requires additional staffing and time. This viewpoint articles describes the clinical challenges associated with implementing 'facilitated tucking'. Although 'facilitated tucking' is described as an efficient method for acute pain relief, the clinical facilitators required to successfully implement such a resource consuming-intervention remain unclear.

CONCLUSION

  Translational research on the feasibility of using 'facilitated tucking' in the management of neonatal pain is warranted, including the economic impact of this intervention. Increased manpower costs need to be weighed against the possible long-term economical consequences of pain exposure in infants.

Differential relationship between physical activity and progression to diabetes by glucose tolerance status: the Inter99 Study

AIMS/HYPOTHESIS

The aim of the study was to analyse how strongly commuting and leisure-time physical activity affect progression to diabetes and to study whether this relationship is different in individuals with isolated impaired fasting glucose (i-IFG) and isolated impaired glucose tolerance (i-IGT).

METHODS

We studied the incidence of diabetes in 4,031 individuals without diabetes at baseline who participated in the baseline and 5 year follow-up examinations of a population-based primary prevention study, the Inter99 Study. Glucose tolerance status at baseline and at follow-up were based on OGTTs. Commuting and leisure-time physical activity at baseline were assessed by questionnaire. We present rate ratios from Poisson regression analyses adjusted for relevant confounders.

RESULTS

The progression rate to diabetes was lower among physically active individuals in the total study population and particularly among those with i-IGT. The associations were attenuated and lost statistical significance after further adjustment for BMI. We observed no impact of physical activity on the progression to diabetes in individuals with i-IFG.

CONCLUSIONS/INTERPRETATION

Physical activity was associated with a lower progression to diabetes in the total study population and in individuals with i-IGT, a condition primarily characterised by muscle insulin resistance. Physical activity did not predict progression to diabetes in individuals with i-IFG, a condition primarily characterised by hepatic insulin resistance. Our results suggest that there is a differential relationship between physical activity and progression to diabetes among those with i-IFG and i-IGT. Therefore, clinical trials testing the effect of physical activity on progression from i-IFG to diabetes are needed.

TRIAL REGISTRATION

ClinicalTrials.gov ID No.: NCT00289237

FUNDING

The Danish Medical Research Council, the Danish Center for Evaluation and Health Technology Assessment, Novo Nordisk, Copenhagen County, the Danish Heart Foundation, the Danish Diabetes Association, the Danish Pharmaceutical Association, the Augustinus Foundation, the Ib Henriksen Foundation and the Becket Foundation.

Variability in pain response to a non-pharmacological intervention across repeated routine pain exposure in preterm infants: a feasibility study

AIM

To explore the variability in pain response in preterm infants across time who received sucrose during routine heel stick.

METHOD

Single group, exploratory repeated measures design.

SETTING

Two tertiary level neonatal intensive care units (NICU) in Switzerland.

SUBJECTS

Nine preterm infants born between 28 2/7 and 31 4/7 weeks of gestation during their first 14 days of life.

MEASUREMENTS

Pain was assessed by the Bernese Pain Scale for Neonates (BPSN), the Premature Infant Pain Profile (PIPP) and the Visual Analogue Scale (VAS). Salivary cortisol was analysed.

RESULTS

72-94% of the variability was within-subject variability, indicating inconsistency of pain responses across the 5 heel sticks. Interrater agreement was highest during heel sticks 1-3 and decreased during heel stick 4 and 5, indicating a possible alteration of pain patterns. No significant differences in the amount of cortisol could be detected before and after the heel sticks (p = 0.55), indicating no stress-induced peak after the painful intervention. However, a general gradual decrease of cortisol levels across time could be detected.

CONCLUSION

A high variability in pain response among preterm neonates across time could be described. Consistency of cortisol levels before and after the heel sticks could indicate the effectiveness of sucrose across time.

