Effect of pelvic floor and transversus abdominis muscle contraction on inter-rectus distance in postpartum women: a cross-sectional experimental study.

OBJECTIVES: To investigate the effect of acute isometric contraction of the pelvic floor muscles (PFM) and transversus abdominis muscle (TrAM) on inter-rectus distance (IRD) from resting values in postpartum women with diastasis rectus abdominis (DRA). DESIGN: Cross sectional experimental study. SETTING: Physiotherapy clinic. PARTICIPANTS: Thirty eight postpartum women presenting with DRA of at least two finger widths. METHODS: Two dimensional ultrasound images of IRD were recorded using a linear probe (5 to 10MHz) at rest, during PFM contraction, during TrAM contraction, and during combined PFM and TrAM contraction. IRD data were normally distributed. MAIN OUTCOME MEASURE: Change in IRD. RESULTS: There was a significant increase in IRD during PFM and TrAM contraction compared with IRD at rest. At 2cm above the umbilicus, mean PFM was 26.9 [standard deviation (SD) 8.8] mm vs rest 25.7 (SD 8.5) mm {mean difference 1.2 [95% confidence interval (CI) 0.7 to 1.7] mm}; and mean TrAM was 28.4 (SD 9.0) mm vs rest 25.7 (SD 8.5) mm [mean difference 2.8 (95% CI 1.9 to 3.6) mm]. Similarly, 2cm below the umbilicus, mean PFM was 22 (SD 8.3) mm vs rest 21 (SD 7.9) mm [mean difference 0.9 (95% CI 0.4 to 1.6) mm]; and mean TrAM was 23.3 (SD 8.7) mm vs rest 21 (SD 7.9) mm [mean difference 2.3 (95% CI 1.5 to 3.1) mm]. Combined TrAM and PFM contraction measured 2cm above the umbilicus caused the greatest increase in IRD: mean PFM+TrAM 29.6 (SD 9.4) mm vs rest 25.7 (SD 8.5) mm [mean difference 3.9 (95% CI 2.8 to 5.0) mm]. CONCLUSION: Both PFM and TrAM contraction, and combined PFM and TrAM contraction increased IRD in postpartum women with DRA.

Cation exchange capacity of biochar: An urgent method modification.

Biochar, produced through pyrolysis of organic matter, is negatively charged, thus contributing to electrostatic adsorption of cations. However, due to its porous structure and contents of alkaline ashes, the determination of the cation exchange capacity (CEC) is challenging. Literature values for the CEC of biochar are surprisingly variable and are often poorly reproducible, suggesting methodological problems. Here, we modify and critically assess different steps in the existing ammonium acetate (NH4OAc) method (pH 7), where ammonium (NH4+) is displaced by potassium chloride (KCl), following removal of excess NH4OAc with isopropanol, in batch mode. We used pigeon pea biochar to develop the method and conducted a test on three additional biochars with different acid neutralizing capacity. A pretreatment step of biochar was introduced, using diluted hydrochloric acid, to decrease biochar pH to near neutral, so that 1 M NH4OAc effectively buffers the biochar suspension pH at 7. This allows the CEC of all biochars to be determined at pH 7, which is crucial for biochar comparison. The dissolution of ashes may cause relatively large weight losses (e.g. for cacao shell biochar), which need to be accounted for when computing the CEC of raw biochar. The sum of NH4OAC-extractable base cations provided a smaller and better estimate of the CEC than KCl-extractable NH4+. We hypothesize that the overestimation of the CEC based on KCl-extractable NH4+ is due to the ineffectiveness of the relatively large isopropanol molecules to remove excess NH4OAc in biochars rich in micro-pores, due to size exclusion. The amount of base cations removed in the pretreatment was about three (rice husk biochar) to ten times (pigeon pea biochar) greater than the amount of exchangeable cations. The CEC values of biochar increased from 10.8 cmol/Kg carbon to 119.6 cmol/Kg carbon. These values are smaller than reported CEC values of soil organic carbon.

Cardiac function associated with previous, current and repeated depression and anxiety symptoms in a healthy population: the HUNT study.

