A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

[Is low intensity ultrasound effective in treatment of disorders of fracture healing?]

This prospective consecutive study judges the effectiveness of pulsed low-intensity ultrasound for treatment of boney healing disorders. 86 out of 100 treatments were successful. Although in these 100 cases 64 delayed unions and 36 nonunions were enrolled ultrasound therapy was performed as an alternative to the indicated operation in every case. Excluding ten cases of ununited fractures of the scaphoid no additional therapy was performed in any case. Stratifying the data no significant differences in healing rate and treatment time were observed between delayed unions and non-unions and between atrophic and hypertrophic healing disorders. Judging the healing rate of 86% one has to take into consideration that according to our in- and excluding criteria we had a preselected sample of patients. Nevertheless the effectiveness of pulsed low-intensity ultrasound for treatment of disorders of the fracture repair process is evident.

A solitary osteochondroma of the pediatric thoracic spine: a case report and review of the literature

The objective of this study design is to describe the diagnosis and successful treatment of a pediatric patient with an osteochondroma of the thoracic spine. An osteochondroma is a bone tumor that rarely occurs in the thoracic spine, especially in the pediatric population. A simple painless mass may be the only presenting symptom. The laboratory findings are usually nonspecific. Radiographs may be nondiagnostic in certain cases, and computed tomography is the imaging modality of choice. The diagnosis, treatment, and outcome of a pediatric patient with an osteochondroma of the thoracic spine, including a possible genetic predisposition, are reviewed, along with a complete review of the literature. Anteroposterior and lateral plain radiographs illustrated a well-defined solid mass arising from the posterior elements of the tenth thoracic vertebrae. A computed tomography (CT) scan further delineated that the mass arose from the spinous process with no obvious impingement of the nerve roots. After excision of the lesion, gross pathological and histologic evaluation was consistent with an osteochondroma. The use of CT allowed accurate diagnosis of the osteochondroma. This led to appropriate surgical intervention, resulting in definitive treatment.

A DNA immunization model study with constructs expressing the tick-borne encephalitis virus envelope protein E in different physical forms

We have conducted a DNA immunization study to evaluate how the immune response is influenced by the physical structure and secretion of the expressed Ag. For this purpose, we used a series of plasmid constructs encoding different forms of the envelope glycoprotein E of the flavivirus tick-borne encephalitis virus. These included a secreted recombinant subviral particle, a secreted carboxyl-terminally truncated soluble homodimer, a nonsecreted full-length form, and an inefficiently secreted truncated form. Mice were immunized using both i.m. injection and Gene Gun-mediated application of plasmids. The functional immune response was evaluated by determining specific neutralizing and hemagglutination-inhibiting Ab activities and by challenging the mice with a lethal dose of the virus. As a measure for the induction of a Th1 and/or Th2 response, we determined specific IgG subclasses and examined IFN-gamma, Il-4, and Il-5 induction. The plasmid construct encoding a secreted subviral particle, which carries multiple copies of the protective Ag on its surface, was superior to the other constructs in terms of extent and functionality of the Ab response as well as protection against virus challenge. As expected, the type of Th response was largely dependent on the mode of application (i.m. vs Gene Gun), but our data show that it was also strongly influenced by the properties of the Ag. Most significantly, the plasmid encoding the particulate form was able to partially overcome the Th2 bias imposed by the Gene Gun, resulting in a balanced Th1/Th2 response.

Nephropathia epidemica and Puumala virus in Austria

To study the epidemiology of hantavirus infections in Austria, 1215 humans and 596 rodents of different species were tested for the presence of antibodies against Puumala and Hantaan virus. Direct virus identification by polymerase chain reaction in lung tissue of serologically positive rodents was performed to verify antibody results and to determine the genetic identity of viral RNA by phylogenetic analysis of a part of the hantavirus M segment. For 32 of the 37 cases of nephropathia epidemica diagnosed in Austria, the location where transmission took place could be traced to specific areas in the Austrian federal states of Carinthia and Styria. The overall seroprevalence in humans was 1.2% and ranged from 0.02% in Villach, Carinthia, to 0.8% in Korneuburg, Lower Austria, and 1.8% in Wolfsberg, Carinthia. Virus RNA could be amplified from three Clethrionomys glareolus voles collected in Klippitztörl, Carinthia, and from one collected in Ernstbrunn, Lower Austria. The sequences were all identified as Puumala virus by phylogenetic analysis and were found to be most closely related to the western European Puumala viruses from Germany and France. No evidence of the existence of Hantaan-like infections and viruses in Austria was found.