Characterization of species-related differences in the pharmacology of tachykinin NK receptors 1, 2 and 3

Tachykinin NK receptors (NKRs) differ to a large degree among species with respect to their affinities for small molecule antagonists. The aims of the present study were to clone NKRs from gerbil (NK2R and NK3R) and dog (NK1R, NK2R and NK3R) in which the sequence was previously unknown and to investigate the potency of several NKR antagonists at all known human, dog, gerbil and rat NKRs. The NKR protein coding sequences were cloned and expressed in CHO cells. The inhibitory concentrations of selective and non-selective NKR antagonists were determined by inhibition of agonist-induced mobilization of intracellular Ca2+. Receptor homology models were constructed based on the rhodopsin crystal structure to investigate and identify the antagonist binding sites and interaction points in the transmembrane (TM) regions of the NKRs. Data collected using the cloned dog NK1R confirmed that the dog NK1R displays similar pharmacology as the human and the gerbil NK1R, but differs greatly from the mouse and the rat NK1R. Despite species-related amino acid (AA) differences located close to the antagonist binding pocket of the NK2R, they did not affect the potency of the antagonists ZD6021 and saredutant. Two AA differences located close to the antagonist binding site of NK3R likely influence the NK3R antagonist potency, explaining the 3-10-fold decrease in potency observed for the rat NK3R. For the first time, detailed pharmacological experiments in vitro with cloned NKRs demonstrate that not only human, but also dog and gerbil NKR displays similar antagonist pharmacology while rat diverges significantly with respect to NK1R and NK3R.

Alternative exon usage selectively determines both tissue distribution and subcellular localization of the acyl-CoA thioesterase 7 gene products

Acyl-CoA thioesterases (ACOTs) catalyze the hydrolysis of acyl-CoAs to free fatty acids and coenzyme A. Recent studies have demonstrated that one gene named Acot7, reported to be mainly expressed in brain and testis, is transcribed in several different isoforms by alternative usage of first exons. Strongly decreased levels of ACOT7 activity and protein in both mitochondria and cytosol was reported in patients diagnosed with fatty acid oxidation defects, linking ACOT7 function to regulation of fatty acid oxidation in other tissues. In this study, we have identified five possible first exons in mouse Acot7 (Acot7a-e) and show that all five first exons are transcribed in a tissue-specific manner. Taken together, these data show that the Acot7 gene is expressed as multiple isoforms in a tissue-specific manner, and that expression in tissues other than brain and testis is likely to play important roles in fatty acid metabolism.

Molecular cloning, mutations and effects of NK1 receptor antagonists reveal the human-like pharmacology of gerbil NK1 receptors

The present study investigates the pharmacology of the cloned neurokinin 1 receptor from the gerbil (gNK(1)R), a species claimed to have human-like NK(1)R (hNK(1)R) pharmacology. The amino acid sequence of NK(1)R was cloned. The hNK(1)R, rat NK(1)R (rNK(1)R), gNK(1)R and mutants of the gNK(1)R were expressed in CHO cells. The affinity and potency of NKR agonists and the NK(1)R antagonists CP99994 and RP67580 (NK(1)R-selective) and ZD6021 (NK1/2R) were assessed in vitro by monitoring [(3)H]-SarMet SP binding and substance P-evoked mobilization of intracellular Ca(2+). The gerbil foot tap (GFT) method was used to assess the potency of the antagonists in vivo. The gNK(1)R coding sequence displayed an overall 95% and 97% homology with hNK(1)R and rNK(1)R, respectively. The affinity of the NK(1)R-selective agonist (3)H-SarMet SP for human and gerbil NK(1)R was similar (2.0 and 3.1 nM) but lower for rNK(1)R (12.4 nM). The rank order potency of the agonists for NK(1)R was SP > or = ASMSP > or = NKA >>> pro7NKB in all species. The NK(1)R antagonists, ZD6021 and CP99994, had comparable affinity and potency for gerbil and human NK(1)R, but were 1000-fold less potent for rNK(1)R. In contrast, RP67580 had comparable affinity and potency for all three species. Mutations in positions 116 and 290 did not affect agonist potency at the gNK(1)R while the potency of the antagonists ZD6021 and CP99994 were markedly decreased (10-20-fold). It is concluded that gNK(1)R has similar antagonist pharmacology as the human-like orthologue and that species differences in antagonist function depend on key residues in the coding sequence and antagonist structure.

