Improving performance in a contracted physician network

Health care organizations face significant performance challenges. Achieving desired results requires the highest level of partnership with independent physicians. Tufts Health Plan invited medical directors of its affiliated groups to participate in a leadership development process to improve clinical, service, and business performance. The design included performance review, gap analysis, priority setting, improvement work plans, and defining the optimum practice culture. Medical directors practiced core leadership capabilities, including building a shared context, getting physician buy-in, and managing outliers. The peer learning environment has been sustained in redesigned medical directors' meetings. There has been significant performance improvement in several practices and enhanced relations between the health plan and medical directors.

Outer membrane lipoprotein e (P4) of Haemophilus influenzae is a novel phosphomonoesterase

Haemophilus influenzae exists as a commensal of the upper respiratory tract of humans but also causes infections of contiguous structures. We describe the identification, localization, purification, and characterization of a novel, surface-localized phosphomonoesterase from a nontypeable H. influenzae strain, R2866. Sequences obtained from two CNBr-derived fragments of this protein matched lipoprotein e (P4) within the H. influenzae sequence database. Escherichia coli DH5alpha transformed with plasmids containing the H. influenzae hel gene, which encodes lipoprotein e (P4), produced high levels of a membrane-associated phosphomonoesterase. The isolated approximately 28-kDa enzyme was tartrate resistant and displayed narrow substrate specificity with the highest activity for arylphosphates, excluding 5-bromo-4-chloro-3-indolylphosphate. Optimum enzymatic activity was observed at pH 5.0 and only in the presence of divalent copper. The enzyme was inhibited by vanadate, molybdate, and EDTA but was resistant to inorganic phosphate. The association of phosphomonoesterase activity with a protein that has also been recognized as a heme transporter suggests a unique role for this unusual phosphohydrolase.

Comparison of the pathogenicity in rats of rat coronaviruses of different neutralization groups

BACKGROUND AND PURPOSE

Rat coronaviruses (RCVs) are common natural pathogens of rats that cause clinical illness, necrosis, and inflammation of respiratory, salivary, and lacrimal organs. The aim of the study was to determine whether antigenically different strains of RCV vary in their pathogenic potential in rats.

METHODS

Neutralization groups were identified by use of RCV strain-specific antisera. Sprague Dawley rats were inoculated oronasally with RCV-SDA, RCV-BCMM, or RCV-W. Histologic examination, immunohistochemical analysis, and reverse transcriptase-polymerase chain reaction analysis were performed on tissues from infected rats.

RESULTS

Clinical illness was not evident in any of the inoculated rats. The RCV-SDA strain caused mild lesions in the exorbital gland of one rat. The RCV-BCMM strain caused severe lesions in the Harderian and parotid glands and mild lesions in the exorbital glands, lungs, and nasal mucosa. The RCV-W strain caused severe lesions in the Harderian, exorbital, and parotid glands and mild lesions in the submandibular glands, lungs, and nasal mucosa. The RNA concentration was highest in the Harderian, parotid, and exorbital glands of RCV-BCMM- and RCV-W-infected rats at postinoculation day 7.

CONCLUSIONS

Although RCV-SDA, RCV-BCMM, and RCV-W caused different degrees and patterns of lesions, neutralization groups are not useful for predicting the pathogenic potential of a new RCV isolate.

Granulomatous peritonitis and pleuritis in interferon-gamma gene knockout mice naturally infected with mouse hepatitis virus

OBJECTIVE

To investigate a disease outbreak in a colony of laboratory mice with targeted disruption of the gene for interferon-gamma. FORMAT: A case report based on necropsy, histopathology, serology and immunohistochemistry.

RESULTS

Affected mice exhibited depression and variable ascites. Necropsy revealed a granulomatous peritonitis and pleuritis with extensive adhesions although parenchymal lesions were minimal. Serum samples had high concentrations of antibody to mouse hepatitis virus and immunohistochemical examination revealed the presence of mouse hepatitis virus antigen in granuloma macrophages. Sero-logical testing for other infectious agents and bacterial culture were negative and wild type mice kept in the same facility remained healthy. Despite the association between the disease and mouse hepatitis virus infection, the precise role played by mouse hepatitis virus was not determined. While the disease is superficially similar to feline infectious peritonitis (another coronavirus-induced serositis), differences exist between the histopathological findings in these two conditions.

CONCLUSION

This unusual disease process illustrates how new diagnostic challenges can arise in novel mouse genotypes created through molecular genetics. Furthermore, the association between the disease and mouse hepatitis virus illustrates the importance of maintaining laboratory animals under specific-pathogen free conditions.

Humoral immunity and protection of mice challenged with homotypic or heterotypic parvovirus

BACKGROUND AND OBJECTIVES

Two serotypes of autonomously replicating parvoviruses infect laboratory mice. Genome regions coding for the nonstructural proteins of minute virus of mice [MVM] and mouse parvovirus [MPV] are almost identical, whereas capsid-coding sequences are divergent. We addressed these questions: Does humoral immunity confer protection from acute infection after challenge with homotypic or heterotypic parvovirus, and if it confers protection against acute MPV infection, does it also protect against persistent MPV infection?

METHODS

Infant mice without maternal antibody or antibody to MVM or MPV and young adult mice given normal mouse serum or antibody to MVM or MPV were challenged with homotypic or heterotypic virus. In situ hybridization with target tissues was the indicator of infection.

