This paper aimed to identify the best way to engage, motivate and support early childhood services (ECS) and primary schools (PS) to create policy and practise changes to promote healthy eating and physical activity. This information would be used to develop a suitable program to implement within these children's settings to reduce the risk of childhood overweight and obesity.The Medical Research Council's (UK) framework for the design and evaluation of complex interventions was used to guide the development of the healthy eating and physical activity program suitable for ECS and PS. Within this framework a range of evaluation methods, including stakeholder planning, in-depth interviews with ECS and PS staff and acceptability and feasibility trials in one local government area, were used to ascertain the best way to engage and support positive changes in these children's settings.Both ECS and PS identified that they had a role to play to improve children's healthy eating and physical activity. ECS identified their role in promoting healthy eating and physical activity as important for children's health, and instilling healthy habits for life. PS felt that these were health issues, rather than educational issues; however, schools saw the link between healthy eating and physical activity and student learning outcomes. These settings identified that a program that provides a simple guide that recognises good practise in these settings, such as an award scheme using a health promoting schools approach, as a feasible and acceptable way for them to support children's healthy eating and physical activity.Kids - 'Go for your life', was developed to promote and support children's healthy eating and physical activity and reduce the risk of childhood overweight and obesity. Kids - 'Go for your life' used an award program, based on a health promoting schools approach, which was demonstrated to be a suitable model to engage ECS and PS and was acceptable and feasible to create policy and practise changes to support healthy eating and physical activity for children.Through the process of design and evaluation a program -  Childhood overweight and obesity are significant public health issues. Recent prevalence data show 17% of Australian children 2-16 years) are overweight and 6% are obese -16 years and highChildhood obesity is an important predictor of adult obesity , leadingTo prevent obesity in the general population it is important to focus on children and their maintenance of healthy weight as an effective public health approach. Children's settings, such as primary schools, kindergartens, child care and family day care services, are key places that can enhance public health gains. These settings provide an opportunity to: reach children from all cultural and socio-economic backgrounds; expose children to nutritional and physical activity opportunities; involve parents in nutrition and physical activity education; and involve stakeholders from the broader community in the work of these settings, such as local dietitians to run parent healthy eating information sessions .Systematic reviews of heterogenous school based interventions implementing strategies to improve healthy eating and/or physical activity present findings on their effectiveness that remain largely inconclusive, although they suggest a combination of nutrition and physical activity interventions may help prevent overweight  and assiBuilt within the health promoting schools approach, healthy award schemes have emerged. Award schemes provide a structured framework, health-related targets and provide external support. These schemes offer recognition for achieving key elements of a health promoting schools approach and can be used to motivate healthy changes and as marketing tool to position the school as a desirable choice for families. The award scheme has become popular among European countries to monitor systems and recognise achievement  and is pWithin Victoria, Australia, primary school attendance is compulsory for children from five years of age. There is a range of education options available, including government, catholic and independent schools. Access to schools is not restricted by residential geography or zoning. Prior to school attendance, kindergartens provide a one-year education program for children aged four years and child care is available for children aged up to six years.These children's settings are primarily focused on learning and development outcomes, as directed by government policy . TherefoKids - 'Go for your life' program aims to improve healthy eating and physical activity levels of children and in doing so reduce the risk of overweight and obesity. To achieve this aim Kids - 'Go for your life' works with primary schools and early childhood services, such as child care, family day care and kindergartens, to support healthy eating and physical activity through an award program, using a health promoting schools approach. The award program provides a comprehensive, yet simple, guide for early childhood services and schools to create healthy environments that support children to be active and eat well. Schools and services join the program as members and receive a range of resources, training and support as they work through a number of criteria to improve their policies and practices and reach award status. Once awarded schools and services receive a sign for their front gate to show to their community their commitment to children's healthy eating and physical activity.The Victorian Kids - 'Go for your life' award program operating in early childhood services and primary schools within Victoria and the methods that lead to its development.The paper aims to describe the design of the To develop an appropriate program for early childhood services and primary schools three phases of evaluation were undertaken. These phases were based on those of the Medical Research Council (UK) frameworThese evaluation methods were approved through the Department of Human Services Victoria, Human Research Ethics Committee (54/07) and the Department of Education and Early Childhood Development Victoria, Research in Schools Committee.The initial phase of development aimed to answer the question - 'what is the most appropriate model for a physical activity and health-eating program for primary schools and early childhood services in Victoria?' A number of methods were employed to answer this question.Eight key stakeholders, who had a vested interest and expertise in healthy eating, physical activity and childhood obesity, were involved in a strategic planning session. These stakeholders represented non-government health organisations, research institutes, a tri-partisan statutory health promotion organisation and a health consultant. The stakeholders identified key health outcomes that they envisioned the program should achieve in 10 years and listed gaps and opportunities in achieving these outcomes. From this process strategic themes were drawn from the discussions and the model of an award program for early childhood services and primary schools was proposed as an appropriate and achievable model to engage settings to make changes in policy and practice that would support healthy eating and physical activity. The success of programs such as SunSmart schools  and Be AA subsequent brief review of published award or multi-strategy health promotion programs operating within children's settings across Australia and internationally was undertaken, to identify program designs, theoretical approaches used and successful features. Where possible discussions with key staff members of these programs assisted understanding of the key features of these programs that contributed to their success. Common features were identified across these programs and included; sustainability; utilising a health promoting schools approach; targeting specific behaviours; providing recognition to settings for their achievements; streamlining settings' access to on-the-ground support and resources; consulting with settings; provision of support through local partnerships; integration and support of settings' existing structures and requirements to reduce added burden; and the ability for settings to progressively work toward change.The award model would also be required to support existing state and national policies for nutrition and physical activity. Relevant polices and regulatory requirements were identified and included; mandated provision of physical education and sport, and curriculum frameworks within government schools; national guidelines for non-government schools on the provision of physical activity; state licensing standards and national accreditation standards for early childhood services relating to nutrition and physical activity; and national government guidelines on physical activity and healthy eating for children 0-12 years.The outcome of this phase was that an award program, that provided recognition to settings for their achievements and was based on a health promoting schools approach, was developed and implemented to engage and drive change within children's settings. This program would focus on improving healthy eating and physical activity policies and practises, be aligned with relevant national and state policies and consider the key success elements of other existing programs.The modelling phase aimed to define the detail of the award program and any supporting materials. The initial methodology for this phase included twenty-six in-depth interviews with settings staff, including school principals (10), assistant principals (1), teachers (4) and early childhood centre managers and coordinators from family day care (5), long day care (3) and kindergartens (3) to ascertain:rationale, and therefore the marketing strategy, that would motivate settings to be involved in the proposed award program.• Underlying Features that would appeal to settings to motivate them to be involved and create healthy eating and physical activity changes.• Feasibility of the proposed design of the award program.• Support that settings would require when undertaking the award program.• Snowball sampling was used to identify relevant interviewees from metropolitan, rural, high and low socio-economic areas, catholic, independent and government schools. All interviews were undertaken either in person or by telephone and taped. Interviews were then reviewed by three people to ascertain common themes emerging from interviewee responses under each of these question areas  and under key health promoting schools approach elements, such as policy, information provided to parents and inclusion in curriculum and program planning. From the list of strategies grouped under each of these areas the two working groups chose one strategy, based on available evidence of effect, through their knowledge and in their experience, they felt was feasible and likely to produce the best behavioural outcomes. See additional file [Additional file It was important to engage stakeholders early in the process of defining the award program to ensure ownership and buy-in and subsequent promotion and support for the award program.On completion of the design and selection of criteria, supporting resources were developed, based on the information from the in-depth interviews to ensure appropriate language and themes to engage and motivate settings. These resources were developed with extensive feedback from the early childhood and primary school working groups, who commented on each draft of the documents. These resources detail rationale for action, tips on how to make healthy changes, tips to support behaviour change with parents and other supporting resources and organisations.The outcomes of the modelling phases confirmed the structure of the award program. This phase also assisted in choosing the best and most relevant criteria and developing supporting resources for settings.The trialling phase aimed to explore the broader acceptability and feasibility of the award program for settings within a defined geographical area of Victoria and provide feedback and allow refinement of the model prior to statewide implementation.The methods for this trial included sending letters to all primary schools (62) and early childhood services (84) residing in one outer metropolitan local government area of Victoria. This local government was chosen due to the high number of children's settings within the defined geographical area. Information on the socio-economic position and cultural diversity of children and families was only available at the local government level, rather than by suburb or school level, therefore this information was not available to compare schools or early childhood services involved in