Deletion of new covalently linked cell wall glycoproteins alters the electrophoretic mobility of phosphorylated wall components of Saccharomyces cerevisiae

The incorporation of radioactive orthophosphate into the cell walls of Saccharomyces cerevisiae was studied. 33P-labeled cell walls were extensively extracted with hot sodium dodecyl sulfate (SDS). Of the remaining insoluble radioactivity more than 90% could be released by laminarinase. This radioactive material stayed in the stacking gel during SDS-polyacrylamide gel electrophoresis but entered the separating gel upon treatment with N-glycosidase F, indicating that phosphate was linked directly or indirectly to N-mannosylated glycoproteins. The phosphate was bound to covalently linked cell wall proteins as mannose-6-phosphate, the same type of linkage shown previously for soluble mannoproteins (L. Ballou, L. M. Hernandez, E. Alvarado, and C. E. Ballou, Proc. Natl. Acad. Sci. USA 87:3368-3372, 1990). From the phosphate-labeled glycoprotein fraction released by laminarinase, three cell wall mannoproteins, Ccw12p, Ccw13p and Ccw14p, were isolated and identified by N-terminal sequencing. For Ccw13p (encoded by DAN1 [also called TIR3]) and Ccw12p the association with the cell wall has not been described before; Ccw14p is identical with cell wall protein Icwp (I. Moukadiri, J. Armero, A. Abad, R. Sentandreu, and J. Zueco, J. Bacteriol. 179:2154-2162, 1997). In ccw12, ccw13, or ccw14 single or double mutants neither the amount of radioactive phosphate incorporated into cell wall proteins nor its position in the stacking gel was changed. However, the triple mutant brought about a shift of the 33P-labeled glycoprotein components from the stacking gel into the separating gel. The disruption of CCW12 results in a pronounced sensitivity of the cells to calcofluor white and Congo red. In addition, the ccw12 mutant shows a decrease in mating efficiency and a defect in agglutination.

[Dislocation of the elbow joint--therapy and treatment outcome]

At our hospital, closed dislocations of the elbow without neurovascular or osseous lesion are treated conservatively after successful reduction in the absence of a tendency to redislocation. Indications for surgery are irreducible dislocations and those with a tendency to redislocation as well as open soft tissue injuries, neurovascular and osseous concomitant injuries. During a period of 10 years 113 patients were treated according to this strategy. Of these patients, 46 had simple dislocations of the elbow and 67 suffered from dislocations with osseous lesions. In 95 patients follow-ups could be performed after a mean period of 55 months. In more than 75% of cases good or excellent functional results were documented; unfavourable results were seen only in patients with osseous lesions. Nearly all of the patients had a stable elbow joint at the end of therapy.

[Ultrasound therapy for nonunions. Three case reports]

Despite of the good results of operative treatment disorders of fracture healing are still a challenge for surgeons. In some cases all endeavours are frustrating and bone does not heal. Low intensity pulsed ultrasound (frequency: 1.5 MHz, pulsed by 1 KHz, signal burst width: 200 musec, intensity: 30 mW/cm2) offers the opportunity of an alternative treatment. In contrast to magnetic field therapy, electric stimulation or use of extracorporal shock waves this therapy is judged positively all over the literature. Within an own series of 76 cases at present time we can show a 86% healing rate under defined conditions. Within this paper we present three case reports, which clearly show the efficiency of low intensity pulsed ultrasound.

Sequence analysis and genetic classification of tick-borne encephalitis viruses from Europe and Asia

The epidemiology of tick-borne encephalitis virus was investigated by comparative sequence analysis of virus strains isolated in endemic areas of Europe and Asia. Phylogenetic relationships were determined from the nucleotide and amino acid sequences of the major envelope (E) protein of 16 newly sequenced strains and nine previously published sequences. Three genetic lineages could be clearly distinguished, corresponding to a European, a Far Eastern and a Siberian subtype. Amino acids characteristic for each of the subtypes ('signature' amino a cids) were identified and their location in the atomic structure of protein E was determined. The degree of variation between strains within subtypes was low and exhibited a maximum of only 2.2% at the amino acid level. A maximum difference of 5.6% was found between the three subtypes, which is in the range of variation reported for other flaviviruses.

