A multifactorial intervention to reduce the risk of falling among elderly people living in the community

BACKGROUND

Since falling is associated with serious morbidity among elderly people, we investigated whether the risk of falling could be reduced by modifying known risk factors.

METHODS

We studied 301 men and women living in the community who were at least 70 years of age and who had at least one of the following risk factors for falling: postural hypotension; use of sedatives; use of at least four prescription medications; and impairment in arm or leg strength or range of motion, balance, ability to move safely from bed to chair or to the bathtub or toilet (transfer skills), or gait. These subjects were given either a combination of adjustment in their medications, behavioral instructions, and exercise programs aimed at modifying their risk factors (intervention group, 153 subjects) or usual health care plus social visits (control group, 148 subjects).

RESULTS

During one year of follow-up, 35 percent of the intervention group fell, as compared with 47 percent of the control group (P = 0.04). The adjusted incidence-rate ratio for falling in the intervention group as compared with the control group was 0.69 (95 percent confidence interval, 0.52 to 0.90). Among the subjects who had a particular risk factor at base line, a smaller percentage of those in the intervention group than of those in the control group still had the risk factor at the time of reassessment, as follows: at least four prescription medications, 63 percent versus 86 percent, P = 0.009; balance impairment, 21 percent versus 46 percent, P = 0.001; impairment in toilet-transfer skills, 49 percent versus 65 percent, P = 0.05; and gait impairment, 45 percent versus 62 percent, P = 0.07.

CONCLUSIONS

The multiple-risk-factor intervention strategy resulted in a significant reduction in the risk of falling among elderly persons in the community. In addition, the proportion of persons who had the targeted risk factors for falling was reduced in the intervention group, as compared with the control group. Thus, risk-factor modification may partially explain the reduction in the risk of falling.

The PedsQL in type 1 and type 2 diabetes: reliability and validity of the Pediatric Quality of Life Inventory Generic Core Scales and type 1 Diabetes Module

OBJECTIVE

The Pediatric Quality of Life Inventory (PedsQL) is a modular instrument designed to measure health-related quality of life (HRQOL) in children and adolescents aged 2-18 years. The PedsQL 4.0 Generic Core Scales are child self-report and parent proxy-report scales developed as the generic core measure to be integrated with the PedsQL disease-specific modules. The PedsQL 3.0 Type 1 Diabetes Module was designed to measure diabetes-specific HRQOL.

RESEARCH DESIGN AND METHODS

The PedsQL Generic Core Scales and Diabetes Module were administered to 300 pediatric patients with type 1 or type 2 diabetes and 308 parents.

RESULTS

Internal consistency reliability for the PedsQL Generic Core Total Scale score (alpha = 0.88 child, 0.89 parent-report) and most Diabetes Module scales (average alpha = 0.71 child, 0.77 parent-report) was acceptable for group comparisons. The PedsQL 4.0 distinguished between healthy children and children with diabetes. The Diabetes Module demonstrated intercorrelations with dimensions of generic and diabetes-specific HRQOL.

CONCLUSIONS

The results demonstrate the reliability and validity of the PedsQL in diabetes. The PedsQL may be used as an outcome measure for diabetes clinical trials and research.

Fatigue in multiple sclerosis: a comparison of different rating scales and correlation to clinical parameters

OBJECTIVES

Fatigue is one of the most common, yet poorly defined, disabling symptoms in patients with multiple sclerosis (MS). To delineate more clearly the frequency and type of fatigue, we first compared four widely used fatigue scales in consecutive MS patients. Secondly, to further clarify the nature of fatigue, we investigated its relation to physical disability, course of the disease, immunotherapy, and depression.

