Impact of applying a diabetes risk score in primary care on change in physical activity: a pragmatic cluster randomised trial

AIM

There is little evidence of the impact of diabetes risk scores on individual diabetes risk factors, motivation for behaviour changes and mental health. The aim of this study was to investigate the effect of applying a noninvasive diabetes risk score in primary care as component of routine health checks on physical activity and secondary outcomes.

METHODS

Cluster randomised trial, in which primary care physicians (PCPs), randomised (1:1) by minimisation, enrolled participants with statutory health insurance without known diabetes, ≥ 35 years of age with a body mass index ≥ 27.0 kg/m². The German Diabetes Risk Score was applied as add-on to the standard routine health check, conducted in the controls. Primary outcome was the difference in participants' physical activity (International Physical Activity Questionnaire) after 12 months. Secondary outcomes included body mass index, perceived health, anxiety, depression, and motivation for lifestyle change. Analysis was by intention-to-treat principle using mixed models.

RESULTS

36 PCPs were randomised; remaining 30 PCPs (intervention: n = 16; control: n = 14) recruited 315 participants (intervention: n = 153; controls: n = 162). A slight increase in physical activity was observed in the intervention group with an adjusted mean change of 388 (95% confidence interval: - 235; 1011) metabolic equivalents minutes per week. There were no relevant changes in secondary outcomes.

CONCLUSIONS

The application of a noninvasive diabetes risk score alone is not effective in promoting physical activity in primary care.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT03234322, registration date: July 31, 2017).

Genetic deletion of aryl hydrocarbon receptor activates cardiac NLRP3-inflammasome and suppresses apoptosis in mice with acute myocardial infarction

Background and purpose

There is great interest in understanding the role of immune cells in the inflammatory mechanisms associated with acute myocardial infarction (AMI). Resident cardiac immune cells are activated by damage-associated molecular patterns interacting with specific pattern recognition receptors (PRRs), triggering inflammatory responses. Activated immune cells and fibroblasts then promote prohypertrophic and profibrotic signalling, which induces cardiac hypertrophy, fibrosis and remodelling after AMI. Nucleotide-binding domain leucine-rich repeat-containing proteins (NLRs) are PRRs that have emerged as key therapeutic targets in cardiovascular disease. NLRP3 assembles the inflammasome, which serves as molecular signalling platform to activate caspase-1 and regulate maturation of the potent proinflammatory cytokine IL-1β.

The aryl hydrocarbon receptor (AhR) is a ligand-activated transcription factor of the basic Helix-Loop-Helix-PER-ARNT-SIM superfamily that mediates responses against environmental pollutants. Beyond its role in metabolising exogenous toxins as part of an adaptive chemical response, there is growing evidence that AhR is activated by endogenous ligands under physiological conditions. AhR has been proposed as a negative regulator of NLRP3-inflammasome activation. Here we studied the effects of defective AhR signalling on apoptosis, NLRP3-inflammasome activation and survival in a mouse model of AMI.

Methods and results

AMI was induced in 8–10-weeks-old AhR+/+ and AhR−/− mice by ligation of the left anterior descending coronary artery. Immunofluorescence analysis revealed that the number of TUNEL-positive nuclei and the expression of the apoptotic effector cleaved caspase-3 was higher in hearts from infarcted AhR+/+ mice than from sham-operated AhR+/+ mice 24 h after surgery. A similar analysis in AhR−/− mice revealed the absence of apoptotic markers after AMI. Gene analysis showed that cardiac levels of Nlrp3, apoptosis-associated speck-like protein (Asc) and Il1b were all significantly higher in AhR−/− mice than in AhR+/+ mice 24 h after AMI. Finally, survival analysis showed that 25% of AhR+/+ mice died 72 h after AMI surgery whereas the mortality in AhR−/− mice was 100%.

Conclusion

Our results show that loss of AhR inhibits cardiac apoptosis and increases NLRP3-mediated inflammation 24 h after AMI, highlighting a possible role for this nuclear receptor in cardiac remodelling post-AMI.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Spanish Ministry of Economy and Competitiveness and the European Regional Development Fund

Study protocol for a mixed methods exploratory investigation of aftercare services for gestational diabetes in women to develop a new patient-centred model in Germany: the GestDiNa_basic study

INTRODUCTION

Women with gestational diabetes mellitus (GDM) have a higher risk of developing type 2 diabetes mellitus compared with women who never had GDM. Consequently, the question of structured aftercare for GDM has emerged. In all probability, many women do not receive care according to the guidelines. In particular, the process and interaction between obstetrical, diabetic, gynaecological, paediatric and general practitioner care lacks clear definitions. Thus, our first goal is to analyse the current aftercare situation for women with GDM in Germany, for example, the participation rate in aftercare diabetes screening, as well as reasons and attitudes stated by healthcare providers to offer these services and by patients to participate (or not). Second, we want to develop an appropriate, effective and patient-centred care model.