Prevalence and recognition of depressive symptoms among homebound older adults with urinary incontinence

Within a group of homebound elders with urinary incontinence, the objectives of this study were to (1) examine the prevalence of depressive symptoms, (2) examine the extent to which depression had previously been recognized by health care providers, (3) describe the type and intensity of antidepressant treatment prescribed for subjects, and (4) identify the demographic and functional characteristics associated with depressive symptomatology. A descriptive correlational design was used. The 15-item Geriatric Depression Scale (GDS-15) was administered to 345 homebound adults age 60 years and over referred to a study examining the effectiveness of behavioral therapy for urinary incontinence. Individuals were referred to the study by home care nurses from two large Medicare-approved home health agencies in a large metropolitan county in Pennsylvania. Data were collected during in-home assessments and by chart review. Measures included the GDS-15, structured medical history, in-home review of medications, Older Americans Research and Service Center Physical and Instrumental Activities of Daily Living scales, Mini-Mental State Examination (MMSE), Clock Drawing Test, Performance-Based Toileting Assessment, and bladder diaries. One half of the participants (n = 173; 50.1%) had significant depressive symptomatology, with 35.7% having scores suggesting mild depression and 14.5% severe depression. Only 26.4% and 34.7% of those with mild and severe depressive symptoms, respectively, had a previous diagnosis of depression and only 21.7% and 34.0%, respectively, had been prescribed an antidepressant. The most commonly prescribed class of antidepressants was tricyclic antidepressants, being taken by 9.0% (n = 31) of the total sample, 14 (11.4%) of those with mild symptoms and 4 (8.0%) of those with severe depressive symptomatology. A little over half (60.0%) of subjects being treated with antidepressants continued to exhibit significant depressive symptomatology. Greater dependence in physical activities of daily living, the need for assistance during ambulation, higher MMSE scores, and higher levels of comorbidity were associated (P < .05) with a GDS-15 score of 5 or higher. Depression symptoms are common in homebound older adults with urinary incontinence, but clinical recognition and treatment are limited.

Effectiveness of behavioral therapy to treat incontinence in homebound older adults

OBJECTIVES

To examine the (1) short-term effectiveness of behavioral therapies in homebound older adults and (2) characteristics of responders and nonresponders to the therapies.

DESIGN

Prospective, controlled clinical trial with cross-over design.

SETTING

Adults aged 60 and older with urinary incontinence and who met Health Care Financing Administration criteria for being homebound were referred to the study by homecare nurses from two large Medicare-approved home health agencies in a large metropolitan county in southwestern Pennsylvania.

MEASURES

Structured continence and medical history, OARS Physical and Instrumental Activities of Daily Living scales, Folstein Mini-Mental State Examination Score, Clock Drawing Test, Geriatric Depression Scale, Performance-Based Toileting Assessment, bladder diaries, and physical examination.

RESULTS

One hundred five subjects were randomized to biofeedback-assisted pelvic floor muscle training (53 to the treatment group and 52 to the control groups). Control subjects with complete pre- and post-control data (n = 45) experienced a median 6.4% reduction in urinary accidents in contrast to a median 75.0% reduction in subjects with complete pre- and post-treatment data (n = 48, P < .001). Following the control phase, subjects crossed over to the treatment protocol. Eighty-five subjects completed treatment, achieving a median 73.9% reduction in UI. Exercise adherence was the most consistent predictor of responsiveness to the behavioral therapy.

CONCLUSIONS

Clinically significant reductions in urinary incontinence are achievable with behavioral therapies in many cognitively intact homebound older adults despite high levels of co-morbidity and functional impairment.

Survival and 2-year outcome with expectant management of second-trimester rupture of membranes

OBJECTIVE

To evaluate the perinatal and 2-year outcomes in pregnancies complicated by preterm premature rupture of membranes (PROM) during the second trimester.

