How do multimorbidity and lifestyle factors impact the perceived health of adults with intellectual disabilities?

BACKGROUND: Adults with intellectual disability (ID) have poorer physical and perceived health than the general population. Knowledge of perceived health predictors is both limited and important for guiding the development of preventive actions. The aims of this study were to investigate (1) the associations between perceived health and demographics, degree of ID, physical health conditions, and weight and physical activity level and (2) lifestyle factors and multimorbidity as predictors for perceived health adjusted for age, gender, and level of ID. METHOD: The North Health in Intellectual Disability study is a community based cross-sectional survey. The POMONA-15 health indicators were used. Univariate and multivariate logistic regression analyses with poor versus good health as the dependent variable were applied. RESULTS: The sample included 214 adults with a mean age 36.1 (SD 13.8) years; 56% were men, and 27% reported perceiving their health as poor. In univariate analyses, there were significant associations between poor health ratings and female gender, lower motor function, number of physical health conditions and several indicators of levels of physical activity. In the final adjusted model, female gender [odds ratio (OR) 2.4, P < 0.05], level of ID (OR 0.65, P < 0.05), numbers of physical health conditions (OR 1.6, P < 0.001) and lower motor function (OR 1.5 P < 0.05) were significant explanatory variables for poor perceived health, with a tendency to independently impact failure to achieve 30 min of physical activity daily (OR 2.0, P = 0.07). CONCLUSION: Adults with ID with female gender, reduced motor function and more physical health conditions are at increased risk of lower perceived health and should be given attention in health promoting interventions. A lack of physical activity tends to negatively influence perceived health.

Measurement Properties of the Nordic Questionnaire for Psychological and Social Factors at Work: A Rasch Analysis.

The main aim of this study was to evaluate the measurement properties of the Nordic Questionnaire for Psychological and Social Factors at Work (QPS Nordic) and the domains of demand, control and support. The Rasch analysis (RUMM 2030) was based on responses from 226 subjects with back pain who completed the QPS Nordic dimensions of demand, control, and social support (30 items) at one year follow up. The Rasch analysis revealed disordered thresholds in a total of 25 of the 30 items. The domains of demand, control and support fit the Rasch model when analyzed separately. The demand domain was well targeted, whereas patients with current neck and back pain had lower control and higher support than reflected by the questions. Two items revealed DIF by gender, otherwise invariance to age, gender, occupation and sick-leave was documented. The demand, control support domains of QPS Nordic comprised unidimensional constructs with adequate measurement properties.

Validation of the Brief ICF core set for low back pain from the Norwegian perspective.

AIM: The aim of this study was to identify candidate categories from the International Classification of Functioning, Disability and Health (ICF) to be included in the Brief ICF Core Set for low back pain (LBP) by examining their relation to general health and functionality. METHODS: This was part of an international multicentre study with 118 participating Norwegian patients with LBP. The Comprehensive ICF Core Set for LBP was filled in by health professionals. The patients reported their health-related quality of life in the Medical Outcome Study Short Form 36 (SF-36) and function in the Oswestry Disability Index. Two questions regarding the patient's general health and functioning were completed by the health professionals and the patients themselves. Regression models were developed in order to identify ICF categories explaining most of the variance of the criterion measures. RESULTS: Twelve ICF categories remained as significant explanatory factors according to the eight regression models, four of which were not included in a previously proposed Brief ICF Core Set for LBP. CONCLUSIONS: The present study complements the development of the Brief ICF Core Set for LBP, and indicates a minimum number of categories needed to explain LBP patients' functioning and health. Further elaboration of the Brief ICF Core Set for LBP with multinational data is needed.

Functional outcome and health-related quality of life 10 years after moderate-to-severe traumatic brain injury.