this feasibility trial and presents a limitation of this feasibility and acceptability data.Kids - 'Go for your life' award program and requesting that they join as members. Primary school principals within this local government area were also presented the award program and asked to join at a regular principals' network meeting. Subsequent reach of the program uptake was measured via the collation of membership forms received from schools and services. Membership forms also requested settings to self assess their current status against each award criteria. From these membership forms baseline policy and practise data were collected. Self-assessments against each award criteria was not validated, and therefore, poses a limitation to the validity of the baseline data.Each school and early childhood service within the trialling local government area were sent a letter promoting the Membership uptake was followed by semi-structured telephone interviews with key contacts from a sample of children's settings that had joined the award program as a member to determine reasons for involvement in the program, their comments on the award program design and criteria, and comment on supporting resources. Interviews were planned with 3 primary schools, 3 kindergartens and 3 child care centres. While the planned numbers of interviews were achieved with primary school and kindergarten contacts, only 2 child care centre contacts were interviewed. Of the available child care centre contacts there were only 2 that either consented to be interviewed or were available.Semi-structured telephone interviews were also held with representatives from a sample of children's settings that had not joined the award program as a member to determine the reasons for not being involved and what would encourage them to join the award program. Interviews were conducted with representatives of 3 primary schools, 3 kindergartens and 3 child care centres.Within four weeks of promoting the award program 26% of primary schools and 23% of early childhood services in the local government had joined the award program, demonstrating a reasonable level of early acceptability and feasibility for the award program  saw a relatively low percentage of schools self-assessing as having already achieved this 31%), or achieving it within 6 months (19%)  and the promotion of active travel (criteria 8) also saw relatively low percentages of schools self-assessing as having already achieved these (38% and 31% respectively). Within six months, providing the self-assessments are accurate, the majority of schools indicated they would have achieved these criteria  had the lowest percentage of settings claiming to have achieved this already (61%), but the majority was planning to have achieved this within 6 months Table .Interviews with representatives from participating schools reported that they saw benefits for students joining the award program. All reported that their school had a commitment to encouraging healthy eating and physical activity for students and many had relevant initiatives happening at their school."When you work with kids, your interests lie with the kids, so it was a direct benefit to the students. Also we are experiencing a fair bit of social, cultural and economic disadvantage - for many kids, the model they have at home is not always a strong one as far as eating."Interviewees from early childhood services reported they were more interested in improving the health of the children in their care than in recognition for their efforts through an award program, and this was their motivation for being involved.All interviewees felt that the award program and the material supplied were clear and well designed. All liked the idea of the award program, and in some cases as a form of recognition of what the school was doing:"I think it gives the parents something to look at and the parents are grateful that we're trying to support what they're doing at home. I find a lot of the parents are having difficulty trying to get children to eat correctly in the first place, and having the support at school makes it that bit easier for them"., "Schools become very isolated, very insular, even though you might have a school no more than 3 or 4 blocks away, you're very isolated because schools have been forced to become very competitive. So you don't always get to know how you're going against what's happening in the broader scene. So it's useful for benchmarking...".One interviewee, the Principal of the school, provided an interesting perspective on the award programTwo school interviewees felt that they would be able to meet all the criteria in the award program within 12 months. The other school felt that achieving the criteria wouldn't be difficult except for the canteen changes required.Overall the award program and materials received were considered clear and easy to understand. All of the early childhood setting interviewees felt that the criteria in the award program were very achievable, and that they were already well on the way to meeting most:"I think I ticked most of them. I think there were only a couple that I didn't tick".All Principals interviewed were interested in the award program and could see that it fitted with existing initiatives and programs the schools were involved in:"A lot of what we are already doing fits in with the focus of Kids - 'Go for your life' as well. It would just be a matter of acknowledging that we are already doing a lot of things that fit in with the program".Two of the Principals pointed to the difficulty of taking on something additional at this stage and felt that it was something they would take on later. One spoke about a major rebuilding project underway at present, including a new gymnasium, which was occupying his time and also that of the Physical Education Coordinator. The consistent theme was competing priorities at this point in time:"We have a number of competing priorities to implementing something new at this stage. It is certainly something that is worthwhile, but needs to be implemented in a coordinated way".All interviewees expressed an interest in getting involved, but reported a variety of reasons for not joining as a member:"We haven't discussed it as a staff, and so haven't decided yet". (Pre-school)"We have put it to our committee of management and the staff are reviewing it to make sure we meet the criteria. It was talked about at the meeting last month, but we are scheduled to meet again in a couple of weeks. Our cook, who is here part-time, wants to get involved with it. So it is something we definitely want to do, it is obviously just practicalities of actually getting the paper work done". (Child care centre)Kids - 'Go for your life', but was planning to refer the information on. In another case the coordinator of one child care centre was shortly taking leave for an overseas holiday, but thought it would be something she would address when she returned.In one case the coordinator/teacher was leaving the pre-school shortly and felt that it would not be appropriate to commit her replacement to something like Kids - 'Go for your life' award program. To become a member, they are required to fill in a member form identifying what criteria they have already achieved, or are planning to achieve. The manager of the early childhood service or principal of the primary school signs the member form making a commitment to work toward reaching each award criteria . If all criteria are met the setting will be awarded with a large metal outdoor sign to hang on their front fence to show that they are a Kids - 'Go for your life' award program is promoted to Victorian early childhood services and primary schools through a range of public relations and communications activities, including, print community service announcements and articles in relevant journals and newsletters, local and statewide media, presentations at relevant forums and conferences and cross promotion with organisations and programs promoting similar or supporting messages.The Kids - 'Go for your life' have funded positions within local governments to support local settings to become members and work toward becoming awarded.Member and awarded settings are also provided with a range of additional supports. These supports include links to local health professionals who are available to support them to reach each criteria and become awarded, and in 10 local government areas Kids - 'Go for your life' award program. However, to the best of our knowledge there is no published evidence of using a health promoting schools approach or award schemes supporting healthy eating and physical activity within early childhood services. One recently published prevention study investigated a comprehensive multi-strategy approach through kindergarten settings [Kids - 'Go for your life' award program provides an innovative approach within an early childhood setting, using well-established components of the health promoting schools approach embedded within an award scheme.There are many examples of programs promoting healthy eating and physical activity within schools, using a health promoting schools approach , or awarsettings  using soKids - 'Go for your life' award program has been developed; and the acceptability and feasibility of this program by children's settings.The formative evaluations that inform the development of programs within schools or early childhood services are not often published, so the motivations and rationales for these settings' involvement are not well known or documented. While this was only a small-scale evaluation, it provided important information on: children's settings' motivations and rationales to become involved in healthy eating and physical activity programs; how the There has clearly been a level of success through the award program developed to encourage children's settings to join the program in the pilot local government area. Success with primary schools was greater than that with early childhood settings, therefore, the award program may need to be promoted and 'sold' more actively to these settings.Concern for the health of children in their setting was the main reason for early childhood services and primary schools to become a member rather than the recognition through the award program. In this sense the program is seen as a way of bringing about change and obtaining support to do this. There was generally a positive reaction to the award program, criteria and materials received.The feedback gathered through interviews with representatives of children's settings that had not responded to the invitation to join the program, indicates that there is a high degree of interest in the program. It is clear, however, that there are a number of competing priorities for settings and reasons for delaying involvement. As a result the need for ongoing promotion targeted individually to settings and through local media is critical, to ensure settings that are committed to other priorities at the moment are reminded of the program into the future.It is significant that the majority of children's settings that joined as members had generally scored themselves quite well against the award program criteria in their self-assessments. This is particularly the case with the early childhood settings, which mostly saw themselves as either having already achieved, or planning to achieve within 6 months, most of the award program criteria. This may reflect an overestimation of settings current status and is a limitation of this evaluation. However, it is likely that the program has been successful in attracting those settings that are already committed and working actively to improving the health of children in their care, through improved nutrition and increased physical activity and active play. The challenge will be to also secure participation of those settings less willing, or feel less able, to join the program.Kids - 'Go for your life' was developed to promote and support children's healthy eating and physical activity and reduce the risk of childhood overweight and obesity. Kids - 'Go for your life' used an award program, based on a health promoting schools approach, which was demonstrated to be a suitable model to engage early childhood services and primary schools and was acceptable and feasible to create policy and practise changes to support healthy eating and physical activity for children.Through the process of design and evaluation outlined in this paper Kids - 'Go for your life' award program will now focus on the reach of the program across a range of demographic categories, including rural and metropolitan areas and areas of low socioeconomic positions. A major focus of the evaluation will also determine if and how the award program affects the policies and practices within children's settings and whether these changes impact on children's healthy eating and physical activity behaviours.The upcoming evaluation for the The authors declare that they have no competing interests.SH, SW, CP and IH have made substantial contributions to conception and design, acquisition of data and analysis and interpretation of data. SH, SW, CP and IH have all been involved in drafting the manuscript, revising it critically for important intellectual content and have given final approval of the version to be published.The pre-publication history for this paper can be accessed here:Kids - 'Go for your life' award program criteria. The table included lists all criteria for primary schools and early childhood services to become awarded.Click here for file