OBJECTIVE: Symptoms of anxiety and depression often co-exist with cardiovascular disease (CVD), yet little is known about the association with left ventricular (LV) subclinical dysfunction. We aimed to study the cross-sectional associations of previous, current and repeated depression or anxiety symptoms, with sensitive indices of LV systolic and diastolic function, based on tissue Doppler (TD) and speckle tracking (ST) imaging methods. METHODS: A random selection of 1296 individuals free from known CVD, hypertension and diabetes were examined with echocardiography at baseline of the third Nord-Trøndelag Health Study, (HUNT3, 2006-2008). The primary outcomes were LV diastolic function (e') and LV systolic function (longitudinal global strain). The primary exposures were self-report on the Hospital Anxiety and Depression Scale (HADS). Associations between outcomes and baseline exposures were available for 1034 (80%), and with previous and repeated exposures for 700 participants who also participated in HUNT2 (1995-1997). RESULTS: Previous and repeated depression symptoms, but not current depression, were linearly associated with a reduction in e'. The average sum of two repeated HADS-D scores 10 years apart had the strongest effect on e' (-8.3%; 95% CI -13.9% to -2.7%) per 5 units. We observed a sex difference between depression symptoms and longitudinal global strain (p for interaction 0.019), where women had a marginal negative effect. Anxiety symptoms, neither previous, current nor repeated were associated with subclinical LV dysfunction. CONCLUSIONS: In a healthy sample, confirmed free of CVD, past and repeated depression symptoms were associated with subclinical LV dysfunction. Thus, depression symptoms might represent a modifiable risk factor for future CVD.

The MOBID-2 pain scale: reliability and responsiveness to pain in patients with dementia.

BACKGROUND: Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) pain scale is a staff-administered pain tool for patients with dementia. This study explores MOBID-2's test-retest reliability, measurement error and responsiveness to change. METHODS: Analyses are based upon data from a cluster randomized trial including 352 patients with advanced dementia from 18 Norwegian nursing homes. Test-retest reliability between baseline and week 2 (n = 163), and weeks 2 and 4 (n = 159) was examined in patients not expected to change (controls), using intraclass correlation coefficient (ICC2.1 ), standard error of measurement (SEM) and smallest detectable change (SDC). Responsiveness was examined by testing six priori-formulated hypotheses about the association between change scores on MOBID-2 and other outcome measures. RESULTS: ICCs of the total MOBID-2 scores were 0.81 (0-2 weeks) and 0.85 (2-4 weeks). SEM and SDC were 1.9 and 3.1 (0-2 weeks) and 1.4 and 2.3 (2-4 weeks), respectively. Five out of six hypotheses were confirmed: MOBID-2 discriminated (p < 0.001) between change in patients with and without a stepwise protocol for treatment of pain (SPTP). Moderate association (r = 0.35) was demonstrated with Cohen-Mansfield Agitation Inventory, and no association with Mini-Mental State Examination, Functional Assessment Staging and Activity of Daily Living. Expected associations between change scores of MOBID-2 and Neuropsychiatric Inventory - Nursing Home version were not confirmed. CONCLUSION: The SEM and SDC in connection with the MOBID-2 pain scale indicate that the instrument is responsive to a decrease in pain after a SPTP. Satisfactory test-retest reliability across test periods was demonstrated. Change scores ≥ 3 on total and subscales are clinically relevant and are beyond measurement error.

Randomized clinical trial of self-gripping mesh versus sutured mesh for Lichtenstein hernia repair.

BACKGROUND: Many patients develop discomfort after open repair of a groin hernia. It was hypothesized that suture fixation of the mesh is a cause of these symptoms. METHODS: This patient- and assessor-blinded randomized multicentre clinical trial compared a self-gripping mesh (Parietene Progrip(®)) and sutured mesh for open primary repair of uncomplicated inguinal hernia by the Lichtenstein technique. Patients were assessed before surgery, on the day of operation, and at 1 and 12 months after surgery. The primary endpoint was moderate or severe symptoms after 12 months, including a combination of chronic pain, numbness and discomfort. RESULTS: The intention-to-treat population comprised 163 patients with self-gripping mesh and 171 with sutured mesh. The 12-month prevalence of moderate or severe symptoms was 17·4 and 20·2 per cent respectively (P = 0·573). There were no significant differences between the groups in postoperative complications (33·7 versus 40·4 per cent; P = 0·215), rate of recurrent hernia within 1 year (1·2 per cent in both groups) or quality of life. CONCLUSION: The avoidance of suture fixation using a self-gripping mesh was not accompanied by a reduction in chronic symptoms after inguinal hernia repair. REGISTRATION NUMBER: NCT00815698 (http://www.clinicaltrials.gov).