METHODS AND ANALYSIS

This is a population-based mixed methods study using both quantitative and qualitative research approaches. In various working packages, we evaluate data of the GestDiab register, of the Association of Statutory Health Insurance Physicians of North Rhine and the participating insurance companies (AOK Rheinland/Hamburg, BARMER, DAK Gesundheit, IKK classic, pronova BKK). In addition, quantitative (postal surveys) and qualitative (interviews) surveys will be conducted with randomly selected healthcare providers (diabetologists, gynaecologists, paediatricians and midwives) and affected women, to be subsequently analysed. All results will then be jointly examined and evaluated.

ETHICS AND DISSEMINATION

The study was approved by the ethics committee of the Faculty of Medicine, Heinrich-Heine-University Düsseldorf (Ethics Committee No.: 2019-738). Participants of the postal surveys and interviews will be informed in detail about the study and the use of data as well as the underlying data protection regulations before voluntarily participating. The study results will be disseminated through peer-reviewed journals, conferences and public information.

TRIAL REGISTRATION NUMBER

DRKS00020283.

RIP2 plays a role in cardiac Ca2+ mishandling prompted by chronic kidney disease

Background

Chronic kidney disease (CKD) is a multifaceted disease that contributes to cardiac dysfunction. However, the mechanisms underlying the complex relationship between CKD and cardiac impairment remains almost completely unknown. Inflammation is a major player in both CKD and cardiovascular disease (CVD) and, in this context, nucleotide-binding oligomerization domain-containing protein 1 (NOD1) is a newly recognized innate immune receptor involved in both CKD and CVD independently. NOD1 activation is due to the recruitment of the receptor-interacting-serine/threonine-protein kinase 2 (RIP2), which induce NOD1 oligomerization and promotes the inflammatory response, being RIP2 a key partner in the NOD1 activation. Unpublished data from our group has demonstrated that genetic deletion of NOD1 prevents Ca2+ mishandling associated to CKD, next step will be to determine whether the absence of its specific adaptor; RIP2 can also mediate these effects.

Purpose

The main aim of this study was to determine whether NOD1-RIP2 axis impairs cardiac dysfunction and Ca2+ mishandling prompted by CKD induced by 5/6 nephrectomy (5/6Nx) in a mice model.

Methods and results

We have analysed intracellular Ca2+ handling in cardiomyocytes obtained from Wild type (Wt), Nod1−/− and Rip2−/− sham operated or nephrectomised mice. Compared with Wt-5/6Nx, cardiomyocytes obtained from Nod1−/−5/6Nx and Rip2−/−5/6Nx mice showed a significant improvement of Ca2+ mishandling, mainly by preventing: i) the reduction in [Ca2+]i transients amplitude; ii) the rise in their decay time; and iii) the lower cell contraction. The lack of NOD1 and RIP2 also prevents the reduced sarcoplasmic reticulum (SR) Ca2+ load and the augmented diastolic Ca2+ leak induced by 5/6Nx. Furthermore, the increased diastolic Ca2+ leak (Ca2+ sparks, spontaneous [Ca2+]i transients and waves) induced by 5/6Nx were also significantly prevented in absence of NOD1 and RIP2. Genetic deletion of NOD1 or RIP2 did not induces any improvement of several markers associated with renal dysfunction (urea, phosphate or fibroblast growth factor-23).

Conclusions

Our results confirmed that the absence of both NOD1 and RIP2 prevents the intracellular cardiac Ca2+ mishandling in experimental CKD. NOD1 and RIP2 emerge as novel targets for the development of innovative therapeutic strategies for the cardiac remodelling in CKD subjects.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This work was supported by Spanish ISCIII (PI17/01093 and PI17/01344), Fondo Europeo de Desarrollo Regional (FEDER), FSE, and CIBER-CV, a network funded by ISCIII. MF-V is Miguel Servet II researcher of ISCIII (MSII16/00047 Carlos III Health Institute). GR-H is Miguel Servet I researcher of ISCIII (CP15/00129 Carlos III Health Institute). MT is a PhD student funded by the FPU program of the Spanish Ministry of Science, Innovation and Universities (FPU17/06135).

Strategies for Improving Influenza Vaccination Rates in Patients with Chronic Renal Disease

BACKGROUND

The influenza vaccination rate among older and chronically ill patients in Germany has declined in the past decade in spite of vaccination campaigns.