The purpose of this study was to quantitatively evaluate the contribution of synovial lymphoid aggregates to autoantibody (rheumatoid factor [RF] and anti-cyclic citrullinated peptide [anti-CCP]) and total immunoglobulin (IgG and IgM) production in rheumatoid arthritis (RA) patients and the effect thereon of the B-cell-depleting antibody, rituximab, in the ARISE  trial.Autoantibodies as well as total IgM and IgG were quantified by enzyme-linked immunosorbent assay in extracts of synovial tissues and matched serum from patients with RA or osteoarthritis (OA). Synovial biopsies and serum were obtained at baseline and 8 weeks following rituximab therapy in 14 RA patients. A synovial/serum index (SSI) was calculated as the ratio of synovial to serum antibody/albumin, with values above 1 representing synovial enrichment. Lymphoid aggregates were evaluated histologically.Anti-CCP IgG, but not RF-IgM, was significantly enriched in RA synovia compared with serum. Total IgM and IgG were also enriched in RA, but not in OA. SSI correlated significantly with mRNA content for both IgM and IgG, demonstrating that it reflected synovial immunoglobulin production. RA synovia with lymphocyte aggregates contained significantly elevated RF-IgM and anti-CCP IgG compared with tissues with diffuse lymphoid infiltration. Rituximab treatment did not affect synovial autoantibody or total immunoglobulin SSI overall. However, in aggregate-containing tissues, rituximab significantly reduced total IgM and IgG SSI as well as IgM and IgG1 mRNA. Surprisingly, RF-IgM and anti-CCP IgG SSIs were unchanged by rituximab in aggregate-containing synovia.Combined with earlier observations that synovial lymphoid aggregates are unaltered by rituximab treatment, these data suggest that lymphoid aggregates may provide a protective niche for autoantibody-producing cells.The ARISE trial is registered at ClinicalTrials.gov as number NCT00147966. Rheumatoid arthritis (RA) is associated with the presence of certain circulating autoantibodies, such as rheumatoid factors (RFs) and anti-cyclic citrullinated peptide (anti-CCP) . The latThe local synthesis of immunoglobulins and autoantibodies by rheumatoid synovium is well appreciated but its contribution to the circulating pool is poorly understood. Explants of rheumatoid synovial tissue are capable of synthesizing immunoglobulins ,10, RF ,10, and Patients with RA or osteoarthritis (OA) were included after informed consent was obtained under approval from the University of California-San Diego Institutional Review Board. A subset of patients who were part of the ARISE  clinical trial, recently described in detail , receive2) were excised using a fine scalpel and snap-frozen in liquid nitrogen in sets of six or were embedded in cryosectioning medium. For ARISE patients, synovial tissue biopsies were obtained under conscious sedation anesthesia from knees or wrists using arthroscopically guided Automated Motorized Shaver technology, a method that rapidly yields greater than 50 synovial tissue fragments rich in synovial lining. Aliquots of the resulting synovial fragments were immediately snap-frozen or embedded. In some cases, a paired serum or plasma sample was obtained at the time of surgery or biopsy. All samples were stored at -80°C until analysis. The presence or absence of lymphoid aggregates was scored on hematoxylin/eosin-stained cryosections. Tissues displaying grade 2 or 3 aggregates [Synovial tissue was collected at the time of joint replacement surgery . The tissue was immediately placed on ice and transported to the laboratory, and synovial tissue fragments . Colorimetric enzyme-linked immunosorbent assay kits were used to detect RF of the IgM subtype (RF-IgM) , anti-CCP IgG , anti-tetanus IgG , total IgM and total IgG, and albumin  in synovial extracts and serum or plasma samples diluted to yield absorbance values in the linear range of the kit. Standard curves were constructed by regression line fitting on log(absorbance) versus log(concentration). In preliminary experiments, recovery of spiked standards in synovial extracts was assessed as described earlier [Frozen synovial fragments were weighed and immediately placed in chilled 1-mL Kontes-Duall tissue grinders, and ice-cold extracting buffer consisting of 1% Brij-35 detergent  in phosphate-buffered saline with protease inhibitor cocktail  was added at 50 μL per 10 mg of tissue. The mixture was ground by hand on ice until only fibrous white insoluble material remained. After incubation of the mixture for at least 10 minutes on ice, it was transferred to a microcentrifuge tube and centrifuged 10 minutes at 20,000  earlier  and foun earlier . For a gMessenger RNA for heavy chain constant regions for IgM and IgG1 was quantified by real-time TaqMan quantitative real-time polymerase chain reaction (qPCR) using cDNA with glyceraldehyde-3-phosphate dehydrogenase (GAPDH) used as a housekeeper. We have previously established that data derived from sets of six or more synovial tissue fragments minimize sampling error  and poolData are expressed as median and quartile and were analyzed by Wilcoxon rank sum test for comparing two unpaired groups. The Wilcoxon sign rank test was used to test locations of nonparametric populations. The effect by rituximab on synovial REU, autoantibody, and immunoglobulin levels is expressed as the geometric mean ± 95% confidence interval (CI) of percentage change pre- to post-treatment .To determine whether autoantibodies were detectable in synovia, RF-IgM and anti-CCP IgG were measured in extracts from 12 OA and 21 RA synovial tissues. Both RF-IgM and anti-CCP IgG were detectable in the majority of RA synovial extracts (17 of 21 in both cases) Figure . In contR = 0.701; P = 0.0017; Figure R = 0.825; P < 0.0001; Figure Total IgM and IgG were quantified in serum and synovial extracts and specific activities calculated. Both subclasses were elevated in RA extracts compared with those in OA Figure . An SSI P = 0.023 and 0.008, SSI above 1 in 7/8 and 8/8, respectively, for RF-IgM and anti-CCP IgG), whereas in tissues with diffuse infiltration the autoantibody SSI was not different from 1 . Total IgM and IgG were also determined in these extracts . A small but significant reduction in circulating RF-IgM, anti-CCP IgG, and total IgM, but not total IgG, was observed Figure . HoweverTrial subjects were grouped according to the presence or absence of lymphoid aggregates in their synovial biopsies prior to rituximab treatment, and the effect of rituximab was determined. Lymphoid aggregates were observed 8 weeks after rituximab treatment in all synovia that contained such aggregates prior to treatment (n = 5). The effect of rituximab on circulating autoantibodies or total immunoglobulins did not differ based on the presence of synovial aggregates. However, in synovia containing lymphoid aggregates, substantial and significant reductions of total IgM and IgG were noted in response to rituximab, whether assayed by constant region mRNA levels Figure  or by prRituximab is a B-cell-depleting antibody approved for treatment of anti-tumor necrosis factor (TNF)-resistant RA but its mechanism of action is unclear. In the synovium, B cells and immunoglobulin constant region mRNA are significantly lowered in patients with a substantial (at or above American College of Rheumatology 50%) clinical response to rituximab . The effIn cross-sectional feasibility studies, both RF and anti-CCP were easily detected in the majority of the RA synovial extracts. The variability among patients was very large (80- to 100-fold when expressed without regard to serum content). To account for variable levels in serum and also to normalize for differing amounts of serum in the tissues, an albumin-normalized SSI was formulated whereby a value above 1 by definition indicates synovial enrichment . A similar approach was employed earlier in synovial fluid . Naturalin vitro survival and differentiation of B cells [Using this method, both anti-CCP IgG and anti-tetanus IgG as well as total IgM and IgG were found to be significantly enriched in RA synovia, whereas the value for RF-IgM did not differ significantly from 1. The reason for the RF-IgM results is unclear; certainly, production of RFs by synovial tissue has been demonstrated earlier ,10,13-15 B cells ,24. Also B cells .Lymphocytic infiltrates in rheumatoid synovia can be diffuse or alternatively occur in more or less organized aggregates, sometimes resembling germinal centers -28. The Finally, we determined the effect of rituximab on synovial autoantibody and immunoglobulin levels in the longitudinal ARISE study (described in detail earlier ). DespitOf note, however, when patients were segregated according to the presence or absence of lymphoid aggregates in their synovia, the results were very different. Rituximab significantly reduced immunoglobulin production at the mRNA level, as well as total IgM and IgG content in synovia containing lymphoid aggregates, but not in synovia where lymphoid infiltration was diffuse. In spite of this, however, the treatment did not have any effect on RF-IgM or anti-CCP IgG content in synovia with lymphoid aggregates, even though these tissues produced massively increased levels of autoantibodies compared with synovia with diffuse infiltration.It is possible that the differential effect of rituximab on total immunoglobulin and autoantibody synovial production is due to a systematic change in the half-life of autoantibody-producing cells such that it may compensate for any effects of rituximab. More likely, however, and in light of the recent finding that the size and number of synovial lymphoid aggregates in RA are unaltered early after rituximab treatment , the aggWe developed quantitative methods for the determination of synovial autoantibody and immunoglobulin enrichment in biopsy materials obtained in clinical trials. Immunoglobulin mRNA correlated with synovial protein levels, consistent with local immunoglobulin synthesis. Both anti-CCP and RF-IgM were significantly enriched in synovial tissues containing lymphoid aggregates. However, in an 8-week study, autoantibody production in RA synovia was not altered by rituximab, whether aggregates were present or not. In addition, aggregates survived treatment. Thus, synovial lymphoid architecture is coupled with immunoglobulin and autoantibody production, but the role of synovial ectopic lymphoneogenesis in the pathogenesis and treatment of RA remains uncertain. It is unclear whether these events are critical to pathogenesis or whether they merely constitute epiphenomena of chronic inflammation. Further studies in patients with earlier disease and using other agents will be required to elucidate the contribution of synovial antibody production and lymphoid architecture to RA pathogenesis.anti-CCP: anti-cyclic citrullinated peptide; ARISE: Assessment of Rituximab's Immunomodulatory Synovial Effects; CI: confidence interval; DAS28: disease activity score using 28 joint counts; GAPDH: glyceraldehyde-3-phosphate dehydrogenase; OA: osteoarthritis; qPCR: quantitative real-time polymerase chain reaction; RA: rheumatoid arthritis; REU: relative expression units; RF: rheumatoid factor; RF-IgM: rheumatoid factor of the IgM subtype; SSI: synovial/serum index; TNF: tumor necrosis factor.AK and DLB received financial support from Genentech  to conduct the ARISE study. The other authors declare that they have no competing interests.SR participated in the design of the study, developed and performed molecular analysis, performed the statistical analysis, and drafted the manuscript. NW and KK performed arthroscopic procedures and collected samples. NZ participated in the design of antibody quantitative assays. AK and DLB conceived of, designed, and coordinated the study. DLB participated in drafting and editing the manuscript and is responsible for this manuscript. All authors read and approved the final manuscript.