RESULTS

Humoral immunity failed to confer protection against acute heterotypic parvovirus infection. In passive transfer studies, MPV DNA was observed occasionally in lymph nodes, intestine, or the spleen of MPV-challenged mice given homotypic antibody and kept for 6 or 28 days. Variable proportions of mice given MPV antibody and homotypic challenge had viral DNA in lymphoid tissues 56 days after virus inoculation.

CONCLUSION

A mouse or colony that has sustained infection with MVM or MPV is probably fully susceptible to infection with the heterotypic virus.

Toxin production by Clostridium botulinum in pasteurized milk treated with carbon dioxide

The addition of carbon dioxide to milk at levels of <20 mM inhibits the growth of selected spoilage organisms and extends refrigerated shelf life. Our objective was to determine if the addition of CO2 influenced the risk of botulism from milk. Carbon dioxide was added to pasteurized 2% fat milk at approximately 0, 9.1, or 18.2 mM using a commercial gas-injection system. The milk was inoculated with a 10-strain mixture of proteolytic and nonproteolytic Clostridium botulinum spore strains to yield 10(1) to 10(2) spores/ml. Milk was stored at 6.1 or 21 degrees C for 60 or 6 days, respectively, in sealed glass jars or high-density polyethylene plastic bottles. Milk stored at 21 degrees C curdled and exhibited a yogurt-like odor at 2 days and was putrid at 4 days. Botulinal toxin was detected in 9.1 mM CO2 milk at 4 days and in all treatments after 6 days of storage at 21 degrees C. All toxic samples were grossly spoiled based on sensory evaluation at the time toxin was detected. Although botulinal toxin appeared earlier in milk treated with 9.1 mM CO2 compared to both the 18.2 mM and untreated milk, gross spoilage would act as a deterrent to consumption of toxic milk. No botulinal toxin was detected in any treatment stored at 6.1 degrees C for 60 days. At 6.1 degrees C, the standard plate counts (SPCs) were generally lower in the CO2-treated samples than in controls, with 18.2 mM CO2 milk having the lowest SPC. These data indicate that the low-level addition of CO2 retards spoilage of pasteurized milk at refrigeration temperatures and does not increase the risk of botulism from treated milk stored at refrigeration or abuse temperatures.

Hepatitis G: viroprevalence and seroconversion in a high-risk group of children

Hepatitis G virus (HGV), a recently discovered flavivirus, is parenterally transmitted and significantly associated with hepatitis C viraemia. Data on the viroprevalence of this agent in children is scant and its seroprevalence is unknown. The aim of this study was to determine the viroprevalence and seroprevalence of HGV in paediatric patients at risk of parenterally transmitted virus infection. Sera from 35 patients, previously tested for hepatitis C virus (HCV) infection, were analysed for the presence of HGV RNA by reverse transcription-polymerase chain reaction (RT-PCR) and for antibody to the E2 envelope protein (anti-E2) of HGV using the HGV-env kit. The mean age of the patients was 9.4 years (range 1-17 years), and risk factors included multiple transfusions and maternal HCV infection. Co-infection with HCV and HGV was a relatively common occurrence (31%). The prevalence of anti-E2, a marker of recovery from infection, was low (5%) when compared with overall viroprevalence (20%). This study highlights the significant association of HGV with HCV in children. The novel finding of a low ratio of anti-E2:HGV RNA contrasts with the pattern seen in adults and may reflect a higher risk of long-term carriage with acquisition of HGV infection at an early age.

Effect of chronic intermittent administration of inhaled tobramycin on respiratory microbial flora in patients with cystic fibrosis

Pseudomonas aeruginosa endobronchial infection causes significant morbidity and mortality among cystic fibrosis patients. Microbiology results from two multicenter, double-blind, placebo-controlled trials of inhaled tobramycin in cystic fibrosis were monitored for longitudinal changes in sputum microbial flora, antibiotic susceptibility, and selection of P. aeruginosa isolates with decreased tobramycin susceptibility. Clinical response was examined to determine whether current susceptibility standards are applicable to aerosolized administration. Treatment with inhaled tobramycin did not increase isolation of Burkholderia cepacia, Stenotrophomonas maltophilia, or Alcaligenes xylosoxidans; however, isolation of Candida albicans and Aspergillus species did increase. Although P. aeruginosa tobramycin susceptibility decreased in the tobramycin group compared with that in the placebo group, there was no evidence of selection for the most resistant isolates to become most prevalent. The definition of resistance for parenteral administration does not apply to inhaled tobramycin: too few patients had P. aeruginosa with a tobramycin MIC >/=16 microgram/mL to define a new break point on the basis of clinical response.

Comparison of a beta-lactam alone versus beta-lactam and an aminoglycoside for pulmonary exacerbation in cystic fibrosis

We determined whether a beta-lactam and an aminoglycoside have efficacy greater than a beta-lactam alone in the management of a pulmonary exacerbation in patients with cystic fibrosis.

STUDY DESIGN

Azlocillin and placebo or azlocillin and tobramycin were administered to 76 patients with a pulmonary exacerbation caused by Pseudomonas aeruginosa in a randomized double-blind, third-party monitored protocol. Improvement was assessed by standardized clinical evaluation, pulmonary function testing, sputum bacterial density, sputum DNA content, and time to the next pulmonary exacerbation requiring hospitalization.