METHODS

The influenza vaccination rate among persons with chronic renal disease was studied with the aid of billing data from various Associations of Statutory Health Insurance Physicians (Kassenärztliche Vereinigungen, ASHIPs) in Germany. It was tested in a randomized controlled trial whether a written vaccination appeal, sent by physicians to patients, led to an increase in the vaccination rate. It was tested in a further such trial whether the vaccination rate among patients with renal disease could be improved by an appeal for vaccination that was sent by the ASHIPs to the treating nephrologists. Finally, it was also tested in a prospective interventional study whether the vaccination rate could be improved by an appeal for vaccination sent by a health- insurance carrier directly to the patients.

RESULTS

In 2012-2017, the vaccination rate among persons with chronically impaired renal function ranged from 41.1% to 46.9%; it ranged from 31.7% to 33.7% in kidney transplant recipients and from 42.7% to 44.7% in dialysis patients. An appeal for vaccination that was sent from physicians to patients raised the vaccination rate by 8.3% in the intervention group compared to the control group (p = 0.03; number needed to treat [NNT]: 13). On the other hand, an appeal for vaccination that was sent to the nephrologists lowered the vaccination rate by 0.8% in the intervention group compared to the control group. Finally, an appeal for vaccination that was sent by the health-insurance fund to the patients raised the vaccination rate by 3.2% (p<0.001; NNT: 32).

CONCLUSION

Fewer than half of all patients with chronic renal failure in Germany are vaccinated against influenza. The vaccination rate was found to be increased only after an appeal for vaccination that was sent directly to the patients. A letter sent to the treating physicians had no positive effect at all.

[Do decision-makers in the German healthcare system misjudge the situation of a branch office? - Motivation of physicians to set up in a GP's practice in the area of the Association of Statutory Health Insurance Physicians North-Rhine]

BACKGROUND

The aim of the study was to illustrate motives for a GP's branch from the current point of view by branch (expectations fulfilled) and before branch (motivation). In addition, obstructive or beneficial factors of a branch should be identified.

METHODS

Using a mixed-methods approach (focus groups, individual interviews) with the target group were used in the qualitative part of experiences, opinions and motivations for the GP's branch and, after evaluation, a pre-tested questionnaire was used. A full survey of 675 identified GPs from the database of the Association of Statutory Health Insurance Physicians North Rhine was carried out. These had settled in the last 5 years before the survey period (09/2015). The questionnaire sent by post contained 17 questions on settlement motivation and 11 biographical aspects.

RESULTS

The number of evaluable data records was 437 (64.7 %). The highest approval values, in the sense of conducive to settlement motivation, were "discontinuation of services in the hospital" (97.2 %) and "being one's own boss" (96.2 %). Rights and duties as a "panel physician" (8.5 %), and the "emergency service for panel physicians/on-call service" (22.7 %) were perceived as more of an obstacle. In terms of fulfilling expectations, the "discontinuation of services" (95.6 %) and the "diversity of age groups to be treated" (88.9 %) emerged. A total of 97 % would settle down again, regardless of the degree to which their wishes were fulfilled, and almost ¾ would only decided to work as family doctors after they had completed their studies.

CONCLUSIONS

The fact that escaping from the stationary sector is the main driving force behind the settlement must be thought-provoking. Since this survey approach was not based on specialist groups or the level of training, but on a complete survey of established persons over a five-year period, it can be stated that the current incentive structures of a branch should be rethought due to the age structure of the interviewees.

Intracellular calcium mishandling leads to cardiac dysfunction and ventricular arrhythmias in a mouse model of propionic acidemia

Propionic acidemia (PA) is a rare metabolic disease associated with mutations in genes encoding the α and β subunits of the enzyme propionyl-CoA carboxylase. The accumulation of toxic metabolites results in mitochondrial dysfunction, increased reactive oxygen species production and oxidative damage, which have been associated with the disease pathophysiology. Clinical symptoms are heterogeneous and include cardiac complications, mainly cardiac dysfunction and arrhythmias, which are recognized as one of the major life-threatening manifestations in patients. We aimed to investigate the molecular mechanisms underlying the cardiac phenotype using a hypomorphic mouse model (Pcca^-/-(A138T)) that recapitulates some biochemical and clinical characteristics of PA. We demonstrate that Pcca^-/-(A138T) mice present with depressed cardiac function along with impaired cell contractility when compared to the wild-type mice. Cardiac dysfunction in Pcca^-/-(A138T) mice was associated with lower systolic Ca²⁺ release ([Ca²⁺]_i transients), impairment in the sarcoplasmic reticulum (SR) Ca²⁺ load and decreased Ca²⁺ re-uptake by SR-Ca²⁺ ATPase (SERCA2a). These functional changes correlated well with the depressed activity of SERCA2a, the elevated ROS levels and SERCA2a oxidation rate in cardiomyocytes isolated from Pcca^-/-(A138T) mice. In addition, decreased SR-Ca²⁺ load in Pcca^-/-(A138T) cardiomyocytes was associated with increased diastolic Ca²⁺ release. The increase in Ca²⁺ sparks, Ca²⁺ waves and spontaneous [Ca²⁺]_i transients in Pcca^-/-(A138T) cardiomyocytes could be responsible for the induction of ventricular arrhythmias detected in these mice. Overall, our results uncover the role of impaired Ca²⁺ handling in arrhythmias and cardiac dysfunction in PA, and identify new targets for the development of therapeutic approaches for this devastating metabolic disease.

Protocol of a cluster randomized trial to investigate the impact of a type 2 diabetes risk prediction model on change in physical activity in primary care

BACKGROUND

Little evidence exists on the impact of diabetes risk scores, e.g. on physicians and patient's behavior, perceived risk of persons, shared-decision making and particularly on patient's health. The aim of this study is to investigate the impact of a non-invasive type 2 diabetes risk prediction model in the primary health care setting as component of routine health checks on change in physical activity.

METHODS

Parallel group cluster randomized controlled trial including 30 primary care physicians (PCPs) and 300 participants in the region of Düsseldorf and surrounding urban and rural municipalities, West Germany. On cluster level, PCPs will be randomized into intervention or control group using a biased coin minimization technique. Participants in the control group are going to have a routine health check "Check-up 35" which is recommended biannually for all people ≥35 years of age in Germany. In the intervention group, the routine health check is expanded by usage of a non-invasive diabetes risk prediction model (German Diabetes Risk Score). Primary outcome is change in physical activity after 1 year. Secondary outcomes include aspects of targeted counseling, motivation of participant's to change lifestyle, perceived and objectively measured diabetes risk, acceptance of diabetes risk scores, quality of life, depression and anxiety. Patients will be followed over 12 months. Hierarchical or mixed models will be conducted, including a random intercept to adjust for cluster, the respective baseline value, and covariates to compare the groups.

DISCUSSION

This pragmatic cluster randomized controlled trial will enhance our knowledge on the clinical impact of diabetes risk scores for the first time in the real-life primary health care setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03234322 , registered on July 28, 2017.

Teamwork: relevance and interdependence of interprofessional education

OBJECTIVE

Determine the perception of university students regarding interprofessional and interdependent work between team members in their inclusion in primary care.

METHODS

Analytical cross-sectional study. The sampling had a probabilistic, stratified random type with 95% confidence and 5% margin of error. Seven-hundred and four students of Public Universities in Santiago (Chile) answered self-administered questionnaire.

RESULTS

Ninety-seven point eight of students say that interprofessional work is important; 27.1% of them declare that their university did not seem to show that their study plans were important. The professionals listed as most important in teams are physicians and nurses.

CONCLUSIONS

Spaces for development and institutional support are key elements to promote interprofessional work. If this competence can involve each academic unit in their different formative spaces there will be a significant contribution to said promotion. Teamwork is a pending task.

Prevalence of gestational diabetes and risk of complications before and after initiation of a general systematic two-step screening strategy in Germany (2012-2014)

AIMS

Information on the prevalence of gestational diabetes mellitus is scarce on national and international level. On July 1st, 2013, a general two-step screening was implemented in Germany harmonizing gestational diabetes diagnoses. We aim to provide prevalence estimates for gestational diabetes and pregnancy-related complications for the large region of North Rhine for the 12 months before and after introduction of the general screening.

METHODS

Routine care data covering all outpatient diagnoses of more than 150,000 pregnancies per 12-month period in women aged 15-55 years was used to determine cases of gestational diabetes. Gestational diabetes diagnosis and pregnancy-related complications were assessed according to the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Relative Risks for pregnancy-related complications were calculated in pregnancies with and without gestational diabetes.

RESULTS

Before the screening, diagnosis of gestational diabetes was made in 6.02% of pregnancies and in 6.81% after this date (other types of diabetes mellitus: 1.67% and 1.76% respectively). The prevalence of GDM increased with age and was highest at age 36-40 years (8.45%). The relative increase in prevalence after introduction of the screening was highest in the age group≤25 years (24.9%). The frequency of pregnancy-related complications such as hypertension, pre-eclampsia, cesarean section was increased in pregnancies with gestational diabetes in comparison to those without independent of observation period.

CONCLUSIONS

We found a high prevalence of gestational diabetes, which has relatively increased by 13.12% after the introduction of the general screening.

Effect of awareness through movement on the head posture of bruxist children

The aim of this study was to evaluate the effectiveness of physiotherapy to improve the head posture and reduce the signs of bruxism in a group of bruxist children. A single-blind randomized clinical trial was performed. All the subjects were 3- to 6-year old, had complete primary dentition, dental and skeletal class I occlusion and were classified as bruxist according to the minimal criteria of the ICSD for bruxism. For each child, a clinical, photographic and radiographic evaluation of the head and cervical posture were realized with standardized techniques. The children were randomized in an experimental (n = 13) and a control (n = 13) group. A physiotherapeutic intervention was applied to the children of the experimental group once a week, until 10 sessions were completed. Afterwards, the cephalogram and the clinical and photographic evaluation of the head posture were measured again. The data were analysed with the t-test and Mann-Whitney test. The subjects of the experimental group showed statistically significant improvement in the natural head posture. The physiotherapeutic intervention showed to be efficient to improve the head posture at the moment of measurement in the studied children. The relationship between bruxism and head posture, if exists, seems to be worthwhile to examine.

Head posture and dental wear evaluation of bruxist children with primary teeth

The aim of the present study was to compare the head position and dental wear of bruxist and non-bruxist children with primary dentition.

METHODS

All the subjects had complete primary dentition, dental and skeletal class I occlusion and were classified as bruxist or non-bruxist according to their anxiety level, bruxism described by their parents and signs of temporomandibular disorders. The dental wear was drawn in dental casts and processed in digital format. Physiotherapeutic evaluation and a cephalometric radiograph with natural head position were also performed for each child to evaluate the cranio-cervical position for the bruxist group (n = 33) and the control group (n = 20). The variables of the two groups were compared, using the Student t-test and Mann-Whitney U-test.

RESULTS

A more anterior and downward head tilt was found in the bruxist group, with statistically significant differences compared with the controls. More significant dental wear was observed in the bruxist children.

CONCLUSIONS

Bruxism seems to be related to altered natural head posture and more intense dental wear. Further studies are necessary to explore bruxism mechanisms.

Novel infectious bronchitis virus S1 genotypes in Mexico 1998-1999

Seventeen infectious bronchitis virus (IBV) field isolates recovered from commercial broiler flocks in Mexico were identified by reverse transcription-polymerase chain reaction cycle sequencing of the S1 gene. The isolates were obtained from broilers on farms from the neighboring states of Queretaro and San Luis Potosi in 1998 and 1999. Flocks had an ongoing history of bacterial-complicated respiratory disease with mortality rates as high as 28% in spite of receiving live vaccinations for Massachusetts and Connecticut strains of IBV. Sequence analysis of the S1 gene identified two unique genotypes that have been described, as of this time, only in Mexico and thus appear to represent strains indigenous to the country. The Mex/1765/99 genotype was isolated from 64% (11/17) of the respiratory disease outbreaks. Three isolates (18%) were similar to the BL-56 genotype, a unique Mexican IBV strain observed initially in 1996. In addition to the two indigenous strains, three isolates (18%) were found to be the Connecticut genotype.

Dissemination of a chloramphenicol- and tetracycline-resistant but penicillin-susceptible invasive clone of serotype 5 Streptococcus pneumoniae in Colombia

A national surveillance conducted in Colombia between 1994 and 1996 identified serotype 5 Streptococcus pneumoniae as the second most frequent cause of invasive disease in children younger than 5 years of age. All 43 serotype 5 isolates collected during this period were shown to be susceptible to penicillin, erythromycin, cefotaxime, and vancomycin, but most (38 of 43, or 88%) were highly resistant to chloramphenicol. In order to clarify a possible genetic relatedness among these isolates, additional microbiological and molecular characterizations were performed. Most (40 of 43, or 93%) of the isolates were found to be resistant to tetracycline. Pulsed-field gel electrophoresis (PFGE) patterns of chromosomal DNAs revealed that all the 43 isolates were closely related and that 38 of the 43 isolates were representatives of a "Colombian clone" of S. pneumoniae isolates which were recovered throughout the 3-year surveillance period from patients in 13 hospitals located in five Colombian cities. Isolates belonging to this Colombian clone were resistant to chloramphenicol and tetracycline, hybridized with the cat and tetM DNA probes in the same 340-kb SmaI fragment, and had identical PFGE patterns after both SmaI and ApaI digestions.

Virtually all methicillin-resistant Staphylococcus aureus (MRSA) infections in the largest Portuguese teaching hospital are caused by two internationally spread multiresistant strains: the 'Iberian' and the 'Brazilian' clones of MRSA

OBJECTIVE: To determine the nature (clonal type and antibiotic resistance pattern) of methicillin-resistant Staphylococcus aureus (MRSA) strains recovered from the largest teaching hospital in Portugal and to detect temporal trends in clonal types during three consecutive surveillance periods in 1992--93, 1994--95 and 1996. METHODS: MRSA strains were characterized by chromosomal SmaI macrorestriction patterns using pulsed-field gel electrophoresis (PFGE) and by DNA fingerprints---applied to ClaI digests---capable of probing two specific areas of the staphylococcal chromosome: (1) the vicinity of the mecA gene, and (2) the attachment site(s) and copy number of transposon Tn554. The combination of these methods can generate 'clonal types' useful for epidemiological tracking of MRSA strains. RESULTS: During the 1992--93 collection period, 65% of MRSA strains carried the mecA polymorph I, Tn554 pattern E and PFGE pattern A (I::E::A)---a clonal type that was used to define the 'Iberian MRSA', which is widely spread throughout southern Europe. The representation of this clone decreased to 42% in 1994--95 and to 20% in 1996. At the same time, a second multiresistant MRSA strain carrying mecA polymorph XI, Tn554 type B and PFGE pattern B (XI::B::B)---a clonal type characteristic of the so-called 'Brazilian MRSA'---increased from 5% in 1992--93 to 36% in 1994--95 and 29% in 1996. CONCLUSIONS: Throughout the four years of surveillance, the Iberian and Brazilian MRSA types and their single subtype variants together have been responsible for the overwhelming majority (close to 90%) of all MRSA infections in the largest teaching hospital of Portugal. The mechanism of epidemicity of these two multiresistant international MRSA clones remains to be elucidated.

Mutation of a gene encoding a protein with extracellular matrix motifs in Usher syndrome type IIa

Usher syndrome type IIa (OMIM 276901), an autosomal recessive disorder characterized by moderate to severe sensorineural hearing loss and progressive retinitis pigmentosa, maps to the long arm of human chromosome 1q41 between markers AFM268ZD1 and AFM144XF2. Three biologically important mutations in Usher syndrome type IIa patients were identified in a gene (USH2A) isolated from this critical region. The USH2A gene encodes a protein with a predicted size of 171.5 kilodaltons that has laminin epidermal growth factor and fibronectin type III motifs; these motifs are most commonly observed in proteins comprising components of the basal lamina and extracellular matrixes and in cell adhesion molecules.

Molecular epidemiology of Vibrio cholerae O1 isolates from Colombia

A total of 173 Vibrio cholerae O1 isolates from the recent cholera epidemic in Colombia was analysed by the polymerase chain reaction (PCR) for the genes encoding the A subunit of cholera toxin (ctxA) and the zonula occludens toxin (zot), and by ribotyping. All isolates were positive for ctx A and zot, which was confirmed by hybridisation. Ribotyping with restriction endonuclease Bg/I digestion of total DNA revealed three ribotypes: B5a comprising 165 (96.4%) isolates, and two new designated ribotypes B20 and B21a in six (3.5%) isolates and two (1.1%) isolates, respectively. These findings have significant public health implications.

Influence of dietary magnesium level on metabolic and growth-performance responses of feedlot cattle to laidlomycin propionate

A metabolism trial and a growth-performance trial were conducted to evaluate the interaction of dietary magnesium level (.18 vs .32%) and laidlomycin propionate (LP) (0 vs 11 ppm, airdry basis) on utilization of a high-energy finishing diet by feedlot steers. There were no treatment effects (P > .10) on ruminal and total tract digestion of OM and ADF. However, there was an interaction (P < .05) between magnesium level and LP on ruminal starch digestion. With LP, magnesium level had no effect on ruminal starch digestion. Without LP, increasing dietary magnesium decreased ruminal starch digestion. Laidlomycin propionate decreased (P < .10) ruminal degradation of feed N (13.9%) and microbial efficiency (8.9%) and increased (P < .10) total tract N digestibility. There were no treatment interactions (P > .10) on site and extent of magnesium digestion. Magnesium absorption decreased with increased dietary magnesium (11.6%, P < .05) and LP (16.9%, P < .01). There was an interaction (P < .10) of treatments on postabomasal calcium absorption. With the low magnesium level LP increased calcium absorption, whereas with the higher magnesium level LP decreased calcium absorption. There was an interaction between magnesium level and LP on ruminal pH at .5 h (P < .05) and 8 h (P < .10) after feeding. In general, ruminal pH increased with LP supplementation at the lower magnesium level and decreased with LP supplementation at the higher magnesium level. There were interactions (P < .05) between magnesium level and LP on ruminal VFA molar proportions and estimated methane production. At the lower magnesium level, the effects of LP on VFA molar proportions were small. At the higher magnesium level, however, LP decreased (13.2%) molar proportions of acetate and increased (26.5%) molar proportions of propionate. There was an interaction (P < .05) between magnesium level and LP on feed intake. At the lower magnesium level, LP increased (3.9%) feed intake; at the higher magnesium level LP decreased (4.4%) intake. Increasing dietary magnesium enhanced ADG (6%, P < .10). Both magnesium and LP enhanced (2.8%, P < .10) diet NE, and this effect was strictly additive. There were no effects (P > .10) of magnesium level or LP on plasma magnesium concentrations. Plasma calcium concentrations were decreased by supplemental magnesium (15.2%, P < .05) and increased by LP (16.0%, P < .01). We conclude that dietary magnesium levels modulate the metabolic and performance responses of feedlot steers to supplemental LP.

Brain magnetic resonance imaging findings in the Opitz G/BBB syndrome: extension of the spectrum of midline brain anomalies

We report the brain magnetic resonance imaging findings in 4 patients with the Opitz BBB/G syndrome. The scans were assessed by subjective interpretation and computerized image analysis. Findings noted in 3 of the 4 patients include hypoplasia or agenesis of the corpus callosum (3 patients), cerebellar vermal hypoplasia (2 patients), cortical atrophy and ventriculomegaly (3 patients), macro cisterna magna (3 patients), and a wide cavum septum pellucidum (1 patient). One patient had a normal scan. The demonstration of a wide cavum septum pellucidum extends the spectrum of midline brain anomalies (ventral induction defects) reported in this condition. This study along with other recent reports suggests that midline brain anomalies may be frequent findings in Opitz syndrome.

Population pharmacokinetics of imipramine in children

The population pharmacokinetics of imipramine (IMI) and its active metabolite desipramine (DMI) have been evaluated using 177 IMI and DMI serum levels from 49 enuretic children (6-13 y) on IMI treatment. Standard two stage (STS) and maximum likelihood (ML) methods were used to estimate fixed and random effect parameters of IMI. Simultaneous estimation of the drug and metabolite parameters was carried out by the STS method. The mean value of the elimination constant of the drug and metabolite were 0.0425 h-1 and 0.0359, h-1 respectively. Significantly higher variability was found in the pharmacokinetic parameters of the metabolite. According to these estimated pharmacokinetic parameters, the recommended dose for enuretic children should be 1.7 mg.kg-1.day-1. The population pharmacokinetic parameters obtained in the study permit dosage individualisation using a bayesian algorithm.

Dosage optimization methods applied to imipramine and desipramine in enuresis treatment

Three methods for estimating maintenance dosage requirements of imipramine were compared retrospectively in 146 enuretic patients. The dosing methods evaluated included individual (serum levels data) and/or population (average pharmacokinetic parameter) information. The use of imipramine and desipramine serum concentrations, as opposed to average population parameters only, improved forecast precision and accuracy for dosage individualization. The clinical acceptability of this was achieved through knowledge of a single serum concentration. No significant differences were seen between non-linear regression and the Bayesian method, this is in agreement with the high contribution of the patient's data to the Bayesian fitting (FF = 0.8). When one or two serum level data were available, a better performance was obtained by estimating pharmacokinetic parameters than level:dose ratios.

[3 cases of postpartum acquired factor VIII inhibitor]

Three cases of postpartum acquired factor VIII inhibitors were seen in our hospital between 1981 and 1989. The clinical picture, which was mild in one patient and severe in two, began several months after delivery (four to nine). After treatment with methylprednisolone, good clinical response was obtained in the three cases. However, normal values of factor VIII:C were obtained more easily with the higher doses of steroids. A new pregnancy and delivery in one of our patients did not induce the reappearance of the inhibitor after several years of follow-up.

The influence of clinical and pharmacological factors on enuresis treatment with imipramine

1. The aim of this study has been to evaluate the response to imipramine treatment in enuretic children through the use of a series of clinical and pharmacological variables and by applying a multivariate (principal components) analysis technique. 2. The study was carried out on 146 children whose ages ranged from 5 to 14 years, and who received variable doses of imipramine (12.5 to 100 mg day-1). 3. The quantitative variables analyzed were: drug dosage, serum levels of imipramine and its metabolite desipramine, the relationship between them both, the duration of treatment, age and weight. 4. The qualitative variables were: compliance, presence of side-effects, enuretic and/or psychiatric antecedents, intelligence quotient (I.Q.), the existence (or absence) of related pathologies, sex, and the type of enuresis. 5. The response to treatment was quantified by means of the percentage of decrease in frequency of enuresis as compared with the initial frequency. 6. The results obtained show that the variables which are most associated with the reduction of enuresis are, in decreasing order: the dosage of imipramine administered, the duration of treatment, compliance and the level/dose ratio for the sum of the drug and metabolite levels.

Prediction of imipramine serum levels in enuretic children by a Bayesian method: comparison with two other conventional dosing methods

The aim of the present study was to characterize the kinetic behavior of imipramine (IMI) and desipramine in enuretic children and to evaluate the performance of different methods for dosage prediction based on individual and/or population data. The study was carried out in 135 enuretic children (93 boys) ranging in age between 5 and 13 years undergoing treatment with IMI in variable single doses (25-75 mg/day) administered at night. Sampling time was one-half the dosage interval at steady state. The number of data available for each patient varied (1-4) and was essentially limited by clinical criteria. Pharmacokinetic calculations were performed using a simple proportional relationship (method 1) and a multiple nonlinear regression program (MULTI 2 BAYES) with two different options: using the ordinary least-squares method (method 2) and the least-squares method based on the Bayesian algorithm (method 3). The results obtained point to a coefficient of variation for the level/dose ratio of the drug (58%) that is significantly lower than that of the metabolite (101.4%). The forecasting capacity of method 1 is deficient both regarding accuracy [mean prediction error (MPE) = -5.48 +/- 69.15] and precision (root mean squared error = 46.42 +/- 51.39). The standard deviation of the MPE (69) makes the method unacceptable from the clinical point of view. The more information that is available concerning the serum levels, the greater are the accuracy and precision of methods (2 and 3). With the Bayesian method, less information on drug serum levels is needed to achieve clinically acceptable predictions.

Predictive techniques applied to imipramine therapeutic drug monitoring

The aim of this study was to establish the performance of pharmacokinetic methods employing little data on serum drug concentrations obtained in routine therapeutic drug monitoring of imipramine. Forty-three and 123 serum levels were obtained in 8 adult depressive patients (aged 57-80 y) and 34 enuretic children (aged 5-13 y), respectively. Forecasting of the serum concentrations was performed based on mean population pharmacokinetic parameters (method A), with knowledge of one steady-state serum concentration (method B), and from two or more steady-state serum concentrations (method C). The accuracy and precision of each method were evaluated from the mean prediction error (ME) and from the root mean squared prediction error (RMSE), respectively. The values of ME and RMSE of methods B and C proved to be significantly lower than those found using method A. Method C was the most precise and accurate in both populations. Method A underestimates the serum concentrations observed in adults (ME greater than 0) but overestimates them in children (ME less than 0), although to a lesser extent. The study shows that it is possible to obtain a good estimation of individual dosage needs from one or more serum concentrations obtained at steady state. Clinical application of these methods (B and C) yields an increase in the efficiency and safety of the treatment, particularly in special populations such as geriatric and pediatric patients.

High levels of tricyclic antidepressants in conventional therapy: determinant factors

The incidence of potentially toxic serum levels (greater than or equal to 400 ng/ml) was analyzed in a group of 196 monitored patients on a standard dosage regimen (75-225 mg/day) of several antidepressants: imipramine, amitriptyline, nortriptyline, maprotiline and clomipramine. Mean incidence was 12%. The maximum antidepressants serum levels in these patients ranged from 403 to 1,776 ng/ml. The drug/metabolite ratio was 1.5 +/- 0.7. Only in 23% of the cases did the clinical symptoms allow us to suspect the presence of potentially toxic serum levels. The factors that may contribute to the appearance of high serum levels were analyzed; these are: association of neuroleptic agents to the antidepressant therapy, advanced age and administration of doses above 2.5 mg/kg/day. In 64% of the patients, the clinical criteria suggested the need for a reduction in the dose, with a mean value of 42%.

Study of different factor VII deficiency variants in nine families from Spain

Twenty-three patients with congenital factor VII (FVII) deficiency, belonging to 9 kindreds were studied. Immunological variants were classified according to the relationship between FVII coagulant activity (FVIIC) and the level of FVII antigen (FVIIAg), considering 3 previously described groups: VII-, VII+ and VIIR. Activation variants were determined by the reactivity pattern with three different thromboplastins. One patient was classified as VII-, 16 as VII+, and 6 as VIIR. Three patients belonging to the same kindred showed a Padua 2 FVII deficiency, and 1 patient showed a Padua 1 variant. There was no correlation between antigenic or activation variants and severity of bleeding tendency. Classical autosomal recessive mode of inheritance was observed in VII- and VII+ families. Nevertheless, a possible autosomal dominant trait was observed in VII+ kindreds.