In 2005, the Centers for Disease Control and Prevention funded five sites to implement the Colorectal Cancer Screening Demonstration Program (CRCSDP). An evaluation is being conducted that includes a multiple case study. Case study results for the start-up period, the time between initial funding and screening initiation, provide details about the program models and start-up process and reveal important lessons learned.The multiple case study includes all five CRCSDP sites, each representing a unique case. Data were collected from August 2005 through September 2006 from documents, observations, and more than 70 interviews with program staff and stakeholders.Sites differed by geographic service area, screening modality selected, and service delivery structure. Program models were influenced by two factors: preexisting infrastructure and the need to adapt programs to fit local service delivery structures. Several sites modeled program components after their National Breast and Cervical Cancer Early Detection Program. Medical advisory boards convened by all sites provided clinical support for developing program policies and quality assurance plans. Partnerships with comprehensive cancer control programs facilitated access to financial and in-kind resources.The program models developed by the CRCSDP sites offer a range of prototypes. Case study results suggest benefits in employing a multidisciplinary staff team, assembling a medical advisory board, collaborating with local partners, using preexisting resources, designing programs that are easily incorporated into existing service delivery systems, and planning for adequate start-up time. Colorectal cancer is the second leading cause of cancer-related death in the United States . AlthougFramework for Program Evaluation in Public Health  member, provider site coordinator, endoscopist, and Comprehensive Cancer Control (CCC) coordinator or other partner. The team identified these roles on the basis of typical staffing patterns among the sites and program policies imposed by CDC . Interview questions were developed on the basis of the role of the interviewee, the evaluation questions, and information gathered during the earlier interviews with program directors and CDC program consultants. The team used purposeful sampling to select interviewees who were likely to provide the most in-depth information ; relevanData analysis involved an iterative approach whereby team members regularly met to discuss impressions, review field notes, identify themes, and consider areas of emphasis for subsequent interviews . The teaThe team developed and refined a codebook with detailed code definitions. A single evaluator was assigned to code all interviews for one program site. The team coded 65 of the 67 on-site interviews, excluding two interviews because the interviewees were unfamiliar with details of their sites' CRCSDP program. Because of resource limitations, the documents were not coded, nor were the five telephone interviews with program directors or the three interviews with program consultants, but these materials were used in the analysis.The team met twice weekly during the coding process to discuss issues and review the memos of each team member. A second team member coded half of all interviews for each site; the two coders discussed discrepancies to make final coding decisions. The constant comparative method  was usedEach member of the evaluation team engaged in all aspects of data collection and analysis, an approach that contributed to a thorough and holistic understanding of each case. Both methodologic and data-source triangulation were used to verify findings; using more than one source of evidence is known to strengthen findings -14. The We present results for two distinct areas. The first, program models, summarizes characteristics of each CRCSDP program model. The second, program processes, presents data related to key start-up processes.The five sites differed in geographic service area: two served a city ; two served counties ; and one served a state (Nebraska).Missouri, Nebraska, and Washington planned to use the guaiac-based fecal occult blood test (FOBT) as the primary screening test, with colonoscopy being used for diagnosis and screening of high-risk people . MarylanThe organizational relationships for the programs' service delivery systems varied Figures –5. NebraThe Missouri Department of Health and Senior Services planned to contract with a provider in St. Louis to assess client eligibility for screening, deliver FOBT services, track and follow up on clients, and provide colonoscopies . The NebOf the sites with decentralized models of service delivery, the Maryland Department of Health and Mental Hygiene  planned Two key factors influenced the program design of all five programs. First, several sites developed the new CRCSDP, or components of it, from existing programs such as the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). For instance, sites planned to use NBCCEDP provider networks to support client in-reach or to distribute FOBT kits and were in the process of integrating other program components with existing NBCCEDP components. One staff member noted, "The easy part for us was having a screening and tracking system in place already that we were comfortable with [NBCCEDP]. . . . We were able to use similarities in our existing system and customize those for CRCSDP." The second factor influencing the CRCSDP program models was the need for sites to tailor service delivery systems in ways that facilitated their integration into existing clinical structures. Participants said such integration was necessary to minimize the burden and disruption for participating clinical sites. For decentralized models, the need to "fit" the provider context resulted in unique patient flow patterns at multiple provider settings.The start-up process lasted 9 to 11 months and involved assembling a staff team, developing program models, convening a MAB to assist in developing policies and procedures, building partnerships, planning for client recruitment, developing a data management system, and identifying resources for the treatment of complications.StaffingEach program recruited a team of two or three people, usually from existing positions, to assist in developing the new program. Teams typically included a program director, a program coordinator working on day-to-day activities, and a data management specialist. Programs that were able to easily access staff with clinical expertise within the grantee organization noted the importance of being able to do so. Nearly all CRCSDP program directors were also managing their state or region's NBCCEDP, and some were managing a Well–Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program, another CDC-funded screening program . ProgramMedical advisory board An MAB was convened by each program and provided essential clinical guidance during the start-up period, especially for CRCSDP sites lacking staff with extensive medical expertise in colorectal cancer. MAB composition varied by site but largely reflected clinical disciplines relevant to colorectal cancer and screening, including primary care specialists, gastroenterologists, and radiologists . One resPartnerships Partnerships provided critical resources, both financial and in-kind, and played an active role during program start-up. Key partners included state or regional CCC groups, the American Cancer Society (ACS), community-based organizations, and universities. Several partners provided in-kind staff support, and CCC groups contributed financial resources for a public education campaign in one site and database development in two others. CCC groups were also valuable in negotiating relationships with MAB members, endoscopists, and representatives of clinical provider sites. An ACS call center planned to recruit CRCSDP clients for one program, and a local university planned to assist with client recruitment and evaluation in another.Client recruitment CRCSDP sites planned public education, outreach, and in-reach strategies to recruit clients for screening . SeveralData management systems During program start-up, CDC, in collaboration with the five CRCSDP sites, developed a set of colorectal clinical data elements to collect patient-level demographic, screening, and diagnostic data on program clients. Whereas one CRCSDP site developed a new data system, others augmented existing systems  to integrate the data elements. With support from MABs and provider sites, each program also developed data collection forms . Although staff suggested that the development of data systems and forms was not particularly difficult, they observed that it was an especially time-consuming component of the start-up period.Treatment resourcesStaff identified challenges in securing resources for cancer treatment. Because CDC funds cannot be used for treatment , programThe program models and start-up process of the CRCSDP offer valuable insight to those with an interest in developing colorectal cancer screening programs. Several key factors emerged from the evaluation of the start-up experience of the five sites studied here. These factors include use of a multidisciplinary team, involvement of an MAB, relationships with partners, the use of preexisting resources, a program model that fits existing service delivery systems, and adequate planning time.In these five programs, two to three staff with expertise in program management and administration , program coordination , and data management  provided an adequate team for program start-up. Clinical expertise and comfort discussing clinical issues with MAB members and service providers were important skills for the management team.Access to clinicians with expertise in colorectal cancer was essential to start-up. A well-rounded MAB that included professionals in disciplines related to the screening process  was beneficial.CDC and other organizations recognize that public health problems demand collaborative efforts rather than "going it