METHODS

Fifty-three consecutive singleton pregnancies with PROM at 14 to 28 weeks of gestation were studied retrospectively. Management goals were to prolong the pregnancies to 32 weeks through expectant management and to avoid fetal compromise through closer monitoring and active intervention, when necessary, after 23 weeks. Outcome of the surviving infants was based on neurologic, audiometric, and ophthalmologic examinations at 2 years of corrected age.

RESULTS

Rupture of membranes occurred at 14-19 weeks (mean 17.4 weeks) in 10 women, at 20-25 weeks (mean 24.0 weeks) in 24, and at 26-28 weeks (mean 27.6 weeks) in 19. The median latency periods to delivery were 72 days, 12 days, and 10 days when rupture of membranes occurred at 14-19 weeks, 20-25 weeks, and 26-28 weeks, respectively. The overall incidence of chorioamnionitis was 28%. There were no fetal deaths and nine neonatal deaths. When rupture of membranes occurred at 14-19 weeks, 20-25 weeks, and 26-28 weeks, the perinatal survival rates were 40%, 92%, and, 100%, respectively. Pulmonary hypoplasia accounted for seven deaths. Of the live-born infants, 81% were alive at 2 years of corrected age. Survival without major impairment was observed in 75%, 80%, and 100% of the survivors when rupture of membranes occurred at 14-19 weeks, 20-25 weeks, and 26-28 weeks, respectively.

CONCLUSION

Expectant management of second-trimester PROM offers better perinatal and long-term survival than previously thought.

In vitro digestion of proteins in human milk fortifiers and in preterm formula

BACKGROUND

Knowledge about the digestibility of the proteins in new products designed for feeding preterm infants is limited. The purpose of this study was to observe in vitro the hydrolysis of the bovine and human whey proteins in such products.

METHODS

Proteins in human milk, in human milk fortifiers (Presemp [Semper AB, Stockholm, Sweden] and Enfamil [Mead Johnson, Evansville, IN, U.S.A.] human milk fortifiers), in preterm formulas (Similac Special Care [Ross, Columbus, OH, U.S.A.] and Enfalac [Mead Johnson]), and whey protein concentrates with varying degrees of denaturation were digested by duodenal juice from healthy preterm infants, from a 3-year-old child, and from adults. Digestion was studied in vitro using polyacrylamide gradient gel electrophoresis, electroimmunoassay, and nonprotein nitrogen analysis.

RESULTS

Casein was the protein most rapidly degraded in all products. Human and bovine whey proteins were more slowly digested; as much as 68% of human lactoferrin was still immunoreactive after 40 minutes of digestion. The corresponding figure for bovine serum albumin was 24-69%; for B-lactoglobulin, 20-40%; for bovine alpha-lactalbumin, 20-51%; and for human alpha-lactalbumin, 41%. Contrary to common belief, digestibility of bovine whey proteins decreased with a high degree of denaturation of the proteins.

CONCLUSIONS

Bovine whey proteins in human milk fortifiers and in preterm formulas are relatively slowly digested in vitro by normal duodenal juice. The results may have implications for the design of products for feeding preterm infants.

Assessment and management of urinary incontinence among homebound older adults: a clinical trial protocol

Urinary incontinence is a common and costly problem among homebound older adults. This article describes the assessment and management protocols utilized in a clinical trial examining the effectiveness of behavioral interventions in treating urinary incontinence in homebound older adults. Individuals with urinary incontinence were identified and referred to the study by home care nurses from two large home health agencies. Following in-home assessment, eligible subjects were randomized to an immediate treatment group or a delayed treatment group (control group). Subjects who were cognitively intact were treated with biofeedback-assisted pelvic floor muscle training, while subjects with cognitive impairments were treated with a program of prompted voiding. Two nurse practitioners assessed and treated subjects participating in the study.