Experience with cardiac troponin T in difficult cases

Recent years have seen the advent of new cardiac markers. These have been shown to be valuable in large controlled clinical trials. The breakthrough of the troponins world-wide for detection of myocardial lesions has meant that the Cardiac Troponin T parameter has been available in our hospital since August 1996. Analysis of the samples is carried out on the Elecsys, an automated immunology analyzer from Roche Diagnostics, Austria. The purpose of the present paper is to investigate whether study results on the diagnostic utility, sensitivity and specificity of troponin T can be confirmed in multimorbid patients in routine clinical practice, who are otherwise excluded from such trials. Troponin T was investigated in five cases including patients presenting with myocarditis and parallel damage of the skeletal muscles, as well as in haemodialysis patients. Cardiac troponin T has proved to be a very reliable parameter in all of these patients due to its high sensitivity and specificity, where other conventional diagnostic procedures were not helpful due to co-morbidity and confounding factors. New clinically relevant information can be obtained by both individual as well as serial measurements. Cardiac troponin T determination is a powerful new tool and should be considered seriously, regardless of other underlying diseases: it is, therefore, not only a diagnostic but also a management tool.

Glucose and Stress Independently Regulate Source and Sink Metabolism and Defense Mechanisms via Signal Transduction Pathways Involving Protein Phosphorylation

In higher plants, sugars are required not only to sustain heterotrophic growth but also to regulate the expression of a variety of genes. Environmental stresses, such as pathogen infection and wounding, activate a cascade of defense responses and may also affect carbohydrate metabolism. In this study, the relationship between sugar- and stress-activated signal transduction pathways and the underlying regulatory mechanism was analyzed. Photoautotrophically growing suspension culture cells of Chenopodium rubrum were used as a model system to study the effects of the metabolic regulator D-glucose and of different stress-related stimuli on photosynthesis, sink metabolism, and defense response by analyzing the regulation of mRNAs for representative enzymes of these pathways. Glucose as well as the fungal elicitor chitosan, the phosphatase inhibitor endothall, and benzoic acid were shown to result in a coordinated regulatory mechanism. The mRNAs for phenylalanine ammonia-lyase, a key enzyme of defense response, and for the sink-specific extracellular invertase were induced. In contrast, the mRNA for the Calvin cycle enzyme ribulose bisphosphate carboxylase was repressed. This inverse regulatory pattern was also observed in experiments with wounded leaves of C. rubrum plants. The differential effect of the protein kinase inhibitor staurosporine on mRNA regulation demonstrates that the carbohydrate signal and the stress-related stimuli independently activate different intracellular signaling pathways that ultimately are integrated to coordinately regulate source and sink metabolism and activate defense responses. The various stimuli triggered the transient and rapid activation of protein kinases that phosphorylate the myelin basic protein. The involvement of phosphorylation in signal transduction is further supported by the effect of the protein kinase inhibitor staurosporine on mRNA levels.

Infectious cDNA clones of tick-borne encephalitis virus European subtype prototypic strain Neudoerfl and high virulence strain Hypr

Infectious cDNA clones of two strains of tick-borne encephalitis (TBE) virus, i.e. European subtype prototypic strain Neudoerfl and the closely related but more virulent strain Hypr, were constructed. The recombinant constructs consisted of cDNAs stably inserted into the bacterial plasmid pBR322 under the control of T7 promoter elements. The genome of TBE virus strain Neudoerfl was successfully cloned, both as a full-length cDNA and as two partial cDNAs. In the case of strain Hypr, the genome is represented by two cDNA clones corresponding to the 5'- and 3'-terminal halves of the genome. Highly infectious RNAs can be produced from the full-length cDNA clone or from the partial clones ligated in vitro to form full-length cDNA templates prior to T7 transcription. The biological properties of the recombinant progeny viruses, including virulence characteristics, were indistinguishable from the corresponding parent virus strains. Thus, the described infectious cDNA clones represent a useful and reliable experimental system for the specific mutagenesis of TBE virus.