alone" ,19. ActiThe five CRCSDP sites leveraged existing resources to build a new colorectal cancer screening program. Partner agencies , other screening programs , and internal agency departments  helped reduce costs and support program development. The length of time needed to develop data systems and data collection forms suggests new programs may benefit from using existing data forms and data collection sets.These five programs used program models that would most easily integrate into existing service delivery systems. For the decentralized models, integration involved allowing for varied implementation approaches within multiple service delivery sites for the same program . Reliance on in-reach to NBCCEDP clients and overall concerns about effectively recruiting men suggest programs may need to consider program models that include unique recruitment efforts for men.Although CDC had anticipated a 6-month start-up period, these programs needed 9 to 11 months to hire staff, convene an MAB, develop policies, build partnerships, organize a service delivery system, plan for client recruitment, secure treatment resources, and develop data management systems. One staff member advised, "The devils are in the details — all the little things that you have to think through that we didn't even think of — things we thought we knew but we didn't."The CRCSDP evaluation team will continue to work with the five sites as they provide colorectal cancer screening to low-income, underserved communities. The case study, in particular, contributes to important process evaluation efforts that improve our understanding of the CRCSDP's program operations, implementation, and service delivery . Recogni


Crimean-Congo Hemorrhagic Fever (CCHF) is a fatal infection, but no clinical case due to AP92 strain was reported. We described the first clinical case due to AP92 like CCHFV.A case infected by a AP92 like CCHFV was detected in Balkanian part of Turkey. Diagnosis was confirmed by RT-PCR and sequencing. A human serologic and tick survey studies were performed in the region, where the case detected.Thirty eight individuals out of 741 were found to be anti CCHFV IgM positive. The attack rate for overall CCHFV was calculated as 5.2%. In univariate analyses, CCHFV IgM positivity was found to be associated with the age (p < 0.001), male gender (p = 0.001), agricultural activity (p = 0.036), and history of tick bite (p = 0.014). In multivariate analysis, older age , male gender were found to be the risk factors  for CCHFV infection.This is the first human case with AP92 like CCHFV infection. Furthermore, this is the first report of AP92 like strain in Turkey. In the region, elderly males carry the highest risk for CCHFV infection. Nairovirus in the Bunyaviridae family and causes severe diseases in humans, with a reported case fatality rate (CFR) of 3–30% [The first Crimean-Congo hemorrhagic fever (CCHF) case in Turkey was reported five years ago . The virof 3–30% . By the of 3–30% . All of Hyalomma spp. ticks. Humans become infected through the bites of ticks, by contact with a patient with CCHF during the acute phase of infection, or by contact with blood or tissues from viremic livestock [The occurrence of CCHF closely approximates the known distribution of ivestock . In a privestock , all of ivestock -6. By thivestock .A mild CCHF case was diagnosed in a community hospital in Istanbul in June 2007. His disease started 3 days after the tick bite, and he was hospitalized 4 days after the tick bite. Serum sample was obtained 5 days after the tick bite was studied by RT-PCR for CCHFV RNA and by ELISA for IgG and IgM antibodies against CCHFV. After this case, a serosurvey and tick survey studies were performed in the region at the end of June 2007. The serosurveillance studies were performed in four major districts, which were depicted in figure ®, Russia) was used for detection of IgM antibodies against CCHFV. Immunoglobulin G antibodies were tested by ELISA kit of the same company . The individuals, who were positive for IgM and/or IgG were prospectively surveyed, and four months later the second sera from these individuals were collected, and were studied for IgM and IgG. The initial sera were re-tested simultaneously with the second samples of sera. The informed consents from each individual were obtained.All the subjects were tested for IgM and IgG. A commercial variant of capture ELISA kit  and cDNA synthesized with Omniscript reverse transcription kit  in accordance with the instructions of the manufacturer.RNA was extracted from 200 μl whole blood using a commercial RNA extraction kit . After initial diagnostic PCR, the amplicon was sequenced and the obtained sequence closely matched with the sequence of AP92 strain. For amplification of exclusively AP92 strain RNA we designed primers from S segment of this strain  , 1.25 U Taq DNA polymerase  and 33.75 μl nuclease free water. For the second round amplification 2 μl first round products were added to the 48 μl reaction mixture with the same concentrations of the first round mixture. Thermal cycling conditions are given in Table In both PCR assays 5.0 μl reverse transcription product was added to the 45 μl reaction mixture consisted of 1 μl forward primer (50 pmol/μl)) and 1 μl reverse primer (50 pmol/μl), 5 μl 10× reaction buffer, 3 μl 25 mM MgCl®, Germany) and the purified products were subjected to the cycle-sequencing using big-dye terminator kit . The excess primers and nucleotides were removed from cycle-sequencing products using sephadex-G50 fine columns, and the products were sequenced using ABI®310  USA sequencer.The second round PCR products were cleaned up with a commercial PCR product purification kit  and Bioedit software packages [The obtained sequence was edited and aligned using Lasergene  software package was used in the analysis.Mean comparisons for continuous variables were done using independent groups The study was approved by the Medical Ethics Committee of Istanbul Branch of Ministry of Health in Turkey.The index case was a 6 years old child. He applied to the emergency department of Haseki Education and Research Hospital in Istanbul with the complaints of fever, malaise, and the loss of appetite. He revealed the history of a tick bite 3 days ago, while he attended to a picnic in Tasoluk region of Istanbul. In his physical examination, the hyperemia in the site of tick bite was detected. In his laboratory investigation, alanine aspartate transaminase (AST) was found to be elevated , activated partial thromboplastine time 43.7 second , and prothrombin time was 20.1 seconds . White blood cell count and platelet counts were found to be in normal limits. He was hospitalized for 10 days. The PCR for CCHFV RNA was found to be positive, and serologic tests for anti-CCHFV IgM and IgG by ELISA were found to be positive. The child was defined as a mild case, and discharged with total cure. His serum was obtained and retested by ELISA three months and one year later. His serum was found to be positive for CCHFV IgM and IgG antibodies three months later, and positive only for CCHFV IgG antibodies one year later.The phylogenetic analysis of the obtained sequence of CCHFV revealed that, the strain was closely related to AP92 strain, which was reported from Greece. The sequence was deposited in gene bank under accession number of EU057975, and named as KMAG-Hu-07-01.In the first run, 39 (5.26%) subjects were found to be IgM positive, and 35 (4.72%) subjects were IgG positive. Thirty four out of 35 (97.4%) IgG positive patients were also IgM positive. Only one subject had IgG positivity, but IgM negativity (0.14%).The second serologic analysis among IgM and/or IgG positives for CCHFV was performed 4 months later. Baseline sera were re-tested simultaneously for both IgG and IgM. All the IgM positivities except one, converted to IgG positivity. One IgG positive individual in the first run was found to be IgG negative in the second run. The first positive result of this individual was accepted as false, and this individual was considered as sero-negative. Accordingly, the analysis was performed among 38 IgM positive individuals versus 703 IgM negative individuals. These 38 IgM positive subjects were asked for the history of myalgia, fever, and flu like illness during summer months. Only one of the subjects had the complaints of myalgia and fever at the same time with the index case. This person attended to the same picnic with the index case.The mean age was higher among IgM positive individuals . Among the IgM seropositive individuals, being older , male gender , performing agricultural activity , and having history of tick bite  were found to be significantly higher than IgM negative individuals Table .In multivariate analysis, IgM positivity was higher among older age  and males   in the region. The infection was more common among the males and older people, who work in the field.The authors declare that they have no competing interests.KM: Study design, laboratory work. AG: Study design, laboratory work, data collection. OE: Interpretation of data, data analysis, manuscript preparation. ME: Clinical diagnosis and follow up of the case. SE: Laboratory work. GS: Data collection. RO: Interpretation of data. MB: Data collection, interpretation of data.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/9/90/prepub