Health-related quality of life in chronic disorders: a comparison across studies using the MOS SF-36

The purpose of this report is to examine health-related quality of life (HRQoL) as measured by the Medical Outcomes Study Short Form-36, across patient populations with chronic disorders and to compare quality of life (QoL) in these subjects with normative data on healthy persons. Six studies, within the Center for Research in Chronic Disorders at the University of Pittsburgh School of Nursing, in patients with urinary incontinence, prostate cancer, chronic obstructive pulmonary disease (COPD), acquired immune deficiency syndrome (AIDS), fibromyalgia and hyperlipidaemia provided the data for analysis. The results demonstrated that not only did the prostate cancer and hyperlipidaemia patients have the highest QoL across the chronic disorders, but their QoL was comparable to normative data on healthy persons. Homebound, elderly, incontinent patients had the lowest QoL for physical functioning, whereas patients hospitalized with AIDS had the lowest QoL in general health and social functioning. Patients with COPD had the lowest QoL in role-physical, role-emotional and mental health. Patients with fibromyalgia had the lowest QoL in bodily pain and vitality. Compared to normative data, patients with urinary incontinence, COPD, AIDS and fibromyalgia generally had lower QoL. Prostate cancer and hyperlipidaemia patients had QoL comparable to normative data. Compared to normative data, patients with urinary incontinence, COPD, AIDS and fibromyalgia had more variability for role-emotional. AIDS patients had more variability on physical functioning, bodily pain and social functioning compared to the normative data. These data suggest that patients with various chronic disorders may have QoL that is lower in most domains compared to a healthy population. However, there may be differences in the domains affected as well as the extent of variation across specific chronic disorders.

Geropsychiatric restraint use

OBJECTIVES

To investigate predictors and reasons for restraint use with geropsychiatric patients.

DESIGN

A prospective, correlational study.

SETTING

The geriatric unit of an acute-care psychiatric hospital.

PARTICIPANTS

Twenty-one staff nurses and 131 patients admitted consecutively over a period of 6 months.

MEASUREMENTS

Disruptive behaviors were measured with the Nursing Home Behavior Problem Scale (NHBPS), cognitive function was measured with the Mini-Mental State Examination (MMSE), mobility was measured with a Functional Mobility Screen (FMS), and reasons for restraint use were obtained with a questionnaire completed by nurses.

RESULTS

Patients with a diagnosis of dementia, impaired mobility, or behavioral problems were more likely to be restrained. The most frequent reasons given by staff for restraint use were an unsteady gait and a risk of falling. The incidence of restraint use was 27.1%.

CONCLUSIONS

The use of restraint with geropsychiatric patients may be more common than previously reported and requires further investigation.

Treatment of urinary incontinence in homebound older adults: interface between research and practice

Urinary incontinence is one of the most common problems afflicting older adults and a major contributor to healthcare costs for homebound older individuals. The authors conducted a randomized controlled clinical study examining the effectiveness of biofeedback-assisted pelvic floor muscle training and prompted voiding in treating urinary incontinence in homebound older adults. This article briefly describes the assessment and treatment protocols utilized during this study and describes their subsequent application to clinical practice within a large urban home health agency.

Digestion of proteins in human milk, human milk fortifier, and preterm formula in infant rhesus monkeys

BACKGROUND

There is limited information in the literature on the capacity of the preterm infant to digest human and bovine milk proteins. We therefore studied in vivo the luminal phase of the hydrolysis of proteins in human milk, human milk fortifier, and preterm formula in preterm rhesus monkeys and in infant rhesus monkeys at 6 weeks and 7 months of age.

METHODS

Protein hydrolysis was followed by polyacrylamide gradient gel electrophoresis and electroimmunoassay. The serum level of absorbed unhydrolyzed human alpha-lactalbumin was measured by a radioimmunoassay method. Trypsin and elastase activities in duodenal contents were measured before and after the meal.

RESULTS

In 6-week-old monkeys, the enzyme activities decreased by 50% postprandially, whereas they increased in 7-month-old monkeys. In preterm and in 6-week-old monkeys, hydrolysis of human and bovine whey proteins was slow, and in 6-week-old monkeys, 30-50% of the proteins could still be detected immunochemically in duodenal contents after 60 min. At these ages, serum level of absorbed alpha-lactalbumin were high. At 7 months of age, no or small (lactoferrin and bovine serum albumin) amounts of the proteins could be detected in duodenal contents after 15 min. At this age alpha-lactalbumin was not measurable in serum.