Fatigue in multiple sclerosis: associations with health-related quality of life and physical performance.

BACKGROUND AND PURPOSE: fatigue is a common, but still one of the least understood symptoms in multiple sclerosis (MS). We aimed to investigate whether fatigue was associated with demographic-, clinical-, health-related quality of life (HRQoL)- and physical performance variables, and whether change in fatigue after treatment was associated with changes in HRQoL and physical performance. METHODS: sixty patients were included for inpatient physiotherapy. Fifty-six patients completed the study and were available for analysis. Fatigue (Fatigue Severity Scale; FSS), HRQoL (Multiple Sclerosis Impact Scale; MSIS-29) and physical performance (walking ability and balance) were assessed at screening, baseline, after treatment and at follow-up after 3 and 6 months. We analysed possible associations between fatigue and other variables at baseline by regression models, and between change in fatigue versus changes in both HRQoL and physical performance variables after physiotherapy by correlation analysis. RESULTS: fatigue at baseline was associated with HRQoL (explained 21.9% of variance), but not with the physical performance tests. Change in fatigue was correlated with change in HRQoL, but not with changes in physical performance. All measures were improved after treatment (P ≤ 0.001). While improvements in fatigue and HRQoL were lost at follow-up, improvements in physical performance tests were maintained for at least 6 months (P ≤ 0.05). CONCLUSIONS: fatigue was associated with HRQoL at baseline. Improvement in fatigue seemed to be related to other factors than improvement in physical performance. A broader strategy including both physical and psychological dimensions seems to be needed to improve fatigue over the long-term.

The influence of warm versus cold climate on the effect of physiotherapy in multiple sclerosis.

OBJECTIVE: To compare the effect of inpatient physiotherapy in a warm versus cold climate in short- and long-term perspectives. METHODS: Sixty multiple sclerosis (MS) patients with gait problems, without heat intolerance, were included in a randomized cross-over study of 4-week inpatient physiotherapy in warm (Spain) and cold (Norway) climate. The primary outcome, 6-min walk test (6MWT), and secondary physical performance and self-reported measures were scored at screening, baseline, after treatment and at 3 and 6 months of follow-up. Treatment effects were analysed by mixed models. RESULTS: After treatment, the mean walking distance had increased by 70 m in Spain and 49 m in Norway (P = 0.060). Improvement in favour of warm climate was demonstrated at 6 months of follow-up, 43 m (Spain) compared to 20 m (Norway) (P = 0.048). The patients reported less exertion after walking (6MWT) in favour of treatment in Spain at all time points (P < 0.05). No significant differences in change were detected for the other physical performance measures. Most self-reported measures showed more improvement after treatment in Spain, but these improvements were not sustained at follow-up. CONCLUSION: The results indicate that MS patients without heat intolerance have additional benefits from physiotherapy in a warm climate.

Serum concentrations of citalopram--dose-dependent variation in R- and S-enantiomer ratios.

INTRODUCTION: The antidepressive effect of racemic citalopram (CIT) is exerted by S-CIT, while R-CIT is a partial antagonist to S-CIT. Since R-and S-CIT are metabolized by different pathways, we investigated whether the ratio of S- and R-CIT may differ between individuals on the same dose of racemic CIT, and if a possible variability in the R/S-ratio could be dose-dependent. METHODS: A chiral analysis of R- and S-CIT in serum samples taken from 88 female patients receiving treatment with racemic CIT was performed using high-pressure liquid chromatography. RESULTS: The mean levels of R-CIT were significantly higher than those of S-CIT in all dose groups. The R/S-CIT ratio increased from 1.99 to 2.45 with an increase in the dose (p<0.05), and the interindividual variance in the R/S-CIT ratio was up to four-fold on the same dosage. DISCUSSION: Our findings show that the stereoselective metabolism of citalopram IN VIVO has pharmacokinetic consequences reflected by dose dependent variations of enantiomeric drug concentrations, as well as substantial interindividual variabilities in the ratios of the concentrations. The clinical consequences, however, are unclear and should be further explored.