In addition, over-expression in mice of the Mecr gene coding for 2-trans-enoyl-thioester reductase, also of mitochondrial FASII, leads to impaired heart function. However, mouse knockouts for mitochondrial FASII have hitherto not been reported and, hence, there is a need to develop alternate metazoan models such as nematodes or fruit flies. Here, the identification of Caenorhabditis elegans W09H1.5/MECR-1 as a 2-trans-enoyl-thioester reductase of mitochondrial FASII is reported. To identify MECR-1, Saccharomyces cerevisiae etr1Δ mutant cells were employed that are devoid of mitochondrial 2-trans-enoyl-thioester reductase Etr1p. These yeast mutants fail to synthesize sufficient levels of lipoic acid or form cytochrome complexes, and cannot respire or grow on non-fermentable carbon sources. A mutant yeast strain ectopically expressing nematode mecr-1 was shown to contain reductase activity and resemble the self-complemented mutant strain for these phenotype characteristics. Since MECR-1 was not intentionally targeted for compartmentalization using a yeast mitochondrial leader sequence, this inferred that the protein represented a physiologically functional mitochondrial 2-trans-enoyl-thioester reductase. In accordance with published findings, RNAi-mediated knockdown of mecr-1 in C. elegans resulted in life span extension, presumably due to mitochondrial dysfunction. Moreover, old mecr-1(RNAi) worms had better internal organ appearance and were more mobile than control worms, indicating a reduced physiological age. This is the first report on RNAi work dedicated specifically to curtailing mitochondrial FASII in metazoans. The availability of affected survivors will help to position C. elegans as an excellent model for future pursuits in the emerging field of mitochondrial FASII research.Our recognition of the mitochondria as being important sites of fatty acid biosynthesis is continuously unfolding, especially in light of new data becoming available on compromised fatty acid synthase type 2 (FASII) in mammals. For example, perturbed regulation of murine  Plasmodium falciparum and Toxoplasma gondiiTrypanosome brucei underscored the importance of this pathway to mitochondrial function In comparison to the long-established research area dedicated to studying cytosolic fatty acid synthase type 1 (FASI), the field of mitochondrial FASII in eukaryotic cells is only just beginning to emerge. Nevertheless, significant advances have been made recently in determining the protein components of mitochondrial FASII in both yeast de novo acyl carrier protein (ACP)-dependent biosynthesis of fatty acids via two methods: i) by way of a cytosolic process comprised of an associative FASI system, and ii) using a compartmentalized FASII design in which the enzyme activities reside on dissociated proteins. Although bacterial FASII has been extensively studied Saccharomyces cerevisiae, a functional FASII is critical for mitochondrial function and morphology, and deletion of FASII genes results in a respiratory growth phenotype characterized by underdeveloped mitochondria lacking assembled cytochromes, insufficient levels of lipoic acid and, in some cases, loss of mitochondrial DNA  contains at least two genes that are homologous to yeast mitochondrial Etr1p : W09H1.5  and Y48A6B.9 . The conceptual amino acid sequences of these proteins were additionally analyzed using three algorithms  which calculate the N-terminal region of a given protein that could support a mitochondrial leader sequence. MitoProt predicted (in brackets) that the polypeptide sequences relating to W09H1.5 (0.8937) and Y48A6B.9 (0.6487) had a probability of representing mitochondrial proteins that was higher than the known yeast mitochondrial protein Etr1p (0.6333). However, when using a further algorithm, PSORT II, W09H1.5 was clearly identified as a mitochondrial protein while Y48A6B.9 was determined to be cytoplasmic. Moreover, TargetP also supported the notion that W09H1.5 (0.887) was more likely to be mitochondrial than Y48A6B.9 (0.207). Since W09H1.5  is also more similar than Y48A6B.9  to the human homologue MECR/NRBF-1, the focus of the subsequent investigation was centered solely on W09H1.5.The C. elegans W09H1.5 could represent a 2-trans-enoyl-ACP reductase, the corresponding gene was expressed behind the promoter of the yeast CTA1 gene encoding peroxisomal catalase A (Cta1p), without resorting to an additional yeast mitochondrial leader sequence (MLS). CTA1 transcription is only weakly derepressed on non-fermentable carbon sources such the glycerol used here for the complementation assays etr1Δ mutant cells lacking mitochondrial 2-trans-enoyl-thioester reductase activity were transformed to uracil prototrophy with URA3-marked plasmids expressing native Etr1p (positive control), fungal Cta1p (negative control), or C. elegans W09H1.5 (tester strain), and cultured overnight in liquid SD-Ura glucose medium. Following sequential tenfold dilution, cells were spotted onto SD-Ura or SCglycerol plates that were incubated at 30°C until single colonies appeared. The results in etr1Δ cells could be rescued by the expression of C. elegans W09H1.5 to a similar extent as by native Etr1p, indicating functional complementation, while those expressing Cta1p could not proliferate on glycerol. Given the homology of W09H1.5 to Etr1p, and that W09H1.5 reversed the physiological defects of etr1Δ yeast cells without requiring an extra fungal MLS, W09H1.5 is likely to represent a mitochondrial 2-trans-enoyl-CoA/ACP reductase and its gene is hereafter referred to as mecr-1.To determine whether etr1Δ cells producing C. elegans MECR-1 were assayed for 2-trans-enoyl-thioester reductase activity. To stimulate elevated transcription and higher protein expression levels from the oleic acid-inducible CTA1 promoter trans-hexenoyl-CoA (trans-C6:1(2)) as substrate were performed on soluble protein extracts obtained from positive control etr1Δ cells over-expressing native Etr1p, and this gave rise to an NADPH-dependent oxidation of the C6 substrate at the rate of 3.21 µmol/mg protein x min−1. Since any reductase activity potentially present in cells over-expressing Cta1p was below the detection limit of the assay used, this confirmed the specificity of the assay to detect only highly active reductases. When soluble protein extracts made from mutant cells over-expressing MECR-1 were applied to this assay, this resulted in an NADPH-dependent oxidation at the rate of 0.21±0.11  µmol/mg protein x min−1, demonstrating that nematode MECR-1 contained appreciable reductase activity.Preparations of soluble protein from BJ1991ETR1 gene results in mutant cells with defective respiration etr1Δ mutants that had recovered the ability to could grow on glycerol as a consequence of expressing nematode MECR-1  gave rise to 14 ng lipoic acid per gram wet weight yeast cells, while mutant cells ectopically expressing fungal Etr1p produced 144 ng lipoic acid per gram wet weight. Since ectopic expression of MECR-1 in the yeast mutant gave rise to a wild-type level of 141 ng lipoic acid per gram wet weight, this provided additional supporting evidence that MECR-1 was functional within FASII.FASII supplies the Cmecr-1(RNAi) animals were used here to determine the extent of life span increase. Animals were subjected to mecr-1 RNAi from hatching onwards, and scored for viability every two days. The mean life span of control animals was 21.5±1 d while mecr-1(RNAi) animals lived on average 34% longer . A representative viability curve is shown in mecr-1(RNAi) worms appeared generally healthier than control animals of the same age (mecr-1(RNAi) worms were more vigorous than control animals, crawling was measured throughout their lifetimes. Worms were chronically subjected to mecr-1 RNAi and assayed for distance crawled in a given time period at weekly intervals for four weeks (mecr-1(RNAi) worms had similar levels of activity at 7 d. Thereafter, control worms exhibited a steady decrease in crawling distances over the subsequent weeks while mecr-1(RNAi) worms remained more active throughout their life.A previous genome-wide RNAi screen suggested that W09H1.5 depletion results in increased longevity same age , which wur weeks . Controlhsp-6::gfp mitochondrial heat shock protein reporter was used. Under mitochondrial stress conditions, hsp-6 induces green fluorescent protein (GFP) expression hsp-6::gfp were analyzed in intact worms during chronic depletion of MECR-1 compared to control worms (mecr-1(RNAi) and control worms exhibited similar levels of hsp-6::gfp induction. However at 14 and 21 d, GFP expression was almost two-fold higher in mecr-1(RNAi) worms relative to controls, indicating that mitochondrial function was abnormal. Thus, MECR-1 was important for mitochondrial function and contributed to life span reduction in C. elegans.To confirm that depletion of MECR-1 affects mitochondrial function, an ol worms . At 7 d,trans-enoyl-thioester reductase MECR was exposed as early as 2003 Lias are in any way instructive to evaluating the chances for success at rapidly generating a FASII knockout mouse, then this does not bode well as these attempts have so far only led to embryonic lethality C. elegans could emerge as an important interim tool for developing our understanding of mitochondrial FASII in animals.Although all of the mammalian components of mitochondrial FASII have now been identified, there appears to be a (temporary) delay in generating FASII mouse knockouts. For example, human mitochondrial 2-C. elegans W09H1.5 was identified as a 2-trans-enoyl-thioester reductase MECR-1 of mitochondrial FASII. By expressing MECR-1 in a yeast mutant devoid of native Etr1p, the nematode protein restored the mutant's missing functions to wild-type levels. C. elegans worms depleted of MECR-1 not only lived longer but were additionally more active and retained better tissue integrity in later life, revealing that their rate of aging was also decreased. This was commensurate with previous genome-wide RNAi results relating to W09H1.5 mecr-1 resulted in longer-lived and more agile nematodes.Here, the gene product of C. elegans mitochondria, a lack of lipoic acid would primarily affect lipoylated enzymes such as the pyruvate dehydrogenase complex (PDH) and the related enzyme α-ketoglutarate dehydrogenase (α-KGDH) of the tricarboxylic acid (TCA) cycle, but also the glycine cleavage enzyme α-KGDH will cause the TCA cycle to accumulate α-ketoglutarate and isocitrate. This will result in a metabolic shift since acetyl-CoA will now only come from the mitochondrial β-oxidation of those fatty acids originating in the bacterial lawn. This shift has been extensively studied β-oxidation, which will contribute to energy generation