PATIENTS AND METHODS

Between February and September 2000, 151 consecutive MS patients entering our outpatient clinic (94 relapsing-remitting, 50 secondary progressive, and 7 primary progressive patients; mean age 29.0 +/- 7.3 years, mean disease duration 9.9 +/- 6.7 years, median EDSS 3.5) filled in a standardized questionnaire induding four fatigue scales--Fatigue Severity Scale (FSS), MS-specific FSS (MFSS), Modified Fatigue Impact Scale (MFIS), and Visual Analogue Scale (VAS). Patients were included in the 'MS-related fatigue group' (MS-F) when they stated in the questionnaire that fatigue: 1) is one of their three most disabling symptoms; 2) occurs daily or on most of the days; and 3) limits their activities at home or at work Patients fulfilling none of these criteria were classified as 'MS-related nonfatigue group' (MS-NF). Depression was measured by Beck's Depression Inventory (BDI).

RESULTS

Although all scales showed significant differences between MS-F and MS-NF, correlation between these scales was, at best moderate (correlation coeffcients ranging from 0.06 to 0.56). The most discriminative scales were FSS and MFIS, showing no overlap of the 10th and 90th percentiles for the MS-F and MS-NF groups, with cut-off values of 4.6 and 38, respectively. Depression (BDI > or = 18) was present in 24 of 148 patients who filled in the BDI (16%). FSS was significantly correlated with physical disability (r=0.33, p<0.0001) and BDI (r=0.41, p<0.0001), but not with age, disease duration, clinical activity, and treatment with interferon-beta. In multivariate analysis, however, only BDI independently predicted fatigue.

CONCLUSIONS

The association of fatigue and depression suggests that there might be either common underlying mechanisms or interdependence by a cause-and-effect relationship that requires further investigation. The weak correlation within various fatigue scales is best explained by the fact that fatigue is a multidimensional symptom and, therefore, the available tests measure and weight different aspects of fatigue. Our findings underline the necessity for a more exact definition of fatigue and the development of more valid tools if these are to be used to evaluate treatments.

The incidence of shoulder arthroplasty: rise and future projections compared with hip and knee arthroplasty

BACKGROUND

There remains a paucity of epidemiologic data from recent years on the incidence of shoulder arthroplasty. We aimed to examine the recent trends and predict future projections of hemiarthroplasty (HA), anatomic (aTSA), and reverse shoulder arthroplasty (RSA), as well as compare these predictions to those for total hip (THA) and knee arthroplasty (TKA).

METHODS

The National Inpatient Sample was queried from 2011 to 2017 for HA, aTSA, and RSA, as well as TKA and THA. Linear and Poisson regression was performed to project annual procedural incidence and volume to the year 2025.

RESULTS

Between 2011 and 2017, the number of primary shoulder arthroplasties increased by 103.7%. In particular, RSA increased by 191.3%, with 63,845 RSAs performed in 2017. All projection models demonstrated significant increases in shoulder arthroplasty volume and incidence from 2017 to 2025. By 2025, the linear model predicts that shoulder arthroplasty volume will increase by 67.2% to 174,810 procedures whereas the Poisson model predicts a 235.2% increase, to 350,558 procedures by 2025. These growth rate projections outpace those of THA and TKA.

CONCLUSIONS

The number of shoulder arthroplasties has been increasing in recent years, largely because of the exponential increases in RSA. The overall incidence is increasing at a greater rate than TKA or THA, with projections continuing to rise over the next decade. These data and projections can be used by policy makers and hospitals to drive initiatives aimed at meeting these projected future demands.

The pathogenesis of the meningitis caused by Streptococcus suis: the unresolved questions

Streptococcus suis is one of the most important swine pathogens world-wide. Among the serotypes described, type 2 is the serotype most frequently associated with disease. Despite increasing research in recent years, knowledge of virulence factors and the pathogenesis of the infection remain limited. This review discusses the currently available information on S. suis serotype 2 virulence factors and the pathogenesis of the meningitis caused by this important bacterial species. In addition, some hypotheses on the critical steps of the infection, such as bacterial invasion from mucosal surfaces to the bloodstream, survival of bacteria in blood, and invasion from blood into the central nervous system, are presented. Finally, the role that the stimulation of the immune system of animals (inflammatory reaction) could play during infection is also discussed. A complete understanding of the cell-interacting pathways that S. suis may follow inside the host could give important insights into the progression of disease. Further studies to delineate the mechanisms through which S. suis induces meningitis will contribute to the development of potential therapies for S. suis infections.