RESULTS

No significant difference was seen between the 2 treatment groups in clinical evaluation, sputum DNA concentration, forced vital capacity, forced expiratory volume in second 1, or peak expiratory flow rate at the end of treatment (33 receiving azlocillin alone and 43 both antibiotics); adverse reactions were equivalent in each group. Sputum P. aeruginosa density decreased more with combination therapy (P =.034). On follow-up evaluation, an average of 26 days after the end of treatment, all outcome indicators had worsened in both groups. Time to readmission for a new pulmonary exacerbation was significantly longer in the group receiving azlocillin plus tobramycin (P <.001). Treatment-emergent tobramycin resistance occurred in both groups and was more frequent with combination therapy.

CONCLUSION

We conclude that the combination of a beta-lactam and an aminoglycoside produces a longer clinical remission than a beta-lactam alone and slightly better initial improvement.

Murine viruses in an island population of introduced house mice and endemic short-tailed mice in Western Australia

House mice (Mus domesticus) were recently introduced to Thevenard Island, off the northwest coast of Western Australia. This island is also habitat for an endangered native rodent, the short-tailed mouse (Leggadina lakedownensis). Concerns have been raised that house mice may pose a threat to L. lakedownensis both through competition and as a source of infection. To assess the threat to L. lakedownensis posed by viral pathogens from M. domesticus, a serological survey was conducted from 1994 to 1996 of both species for evidence of infection with 14 common murine viruses (mouse hepatitis virus, murine cytomegalovirus, lymphocytic choriomeningitis virus, ectromelia virus, mouse adenovirus strains FL and K87, minute virus of mice, mouse parvovirus, reovirus type 3, Sendai virus, Theiler's mouse encephalomyelitis virus, polyoma virus, pneumonia virus of mice, and encephalomyocarditis virus) and Mycoplasma pulmonis. Despite previous evidence that populations of free-living M. domesticus from various locations on the Australian mainland were infected with up to eight viruses, M. domesticus on Thevenard Island were seropositive only to murine cytomegalovirus (MCMV). Antibodies to MCMV were detected in this species at all times of sampling, although seroprevalence varied. Infectious MCMV could be isolated in culture of salivary gland homogenates from seropositive mice. In contrast, L. lakedownensis on Thevenard Island showed no serological evidence of infection with MCMV, any of the other murine viruses, or M. Pulmonis, and no virus could be isolated in culture from salivary gland homogenates. Although MCMV replicated to high titers in experimentally infected inbred BALB/c laboratory mice as expected, it did not replicate in the target organs of experimentally inoculated L. lakedownensis, indicating that the strict host specificity of MCMV may prevent its infection of L. lakedownensis. These results suggest that native mice on Thevenard Island are not at risk of MCMV infection from introduced house mice, and raise interesting questions about the possible selective survival of MCMV in small isolated populations of M. domesticus.

Spatiotemporal patterning of glutamate receptors in developing ferret striate cortex

We have studied glutamate receptor levels during very early phases of cortical formation by using quantitative in vitro autoradiography to map the expression of NMDA, AMPA and kainate receptors in the developing primary visual cortex of the ferret. NMDA and non-NMDA receptors exhibit very different developmental profiles in primary visual cortex. NMDA receptor density is low at birth and increases throughout the first 2 postnatal months, rising between threefold (layers II/III) and ninefold (layer VI). In contrast, AMPA receptors are abundant at birth and their density remains constant for the first postnatal month, before rising by a maximum of 1.7-fold (layer I) at around the time of eye-opening (postnatal day 32). Kainate receptors are also present in high levels at birth and their expression levels rise in the early postnatal period by between 1. 5-fold (layer I) and threefold (layers V/VI) to a peak just after eye-opening. The proportion of the total ionotropic glutamate receptor binding contributed by NMDA receptors thus rises from 5% at birth to a maximum of 22% at 2 months of age, while the AMPA receptor contribution falls from 87% to 72% over the same period. Below cortex, all three glutamate receptor subtypes are expressed in the subplate region for the first 3 postnatal weeks. These developmental patterns, combined with the fact that AMPA receptors are densely expressed in the proliferative zones underlying presumptive area 17, indicate that non-NMDA receptor expression levels in primary visual cortex are mostly specified much earlier than those of NMDA receptors.

An unusual cause of rectal bleeding in a patient with cystic fibrosis

Here we identify a previously unreported cause of rectal bleeding (juvenile polyposis) in a patient with cystic fibrosis (CF). We believe this patient most likely has two coexisting genetic diseases. It also raises many issues about organ transplantation in a patient with medical conditions that individually increase the risk of gastrointestinal malignancy and stresses the diagnostic value of endoscopy in CF patients with rectal bleeding.

Five case studies of soldiers with painful clavicular fracture non-union

We report a short case series of 5 servicemen who had sustained closed clavicular fractures, 4 of whom presented to our clinic with a painful non-union, and 1 required primary fixation for tenting of the skin. Our treatment consisted of open reduction and internal fixation of these non-unions. This resulted in all these men returning to duties with painfree shoulder girdles within 6 months. A complication in these cases was one of a prominent plate which rubbed on straps and required removal of the plate after union had occurred resulting once again in a painfree shoulder girdle and a return to full duties. We advocate early orthopaedic referral in cases of painful clavicular non-union and where appropriate, open reduction and internal fixation with the expectation of an early return to full duties with a pain free shoulder girdle.