through the electron transfer chain, whereas isocitrate will enter the glyoxylate cycle to provide C4 building blocks for carbohydrate synthesis. Interestingly, interference with two other potential TCA cycle enzymes has been reported to extend life span in nematodes: subunits of NAD+-dependent isocitrate dehydrogenase represented by F43G9.1 and F35G12.2, and aconitase F54H12.1 As mentioned in the introduction, yeast mutants with a defective FASII present a number of mitochondrial anomalies, including underdeveloped organellar morphology, lack of assembled cytochrome complexes, an inability to synthesize lipoic acid, and in some cases a further loss of mitochondrial DNA mecr-1 could affect indirectly the excision of mitochondrial tRNAs, which would be deleterious to the translation of mitochondrially encoded polypeptides and their assembly into the mitochondrial respiratory chain, akin to the situation found in yeast.As intimated above, a further way in which nematodes with depleted MECR-1 might be affected is represented by a defective mitochondrial tRNA processing machinery. Removal of tRNA sequences from these precursors involves two activities; i) a 3′-end endonucleolytic activity carried out by tRNase Z C. elegans due to RNAi of mecr-1. However, a search of the literature and worm databases shows that RNAi of open reading frames with the potential to encode additional mitochondrial FASII participants, including candidates for mitochondrial acyl carrier protein (ACP), 3-oxoacyl-ACP reductase and 3-hydroxyacyl-ACP dehydratase, all result in life span extension C. elegans is likely to be a useful model.Clearly, it is not yet possible to explain the reason behind the increased longevity observed in S. cerevisiae strains, plasmids, and oligonucleotides used are listed in E. coli strains DH10B and TOP 10 F' were used for plasmid amplifications and isolations. The wild-type yeast strain BJ1991 etr1Δ derivative URA3-marked plasmids were introduced into BJ1991etr1Δ cells using a published protocol EcoRV-digested pBluescript II plasmid vector  are described XbaI and XhoI restriction enzymes, and tethered to the CTA1 promoter in a similarly digested pYE352:CTA1 CTA1 open reading frame encoding yeast peroxisomal catalase A was removed. Nucleotides for a yeast MLS were not added. DNA sequencing of the insert encoding W09H1.5 verified that no mutations were introduced during the amplification process. Plasmid YEp352:ETR1 has been described previously C. elegans wild type N2 and SJ4100 [zcIs13 hsp-6::gfp] mecr-1(RNAi) worms are as follows: chi-square  = 0.9, df  = 1, p = 0.338, indicating that the survival time was statistically different. The number of worms varied from test to test, and n refers to the number of replicates performed. Each longevity test contained 25–50 worms. Values are given as percentage alive due to the problem of worms escaping in the course of these experiments. In separate experiments, worm mobility, morphology, and mitochondrial dysfunction were measured on days 7, 14, 21, and 28 for five worms per analysis (new worms were used for each day). By day 28, the number of viable control worms was too small to obtain accurate measurements. Mobility was analyzed by transferring five worms to the bacterial lawn of individual NGM/OP50 plates, incubating the plates at room temperature for five min, removing the worms, and imaging the worm tracks using a Zeiss MZ Apo stereo microscope equipped with a SPOT camera. The magnification was kept constant throughout the experiment. Track length was calculated (in pixels) by tracing the axis of the tracks in Metamorph . For morphological and mitochondrial function analysis, images were performed at 10× magnification on a Zeiss Axioplan 2 microscope equipped with a CoolSnapfx cooled CCD and controlled by Metamorph. Morphology was analyzed in anesthetized (1% tricaine +0.1% tetramisole in 1X M9) worms. Worm length and width were measured in Metamorph. Mitochondrial stress was estimated from fluorescence intensity of worms expressing GFP under control of the mitochondrial heat shock factor hsp-6 gene promoter. Anesthetized worms were imaged using an acquisition time of 200 msec, and the average GFP intensity of a 20-pixel diameter circle in the worm posterior was determined in Metamorph. Brood size was calculated by counting total eggs laid and hatched larvae from 10 individual worms throughout the egg-laying period. All values are given as mean ± s.e.m.Times are relative to when eggs were laid, day 0. To calculate life span, worms were assessed every two days for movement . If any movement was detectable, worms were considered alive. The log-rank test statistics for control versus E. coliURA3 gene trans-enoyl-CoA reductase activity is described Standard yeast http://www.bio-rad.com/LifeScience/pdf/Bulletin_9004.pdf) according to the method of Bradford trans-hexenoyl-CoA that was synthesized by way of the mixed anhydride system npsa-pbil.ibcp.fr/cgi-bin/npsa_automat.pl?page=/NPSA/npsa_multalin.html) and Genedoc (www.nrbsc.org/gfx/genedoc/index.html).Prior to the reductase activity assays, cells were ruptured using glass beads in an equal volume of breakage buffer made up of 50 mM KPi (pH 7.0), 200 mM KCl and 0.1% (wt/vol) Triton X-100. Protein concentrations were measured using the Bio-Rad protein assay (


An education self-management program for people with osteoarthritis (OA) of the knee was designed to be delivered by health professionals, incorporating their knowledge and expertise. Improvement in quality of life, health status and pain in response to this program has previously been demonstrated in an uncontrolled pilot study. To more rigorously test the effectiveness of the program we will undertake a randomised controlled trial of people with OA of the knee offering specific self-administered exercises and education, in accordance with the principles of self-management.Aim: To determine whether an education self management program for subjects with Osteoarthritis (OA) of the knee (OAK program) implemented by health professionals in a primary health care setting can achieve and maintain clinically meaningful improvements compared standard medical management in a control group.The effects of standard medical management will be compared with the effects of the OAK program in a single-blind randomized study.Participants: 146 male and female participants with established OA knee will be recruited. Volunteers with coexistent inflammatory joint disease or serious co-morbidities will be excluded.Interventions: Participants will be randomized into either intervention or control groups (delayed start). The intervention group will complete the OA knee program and both groups will be followed for 6 months.Measurements: Assessments will be at baseline, 8 weeks and 6 months. SF-36, WOMAC and VAS pain questionnaires will be completed. Isometric quadriceps and hamstring strength will be measured using a dynamometer; knee range of movement using a goniometer; and physical function will be determined by a modified timed up and go test. Data will be analysed using repeated measures ANOVA.While there is evidence to support the effectiveness of SM programs for people with hypertension, diabetes and asthma, the evidence available for treatment of arthritis remains equivocal. The aim of this study is to determine the effectiveness of a disease specific self-management program for people with OA knee.The study design includes all the important features of a clinical experimental study to minimize bias so the results of the study will provide a high level of evidence. People with OA of the knee have identified pain and problems with daily activities as the most important problems associated with their condition. The outcome measures selected specifically address these issues and have demonstrated validity and are responsive within the range of change expected in response to the intervention. Hence the results of the study will reflect their priorities.The results of the study will provide evidence to guide clinicians and funding bodies seeking to establish priorities regarding the provision of this disease specific program.ACTR number: 12607000080426 Self-management is a primary care intervention that has become a popular component of management in a number of chronic conditions including arthritis. Unlike traditional patient education programs, self-management programs aim to achieve more than the provision of information to increase knowledge. They also aim to change health behavior and health status, teaching patients to identify and solve problems, set goals and plan actions .Numerous self-management programs have been developed for different health conditions. Various models have been employed including individual and group-based programs that may be disease specific or generic . Face-toThere is a considerable body of research evaluating self-management programs. Reviews and meta-analyses ,4 have sOne systematic review of self-management interventions for a number of chronic diseases, found a trend towards a small benefit from arthritis programs, but the results were not significant and there was a suggestion of publication bias . Many ofThe ASMP has been tested widely with the majority of studies conducted in the USA or UK. Many, but not all of these studies have found the program to be effective. Overall, Warsi et al 2004), in their systematic review of self-management interventions for various chronic diseases, found a trend towards a small benefit from arthritis programs, the majority being ASMP or ASMP derivatives, but the results were not significant and here too it was suggested that there was publication bias [004, in tWe hypothesised that a program designed for a specific diagnostic group may be more effective. We considered a program of this nature would be justified for more prevalent conditions such as osteoarthritis of the knee.Accordingly, we developed a self-management program for people with osteoarthritis of the knee. The program was designed to be delivered by health