Description of 14 new capsular types of Streptococcus suis

Fourteen new capsular types of Streptococcus suis (types 9 to 22) are described. All reference strains are morphologically and biochemically similar to types previously described. Reference strain types 9 to 13, 15, 16, and 22 were isolated from diseased pigs, whereas types 17 to 19 and 21 came from clinically healthy pigs; type 14 was isolated from a human case of meningitis, and type 20 was isolated from a diseased calf. The group T streptococcus of de Moor has been included in the typing system as type 15. Two-way cross-reactions between types 6 and 16 and a one-way cross-reaction between types 2 and 22 have been demonstrated. In addition, several cross-reactions probably not due to capsular material were detected among different types by using the coagglutination test. This test should not be used alone; weak or multiple positive reactions must be confirmed by the capsular reaction test or the capillary precipitation test.

A disease-associated cellular immune response in type 1 diabetics to an immunodominant epitope of insulin

The 9-23 amino acid region of the insulin B chain (B9-23) is a dominant epitope recognized by pathogenic T lymphocytes in nonobese diabetic mice, the animal model for type 1 diabetes. We describe herein similar (B9-23)-specific T-cell responses in peripheral lymphocytes obtained from patients with recent-onset type 1 diabetes and from prediabetic subjects at high risk for disease. Short-term T-cell lines generated from patient peripheral lymphocytes showed significant proliferative responses to (B9-23), whereas lymphocytes isolated from HLA and/or age-matched nondiabetic normal controls were unresponsive. Antibody-mediated blockade demonstrated that the response was HLA class II restricted. Use of the highly sensitive cytokine-detection ELISPOT assay revealed that these (B9-23)-specific cells were present in freshly isolated lymphocytes from only the type 1 diabetics and prediabetics and produced the proinflammatory cytokine IFN-gamma. This study is, to our knowledge, the first demonstration of a cellular response to the (B9-23) insulin epitope in human type 1 diabetes and suggests that the mouse and human diseases have strikingly similar autoantigenic targets, a feature that should facilitate development of antigen-based therapeutics.

Preparing adolescents with chronic disease for transition to adult care: a technology program

BACKGROUND

Adolescents with chronic disease (ACD) must develop independent disease self-management and learn to communicate effectively with their health care team to transition from pediatric to adult-oriented health care systems. Disease-specific interventions have been implemented to aid specific ACD groups through transition. A generic approach might be effective and cost-saving.

METHODS

Eighty-one ACD, aged 12 to 20 years, were recruited for a randomized clinical trial evaluating an 8-month transition intervention (MD2Me). MD2Me recipients received a 2-month intensive Web-based and text-delivered disease management and skill-based intervention followed by a 6-month review period. MD2Me recipients also had access to a texting algorithm for disease assessment and health care team contact. The intervention was applicable to adolescents with diverse chronic illnesses. Controls received mailed materials on general health topics. Disease management, health-related self-efficacy, and health assessments were performed at baseline and at 2 and 8 months. Frequency of patient-initiated communications was recorded over the study period. Outcomes were analyzed according to assigned treatment group over time.

RESULTS

MD2Me recipients demonstrated significant improvements in performance of disease management tasks, health-related self-efficacy, and patient-initiated communications compared with controls.

CONCLUSIONS

Outcomes in ACD improved significantly among recipients of a generic, technology-based intervention. Technology can deliver transition interventions to adolescents with diverse chronic illnesses, and a generic approach offers a cost-effective means of positively influencing transition outcomes. Further research is needed to determine whether improved short-term outcomes translate into an improved transition for ACD.

Obesity in Youth with Type 1 Diabetes in Germany, Austria, and the United States

OBJECTIVE

To examine the current extent of the obesity problem in 2 large pediatric clinical registries in the US and Europe and to examine the hypotheses that increased body mass index (BMI) z-scores (BMIz) are associated with greater hemoglobin A1c (HbA1c) and increased frequency of severe hypoglycemia in youth with type 1 diabetes (T1D).