OBJECTIVES: To describe the functional outcome and health-related quality of life (HRQL) 10 years after moderate-to-severe traumatic brain injury (TBI). MATERIAL AND METHODS: A retrospective, population-based study of 62 survivors of working-age with moderate-to-severe TBI injured in 1995/1996, and hospitalized at the Trauma Referral Center in Eastern Norway. Functional status was measured by the Glasgow Outcome Scale-Extended (GOS-E). HRQL was assessed by the SF-36 questionnaire. RESULTS: The mean current-age was 40.8 years. The frequency of epilepsy was 19% and the depression rate 31%. A majority had good recovery (48%) or moderate disability (44%). Employment rate was 58%. Functional and employment status were associated with initial injury severity in contrast to HRQL. Study patients had significantly lower scores in all SF-36 dimensions when compared with the general Norwegian population. CONCLUSION: At 10-years follow-up, our study population is still in their most productive years and affected domains should be considered in long-term follow-up and intervention programs.

Does the International Classification of Functioning, Disability and Health (ICF) core set for low back pain cover the patients' problems? A cross-sectional content-validity study with a Norwegian population.

AIM: The aim of this work was to evaluate the Norwegian form of the International Classification of Functioning, Disability and Health (ICF) Core Set for low back pain patients and investigate the feasibility of the Core Set in clinical practice. METHODS: This was part of an international multicenter study with 118 participating Norwegian patients referred to Departments of Physical Medicine and rehabilitation with low back pain (LBP). The ICF Core Set for LBP was filled in by the health professionals. The patients reported their problems using the Medical Outcome Study Short Form 36 (SF-36) and the Oswestry Low Back Pain Disability Questionnaire (ODI). RESULTS: The ICF Core Set categories capture the problems of the LBP patients, and few categories were reported to be missing. Many problems were reported within body function, and problems within work and employment were captured by the activity and participation component. The environmental factors in ICF were most frequently scored as facilitators, but the same factor could also represent a barrier in other individuals. Health professionals, family and friends were important factors within this domain. Few problems were scored as severe or complete indicating the need of collapsing the qualifier levels. Scoring of the ICF Core Set was feasibly, but rather time-consuming. CONCLUSION: The ICF Core Set for LBP captures the problems of LBP, and adds important aspects to clinical practice in the field of LBP. However, the ICF Core Set for LBP needs further elaboration in order to improve the clinical feasibility.

Cytomegalovirus DNA concentration in plasma predicts development of cytomegalovirus disease in kidney transplant recipients.

The clinical significance of cytomegalovirus (CMV) DNA detection in post-kidney transplantation infection surveillance was examined by comparing the performance of three assays for detection of CMV in blood: the test for CMV-pp65-antigen in leukocytes, which is routinely employed in our laboratory, the quantitative plasma CMV-DNA-polymerase chain reaction (PCR; Cobas Amplicor CMV Monitor test) and the qualitative plasma CMV-DNA-PCR (Amplicor CMV test). Thirteen kidney transplant recipients were monitored with serial samples taken over a period of 3 months following transplantation. The quantitative CMV-PCR was the test with highest sensitivity, 95.9%, vs. 88.9% and 76.9% for the CMV-pp65 antigen assay and qualitative CMV-PCR, respectively. The virus load in the first positive specimens, assessed as DNA-copies/mL, was significantly associated with CMV disease because five of the six patients who developed disease, but only one of the seven who did not develop disease, had more than 3000 CMV-DNA-copies/mL. The number of CMV-pp65 antigen-positive cells in the first positive specimens did not have predictive value for development of CMV disease. Assessment of CMV in plasma by the quantitative CMV-PCR is especially useful since it has a high sensitivity and the amount of CMV DNA in plasma is a good predictor of CMV disease.

Early supported discharge of patients with acute stroke: a randomized controlled trial.

PURPOSE: To evaluate the feasibility and effectiveness of early supported discharge (ESD) following acute stroke. METHOD: An ESD scheme was compared to conventional rehabilitation in a randomized controlled trial. All patients admitted with acute stroke were considered for inclusion. Eighty-eight (20.2%) were found to be eligible and 82 were randomized either to early supported discharge (n = 42) or conventional rehabilitation (n = 40). The primary outcome measure was the Nottingham Extended Activities of Daily Living Scale. The General Health Questionnaire, the Montgomery Aasberg Depression Rating Scale, mortality, placement and patient and career satisfaction served as secondary outcome measures. RESULTS: Median length of stay was reduced from 31 days in the conventional hospital rehabilitation group to 22 days in the early supported discharge group (p = 0.09). No differences were found regarding primary outcome. The General Health Questionnaire score showed a significant difference in favour of the early supported discharge group at three months (19.5/24, p = 0.02), but not at six. At six months, the proportion of patients being dead or in institution showed a trend of being higher in the conventional rehabilitation group (OR 3.8, 95% CI 0.8-23). CONCLUSIONS: Early supported discharge after stroke is feasible and it is possible that it has benefits compared with conventional rehabilitation.

Members of the nuclear factor 1 family reduce the transcriptional potential of the nuclear receptor LXRalpha promoter.

Expression of the LXRalpha nuclear receptor in liver is predicted to affect cholesterol and lipid metabolism. Here we show that a short fragment from the LXRalpha gene promoter spanning the region from -144 to +43 relative to the mRNA initiation site can drive transcription of a reporter gene. Under basal conditions, in vitro DNase I footprinting demonstrated interaction between nuclear proteins and an NF1 recognition site in close vicinity to the transcriptional initiation. Both supershift, mutational analyses in EMSA and transfections provided evidence that the NF1 (nuclear factor I) transcription factor interacts with the LXRalpha promoter. All four members of the NF1 family were found to suppress the transcriptional activity indicating a general inhibitory effect on LXRalpha expression. A similar regulation by NF1 was also observed when using a fragment from the LXRalpha promoter extending up to position -3033 therefore giving the inhibitory effect of NF1 a significant impact on LXRalpha gene expression.

Detection of human cytomegalovirus (HCMV) pp67-mRNA and pp65 antigenemia in relation to development of clinical HCMV disease in renal transplant recipients.

OBJECTIVE: To evaluate the performance of the recently introduced method based on detection of human cytomegalovirus (HCMV) pp67 mRNA in blood by the nucleic acid sequence-based amplification (NucliSens), in comparison to semiquantitative detection of pp65 HCMV antigen in white blood cells, in relation to development of clinical HCMV disease. METHODS: Thirty patients, recipients of renal transplants, were monitored prospectively for the presence of pp67 mRNA, the presence and level of pp65 antigenemia, IgG and IgM antibodies, and the development of clinical HCMV disease. A total of 148 samples were examined during the observation period. RESULTS: Twenty-five samples were positive for pp67-mRNA and 45 samples contained at least one pp65 positive cell, with 68% agreement between the two assays. Both assays predicted correctly the development of clinical disease in five patients, giving a sensitivity of 100%. However, the specificity of the pp67-mRNA test was 72%, and of the pp65 antigenemia test from 20 to 64%, depending on the level of antigenemia chosen for cut-off. pp67-RNA appeared somewhat earlier than pp65 antigenemia, and responded earlier to treatment. Sero-conversion and appearance of IgM antibodies were of very little clinical value. CONCLUSION: Both the pp67-mRNA and the pp65 antigenemia assay predicted correctly the development of clinical HCMV disease in renal transplant recipients. However, the specificity of both tests with respect to development of HCMV disease, especially the pp65 antigen test was moderate. Significantly positive tests not necessarily prove the development of clinical disease. Testing for pp67-mRNA may improve the diagnosis and management of HCMV disease in renal transplant patients.

Acute phase predictors of subsequent psychosocial burden in carers of elderly stroke patients.

The objective was to describe the psychosocial burden experienced by informal carers of elderly stroke victims, and to identify its predictors among baseline characteristics of the patients. From a prospective study of 171 elderly stroke patients admitted to a geriatric ward for rehabilitation in the acute phase, 68 patients living at home with a primary caregiver were identified 6 months after the stroke. At baseline, all the patients were assessed with respect to motor function, cognitive function, global handicap and activities of daily living, and after 6 months the caregivers were assessed, using the Relatives' Stress Scale. According to this, the most frequent impacts were worries that an accident might befall their relatives, that they had to reorganise their household routines and further, that their social life and ability to take holidays had been reduced. Impaired cognitive function was the only baseline patient characteristic that predicted a subsequent psychosocial burden on the carer. Special attention should be paid to elderly stroke patients initially assessed with impaired cognitive function and their caregivers.

Regulation of glucocorticoid receptor activity by 14--3-3-dependent intracellular relocalization of the corepressor RIP140.

Proteins belonging to the 14--3-3 family interact with various regulatory proteins involved in cellular signaling, cell cycle regulation, or apoptosis. 14--3-3 proteins have been suggested to act by regulating the cytoplasmic/nuclear localization of their target proteins or by acting as molecular scaffolds or chaperones. We have previously shown that overexpression of 14--3-3 enhances the transcriptional activity of the glucocorticoid receptor (GR), which is a member of the nuclear receptor family. In this study, we show that 14--3-3 interacts with the nuclear receptor corepressor RIP140. In transfection assays, RIP140 antagonizes 14--3-3- enhanced GR transactivation. Using colocalization studies we demonstrate that 14--3-3 can export RIP140 out of the nucleus and, interestingly, can also change its intranuclear localization. Moreover, we also observed that 14--3-3 can bind various other nuclear receptors and cofactors. In summary, our findings suggest that 14--3-3-mediated intracellular relocalization of the GR corepressor RIP140 might be a novel mechanism to enhance glucocorticoid responsiveness of target genes. They furthermore indicate a more general role for 14--3-3 protein by influencing the nuclear availability of nuclear receptor-associated cofactors.

A prospective study of the natural course of cytomegalovirus infection and disease in renal allograft recipients.

BACKGROUND: Cytomegalovirus (CMV) infection is the single most frequent infectious complication in renal transplant recipients. Because no CMV-prophylaxis is given and ganciclovir is used only as deferred therapy for CMV disease at our center, we have been able to study the natural course of CMV infections. The aim was to assess risk factors for CMV infection and disease and thus identify subgroups of patients likely to benefit from CMV prophylaxis or preemptive therapy. METHODS: Between October 1994 and July 1997, 477 consecutive renal transplant recipients (397 first transplants and 80 retransplants) were included in the study. The patients were followed prospectively for 3 months with serial measurements of CMV pp65 antigen for monitoring activity of CMV infections. RESULTS: The incidence of CMV infections in first transplants was 68% in D+R- and D+/-R+ serostatus groups, whereas the incidence of CMV disease was higher in D+R- (56%) than in D+/-R+ (20%, P<0.001). No difference in severity of CMV disease in D+R- and D+/-R+ was seen except for an increased incidence of hepatitis in primary infections. One of 14 deaths could be associated with CMV disease in a seropositive recipient. Cox regression analysis showed that rejection (RR 2.5, P<0.01) and serostatus group D+R- (RR 3.9, P<0.001) were significant risk factors for development of CMV disease. The maximum CMV pp65 antigen count had significant correlation to disease only in CMV seropositive recipients, P<0.001. Conclusion. Renal transplant recipients can safely be given deferred ganciclovir therapy for CMV disease if they are intensively monitored for CMV infection. Patients with primary CMV infection (D+R-), CMV infected patients undergoing anti-rejection therapy and R+ patients with high CMV pp65 counts seem to have a particular potential for benefit from preemptive anti-CMV-therapy.

Evaluation of 12 commercial tests for detection of Epstein-Barr virus-specific and heterophile antibodies.

Ten microbiological departments in Norway have participated in a multicenter evaluation of the following commercial tests for detection of Epstein-Barr virus (EBV)-specific and heterophile antibodies: CAPTIA Select viral capsid antigen (VCA)-M/G/EBNA (Centocor Inc.), Enzygnost anti-EBV/immunoglobulin M (IgM) and IgG (Dade Behring), Vironostika EBV VCA IgM/IgG/EBNA enzyme-linked immunosorbent assay (ELISA) (Organon Teknika), SEROFLUOR immunofluorescence assay and EBV Combi-Test (Institute Virion Ltd.), anti-EBV recombinant IgM- and IgG-early antigen/EBNA IgG ELISA (Biotest Diagnostics), EBV IgM/IgG/EBNA ELISA (Gull Laboratories), Paul-Bunnell-Davidsohn test (Sanofi Diagnostics Pasteur), Monosticon Dri-Dot (Organon Teknika), Avitex-IM (Omega Diagnostics Ltd.), Alexon Serascan infectious mononucleosis test (Alexon Biomedical Inc. ), Clearview IM (Unipath Ltd.), and Cards+/-OS Mono (Pacific Biotech, Inc.). The test panel included sera from patients with primary EBV infection, immunocompromised patients with recent cytomegalovirus infection, healthy persons (blood donors), and EBV-seronegative persons. Among the tests for EBV-specific antibodies the sensitivity was good, with only small differences between the different assays. However, there was a greater variation in specificity, which varied between 100% (Enzygnost) and 86% (Biotest). Tests for detection of heterophile antibodies based on purified or selected antigen (Avitex, Alexon, Clearview IM, and Cards+/-OS Mono) were more sensitive than the Paul-Bunnell-Davidsohn and Monosticon tests.

Inter-rater reliability of the Sødring Motor Evaluation of Stroke patients (SMES).

The Sødring Motor Evaluation of Stroke patients is an instrument for physiotherapists to evaluate motor function and activities in stroke patients. The rating reflects quality as well as quantity of the patient's unassisted performance within three domains: leg, arm and gross function. The inter-rater reliability of the method was studied in a sample of 30 patients admitted to a stroke rehabilitation unit. Three therapists were involved in the study; two therapists assessed the same patient on two consecutive days in a balanced design. Cohen's weighted kappa and McNemar's test of symmetry were used as measures of item reliability, and the intraclass correlation coefficient was used to express the reliability of the sumscores. For 24 out of 32 items the weighted kappa statistic was excellent (0.75-0.98), while 7 items had a kappa statistic within the range 0.53-0.74 (fair to good). The reliability of one item was poor (0.13). The intraclass correlation coefficient for the three sumscores was 0.97, 0.91 and 0.97. We conclude that the Sødring Motor Evaluation of Stroke patients is a reliable measure of motor function in stroke patients undergoing rehabilitation.

Association between impairments, self-care ability and social activities 1 year after stroke.

PURPOSE: To explore how motor and cognitive impairments relate to physical activities of daily living (PADL) and social activities after stroke. METHOD: The data related to 65 patients (mean age 74.4 years, 43% females), assessed 1 year after stroke by means of the Sødring Motor Evaluation of Stroke patients and the Assessment of Stroke and other Brain damage instruments. The self-care and social activities scales applied were the Barthel ADL Index and the Frenchay Activities Index (FAI). The association between impairment variables on the one hand and PADL and FAI scores on the other was estimated using Kendall rank correlations. RESULTS: Arm motor function correlated most strongly with the Barthel score (tau = 0.76), and visuospatial function came second (tau = 0.58). Factor analysis of the FAI produced three subscales: a 'domestic' factor most strongly related to arm motor function (tau = 0.49); 'outdoor' related to visuospatial ability (tau = 0.48); and 'hobby' which had no significant correlates. CONCLUSION: In the chronic phase of stroke, self-care and involvement in social activities relate most strongly to arm motor function and visuospatial ability. Outdoor activities depend mainly on visuospatial function.

Predictors of outcome of rehabilitation of elderly stroke patients in a geriatric ward.

PURPOSE: To identify predictors of outcome after 12 months in elderly stroke patients rehabilitated in a geriatric ward. DESIGN: Prospective with evaluation in the subacute phase and after 12 months. SETTING: Geriatric ward and outpatient clinic. SUBJECTS: All stroke patients admitted from the acute unit to a geriatric ward for rehabilitation during a 16-month period (n = 171). MAIN OUTCOME MEASURES: Place of living, mortality and social functioning (Frenchay Activities Index) 12 months following stroke. RESULTS: Age, urinary incontinence and cognitive function were significantly associated with place of living (home versus nursing home) 12 months post stroke in bivariate analyses. However, using multivariate logistic regression analyses, only age (p = 0.005) and urinary incontinence at baseline (p = 0.028) remained independent predictors of place of living. Mortality during the first year was significantly predicted by urinary incontinence and gender (men doing worse), whereas the Barthel Activities of Daily Living (ADL) Index sumscore was the only significant independent predictor of social activities. CONCLUSION: Urinary incontinence at baseline seems to be a most important predictor of outcome 12 months post stroke in geriatric patients. However, with regard to social activities (Frenchay Activities Index), functional impairment in the initial phase as reflected by the Barthel ADL Index supersedes other predictors.

Screening by nurses for aphasia in stroke--the Ullevaal Aphasia Screening (UAS) test.

PURPOSE: In Norway, the speech therapist is responsible for the assessment of language impairment after stroke, but many hospitals have no speech therapist. This study therefore developed and evaluated a simple method to be used by nurses to detect aphasia in the acute stage of stroke; the Ullevaal Aphasia Screening (UAS) test. METHOD: The study was carried out among 37 stroke patients admitted to an acute stroke unit. They were assessed by nurses using the UAS, while the results of a comprehensive assessment by a speech therapist acted as the 'gold standard'. RESULTS: The predictive value of a positive test was 0.67 and that of a negative test 0.93; only two out of 28 who screened negative on the UAS were diagnosed with mild aphasia by the speech therapist. The weighted kappa coefficient of agreement was 0.83, indicating a strong agreement between the nurses' and speech therapists' scoring. The screening took 5-15 minutes to complete. CONCLUSION: The Ullevaal Aphasia screening test seems to be a short and valid screening instrument for aphasia in the acute stage of stroke, but further studies would be needed to substantiate the efficacy of the UAS test.

Validation of the screening instrument for neuropsychological impairment in stroke.

BACKGROUND AND PURPOSE: Full neuropsychological assessment is time-consuming and exhausting for the patient in the early phase of stroke. The screening instrument for neuropsychological impairment in stroke (SINS) is a brief, bedside-applicable instrument designed to screen perceptual and cognitive dysfunction related to functional activities in stroke. It has been developed by physiotherapists to be incorporated in the general assessment of the patient. This study evaluates the validity of the method against a more extensive reference method assessing cognitive function. METHODS AND RESULTS: An unselected group of hospitalized stroke patients (N = 87) was assessed 10 days and 12 months after stroke. Factor analyses (52% explained variance), identified three factors: 'aphasia', 'apraxia' and 'visuocognitive dysfunction'. Receiver operating characteristics (ROC) curves demonstrated that for all factors, high specificity was maintained at the high sensitivity needed for a screening method. Kendall rank correlation coefficients between the scorings on the new instrument and the reference method were high. Effect size analysis showed that the ability of the new instrument to detect change in cognitive functioning during the first year was of the same magnitude as the reference method. CONCLUSIONS: SINS has a high sensitivity regarding cognitive dysfunction, as diagnosed by the more comprehensive and time-consuming reference method. The instrument would be useful as an initial step in the assessment of neuropsychological impairment in stroke patients.