Characterization of monoclonal antibody-escape mutants of tick-borne encephalitis virus with reduced neuroinvasiveness in mice

Escape mutants of tick-borne encephalitis (TBE) virus were selected using neutralizing monoclonal antibodies (MAbs) that react with three different and previously unrecognized epitopes in the envelope protein E of TBE virus. Two of these variants (V-IC3 and V-IE3) exhibited a significantly reduced reactivity with their selecting MAbs, as determined by ELISA, whereas with one variant (V-IO3), reactivity was completely unchanged. Comparative sequence analyses demonstrated that each of the variants differed from the wild-type virus by a single amino acid substitution located at exposed positions within domains I, II and III of protein E. In the mouse model, all three mutants were still neuro-virulent but exhibited a significantly reduced neuro-invasiveness after subcutaneous inoculation. Virus replication, however, was sufficient to induce a specific antibody response. The observed alterations in virulence properties were not associated with reduced growth rates in vertebrate cell cultures, but one variant (V-IE3) exhibited a small plaque phenotype. The mutation of variant V-IO3 resulted in a temperature-sensitive phenotype and a significant elevation of the pH-threshold of the conformational change necessary for fusion activity.

Prevention of recurrent fetal loss caused by antiphospholipid syndrome

Repeated fetal loss presents a challenge for both patients and health care professionals. Antiphospholipid syndrome (APS) may account for as much as 10% to 48% of recurrent fetal loss. Suggested pathophysiologic mechanisms of APS in fetal loss include the action of autoantibodies, the lupus anticoagulant, and anticardiolipin antibodies on the endothelial cells, which may lead to platelet aggregation, thrombosis, placental infarcts, and subsequently reduced oxygenation to the fetus. This study explores fetal loss caused by APS, its pathophysiologic features, treatment, and nursing implications. Heparin therapy is presented as a method to prevent intrauterine growth retardation and fetal death. The educational and psychosocial needs of patients receiving this therapy and necessary patient follow-up and coordination of services are reviewed.

Characterization and complete genome sequences of high- and low- virulence variants of tick-borne encephalitis virus

The entire genomic sequences of two strains (Hypr and 263) of the flavivirus tick-borne encephalitis (TBE) virus differing in virulence from the prototypic strain Neudoerfl were determined. Strain Hypr is a human isolate of TBE virus with a high laboratory passage history which exhibits a significantly higher neuro-invasiveness in mice compared to the prototype strain. Strain 263 is a low-passage tick-isolate with a temperature-sensitive and attenuated phenotype. Except for the heterogeneous 3' non-coding regions strains Hypr and 263 share, respectively, 97.2% and 97.6% nucleotide sequence identity with strain Neudoerfl, and differ by a total of 42 and 36 amino acids from the prototypic strain. Of these, only 12 amino acids for each of the two strains represent non-conservative differences unique to an individual strain and some of these are located at positions highly conserved among flaviviruses. Based on these observations, the potential biological significance of particular sequence differences is discussed in the context of the current knowledge about molecular determinants of flavivirus virulence.

Career development of female and male physicians

In this article, the authors compare the career development of female and male physicians who were graduated from medical school in 1960 and followed through 1976. Working with a sample matched for type and location of medical school and admission test scores, the authors analyzed the effects of achievement motivation, performance in medical school, peer evaluation, prestige of internship hospital, and family responsibilities on professional attainment. The findings indicate that the careers of male physicians build in a sustained way, with the input factors during and following medical school remaining consistent in their effects; in the careers of female physicians, factors crosscut each other, with some being positive and some negative in their effect on professional attainment. Family responsibility is not the only negative factor for women, and this indicates that other elements in career development that help men do not similarly contribute to the advancement of women physicians. A strong positive factor for women is prestige of internship hospital.

Serratus anterior paralysis in the young athlete

Ten cases of isolated, complete paralysis of the serratus anterior muscle were diagnosed in young athletes during a three-year period. One patient had recurrent partial paralysis of the serratus anterior muscle, the first such case reported. From studies on cadavera and clinical observations, we concluded that paralysis of the serratus anterior muscle results from a traction injury to the long thoracic nerve of Bell. Since full recovery usually occurs in an average of nine months, surgical methods of treatment should be reserved for patients in whom function fails to return after a two-year period. Non-strenuous use of the involved extremity with avoidance of the precipitating activity, followed by exercises designed to maintain the range of motion of the shoulder and to increase the strength of associated muscles, is advocated for treatment of acute or repetitive injuries to the long thoracic nerve of Bell.