STUDY DESIGN

International (World Health Organization) and national (Centers for Disease Control and Prevention/German Health Interview and Examination Survey for Children and Adolescents) BMI references were used to calculate BMIz in participants (age 2-<18 years and ≥ 1 year duration of T1D) enrolled in the T1D Exchange (n = 11,435) and the Diabetes Prospective Follow-up (n = 21,501). Associations between BMIz and HbA1c and severe hypoglycemia were assessed.

RESULTS

Participants in both registries had median BMI values that were greater than international and their respective national reference values. BMIz was significantly greater in the T1D Exchange vs the Diabetes Prospective Follow-up (P < .001). After stratification by age-group, no differences in BMI between registries existed for children 2-5 years, but differences were confirmed for 6- to 9-, 10- to 13-, and 14- to 17-year age groups (all P < .001). Greater BMIz were significantly related to greater HbA1c levels and more frequent occurrence of severe hypoglycemia across the registries, although these associations may not be clinically relevant.

CONCLUSIONS

Excessive weight is a common problem in children with T1D in Germany and Austria and, especially, in the US. Our data suggest that obesity contributes to the challenges in achieving optimal glycemic control in children and adolescents with T1D.

Update on Actinobacillus pleuropneumoniae-knowledge, gaps and challenges

Porcine pleuropneumonia, caused by the bacterial porcine respiratory tract pathogen Actinobacillus pleuropneumoniae, leads to high economic losses in affected swine herds in most countries of the world. Pigs affected by peracute and acute disease suffer from severe respiratory distress with high lethality. The agent was first described in 1957 and, since then, knowledge about the pathogen itself, and its interactions with the host, has increased continuously. This is, in part, due to the fact that experimental infections can be studied in the natural host. However, the fact that most commercial pigs are colonized by this pathogen has hampered the applicability of knowledge gained under experimental conditions. In addition, several factors are involved in development of disease, and these have often been studied individually. In a DISCONTOOLS initiative, members from science, industry and clinics exchanged their expertise and empirical observations and identified the major gaps in knowledge. This review sums up published results and expert opinions, within the fields of pathogenesis, epidemiology, transmission, immune response to infection, as well as the main means of prevention, detection and control. The gaps that still remain to be filled are highlighted, and present as well as future challenges in the control of this disease are addressed.

Characterization of six new capsular types (23 through 28) of Streptococcus suis

Six new capsular types of Streptococcus suis (types 23 to 28) are described. All reference strains were isolated from diseased pigs and were morphologically and biochemically similar to previously described capsular types 1 to 22. Clear and specific reactions were obtained for each of the new capsular types with three different typing techniques; no cross-reactions were detected among them or with other S. suis capsular types. Their capsular material presented similar ultrastructural characteristics, as shown by electron microscopy, and fimbriae similar to those described for other capsular types of S. suis were observed. When untypeable field isolates were tested with antisera raised against the six new capsular types, capsular type 23 appeared to be the most prevalent, representing more than 50% of all these isolates. Most isolates were recovered from cases of pneumonia, septicemia, and meningitis. Presumptive biochemical identification described for S. suis capsular types 1 to 22 may also be used for capsular types 23 to 28.

Home-based multicomponent rehabilitation program for older persons after hip fracture: a randomized trial

OBJECTIVE

To determine whether a home-based systematic multicomponent rehabilitation strategy leads to improved outcomes relative to usual care.

DESIGN

A randomized controlled trial with 12 months of follow-up.

SETTING

General community; 27 home care agencies.

PARTICIPANTS

Three hundred four nondemented persons at least 65 years of age who underwent surgical repair of a hip fracture at two hospitals in New Haven, CT, and returned home within 100 days.

INTERVENTION

Systematic multicomponent rehabilitation strategy addressing both modifiable physical impairments (physical therapy) and activities of daily living (ADL) disabilities (functional therapy) versus usual care.

MAIN OUTCOME MEASURES

A battery of self-report and performance-based measures of physical and social function.

RESULTS

There was no significant difference in the proportion of participants in the two groups who recovered to prefracture levels in self-care ADL at 6 months (71% vs 75%) or 12 months (74% in both groups) or in home management ADL at 6 months (35% vs 44%) or 12 months (44% vs 48%). There also was no difference between the two groups in social activity levels, two timed mobility tasks, balance, or lower extremity strength at either 6 or 12 months. Compared with participants who received usual care, those in the multicomponent rehabilitation program showed slightly greater upper extremity strength at 6 months (p = .04) and a marginally better gait performance (p = .08).

CONCLUSIONS

The systematic multicomponent rehabilitation program was no more effective in promoting recovery than usual home-based rehabilitation. Compared with previous cohorts, however, participants randomized to usual care in our study received more rehabilitative and home care services and experienced a higher rate of recovery. This finding is important given the current pressures to reduce home services. The challenge is to determine the composition and duration of rehabilitation and home services that will ensure optimal functional recovery most efficiently in older persons after hip fracture.

Cytokine mRNA expression in patients with multiple sclerosis and fatigue

Background: Fatigue is one of the most common disabling symptoms in patients with multiple sclerosis (MS), but the putative role of proinflammatory cytokines remains to be elucidated. Methods: Thirty-seven patients (27 women, 10 men) with relapsing-remitting (n =29) and secondary progressive (n =8) MS, aged 41.0 ± 10.2 years, were studied. Fatigue was assessed by Krupp’s Fatigue Severity Scale (FSS). C ytokine mRNA expression for interferon (IFN)-g, tumor necro sis factor (TNF)-a and interleukin (IL)-10 were measured by real time RT PC R. A utonomic function was evaluated by standard tests for parasympathetic and sympathetic function, as well as by serum levels of norepinephrine and epinephrine. Results: Median levels of TNF-a mRNA expression were significantly higher in MS patients with (FSS]-4.0 and]-5.0, n=26 and n=14, respectively) than in those without fatigue (FSSB-4.0, n =11). No differences were seen for IFN-g and IL-10 mRNA expression. C ytokine levels were not correlated to autonomic tests or to serum catecho lamine levels. Conclusions: These results suggest that TNF-a, as a principal proinflammatory mediator, is associated with MS-related fatigue. This is in support of a patho genic role of the MS-related inflammatory process in the development of fatigue.

Streptococcus suis serotype 2 interactions with human brain microvascular endothelial cells

Streptococcus suis serotype 2 is a worldwide causative agent of many forms of swine infection and is also recognized as a zoonotic agent causing human disease, including meningitis. The pathogenesis of S. suis infections is poorly understood. Bacteria circulate in the bloodstream in the nonimmune host until they come in contact with brain microvascular endothelial cells (BMEC) forming the blood-brain barrier. The bacterial polysaccharide capsule confers antiphagocytic properties. It is known that group B streptococci (GBS) invade and damage BMEC, which may be a primary step in the pathogenesis of neonatal meningitis. Interactions between S. suis and human endothelial cells were studied to determine if they differ from those between GBS and endothelial cells. Invasion assays performed with BMEC and human umbilical vein endothelial cells demonstrated that unlike GBS, S. suis serotype 2 could not invade either type of cell. Adherence assays showed that S. suis adhered only to BMEC, whereas GBS adhered to both types of cell. These interactions were not affected by the presence of a capsule, since acapsular mutants from both bacterial species adhered similarly compared to the wild-type strains. Lactate dehydrogenase release measurements indicated that some S. suis strains were highly cytotoxic for BMEC, even more than GBS, whereas others were not toxic at all. Cell damage was related to suilysin (S. suis hemolysin) production, since only suilysin-producing strains were cytotoxic and cytotoxicity could be inhibited by cholesterol and antisuilysin antibodies. It is possible that hemolysin-positive S. suis strains use adherence and suilysin-induced BMEC injury, as opposed to direct cellular invasion, to proceed from the circulation to the central nervous system.

Antithymocyte globulin treatment for patients with recent-onset type 1 diabetes: 12-month results of a randomised, placebo-controlled, phase 2 trial

BACKGROUND

Type 1 diabetes results from T-cell-mediated destruction of β cells. Findings from preclinical studies and pilot clinical trials suggest that antithymocyte globulin (ATG) might be effective for reducing this autoimmune response. We assessed the safety and efficacy of rabbit ATG in preserving islet function in participants with recent-onset type 1 diabetes, and report here our 12-month results.

METHODS

For this phase 2, randomised, placebo-controlled, clinical trial, we enrolled patients with recent-onset type 1 diabetes, aged 12-35 years, and with a peak C-peptide of 0.4 nM or greater on mixed meal tolerance test from 11 sites in the USA. We used a computer generated randomisation sequence to randomly assign patients (2:1, with permuted-blocks of size three or six and stratified by study site) to receive either 6.5 mg/kg ATG or placebo over a course of four days. All participants were masked and initially managed by an unmasked drug management team, which managed all aspects of the study until month 3. Thereafter, to maintain masking for diabetes management throughout the remainder of the study, participants received diabetes management from an independent, masked study physician and nurse educator. The primary endpoint was the baseline-adjusted change in 2-h area under the curve C-peptide response to mixed meal tolerance test from baseline to 12 months. Analyses were by intention to treat. This is a planned interim analysis of an on-going trial that will run for 24 months of follow-up. This study is registered with ClinicalTrials.gov, number NCT00515099.

FINDINGS

Between Sept 10, 2007, and June 1, 2011, we screened 154 individuals, randomly allocating 38 to ATG and 20 to placebo. We recorded no between-group difference in the primary endpoint: participants in the ATG group had a mean change in C-peptide area under the curve of -0.195 pmol/mL (95% CI -0.292 to -0.098) and those in the placebo group had a mean change of -0.239 pmol/mL (-0.361 to -0.118) in the placebo group (p=0.591). All except one participant in the ATG group had both cytokine release syndrome and serum sickness, which was associated with a transient rise in interleukin-6 and acute-phase proteins. Acute T cell depletion occurred in the ATG group, with slow reconstitution over 12 months. However, effector memory T cells were not depleted, and the ratio of regulatory to effector memory T cells declined in the first 6 months and stabilised thereafter. ATG-treated patients had 159 grade 3-4 adverse events, many associated with T-cell depletion, compared with 13 in the placebo group, but we detected no between-group difference in incidence of infectious diseases.

INTERPRETATION

Our findings suggest that a brief course of ATG does not result in preservation of β-cell function 12 months later in patients with new-onset type 1 diabetes. Generalised T-cell depletion in the absence of specific depletion of effector memory T cells and preservation of regulatory T cells seems to be an ineffective treatment for type 1 diabetes.

Protein self-association in solution: the bovine beta -lactoglobulin dimer and octamer

We have used proton magnetic relaxation dispersion (MRD) to study the self-association of bovine beta-lactoglobulin variant A (BLG-A) as a function of temperature at pH 4.7 (dimer-octamer equilibrium) and as a function of NaCl concentration at pH 2.5 (monomer-dimer equilibrium). The MRD method identifies coexisting oligomers from their rotational correlation times and determines their relative populations from the associated dispersion amplitudes. From MRD-derived correlation times and hydrodynamic model calculations, we confirm that BLG-A dimers associate to octamers below room temperature. The tendency for BLG-A dimers to assemble into octamers is found to be considerably weaker than in previous light scattering studies in the presence of buffer salt. At pH 2.5, the MRD data are consistent with an essentially complete transition from monomers in the absence of salt to dimers in 1 M NaCl. Because of an interfering relaxation dispersion from nanosecond water exchange, we cannot determine the oligomer populations at intermediate salt concentrations. This nanosecond dispersion may reflect intersite exchange of water molecules trapped inside the large binding cavity of BLG-A.

Glimepiride versus metformin as monotherapy in pediatric patients with type 2 diabetes: a randomized, single-blind comparative study

OBJECTIVE

To compare the efficacy and safety of glimepiride versus metformin in pediatric subjects with type 2 diabetes inadequately controlled with diet and exercise alone or oral monotherapy.

RESEARCH DESIGN AND METHODS

This 26-week, single-blind, active-controlled, multinational study randomized 285 subjects to receive glimepiride (1-8 mg once daily) or metformin (500-1000 mg twice daily) for 24 weeks. The primary end point was mean change in A1C from baseline to week 24. Safety was assessed by incidence of hypoglycemia and other adverse events.

RESULTS

Significant reductions from baseline A1C were seen in both the glimepiride (-0.54%, P = 0.001) and metformin (-0.71%, P = 0.0002) groups. A total of 42.4% (56 of 132) and 48.1% (63 of 131) of subjects in the glimepiride and metformin groups, respectively, in the intent-to-treat population achieved A1C <7.0% at week 24. No significant differences were observed between groups in reductions in A1C and self-monitored blood glucose levels, changes in serum lipid concentrations, or hypoglycemia incidence. Significant differences were observed in mean changes from baseline in BMI between groups (0.26 kg/m(2) for glimepiride and -0.33 kg/m(2) for metformin; P = 0.003). The adjusted mean body weight increase was 1.97 kg for glimepiride and 0.55 kg for metformin (P = 0.005). A hypoglycemic episode with blood glucose <50 mg/dl (<2.8 mmol/l) was experienced by 4.9 and 4.2% of glimepiride- and metformin-treated subjects, respectively. A single severe hypoglycemic event occurred in each group.

CONCLUSIONS

Glimepiride reduced A1C similarly to metformin with greater weight gain, and there was comparable safety over 24 weeks in the treatment of pediatric subjects with type 2 diabetes.

Actinobacillus pleuropneumoniae surface polysaccharides: their role in diagnosis and immunogenicity

Actinobacillus pleuropneumoniae is an important pig pathogen that is responsible for swine pleuropneumonia, a highly contagious respiratory infection. Knowledge of the importance, composition and structural determination of the major antigens involved in virulence provides crucial information that could lead to the development of a rationale for the production of specific serodiagnostic tools as well as vaccine development. Thus, efforts have been devoted to study mainly A. pleuropneumoniae virulence determinants with special emphasis on the Apx toxins (for A. pleuropneumoniae RTX toxins). In comparison, little attention has been given to the surface polysaccharides, which include capsular polysaccharides (CPS) and cell-wall lipopolysaccharides (LPS). Here, we review current knowledge on CPS and LPS of A. pleuropneumoniae used as diagnostic tools to monitor the infection and as immunogens for inclusion in vaccine preparations for animal protection.

Identification and detection of Actinobacillus pleuropneumoniae by PCR based on the gene apxIVA

The apxIVA gene, a recently discovered RTX determinant of Actinobacillus pleuropneumoniae, was shown to be species-specific. DNA hybridization experiments using probes for various regions of apxIVA revealed that the 3'-terminus of this gene was present in all 14 serotypes of A. pleuropneumoniae but absent from phylogenetically related species. A primer pair spanning this region specifically amplified a 422bp fragment in PCR experiments with DNA from the reference strains of the 14 serotypes and 194 field strains isolated from various geographic locations worldwide. DNA sequence analysis of PCR products derived from all serotypes were identical except in serotypes 3, 8, and 10, which showed minor differences. The PCR did not amplify any product when DNA from 17 different bacterial species closely related to A. pleuropneumoniae was used as template. In addition, the PCR was negative with DNA of several Actinobacillus sp. which were initially characterized as A. pleuropneumoniae using routine phenotypic and serological analyses but which were subsequently shown by 16S rRNA sequence analysis to belong to yet undefined Actinobacillus species. The sensitivity of the PCR was determined to be 10pg of A. pleuropneumoniae DNA. A set of nested primers amplified a 377bp fragment specifically with A. pleuropneumoniae DNA. DNA titration experiments using the flanking and nested primer pairs showed an improved level of sensitivity to approximately 10fg of genomic DNA. The nested PCR was used to monitor the spread of A. pleuropneumoniae in pigs experimentally infected with a virulent serotype 1 strain and housed in a controlled environment facility. A. pleuropneumoniae DNA could be detected by nested PCR in nasal swab samples of infected pigs receiving either a high dose (5x10(5)) or a low dose (1x10(4)) challenge and in unchallenged cohorts that were contact-infected by the inoculated animals. Furthermore, PCR confirmed the presence of A. pleuropneumoniae in 16/17 homogenates from necrotic lung lesions, while the bacterium was successfully recovered from 13 of these lesions by culture.

Multilineage somatic activating mutations in HRAS and NRAS cause mosaic cutaneous and skeletal lesions, elevated FGF23 and hypophosphatemia

Pathologically elevated serum levels of fibroblast growth factor-23 (FGF23), a bone-derived hormone that regulates phosphorus homeostasis, result in renal phosphate wasting and lead to rickets or osteomalacia. Rarely, elevated serum FGF23 levels are found in association with mosaic cutaneous disorders that affect large proportions of the skin and appear in patterns corresponding to the migration of ectodermal progenitors. The cause and source of elevated serum FGF23 is unknown. In those conditions, such as epidermal and large congenital melanocytic nevi, skin lesions are variably associated with other abnormalities in the eye, brain and vasculature. The wide distribution of involved tissues and the appearance of multiple segmental skin and bone lesions suggest that these conditions result from early embryonic somatic mutations. We report five such cases with elevated serum FGF23 and bone lesions, four with large epidermal nevi and one with a giant congenital melanocytic nevus. Exome sequencing of blood and affected skin tissue identified somatic activating mutations of HRAS or NRAS in each case without recurrent secondary mutation, and we further found that the same mutation is present in dysplastic bone. Our finding of somatic activating RAS mutation in bone, the endogenous source of FGF23, provides the first evidence that elevated serum FGF23 levels, hypophosphatemia and osteomalacia are associated with pathologic Ras activation and may provide insight in the heretofore limited understanding of the regulation of FGF23.

Yale FICSIT: risk factor abatement strategy for fall prevention

Based on finding a strong association between number of impairments and risk of falling in earlier studies, Yale FICSIT investigators are conducting an intervention trial comparing the effectiveness of usual care plus social visits (SV) and a targeted risk abatement intervention (TI) strategy in reducing falls among at risk community elderly persons. Subjects include members of a participating HMO who are > or = 70 years of age, cognitively intact, not terminally ill, not too physically active, and possess at least one fall risk factor. The targeted risk factors include postural hypotension; sedative use; at least four targeted medications; upper and lower extremity strength and range of motion impairments; foot problems; and balance, gait, and transfer dysfunctions. The interventions include medication adjustments, behavioral change recommendations, education and training, and home-based exercise regimens targeting the identified risk factors. The interventions are carried out by the study nurse practitioner and physical therapist in TI subjects' homes. The SV subjects receive a comparable number of home visits as the TI subjects during which a structured life review is performed by social work students. The primary outcome is occurrence of falls during the 12-month followup. Secondary outcomes include change in mobility performance and fall-related efficacy.

Multiplex PCR assay for detection of Streptococcus suis species and serotypes 2 and 1/2 in tonsils of live and dead pigs

A PCR assay was developed for the detection of Streptococcus suis serotypes 2 and 1/2. This multiplex PCR is based on the amplification of the gene coding for 16S rRNA of S. suis and on the amplification of the cps2J gene coding for the capsule of S. suis serotypes 2 and 1/2. An internal control was constructed and added in this test to monitor the efficiency of amplification in each reaction. To evaluate the specificity of the test, 31 strains of other bacterial species related to S. suis or isolated from pigs and 42 strains of S. suis serotypes 1 and 3 to 34 were analyzed. The detection threshold of the test was 28 S. suis CFU/ml. The specificity and the sensitivity of the multiplex PCR test and the presence of an internal control allowed the analysis of biological samples without a culture step. The PCR assay was then applied to the detection of 14 S. suis serotype 1/2 strains, 88 S. suis serotype 2 strains isolated from pigs, and 25 S. suis serotype 2 strains isolated from humans. This test was also applied to analyze tonsil samples of pigs experimentally infected and carrier pigs without any symptoms.