CONCLUSIONS

The low capacity to digest whey proteins in suckling monkeys may depend upon an immaturity of the exocrine pancreas to respond to secretogogues.

Spread of Klebsiella in a neonatal ward

The colonization of infants with Klebsiella pneumoniae was prospectively studied. Samples were taken from nose, throat, umbilicus and rectum on the day of arrival and thereafter once a week. Phage typing was performed the first time K. pneumoniae was found at any of these sites. Settle plates were exposed in the incubators and in the patient rooms 5 h/day. The study lasted for 32 weeks. The first 15 weeks was a control period with no information to the staff, the following 4 weeks was a period of intervention and education and the last 13 weeks was a second control period. In all, 603 infants were investigated. The number of infants nursed per week and severity of their disease was comparable in the 3 periods. The colonization rates were 65, 34 and 58%, respectively. The acquisition of new strains was 1.4 per infant in the first and last periods, but only 0.4 in the period of intervention. Thus, colonization rates decreased only during the period of continuous education in hygiene.

Surface ultrastructure of the small intestine mucosa in children with celiac disease. I. Untreated disease and effects of long-term gluten elimination and challenge

Forty-eight gut mucosa specimens from 27 children with celiac disease, diagnosed by means of conventional serial biopsies taken at different dietary conditions, were studied by means of scanning electron microscopy (SEM). The observations were correlated with those made by concomitant dissection microscope (DM), light microscope (LM), and transmission electron microscope (TEM) examinations. Five children with constitutional short stature served as controls. The results of the SEM analyses were in good conformity with the observations made by DM, LM, and TEM. In addition, SEM was found to offer further structural variables to be analyzed. In active celiac disease and after challenge with dietary gluten, which is necessary to establish the diagnosis of children, the lesions specifically observed by SEM were (1) a strikingly uniform destruction of the villi and a distortion of the enterocytes but with preserved extrusion zones, and (2) a decrease and disruption of the glycocalyx of the enterocytes with marked irregularity of the microvilli. After successful dietary treatment and despite a normalization of the gut mucosa by routine LM, SEM often disclosed persisting lesions of the enterocytes. It was concluded that by inclusion of SEM in the routine assessments of gut biopsy specimens in children with celiac disease, the diagnostic precision becomes increased.

Influence of type of feeding on lymphocyte function and development of infantile allergy

Symptom scores indicating infantile allergy were recorded longitudinally in a group of infants during the first year of life. The symptom scores were related to duration of breast-feeding. Lymphocyte function, measured as the proliferative responsiveness to PHA-stimulation, was related to feeding with breast-milk or cow's milk. Babies with a short duration of breast-feeding; i.e. 1 month or less had significantly higher symptom scores at the ages of 1 month (P less than 0.05), 3 months (P less than 0.05), 6 months (P less than 0.001) and 12 months (P less than 0.05), than babies who were breast-fed for more than 1 month. The lymphocyte responsiveness to PHA was significantly higher at 3 and 6 months in babies who were fed cow's milk compared with those who were solely or partially breast-fed (P less than 0.05 and P less than 0.01 respectively). There was no correlation between symptom scores and lymphocyte responsiveness. It is concluded that infantile allergy is more common in babies with a short duration of breast-feeding and that feeding with cow's milk, compared to breast-feeding, causes a changed lymphocyte reactivity to PHA, which latter finding indicates an altered T-cell function between the two feeding groups.

Treatment of infantile atopic dermatitis with a strict elimination diet

Of twenty-one infants with atopic dermatitis, twenty were treated with a strict elimination diet for a period of up to 6 weeks. Seven infants healed and twelve improved. The infants who healed were less than 6 months old and had had a short duration of dermatitis. For one infant the skin condition was unchanged. Another infant was breast-fed throughout the period with dermatitis. Blood eosinophilia and/or elevated serum IgE commonly found on admission decreased significantly (P less than 0.01) during the diet period. On challenge with cows' milk, twelve infants were considered as intolerant. At the age of 2 years the dermatitis had cleared in all but four children. Of these four children, two were still cows' milk intolerant. Another two infants were also cows' milk intolerant, but without dermatitis.