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Falls among older adults result in substantial morbidity and mortality. Community-based programs have been shown to decrease the rate of falls. In 2007, the Centers for Disease Control and Prevention funded a research study to determine how to successfully disseminate the evidence-based fall prevention program (Stepping On) in the community setting. As the first step for this study, a panel of subject matter experts were convened to suggest which parts of the Stepping On fall prevention program were considered key elements, which could not be modified by implementers. Methods: Older adult fall prevention experts from the United States, Canada, and Australia participated in a modified Delphi technique process to suggest key program elements of Stepping On. Forty-four experts were invited to ensure that the panel of experts would consist of equal numbers of physical therapists, occupational therapists, geriatricians, exercise scientists, and public health researchers. Consensus was determined by percent of agreement among panelists. A Rasch analysis of item fit was conducted to explore the degree of diversity and/or homogeneity of responses across our panelists. Results: The Rasch analysis of the 19 panelists using fit statistics shows there was a reasonable and sufficient range of diverse perspectives (Infit MnSQ 1.01, Z score -0.1, Outfit MnSQ 0.96, Z score –0.2 with a separation of 4.89). Consensus was achieved that these elements were key: 17 of 18 adult learning elements, 11 of 22 programming, 12 of 15 exercise, seven of eight upgrading exercises, two of four peer co-leader’s role, and all of the home visits, booster sessions, group leader’s role, and background and training of group leader elements. The top five key elements were: 1) use plain language, 2) develop trust, 3) engage people in what is meaningful and contextual for them, 4) train participants for cues in self-monitoring quality of exercises, and 5) group leader learns about exercises and understands how to progress them. Discussion: The Delphi consensus process suggested key elements related to Stepping On program delivery. These elements were considered essential to program effectiveness. Findings from this study laid the foundation for translation of Stepping On for broad U.S. dissemination.

Objective: Falls are a leading cause of injury death. Stepping On is a fall prevention program developed in Australia and shown to reduce falls by up to 31%. The original program was implemented in a community setting, by an occupational therapist, and included a home visit. The purpose of this study was to examine aspects of the translation and implementation of Stepping On in three community settings in Wisconsin. Methods: The investigative team identified four research questions to understand the spread and use of the program, as well as to determine whether critical components of the program could be modified to maximize use in community practice. The team evaluated program uptake, participant reach, program feasibility, program acceptability, and program fidelity by varying the implementation setting and components of Stepping On. Implementation setting included type of host organization, rural versus urban location, health versus non-health background of leaders, and whether a phone call could replace the home visit. A mixed methodology of surveys and interviews completed by site managers, leaders, guest experts, participants, and content expert observations for program fidelity during classes was used. Results: The study identified implementation challenges that varied by setting, including securing a physical therapist for the class and needing more time to recruit participants. There were no implementation differences between rural and urban locations. Potential differences emerged in program fidelity between health and non-health professional leaders, although fidelity was high overall with both. Home visits identified more home hazards than did phone calls and were perceived as of greater benefit to participants, but at one year no differences were apparent in uptake of strategies discussed in home versus phone visits. Conclusion: Adaptations to the program to increase implementation include using a leader who is a non-health professional, and omitting the home visit. Our research demonstrated that a non-health professional leader can conduct Stepping On with adequate fidelity, however non-health professional leaders may benefit from increased training in certain aspects of Stepping On. A phone call may be substituted for the home visit, although short terms benefits are greater with the home visit.

OBJECTIVES: To decrease the rate of falls in high-risk community-dwelling older adults. DESIGN: Randomized, controlled trial. SETTING: Community-based. PARTICIPANTS: Three hundred forty-nine adults aged 65 and older with two falls in the previous year or one fall in the previous 2 years with injury or balance problems. INTERVENTION: Subjects received two in-home visits from a trained nurse or physical therapist who assessed falls risk factors using an algorithm. The intervention consisted of recommendations to the subject and their primary physician, referrals to physical therapy and other providers, 11 monthly telephone calls, and a balance exercise plan. Control subjects received a home safety assessment. MEASUREMENTS: The primary outcome was rate of falls per year in the community. Secondary outcomes included all-cause hospitalizations and nursing home admissions per year. RESULTS: There was no difference in rate of falls between the intervention and control groups (rate ratio (RR)=0.81, P=.27). Nursing home days were fewer in the intervention group (10.3 vs 20.5 days, P=.04). Intervention subjects with a Mini-Mental State Examination (MMSE) score of 27 or less had a lower rate of falls (RR=0.55; P=.05) and, if they lived with someone, had fewer hospitalizations (RR=0.44, P=.05), nursing home admissions (RR=0.15, P=.003), and nursing home days (7.5 vs 58.2, P=.008). CONCLUSION: This multifactorial intervention did not decrease falls in at-risk community-living adults but did decrease nursing home utilization. There was evidence of efficacy in the subgroup who had an MMSE score of 27 or less and lived with a caregiver, but validation is required. Language: en

Badke MB, Shea TA, Miedaner JA, Grove CR. Outcomes after rehabilitation for adults with balance dysfunction. Arch Phys Med Rehabil 2004;85:227–33. Objectives To assess balance, dynamic gait, and dynamic visual acuity outcomes after a vestibular and balance rehabilitation program and to determine which variables were significantly associated with improved balance and ambulation. Design Retrospective case series. Setting Outpatient setting at a tertiary care facility. Participants Twenty patients who were seen for vestibular and balance therapy between July 1999 and June 2000. Interventions A customized exercise program was developed for each patient according to the results of the assessment and included the following interventions, as indicated: gaze stabilization, balance and gait training, and habituation exercises. Main outcome measures The Dynamic Gait Index (DGI), Berg Balance Scale (BBS), Dynamic Visual Acuity Test (DVAT), and computerized posturography (Sensory Organization Test [SOT]). Results The mean change scores for the DGI showed significant improvement for both patients with peripheral vestibular dysfunction and patients with central balance disorders. For the central balance disorders group, the BBS score also showed significant improvement. No difference was noted for pretherapy and posttherapy SOT scores between groups. The total group appeared to show an average improvement of more than 2 lines on the visual acuity chart on the clinical DVAT. Patients who were 66 years or older were 1.5 times more likely to score less than 20 on the DGI, and those whose pretherapy vertical dynamic visual acuity was 20/80 or worse were 1.3 times more likely to score less than 20 on the DGI. Conclusions Patients showed functional improvements in balance, visual acuity, and gait stability after balance and vestibular physical therapy. Age and pretherapy vertical dynamic visual acuity score influenced dynamic gait outcome after a balance rehabilitation program.

Objective To assess dizziness handicap and postural recovery in 17 patients undergoing a vestibular ablative procedure. Study design Outcomes were compared between nine patients who underwent selective vestibular neurectomy and eight patients who underwent a transmastoid labyrinthectomy. Setting Patients underwent ablative procedures at a tertiary care facility. Methods Patients were tested with posturography (sensory organization test [SOT]) and the Dizziness Handicap Inventory (DHI) before and 4 to 5 weeks after their procedure. Results The mean change scores for each of the DHI subscales and the total DHI score showed significant improvement for the labyrinthectomy group. For the neurectomy group, only the emotional DHI subscale change score showed significant improvement. No difference was noted between preprocedure and postprocedure SOT scores for either group. The results indicated that the largest proportion of significant correlations existed between DHI and the somatosensory and vestibular subtests of platform posturography. In regression analyses, a model with age (p = 0.04) and vestibular score (p = 0.001) fitted the data well and explained 52.9% of the variance. Persons who were less than 69 years old were three times more likely to report persistent episodes of dizziness after the ablative procedure, and those who had neurectomies were 2.3 times more likely to report episodes of dizziness than those who underwent transmastoid labyrinthectomy. Conclusion Dizziness handicap after an ablative procedure is influenced by the type of procedure (labyrinthectomy versus neurectomy), age, and preoperative vestibular score on the SOT. Preoperative vestibular SOT score is highly associated with the emotional, physical, and functional domains of perceived handicap and quality of life after the surgery.

The enterococci are low-GC Gram-positive bacteria that have emerged as leading causes of hospital-acquired infection. They are also commensals of the gastrointestinal tract of healthy humans and most other animals with gastrointestinal flora and are important for food fermentations. Here we report the availability of draft genome sequences for 28 enterococcal strains of diverse origin, including the species Enterococcus faecalis , E. faecium , E. casseliflavus , and E. gallinarum .

This retrospective study was undertaken to assess balance recovery and dizziness handicap in 32 patients after a vestibular and balance rehabilitation program. Outcomes were compared between 12 patients with peripheral vestibular disorders and 20 patients with central or mixed balance disorders. The patients were tested with posturography (sensory organization test [SOT]) and the Dizziness Handicap Inventory (DHI) before and after their therapy program. The vestibular SOT, composite SOT, and functional DHI scores obtained before and after exercise were significantly improved in both the peripheral and central groups. The visual SOT mean scores obtained before and after therapy were significantly different only for the group with central or mixed vestibular disorders. Changes in SOT scores were not directly correlated with changes in DHI scores. Outcome measures of vestibular rehabilitation protocols confirmed objective and subjective improvement of balance and dizziness handicap in patients with peripheral and central vestibular disorders.

Herpes simplex virus 2 is an important human pathogen as the causative agent of genital herpes, neonatal herpes, and increased risk of HIV acquisition and transmission. Nevertheless, the only genomic sequence that has been completed is the attenuated HSV-2 HG52 laboratory strain. In this study we defined the genomic sequence of the HSV-2 SD90e low passage clinical isolate and a plaque-purified derivative, SD90-3P. We found minimal sequence differences between SD90e and SD90-3P. However, in comparisons with the HSV-2 HG52 reference genome sequence, the SD90e genome ORFs contained numerous point mutations, 13 insertions/deletions (indels), and 9 short compensatory frameshifts. The indels were true sequence differences, but the compensatory frameshifts were likely sequence errors in the original HG52 sequence. Because HG52 virus is less virulent than other HSV-2 strains and may not be representative of wildtype HSV-2 strains, we propose that the HSV-2 SD90e genome serve as the new HSV-2 reference genome.