The interrater reliability of SAPS II and SAPS 3.

PURPOSE: In this study we evaluated and compared the interrater reliability of SAPS II and SAPS 3 in order to measure the consistency of performance among different raters. METHOD: Ten junior doctors working at two general ICUs were trained in the use of SAPS II and SAPS 3 using a 2.5-h training program. After training they scored 24 cases in both systems. Scores were analyzed using intraclass correlation coefficient (ICC) statistics. In order to identify variables with low reliability, subscores were analyzed using the ICC, and single-variables were compared to a template score using weighted kappa statistics. RESULTS: The ICC (95% CI) of the scores was 0.84 (0.74, 0.91) in SAPS II and 0.80 (0.68, 0.89) in SAPS 3, which is considered adequate for both systems. Mean mortality predictions among the raters had a range of 0.12 in SAPS II and 0.19 in SAPS 3. Administrative data including age had high reliability, whereas variables based on diagnostic information had only moderate reliability. Laboratory data had consistently higher reliability than variables based on the interpretation of charts. CONCLUSION: Both SAPS II and SAPS 3 have adequate interrater reliability, but the standardized mortality ratios are still likely to be influenced by the rater's scoring practice.

Mutant ftsI genes in the emergence of penicillin-binding protein-mediated beta-lactam resistance in Haemophilus influenzae in Norway.

The most important mechanism for beta-lactam resistance in beta-lactamase-negative ampicillin-resistant (BLNAR) isolates of Haemophilus influenzae is the alteration of penicillin-binding protein 3 (PBP3) as a result of ftsI gene mutations. The present study aimed to map PBP3 alterations and to determine the correlation to beta-lactam resistance in respiratory tract isolates of H. influenzae in Norway, as well as assess the contribution of clonal spread to the emergence of PBP3-mediated resistance. Twenty-three beta-lactamase negative respiratory tract isolates with resistance to penicillins and 23 susceptible control isolates were examined by determination of beta-lactam MICs, ftsI sequencing and molecular typing by pulsed-field gel electrophoresis (PFGE). Ampicillin MIC ranges in the resistant group and the control group were 1-2 mg/L and 0.125-0.5 mg/L, respectively. All isolates in the resistant group had the PBP3 substitution Asn526-->Lys and were thus categorized as group II low-BLNAR. No control isolate met the genetic BLNAR (gBLNAR) criteria. The PBP3 substitution patterns corresponded well to those observed in previous European studies. Eighty-three percent (19/23) of the resistant isolates belonged to two clones, demonstrating the capability of low-BLNAR strains of clonal dissemination. Combined analysis of ftsI DNA sequences and PFGE patterns revealed distinctly different ftsI alleles in genetically indistinguishable isolates and identical copies of the same ftsI allele in unrelated isolates. A possible explanation of this observation is the recombinational exchange of ftsI alleles. This phenomenon, as well as the possibility of endemic European gBLNAR strains, should be further investigated.

Measurement properties of the Non-Communicating Adult Pain Checklist (NCAPC): a pain scale for adults with Intellectual and Developmental Disabilities, scored in a clinical setting.

The 18 items' Non-Communicating Adult Pain Checklist (NCAPC) has been developed from the 27 items Non-Communicating Children Pain Checklist to better capture pain behavior of adults with Intellectual and Developmental Disabilities (IDD). As part of the NCAPC's measurement properties, internal consistency, reliability and sensitivity to pain have been evaluated and found satisfactory, using scores based on video-uptakes. The aim of the article therefore was to examine the instrument's discriminative ability and sensitivity to pain of adults at different levels of IDD when scored within a clinical situation as well as through video-uptakes. Participants were 59 adults at different levels of IDD who were observed for pain behavior, before and during dental hygiene treatment (scored directly) and influenza injection (scored from video-uptakes), using the NCAPC. The results suggest that the NCAPC differentiated between pain and non-pain situations, as well as between pain reaction during two different medical procedures expected to cause more or less pain, and it was found sensitive to pain at all levels of IDD. We conclude that the present findings add to previous findings of measurement properties of the NCAPC, and support that it can be scored directly in a clinical setting.