professionals. Strategies for pain management; the benefits of different types of exercise ; and approaches for falls prevention were included. In keeping with a social cognitive theory approach, individual problem identification, goal setting and action planning were encouraged to facilitate improvements in self-efficacy. This program was tested in an uncontrolled quality assurance study. The results indicated improvement in pain, quality of life and physical function . The purTo compare the effectiveness of an osteoarthritis of the knee self-management education program delivered by health professionals with a control group, as determined by improvements in pain, quality of life and physical function.A two group randomized, controlled repeated measures study design will compare the osteoarthritis of the knee program (OAK) with a similar group of control participants. Independently of the study all participants will be able to receive standard medical management of OA knee. In addition, the intervention group will participate in a disease specific knee osteoarthritis self-management program (OAK). Blinding of participants will not be possible due to the nature of the intervention; however, assessors will be blinded to group allocation. The OAK program will be conducted in a community setting at Arthritis Western Australia.People with osteoarthritis of the knee who complete the OAK Program will report improved quality of life, improved knee function and decreased pain compared with those managed conventionally.This study has been approved by the Human Research Ethics Committee at Curtin University of Technology . All participants will provide written informed consent prior to randomisation. Data access and storage will be in keeping with National Health and Medical Research Council guidelines, as approved. License agreements have been obtained for SF-36 Questionnaire and WOMAC Questionnaire. This trial is registered with the Australian and New Zealand Clinical Trial Registry, number: 12607000080426.146 participants with established OA of one or both knees will be recruited into the study. As the OAK program is generally provided as a clinical service, subjects will be recruited from among people presenting to enroll in the OAK program. The operational definition for OA knee is diagnosis by a medical practitioner based on either clinical examination or radiological evidence. Disease severity is not a selection criterion. Exclusion criteria will be rheumatoid arthritis or other inflammatory joint disease; knee surgery planned within 6 months of commencing the study; physical impairments that preclude full participation; inability to communicate in English within a group setting or aged ≤ 18 years (Table Volunteers for the study will be randomized to an intervention group (immediate start) or a control group (delayed start). As there is evidence that SM is an effective addition to usual care ,10, all Volunteers will be randomized in blocks to ensure manageable numbers for intervention groups. Pre-prepared cards indicating group assignment will be placed in sealed opaque envelopes and drawn as a lottery by a third party for allocation to treatment groups. In order to ensure optimum group sizes, allocation will not take place until a whole block has been recruitedThe OAK program will be conducted over a 6-week period enabling participants to incorporate and consolidate information learned from week to week. In addition to the weekly sessions, participants will be given printed information relevant to the course component discussed each week. Program leaders will be health professionals including nurses, physiotherapists, and occupational therapists that have the knowledge and skills to present information on disease specific topics and accurately respond to complex questions. It is necessary that health professionals who deliver this program meet minimum musculoskeletal knowledge requirements. The fidelity of the OAK program will be maintained by the use of a facilitator's manual with modules for program delivery each week.To facilitate optimum group dynamics, the target group size will be 12 participants, although this may vary from 8 to 16 depending on recruitment and randomisation. The program approach is holistic and will not exclusively focus on one aspect of care. Self-management constructs will be employed to promote behavioral changes that will be aimed at optimizing participants' health status. Goal setting and the development of strategies to achieve these goals long term  will be Topics that will be covered in the weekly sessions include:• Pain management strategies • Joint protection• Fitness/exercise• Correct use of analgesia/medications• Balance/falls prevention/proprioception• Cognitive techniques• Pathophysiology• Nutrition/weight control• Self-management skills• Team approach to health careSpecific, Measurable, Achievable, Realistic, Time-framed)• SMART goals  and on the week following the sixth and final session (week 8). The physiotherapists performing assessments will have no contact with the participants other than during the assessment sessions and will not participate in facilitation of the program. Participants will be assessed by the same physiotherapist whenever possible to ensure consistency.Members of the control group will also attend assessments at baseline, and week 8. All volunteers will be assessed again 6 months after randomisation. In keeping with intention to treat principles, all participants will be encouraged to attend for follow-up measurements regardless of level of attendance at the self-management intervention. Self reported questionnaires  would be mailed out to participants that are unable to attend assessment visits. Program and assessment attendance  will also be collected and collated.Demographic information will include age, sex, co-morbidities and socioeconomic information. Socio-economic scales will be compiled using "The Index of Relative Socio-Economic Disadvantage" scales . This inThe dependent variables for the study are listed below.• Health status; measured using the WOMAC Osteoarthritis Index for OA of the knee (WOMAC LK3.0). Also self-administered, the WOMAC assesses pain, stiffness and physical function  and can • Quality of life; measured using the Short Form 36v1 (SF-36) questionnaire. This 36 item questionnaire is self administered, and can be completed in about 15 minutes . Scores • Active range of motion of the knee joints; measured using a long armed Goniometer . The rel• Strength of the hamstrings and quadriceps muscles will be measured using a Mecmesin Force Gauge Dynamometer. The dynamometer will be fixed via an adjustable arm to a portable steel frame and stool. Subjects will sit on the stool with hips and knees flexed to 90 degrees. Isometric strength in flexion and extension will be measured in this position. Each knee will be measured 3 times. The first measurement will be a practice and will be excluded from analysis. The two subsequent measures will be averaged for analysis.• Pain will be assessed at weekly intervals from baseline to the 8-week follow-up assessment.  will be assessed using a modification of the "Timed Up and Go" test (TUG). TUG is widely used to assess basic functional mobility in the elderly -23. The A priori power calculations for this study will be based on the quality of life outcome as measured by the SF-36. Sample size was calculated according to guidelines in the SF-36 Users Manual to determine differences in changes over time between the intervention and control groups using a repeated measures design allowing an inter temporal correlation between scores of 0.60 . The pilData will be analyzed in a blinded manner. Treatment groups will be examined for comparability at baseline. Main comparisons between treatment groups will be performed using an intention to treat analysis. To test the effects of treatment, between group differences in changes over time will be examined using repeated measures ANOVA. Separate analysis will be conducted for each outcome variable. Statistical significance will be inferred at a 2-tailed p < 0.05. Results will not be adjusted for multiple comparisons as all outcomes of interest have been nominated a priori and such adjustment would likely render all findings of interest, despite their clinical importance, non-significant.Self-management aims to motivate people to undertake the changes in behavior necessary to improve their lives. The preference of patients to actively manage their condition themselves is well matched to the aim of the multidisciplinary SM program to empower people to manage their condition . People This disease specific self-management program differs from other more generic arthritis programs. Using the skills and expertise of health professionals in a program providing disease specific education and self-management will provide a platform for behavior change that is not feasible with the limited knowledge base of lay leaders. The outcome measures are designed to reflect positive changes in pain, knee function and quality of life (intervention group), compared with those participants that are managed with conventional treatment (control group).The study design compares the OAK program with the usual management of people with OA in the community. Randomisation to treatment or no treatment groups prevents conscious or unconscious bias . AlthougThere is insufficient evidence to unequivocally claim that self-management is an effective treatment for osteoarthritis of the knee. The results of the study will provide evidence to guide clinicians and funding bodies to establish priorities regarding the provision of this disease specific program.The authors declare that they have no competing interests.SC and KB were responsible for writing the study protocol and drafting the manuscript. GC, CI, NC and JM assisted with study design and provided comments on the drafts and all authors approved the final version of the manuscript.The pre-publication history for this paper can be accessed here: