Fitness and mobility training in patients with Intensive Care Unit-acquired muscle weakness (FITonICU): study protocol for a randomised controlled trial.

BACKGROUND: Critical illness myopathy (CIM) and polyneuropathy (CIP) are a common complication of critical illness. Both cause intensive-care-unit-acquired (ICU-acquired) muscle weakness (ICUAW) which increases morbidity and delays rehabilitation and recovery of activities of daily living such as walking ability. Focused physical rehabilitation of people with ICUAW is, therefore, of great importance at both an individual and a societal level. A recent systematic Cochrane review found no randomised controlled trials (RCT), and thus no supporting evidence, for physical rehabilitation interventions for people with defined CIP and CIM to improve activities of daily living. Therefore, the aim of our study is to compare the effects of an additional physiotherapy programme with systematically augmented levels of mobilisation with additional in-bed cycling (as the parallel group) on walking and other activities of daily living. METHODS/DESIGN: We will conduct a prospective, rater-masked RCT of people with ICUAW with a defined diagnosis of CIM and/or CIP in our post-acute hospital. We will randomly assign patients to one of two parallel groups in a 1:1 ratio and will use a concealed allocation. One intervention group will receive, in addition to standard ICU treatment, physiotherapy with systematically augmented levels of mobilisation (five times per week, over 2 weeks; 20 min each session; with a total of 10 additional sessions). The other intervention group will receive, in addition to standard ICU treatment, in-bed cycle sessions (same number, frequency and treatment time as the intervention group). Standard ICU treatment includes sitting balance exercise, stretching, positioning, and sit-to-stand training, and transfer training to get out of bed, strengthening exercise (in and out of bed), and stepping and assistive standing exercises. Primary efficacy endpoints will be walking ability (defined as a Functional Ambulation Category (FAC) level of ≥3) and the sum score of the Functional Status Score for the Intensive Care Unit (FSS-ICU) (range 0-22 points) assessed by a blinded tester immediately after 2 weeks of additional therapy. Secondary outcomes will include assessment of sit-to-stand recovery, overall limb strength (Medical Research Council, MRC) and grip strength, the Physical Function for the Intensive Care Unit Test-Scored (PFIT-S), the EuroQol 5 Dimensions (EQ-5D) questionnaire and the Reintegration to Normal Living Index (RNL-Index) assessed by a blinded tester. We will measure primary and secondary outcomes with blinded assessors at baseline, immediately after 2 weeks of additional therapy, and at 3 weeks and 6 months and 12 months after the end of the additional therapy intervention. Based on our sample size calculation 108 patients will be recruited from our post-acute ICU in the next 3 to 4 years. DISCUSSION: This will be the first RCT comparing the effects of two physical rehabilitation interventions for people with ICUAW due to defined CIP and/or CIM to improve walking and other activities of daily living. The results of this trial will provide robust evidence for physical rehabilitation of people with CIP and/or CIP who often require long-term care. TRIAL REGISTRATION: We registered the study on 6 April 2016 before enrolling the first patient in the trial at the German Clinical Trials Register ( www.germanctr.de ) with the identifier DRKS00010269 . This is the first version of the protocol (FITonICU study protocol).

Phage-mediated transfer of a dextranase gene in Lactobacillus sanfranciscensis and characterization of the enzyme.

While phages of lactobacilli are extensively studied with respect to their structure and role in the dairy environment, knowledge about phages in bacteria residing in sourdough fermentation is limited. Based on the previous finding that the Lactobacillus sanfranciscensis phage EV3 carries a putative dextranase gene (dex), we have investigated the distribution of similar dex(+) phages in L. sanfranciscensis, the chance of gene transfer and the properties of the dextranase encoded by phage EV3. L. sanfranciscensis H2A (dex(-)), originally isolated from a wheat sourdough, expressed a Dex(+) phenotype upon infection with EV3. The dextranase gene was isolated from the transductant and heterologously expressed in Escherichia coli. The gene encoded a protein of 801 amino acids with a calculated molecular weight (Mw) of 89.09 kDa and a calculated pI of 5.62. Upon purification aided by a 6-His tag, enzyme kinetic parameters were determined. The Km value was 370 mM, and the Vmax was calculated in about 16 µmol of glucose released from dextran by 1 mg of enzyme in 1 min in a buffer solution at pH 5.0. The optimum conditions were 60 °C and pH 4.5. The enzyme retained its activity for >3h at 60 °C and exhibited only 40% activity at 30 °C; the highest homology of 72% was found to a dextranase gene from Lactobacillus fermentum phage φPYB5. Within 25 L. sanfransiscensis isolates tested, the strain 4B5 carried a similar prophage encoding a dextranase gene. Our data suggest a phage-mediated transfer of dextranase genes in the sourdough environment resulting in superinfection-resistant L. sanfranciscensis Dex(+) strains with a possible ecological advantage in dextran-containing sourdoughs.

Identification and characterization of a glucan-producing enzyme from Lactobacillus hilgardii TMW 1.828 involved in granule formation of water kefir.

Water kefir is a home made fermented beverage based on a sucrose solution with fruit extracts. The inoculum of such fermentations consists of macroscopic granula containing lactic and acetic acid bacteria, and yeasts, which are embedded in an exopolysaccharide (EPS) matrix. In this work, a strain of Lactobacillus hilgardii producing large amounts of the granule-forming dextran could be isolated. The glycosyltransferans (Gtf) commonly called glucansucrase responsible for the production of this dextran was purified from L. hilgardii. Characteristic enzyme kinetic data were obtained. Optimum activity was observed between pH 4.3 and 4.6 and temperatures between 40 degrees C and 45 degrees C. A Michaelis-Menten kinetic could be fit to the experimental data and a K(M) of 0.0385 M was calculated. The corresponding gtf gene was identified and characterized. It encodes a 1448 amino acid protein with higher homologies to Gtfs of Lactobacillus parabuchneri, Lactobacillus sakei and Lactobacillus fermentum followed by lower homologies to Lactobacillus reuteri Gtfs. By knockout experiments the role of this gene in granule dextran production was demonstrated.

Genetic and functional characterization of Lactobacillus panis levansucrase.

Exopolysaccharides (EPS) can affect the rheological properties of foods, act as stabilizers or stimulate preferential growth of bifidobacteria in the gut and therefore function as prebiotics. The latter is referred to fructans, which are synthesized from sucrose by fructosyl transferases (FTFs). In this work, the FTF enzyme of Lactobacillus panis TMW1.648 isolated from sourdough was characterized. The coding gene was identified, sequenced and expressed heterologously in E. coli. Enzyme activity was maximal at pH 4.0-4.6, 45 degrees C and a substrate concentration of 300 mmol l(-1). It produced free fructose, a high molecular fructan and the oligosaccharide kestose from sucrose. Calcium ions proved to be essential for the enzymatic activity. In comparison to published data of other FTF enzymes of lactobacilli the described enzyme showed significant differences.

Predictive validity and responsiveness of the functional ambulation category in hemiparetic patients after stroke.

OBJECTIVE: To determine the reliability, concurrent and predictive validity, and responsiveness of the Functional Ambulation Category (FAC) in hemiparetic patients after stroke. DESIGN: Prospective cohort. SETTING: An early rehabilitation center for patients with neurologic disorders. PARTICIPANTS: Fifty-five nonambulatory patients after first-ever stroke, with duration of illness between 30 and 60 days, were included. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FAC, Rivermead Mobility Index (RMI), walking velocity, step length, and six-minute walking test (6MWT) were assessed at the beginning, after 2 and 4 weeks of rehabilitation, and again 6 months later. After 6 months, community ambulation was also assessed. Test-retest and interrater reliability, concurrent, discriminant, and predictive validity and responsiveness of the FAC were calculated. RESULTS: Based on video examinations, high test-retest reliability (Cohen kappa=.950) and interrater reliability (kappa=.905) were found. FAC scores at the beginning and after 2 weeks, 3 weeks, and 6 months correlated highly with the RMI (Spearman rho=.686, rho=.787, rho=.825, rho=.893, respectively), distance walked in the 6MWT (rho=.949, rho=.937, rho=.931, rho=.906, respectively), walking velocity (rho=.952, rho=.939, rho=.902, rho=.901, respectively), and step length (rho=.952, rho=.932, rho=.896, rho=.877, respectively) at the same time points (all P<.001). The RMI, walking velocity, step length, and distance walked in the 6MWT differed for each FAC category (P<.001). After 4 weeks of rehabilitation, an FAC score of 4 or higher predicted community ambulation at 6 months with 100% sensitivity and 78% specificity. FAC scores changed significantly between the first 2 and second 2 weeks (Wilcoxon z=8.7, z=7.9, respectively; both P<.001) of the inpatient rehabilitation program. CONCLUSIONS: The FAC has excellent reliability, good concurrent and predictive validity, and good responsiveness in patients with hemiparesis after stroke.

Comparative analysis of twin-arginine (Tat)-dependent protein secretion of a heterologous model protein (GFP) in three different Gram-positive bacteria.

In contrast to the general protein secretion (Sec) system, the twin-arginine translocation (Tat) export pathway allows the translocation of proteins across the bacterial plasma membrane in a fully folded conformation. Due to this feature, the Tat pathway provides an attractive alternative to the secretory production of heterologous proteins via the Sec system. In this study, the potential for Tat-dependent heterologous protein secretion was compared in the three Gram-positive bacteria Staphylococcus carnosus, Bacillus subtilis, and Corynebacterium glutamicum using green fluorescent protein (GFP) as a model protein. In all three microorganisms, fusion of a Tat signal peptide to GFP resulted in its Tat-dependent translocation across the corresponding cytoplasmic membranes. However, striking differences with respect to the final localization and folding status of the exported GFP were observed. In S. carnosus, GFP was trapped entirely in the cell wall and not released into the supernatant. In B. subtilis, GFP was secreted into the supernatant, however, in an inactive form. In contrast, C. glutamicum effectively secreted active GFP. Our results clearly demonstrate that a comparative evaluation of different Gram-positive host microorganisms is a crucial step on the way to an efficient Tat-mediated secretory production process for a desired heterologous target protein.

Reliable stabilization and functionalization of nanoparticles through tridentate thiolate ligands.

Novel amphiphilic trithiolates possess excellent properties for gold nanoparticle (AuNP) stabilization and functionalization and cannot be replaced by exchange reactions.

Reliability of the Modified Tardieu Scale and the Modified Ashworth Scale in adult patients with severe brain injury: a comparison study.

OBJECTIVE: To assess and to compare the reliability of the Modified Tardieu Scale with the Modified Ashworth Scale in patients with severe brain injury and impaired consciousness. DESIGN: Cross-sectional observational comparison study. SETTING: An early rehabilitation centre for adults with neurological disorders. SUBJECTS: Thirty patients with impaired consciousness due to severe cerebral damage of various aetiologies. MEASUREMENT PROTOCOL: Four experienced physical therapists rated each patient in a randomized order once daily for two consecutive days. Shoulder, elbow, wrist, hip, knee and ankle spasticity were assessed by the use of Modified Tardieu Scale and Modified Ashworth Scale data collection procedures. MAIN OUTCOME MEASURES: Test-retest and inter-rater reliability (kappa = kappa value) of the Modified Tardieu Scale and the Modified Ashworth Scale. RESULTS: The test-retest reliability of the Modified Ashworth Scale was moderate to good (kappa = 0.47-0.62) and of the Modified Tardieu Scale moderate to very good (kappa = 0.52-0.87). Test-retest reliability was significantly higher within the Modified Tardieu Scale in comparison with the Modified Ashworth Scale (Z > 1.96; p < 0.05) except for shoulder extensor and internal rotator muscles (Z < 1.96; p > 0.05). Although inter-rater reliability of both scales was poor to moderate (Modified Ashworth Scale: kappa = 0.16-0.42; Modified Tardieu Scale: kappa = 0.29-0.53), significantly higher K-values were revealed with the Modified Tardieu Scale for all tested muscle groups (Z > 1.96; p < 0.05) except for wrist extensors (Z < 1.96; p > 0.05). CONCLUSION: In patients with severe brain injury and impaired consciousness the Modified Tardieu Scale provides higher test retest and inter-rater reliability compared with the Modified Ashworth Scale and may therefore be a more valid spasticity scale in adults.

The influence of contractures and variation in measurement stretching velocity on the reliability of the Modified Ashworth Scale in patients with severe brain injury.

OBJECTIVE: To determine the influence of contractures and different stretching velocities on the reliability of the Modified Ashworth Scale (MAS) in patients with severe brain injury and impaired consciousness. DESIGN: Cross-section observational study. SETTING: A rehabilitation centre for adult persons with neurological disorders. SUBJECTS: Fifty patients with impaired consciousness due to severe cerebral damage of various aetiologies. MEASUREMENT PROTOCOL: Three experienced and trained medical professionals rated each patient in a randomized order once daily for two consecutive days. Shoulder, elbow, wrist, knee and ankle spasticity were assessed by the use of the MAS with different stretching velocities. The presence of contractures was assessed by a goniometer. MAIN OUTCOME MEASURES: Retest and inter-rater reliability (k(w) = weighted kappa) of the MAS. RESULTS: The retest reliability of the MAS was good (shoulder joints (k(w) 0.74), elbow joints (k(w) 0.74), wrist joints (k(w) 0.72), knee joints (k(w) 0.72), ankle joints (k(w) 0.77)) and the inter-rater reliability was moderate (shoulder joints (k(w) 0.49), elbow joints (k(w) 0.52), wrist joints (k(w) 0.51), knee joints (k(w) 0.54) ankle joints (k(w) 0.49)). The presence of contractures significantly influenced the reliability of MAS in shoulder and wrist joints. No influence of stretching velocity on the reliability of the MAS was found. CONCLUSION: In patients with impaired consciousness due to severe brain injury the MAS has good retest, but only limited inter-rater, reliability. The presence of contractures may influence reliability of the MAS, but stretching velocity does not.

Treatment of pressure ulcers by serial casting in patients with severe spasticity of cerebral origin.

OBJECTIVE: To assess the effectiveness of serial casting in the treatment of pressure ulcers caused by severe spasticity. DESIGN: Case series. SETTING: A clinic for the rehabilitation of persons with neurologic disorders. PATIENTS: Nine patients with 11 pressure ulcers resulting from severe cerebral spasticity, the ulcers being intractable to conventional management because of repeated friction and/or inaccessibility. INTERVENTION: Serial casting of the limb(s) with the pressure ulcer(s), with either fenestration or a cast arch providing access to the wound. MAIN OUTCOME MEASURES: Improved healing of pressure ulcers, as quantified with the National Pressure Ulcer Advisory Panel classification system. RESULTS: Within a mean of 4.6 weeks, 7 ulcers healed completely and 4 improved markedly. The casting caused no complications. Moreover, extension deficits improved markedly in all patients (105 degrees +/- 27 degrees to 17 degrees +/- 10 degrees ). CONCLUSION: Serial casting may be a valuable tool in the treatment of pressure ulcers at the extremities of patients with severe cerebral spasticity.