Psychometric properties of a Norwegian version of Multiple Sclerosis Impact Scale (MSIS-29).

OBJECTIVES: To examine psychometric properties of Multiple Sclerosis Impact Scale (MSIS-29) for use in Norwegian patients with multiple sclerosis. METHODS: Translation was performed according to international guidelines. The questionnaire was answered by 64 patients prior to and at a screening session, and re-answered by 59 patients before and after 4 weeks of physiotherapy. RESULTS: Internal consistency (α) was 0.92 for the physical and 0.85 for the psychological subscales. Reliability by intraclass correlation coefficients were 0.86 for the physical and 0.81 for the psychological subscales, smallest detectable change being 18.4 and 21.1, respectively. The physical but not the psychological subscale demonstrated mostly satisfactory associations with other physical measures. Responsiveness by area under the receiver operating characteristics curve was 0.83 and 0.76, respectively. As hypothesized, effect size was larger for the physical (1.01) than for the psychological (0.76) subscale after treatment. CONCLUSIONS: MSIS-29, Norwegian Version demonstrated satisfactory psychometric properties.

Reliability of the Non-Communicating Adult Pain Checklist (NCAPC), assessed by different groups of health workers.

Evaluating pain in adults with intellectual and developmental disability (IDD) is a challenge. The Non-Communicating Adults Pain Checklist (NCAPC) was recently developed from the Non-Communicating Children's Pain Checklist (NCCPC) and examined in a group of adults with IDD (N=228) and found to hold satisfactory construct validity, internal consistency and sensitivity to pain. To further explore its basis for clinical use, intra and interrater reliability of the NCAPC was investigated. Data collection was done by videotaping the participants before and during influenza vaccination. Intrarater reliability was evaluated by the first author on a group of 50 randomly selected individuals (mean age 42.5, range 19-72) and was found at 0.94. Interrater reliability was investigated in two stages. In the initial step different groups of health care workers (caregivers, nurses, case managers, and therapists), each including five raters, viewed a sample of 12 adult participants with IDD (3 at each level of IDD mean age was 49 years, range 16-72), that were extracted from the population sample. Interrater reliability of all raters within the groups varied from low to very high (ICC(1,1)=0.40-0.88). Interrater reliability was very high in caregivers. The Physical -and Occupational therapists are one group were considered potential users of the measure. In the second stage 3 participants from each of the groups showing high interrater reliability (caregivers and therapist) evaluated interrater reliability in a randomly selected group of 40 individuals (mean age 41.2, range 15-72). Interrarter reliability for the therapists and caregivers was found at 0.91 and 0.92 correspondingly. The researchers conclude that that the NCAPC have been found to hold high reliability values.

A case of thanatophoric dysplasia: the early prenatal 2D and 3D sonographic findings and molecular confirmation of diagnosis.

OBJECTIVE: To present the early 2D and 3D ultrasound findings and the molecular confirmation in a case of thanatophoric dysplasia. METHODS: On ultrasound examination, there was frontal bossing, increased nuchal translucency and short limbs at 12 weeks' gestation and a small thorax and short and bowed long bones on 3D at 16 weeks. Amniocentesis and DNA analysis confirmed the mutation of FGFR3 gene indicating thanatophoric dysplasia. RESULTS: After medical termination of pregnancy, the postmortem X-ray and pathology examination findings were consistent with the diagnosis. CONCLUSION: 3D anatomy scan and molecular confirmation may be helpful in early diagnosis and genetic counseling of thanatophoric dysplasia.

Fluoroquinolone-resistant uropathogenic Escherichia coli in Norway: evidence of clonal spread.

Prevalence, resistance profiles, virulence gene complements, and phylogenetic and clonal affinities of fluoroquinolone-resistant Escherichia coli from urinary tract infections (UTIs) in Norway were investigated. Of 7302 E. coli UTI isolates from 2003, 1.2% were fluoroquinolone-resistant; 35 of these fluoroquinolone-resistant isolates were included in the present study. The isolates were predominantly multiresistant, carried few virulence factors, and tended to belong to the less-virulent phylogroups A and B1. Although the isolates were genetically heterogeneous, there was evidence of a limited degree of clonal dissemination.

A comparison of phylogenetic group, virulence factors and antibiotic resistance in Russian and Norwegian isolates of Escherichia coli from urinary tract infection.

Isolates of Escherichia coli from 31 Norwegian and 31 Russian females with significant bacteruria who presented with clinical signs of urinary tract infection (UTI) were tested for antimicrobial sensitivity, the presence of virulence genes, phylogroup distribution and clonal affinity. Twenty isolates, representing the full clonal diversity of a collection of 138 intestinal isolates of E. coli from healthy Norwegian females, served as a reference group. Russian UTI isolates belonged more often to phylogroup A and possessed fewer virulence genes than did Norwegian isolates. UTI isolates of E. coli were genetically heterogeneous and had a high degree of antimicrobial sensitivity.

Leaching from organic matter-rich soils by rain of different qualities: I. Concentrations.

Soil monoliths from an area exposed to acid precipitation and from an unpolluted area were used in a lysimeter experiment to study effects of different rain qualities on the chemical composition of the leachate from shallow soils rich in organic matter. The vegetation was either dominated by moorgrass [Molinia caerulea (L.) Moench] or heather [Calluna vulgaris (L.) Hull]. The lysimeters received either "acid rain" (pH 4.3) or "normal rain" (pH 5.3). High concentrations of dissolved organic carbon (DOC) were characteristic of the leachate. The different "rain" qualities had no significant influence on the DOC concentration. More DOC was, however, leached from lysimeters with heather vegetation. Roughly 50% of the aluminum (Al) was in complex with organic material and the Al charge was calculated to be between +1.4 and +2.0. Sulfate (SO4(2-)) was the only component that was significantly influenced by the treatment, as more was leached from lysimeters receiving "acid rain." Sulfate was poorly correlated with pH, suggesting that reduced SO4(2-) input would not necessarily lead to reduced acidity. Differences in the pH of the leachate due to the treatments were less than 0.15 pH units. Nitrate (NO3-) was only leached in very low concentrations and of little consequence for the leachate acidity. Some observations do, however, suggest that NO3- may contribute to acidification in episodes with high precipitation. High concentrations of Cl- in the leachate and a significant positive correlation between Cl-, H+, and base cations indicate that sea salt episodes may be important for soil acidification and acidity of the leachate.

Quality assessment of 26,304 herniorrhaphies in Denmark: a prospective nationwide study.

BACKGROUND: Groin hernia repair is one of the most frequent operations, but there is no consensus about surgical or anaesthetic technique. Furthermore, no nationwide studies have been done. Our aim was to investigate outcome results of groin hernia surgery to improve quality of treatment. METHODS: We prospectively recorded 26304 groin hernia repairs done in Denmark from Jan 1, 1998, to June 30, 2000, in a nationwide Danish hernia database. FINDINGS: 93% of all groin herniorrhaphies done in Denmark in the 30 months of the study were recorded in the database. Kaplan-Meier estimates of reoperation rates 30 months after anterior mesh repair and laparoscopic repair were significantly lower than after sutured posterior wall repairs in primary inguinal hernia (2.2% and 2.6% vs 4.4%; p<0.0001). Reoperation rates were also lower with anterior mesh repair (6.1%; p<0.0001) and laparoscopic repair (3.4%; p<0.0001) than with sutured posterior wall repair (10.6%) after recurrent hernia. Use of Lichtenstein mesh repair increased from 33% in January, 1998, to 62% in June, 2000, whereas use of laparoscopic repair remained constant at about 5%. Kaplan-Meier estimates of reoperation rates were 2.8% in the first 15 months and 1.6% in the second (p=0.03). For elective repairs, only 59% of patients were treated on an outpatient basis, and only 18% had local anaesthesia. INTERPRETATION: Mesh repairs have a lower reoperation rate than conventional open repairs. Systematic prospective recording of treatment and outcome variables in a national clinical database improved the overall quality of surgical care. However, there is a large potential for cost savings and more efficient patient care with extended use of mesh techniques, outpatient surgery, and local anaesthesia.