Antigen-pulsed CD8alpha+ dendritic cells generate an immune response after subcutaneous injection without homing to the draining lymph node

Two subsets of murine splenic dendritic cells, derived from distinct precursors, can be distinguished by surface expression of CD8alpha homodimers. The functions of the two subsets remain controversial, although it has been suggested that the lymphoid-derived (CD8alpha+) subset induces tolerance, whereas the myeloid-derived (CD8alpha-) subset has been shown to prime naive T cells and to generate memory responses. To study their capacity to prime or tolerize naive CD4(+) T cells in vivo, purified CD8alpha+ or CD8alpha- dendritic cells were injected subcutaneously into normal mice. In contrast to CD8alpha- dendritic cells, the CD8alpha+ fraction failed to traffic to the draining lymph node and did not generate responses to intravenous peptide. However, after in vitro pulsing with peptide, strong in vivo T cell responses to purified CD8alpha+ dendritic cells could be detected. Such responses may have been initiated via transfer of peptide-major histocompatibility complex complexes to migratory host CD8alpha- dendritic cells after injection. These data suggest that correlation of T helper cell type 1 (Th1) and Th2 priming with injection of CD8alpha+ and CD8alpha- dendritic cells, respectively, may not result from direct T cell activation by lymphoid versus myeloid dendritic cells, but rather from indirect modification of the response to immunogenic CD8alpha- dendritic cells by CD8alpha+ dendritic cells.

Spontaneous tibial compartment syndrome in Type 1 diabetes mellitus

We present a case of a patient with Type 1 diabetes mellitus (DM) who spontaneously developed severe bilateral anterior tibial compartment syndromes which required extensive surgical treatment. While infarction of skeletal muscle in Type 1 DM remains rare and usually affects the larger compartments of the thigh, this diagnosis must be entertained in any patient presenting with acute leg pain. If a patient displays any features of acute compartment syndrome, prompt fasciotomy must be undertaken.

Intermittent administration of inhaled tobramycin in patients with cystic fibrosis. Cystic Fibrosis Inhaled Tobramycin Study Group

BACKGROUND AND METHODS

We conducted two multicenter, double-blind, placebo-controlled trials of intermittent administration of inhaled tobramycin in patients with cystic fibrosis and Pseudomonas aeruginosa infection. A total of 520 patients (mean age, 21 years) were randomly assigned to receive either 300 mg of inhaled tobramycin or placebo twice daily for four weeks, followed by four weeks with no study drug. Patients received treatment or placebo in three on-off cycles for a total of 24 weeks. The end points included pulmonary function, the density of P. aeruginosa in sputum, and hospitalization.

RESULTS

The patients treated with inhaled tobramycin had an average increase in forced expiratory volume in one second (FEV1) of 10 percent at week 20 as compared with week 0, whereas the patients receiving placebo had a 2 percent decline in FEV1 (P<0.001). In the tobramycin group, the density of P. aeruginosa decreased by an average of 0.8 log10 colony-forming units (CFU) per gram of expectorated sputum from week 0 to week 20, as compared with an increase of 0.3 log10 CFU per gram in the placebo group (P<0.001). The patients in the tobramycin group were 26 percent (95 percent confidence interval, 2 to 43 percent) less likely to be hospitalized than those in the placebo group. Inhaled tobramycin was not associated with detectable ototoxic or nephrotoxic effects or with accumulation of the drug in serum. The proportion of patients with P. aeruginosa isolates for which the minimal inhibitory concentration of tobramycin was 8 microg per milliliter or higher increased from 25 percent at week 0 to 32 percent at week 24 in the tobramycin group, as compared with a decrease from 20 percent at week 0 to 17 percent at week 24 in the placebo group.

CONCLUSIONS

In a 24-week study of patients with cystic fibrosis, intermittent administration of inhaled tobramycin was well tolerated and improved pulmonary function, decreased the density of P. aeruginosa in sputum, and decreased the risk of hospitalization.

Observational learning and the fearful child: influence of peer models on swimming skill performance and psychological responses

This study examined the role of peer mastery and coping models on children's swimming skills, fear, and self-efficacy. Children (N = 24; M age = 6.2 years), who were identified as fearful of the water, were matched to control, peer-mastery, or peer-coping model conditions. Day 1 included a preintervention assessment. Days 2-4 included exposure to model conditions followed by a 20-min swimming lesson, Day 5 consisted of postintervention assessments, and a follow-up test was conducted 4 days later. Data were analyzed in a series of 3 x 3 (Model Type x Assessment Period) repeated measures analyses of variance on the dependent variables. Results revealed differences between modeling and control groups at postintervention and follow-up, but the small sample size and large within-group variability compromised many statistically significant findings. Calculation of effect sizes indicated moderate-to-large pre- to posintervention differences between control and modeling groups on skill, self-efficacy, and fear of swimming. These findings suggest that a modeling intervention combined with swimming lessons is a more effective behavior change agent for fearful children than swimming lessons alone.

Molecular evidence for distinct genotypes of monkey B virus (herpesvirus simiae) which are related to the macaque host species

Although monkey B virus (herpesvirus simiae; BV) is common in all macaque species, fatal human infections appear to be associated with exposure to rhesus macaques (Macaca mulatta), suggesting that BV isolates from rhesus monkeys may be more lethal to nonmacaques than are BV strains indigenous to other macaque species. To determine if significant differences that would support this supposition exist among BV isolates, we compared multiple BV strains isolated from rhesus, cynomolgus, pigtail, and Japanese macaques. Antigenic analyses indicated that while the isolates were very closely related to one another, there are some antigenic determinants that are specific to BV isolates from different macaque species. Restriction enzyme digest patterns of viral DNA revealed marked similarities between rhesus and Japanese macaque isolates, while pigtail and cynomolgus macaque isolates had distinctive cleavage patterns. To further compare genetic diversity among BV isolates, DNA sequences from two regions of the viral genome containing genes that are conserved (UL27 and US6) and variable (US4 and US5) among primate alphaherpesviruses, as well as from two noncoding intergenic regions, were determined. From these sequence data and a phylogenetic analysis of them it was evident that while all isolates were closely related strains of BV, there were three distinct genotypes. The three BV genotypes were directly related to the macaque species of origin and were composed of (i) isolates from rhesus and Japanese macaques, (ii) cynomolgus monkey isolates, and (iii) isolates from pigtail macaques. This study demonstrates the existence of different BV genotypes which are related to the macaque host species and thus provides a molecular basis for the possible existence of BV isolates which vary in their levels of pathogenicity for nonmacaque species.

Single-field total lymphoid irradiation in the treatment of refractory rejection after heart transplantation

Nine heart transplant recipients were treated with single-field total lymphoid irradiation (TLI) for early (<1 year) or late (>1 year) rejection that was refractory to multiple regimens of immunosuppressive therapy. For patients with early rejection (n = 6), the rejection frequency (rejections/patient/month) decreased from pre-TLI of 1.63 to post-TLI of .02 (p < .001), and for patients with late rejection (n = 3), the rejection frequency decreased from pre-TLI of .23 to post-TLI of .05 (p < .02). The reduced rejection frequencies have been maintained for a mean follow-up of 28.6 (8 to 78) months, and adverse events during or late after TLI were uncommon. Single-field TLI is a safe and effective technique in the management of refractory rejection early or late after heart transplantation.

Child psychosis due to hypothyroidism

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Evolution of the major pilus gene cluster of Haemophilus influenzae

Haemophilus influenzae is a ubiquitous colonizer of the human respiratory tract and causes diseases ranging from otitis media to meningitis. Many H. influenzae isolates express pili (fimbriae), which mediate adherence to epithelial cells and facilitate colonization. The pilus gene (hif) cluster of H. influenzae type b maps between purE and pepN and resembles a pathogenicity island: it is present in invasive strains, absent from the nonpathogenic Rd strain, and flanked by direct repeats of sequence at the insertion site. To investigate the evolution and role in pathogenesis of the hif cluster, we compared the purE-pepN regions of various H. influenzae laboratory strains and clinical isolates. Unlike Rd, most strains had an insert at this site, which usually was the only chromosomal locus of hif DNA. The inserts are diverse in length and organization: among 20 strains, nine different arrangements were found. Several nontypeable isolates lack hif genes but have two conserved open reading frames (hicA and hicB) upstream of purE; their inferred products are small proteins with no data bank homologs. Other isolates have hif genes but lack hic DNA or have combinations of hif and hic genes. By comparing these arrangements, we have reconstructed a hypothetical ancestral genotype, the extended hif cluster. The hif region of INT1, an invasive nontypeable isolate, resembles the hypothetical ancestor. We propose that a progenitor strain acquired the extended cluster by horizontal transfer and that other variants arose as deletions. The structure of the hif cluster may correlate with colonization site or pathogenicity.

The development of topography in the hamster geniculo-cortical projection

Precise point-to-point connectivity is the basis of ordered maps of the visual field. The immaturity of the newborn hamster's visual system has allowed us to examine emerging topography in the geniculo-cortical projection well before thalamic axons have reached their cortical target, layer IV. Using anterograde transneuronal labeling with wheat germ agglutinin conjugated to horseradish peroxidase (WGA-HRP), we visualized the ingrowth of the whole population of geniculate fibers in the neonatal hamster. Two days after birth (P2), the bulk of the fibers is in the deep cortical layers and the subplate. At the same age, injections of paired retrograde tracers (red and green fluorescent latex microspheres) into area 17 reveal an unordered projection from the dorsal lateral geniculate nucleus (dLGN) to cortex. Individual labeled cells are found throughout the dLGN, and quantitative analysis reveals no segregation of the red and the green populations. At P6, when the pattern of geniculate back label appears ordered and essentially adult-like, geniculate fibers have reached layer IV. The role of selective cell death in this process was investigated by making a tracer injection at P2 and allowing the animals to survive to P6 or P12, when the map is mature. The results show early labeled neurons that made inappropriate connections when the projection was scattered surviving through the period of geniculate cell death. We conclude that the geniculo-cortical map develops from an initially unordered projection to the subplate and the lower cortical layers. Selective cell death appears not to contribute significantly to this process.

Genetic analysis of the essential components of the immunoprotective response to infection with Eimeria vermiformis

The immune responses generated after infection with Eimeria spp. are complex, include both cellular and humoral components, and lead to protection against re-infection. To facilitate the rational development of the next generation of anticoccidial vaccines it is important that the nature of the immunoprotective response against infection with Eimeria spp. is determined. In this brief report we discuss results that were obtained using a combination of genetic and cellular approaches to dissect the essential immune effector components that operate against infection with Eimeria vermiformis. Mice rendered deficient of immune function by targeted gene disruption at a variety of immune loci represent an integral component of our studies and include those with targeted gene disruption at loci that encode the B- and T-cell receptors (BCR, TCR), antigen presentation molecules and immune-effector molecules. Our studies demonstrated that TCR-alpha-beta + T cells are essential for immunoprotection during both primary and secondary infection. Moreover, during primary infection the major effector cell type is a population of major histocompatibility complex class II-restricted, interferon-gamma-producing TCR-alpha-beta T cell consistent with a T helper 1 phenotype. In addition, there is a supplementary role for another class of cells (presumably T cells) that are restricted to either non-classical antigen presentation molecules or classical major histocompatibilty complex class I loaded via an atypical pathway. Mice with a deficiency in interleukin-6 were slightly more susceptible to primary infection than intact animals, consistent with the reported effects of interleukin-6 upon the generation of T helper 1-type responses in vivo. In terms of the host response to re-infection, TCR-alpha-beta T cells were essential for immunity, but the requirement for specific cell subsets and effector mechanisms was much less stringent. Mice deficient in gamma-delta T cells, classical major histocompatibility complex class I, non-classical antigen presentation pathways, the cytokines interferon-gamma, interleukin-4, interleukin-6 and the cytolytic effector molecules perforin or FasL were completely immune to secondary infection. Moreover, major histocompatibility complex class II-deficient I-A-beta-/- mice were capable of mounting a substantial response to secondary infection, manifest by a 95% reduction in oocyst output compared with primary infection. These data have important consequences for the development of immune intervention strategies and indicate that vaccine development may be targeted toward the generation of a wider range of effector mechanisms than those that operate during primary infection.

Mouse parvovirus infection potentiates allogeneic skin graft rejection and induces syngeneic graft rejection

BACKGROUND

The recently identified autonomous mouse parvovirus designated mouse parvovirus-1 (MPV-1) persists in adult BALB/c mice for at least 9 weeks, infects lymphoid tissues, interferes with the ability of cloned T cells to proliferate, and exhibits immunomodulatory properties. As a consequence of these findings, the present studies were undertaken to characterize further the inmunomodulatory effects of MPV-1 on T cell-mediated immune responses in vivo and in vitro.

METHODS

To evaluate the effect of MPV-1 infection on CD8+ T cell-mediated responses, BALB/c-H2dm2 mice were infected after transplantation of allogeneic BALB/c skin.

RESULTS

MPV-1 potentiated the rejection of allogeneic skin grafts. This potentiation was not a result of virus infecting the cellular or vascular component of the graft as determined by in situ hybridization, but was mediated by T cells. However, the proliferative capacity of alloantigen-reactive lymphocytes from graft-sensitized infected mice was diminished. MPV-1 also induced the rejection of syngeneic skin grafts, and T cells from these infected graft-sensitized mice lysed syngeneic P815 target cells.

CONCLUSIONS

These results suggest that MPV-1 infection of skin-grafted mice may disrupt normal mechanisms of peripheral tolerance and provide a unique model to study virus-induced autoimmunity.

Treatment of septic shock with immunotherapy

Sepsis is the thirteenth leading cause of death in the United States. Despite increased knowledge about its pathophysiology, availability of powerful antibiotics, and advanced diagnostic and monitoring techniques, mortality rates have not changed significantly over the past 30 years. Immunotherapy may improve outcome in the critically ill with sepsis, although trial results have been disappointing to date.

Development of laminar distributions of kainate receptors in the somatosensory cortex of mice

Kainate receptors were present at birth in the murine somatosensory cortex as revealed by quantitative in vitro autoradiography. During the first five postnatal days [3H]kainate binding rapidly increased and the maximum density in layer IV was reached at P12. The adult laminar pattern of receptor binding distribution was established by the third postnatal week with the heaviest labeling of infragranular layers. The sharp increase of kainate receptor during the first postnatal week coincides with the critical period for cytoarchitectonic plasticity of the barrels and establishment of functional thalamo-cortical connections in the barrel field.

Progress in the management of Alzheimer's disease

As the population of the United States continues to age, age-related diseases such as Alzheimer's, the most common form of dementia, pose an increasing clinical challenge. The diagnosis of Alzheimer's disease hinges on the evaluation of cognitive function. Management options are expanding and include new cholinesterase inhibitors, cholinergic agonists, antioxidants, monoamine oxidase inhibitors, and estrogen.

Flare during drug withdrawal as a method to support efficacy in rheumatoid arthritis: amiprilose hydrochloride as an example in a double blind, randomized study

OBJECTIVE

To evaluate the use of a randomized, double blind, drug withdrawal design as a means to test the efficacy of longterm therapy with antirheumatic drugs.

METHODS

We evaluated 286 patients with rheumatoid arthritis (RA) treated with amiprilose hydrochloride for 1-3 years, with response, with or without other antirheumatic therapy, in a double blind, 12 week withdrawal study that compared patients randomized to continue amiprilose therapy vs patients randomized to placebo. The primary efficacy variable was preventing a predefined degree of clinical reactivation, or flare; the statistical tests of success were a difference in the proportion of flares and in the mean time to flare.

RESULTS

Thirty percent of patients taking amiprilose and 43% of placebo patients experienced flare (p = 0.026). Patients taking amiprilose had a longer flare-free interval compared to placebo patients (p = 0.027), with the time to reactivation or flare becoming statistically different 73 days after withdrawal.

CONCLUSION

Placebo controlled withdrawal designs are useful as evidence to support the longterm effectiveness of therapy in a proportion of patients with RA.

A first-generation whole genome-radiation hybrid map spanning the mouse genome

We have assembled a first-generation anchor map of the mouse genome using a panel of 94 whole-genome-radiation hybrids (WG-RHs) and 271 sequence-tagged sites (STSs). This is the first genome-wide RH anchor map of a model organism. All of the STSs have been previously localized on the genetic map and are located 8.8 Mb apart on average. This mouse WG-RH panel, known as T31, has an average retention frequency of 27.6% and an estimated potential resolution of 145 kb, making it a powerful resource for efficient large-scale expressed sequence tag mapping. [All of the mapping data for the maps presented here have been deposited at the Research Genetics, Inc., web site and can be freely accessed and downloaded at http://www.resgen.com/.]

A study of the factors affecting the metabolic clearance of quinine in malaria

OBJECTIVE

To assess the factors that contribute to impaired quinine clearance in acute falciparum malaria.

PATIENTS

Sixteen adult Thai patients with severe or moderately severe falciparum malaria were studied, and 12 were re-studied during convalescence.

METHODS

The clearance of quinine, dihydroquinine (an impurity comprising up to 10% of commercial quinine formulations), antipyrine (a measure of hepatic mixed-function oxidase activity), indocyanine green (ICG) (a measure of liver blood flow), and iothalamate (a measure of glomerular filtration rate) were measured simultaneously, and the relationship of these values to the biotransformation of quinine to the active metabolite 3-hydroxyquinine was assessed.

RESULTS

During acute malaria infection, the systemic clearance of quinine, antipyrine and ICG and the biotransformation of quinine to 3-hydroxyquinine were all reduced significantly when compared with values during convalescence. Iothalamate clearance was not affected significantly and did not correlate with the clearance of any of the other compounds. The clearance of total and free quinine correlated significantly with antipyrine clearance (rs = 0.70, P = 0.005 and rs = 0.67, P = 0.013, respectively), but not with ICG clearance (rs = 0.39 and 0.43 respectively, P > 0.15). In a multiple regression model, antipyrine clearance and plasma protein binding accounted for 71% of the variance in total quinine clearance in acute malaria. The pharmacokinetic properties of dihydroquinine were generally similar to those of quinine, although dihydroquinine clearance was less affected by acute malaria. The mean ratio of quinine to 3-hydroxyquinine area under the plasma concentration-time curve (AUC) values in acute malaria was 12.03 compared with 6.92 during convalescence P = 0.01. The mean plasma protein binding of 3-hydroxyquinine was 46%, which was significantly lower than that of quinine (90.5%) or dihydroquinine (90.5%).

CONCLUSION

The reduction in quinine clearance in acute malaria results predominantly from a disease-induced dysfunction in hepatic mixed-function oxidase activity (principally CYP 3A) which impairs the conversion of quinine to its major metabolite, 3-hydroxyquinine. The metabolite contributes approximately 5% of the antimalarial activity of the parent compound in malaria, but up to 10% during convalescence.

Safety of repeated intermittent courses of aerosolized recombinant human deoxyribonuclease in patients with cystic fibrosis

OBJECTIVES

To determine the effect of repeated doses of aerosolized recombinant human deoxyribonuclease (rhDNase) on the development of anti-rhDNase antibodies, acute allergic reactions, and pulmonary function in patients with cystic fibrosis.

DESIGN

A multicenter, open-label study in which 184 patients received 10 mg aerosolized rhDNase twice a day for 14 days followed by a 14-day washout period for a total of 6 treatment cycles. Serial determinations of anti-rhDNase antibodies and pulmonary functions were performed.

RESULTS

Detectable anti-rhDNase antibodies developed in 16 (8.7%) patients. These patients had no changes in their symptoms from the time they entered the trial. Antibodies detected were all of the IgG isotype. Increases in both forced expired volume in 1 second and forced vital capacity were noted from the beginning to the end of each cycle of treatment returning to baseline during the off-treatment period of each cycle. Seropositivity to rhDNase was not associated with allergic reactions and had no relationship on improvement in pulmonary function.

CONCLUSIONS

Development of anti-rhDNase antibodies occurred in a small number of patients and was not associated with side effects. Intermittent administration of rhDNase for 24 weeks to patients with cystic fibrosis was well tolerated and was not associated with anaphylaxis in any patient. Pulmonary function improved significantly during the 14-day cycles while rhDNase was administered and returned to baseline when rhDNase was discontinued.

Sterile abscess formation following plague vaccination

As part of the immunisation programme of servicemen on OP Granby, deployed in the Gulf, plague vaccine was recommended as a prophylaxis. Out of a total of 524 vaccinations at our location, one sterile abscess formation was noted. The case report is described.

Immunologic and autoradiographic localisation of the Na+, K(+)-ATPase in articular cartilage: upregulation in response to changes in extracellular Na+ concentration

The maintenance of a relatively low intracellular Na+:K+ ratio is essential for the functioning of a wide range of cellular processes, and is achieved principally by the activity of the membrane-bound Na+, K(+)-ATPase. Chondrocytes, the cells of articular cartilage, exist in an ionic environment where the free extracellular [Na+] is higher (250-400 mM) than that of most other tissues (approximately 140 mM) owing to the fixed negative charges on glycosaminoglycans in the extracellular matrix. This can increase further during static joint loading when fluid expression occurs. To determine aspects of how chondrocytes regulate their ionic composition, in this study, the in situ distribution, pattern of isoform expression and density of the Na+, K(+)-ATPase within cartilage has been investigated. The density of the Na+, K(+)-ATPase was found to be high in the mid-zone, but lower in the surface and deep zones. Immunofluorescence microscopy using monoclonal antibodies to the catalytic alpha subunits of the Na+, K(+)-ATPase revealed the expression of isoforms alpha 1 and alpha 3. Alterations to the extracellular [Na+] (from 80-220 mM, or 120-220 mM) significantly elevated Na+, K(+)-ATPase density of in situ chondrocytes. The results indicate that the Na+, K(+)-ATPase is abundantly expressed in articular chondrocytes and its density is sensitive to the extracellular [Na+]. The expression of the alpha 3 isoform is surprising for a non-neuronal cell, and may indicate a physiological adaptation to the unusually high extracellular [Na+] to which chondrocytes are exposed in the extracellular matrix of cartilage.

A comparison of peak sputum tobramycin concentration in patients with cystic fibrosis using jet and ultrasonic nebulizer systems. Aerosolized Tobramycin Study Group

STUDY OBJECTIVE

To determine whether adequate concentrations of a new formulation of tobramycin could be delivered to the lower respiratory tract of patients with cystic fibrosis (CF) using a jet nebulizer delivery system.

DESIGN

A multicenter, open-label, randomized, crossover study.

SETTING

Ten tertiary care, university-affiliated, teaching hospitals in the United States.

PATIENTS AND CONTROL SUBJECTS

Sixty-eight patients recruited from 10 CF Foundation centers and who were at least 8 years of age, had a diagnosis of CF, and expectorated daily sputum. No control subjects enrolled.

INTERVENTIONS

Each patient received one administration of aerosolized tobramycin from each of the three nebulizer systems in random order. Each administration was separated by a minimum of 48 h. The two jet nebulizer systems tested were the Sidestream (Medic-Aid; Sussex, UK), and the Pari LC (Pari Respiratory Equipment; Richmond, Va), with a DeVilbiss Pulmoaide compressor (DeVilbiss Health Care; Somerset, Pa), both administering 300 mg tobramycin in 5 mL of 1/4 normal saline solution (NS). Patients were also administered 600 mg tobramycin in 30 mL of 1/2 NS with the UltraNeb 99/100 (DeVilbiss).

MEASUREMENTS

Sputum and serum tobramycin concentration and pulmonary function were monitored. An adequate peak sputum tobramycin concentration was defined as > 128 microg/g sputum at any of three time points (10, 60, or 120 min) after completion of treatments.

RESULTS

The peak tobramycin concentrations in expectorated sputum were 687+/-663 microg/g (mean+/-SD) with the Pari LC and 489+/-402 microg/g with the Sidestream. Adequate peak sputum tobramycin concentration was achieved in 93% of the patients with the Sidestream, and in 87% of the patients with the Pari LC. Peak sputum concentrations were found to be substantially higher when patients received tobramycin administered with the UltraNeb 99/100, 1,498+/-1,331 microg/g with 30% of patients having levels exceeding 2,000 microg/g. Serum tobramycin concentrations were < or = 4 microg/mL for all patients following administration with each nebulizer.

CONCLUSIONS

Adequately high sputum tobramycin concentrations were documented in sputum in > 85% of patients following the administration of 300 mg/5 mL formulation of tobramycin aerosolized by the two jet nebulizer delivery systems, Sidestream and Pari LC. The single tobramycin administration delivered by these two systems is well-tolerated.

Xanthogranulomatous pyelonephritis--a rare case of fistula between colon and kidney

We report the case of a 63 year old lady with xanthogranulomatous pyelonephritis. The treatment of choice is nephrectomy. At operation a fistula between large bowel and kidney was found requiring bowel resection. This is a rare complication of xanthogranulomatous pyelonephritis.

The role of T cells in the regulation of B cell tolerance

The study of conventional models of B cell tolerance has suggested that self-tolerance is imposed on B cells at an early stage in their development due to a peculiar sensitivity of immature B cells to tolerance induction. While this concept accounts for some aspects of central B cell tolerance, it is inconsistent with recent reports of tolerance induction in mature splenic B cells from immunoglobulin transgenic mice. We present an alternative model, the hierarchical model (Aust. N. Z. J. Med. 25, 761-767, 1995), in which regulation of naive B cell reactivity is a function of antigen signal strength and availability of T cell help, but is independent of B cell maturation stage. In turn, the development of tolerance or memory in the T cell compartment is dependent on a combination of antigen-MHC recognition by T cells and antigen-nonspecific signalling by antigen-presenting cells. Using a transgenic model of T-B collaboration, we have shown that both immature and mature self-reactive B cells can be rescued and induced to secrete auto-antibody if the B cell determinant is linked to a carrier protein bearing a foreign T cell determinant.

Haemophilus influenzae pili are composite structures assembled via the HifB chaperone

Haemophilus influenzae is a Gram-negative bacterium that represents a common cause of human disease. Disease due to this organism begins with colonization of the upper respiratory mucosa, a process facilitated by adhesive fibers called pili. In the present study, we investigated the structure and assembly of H. influenzae pili. Examination of pili by electron microscopy using quick-freeze, deep-etch and immunogold techniques revealed the presence of two distinct subassemblies, including a flexible two-stranded helical rod comprised of HifA and a short, thin, distal tip structure containing HifD. Genetic and biochemical studies demonstrated that the biogenesis of H. influenzae pili is dependent on a periplasmic chaperone called HifB, which belongs to the PapD family of immunoglobulin-like chaperones. HifB bound directly to HifA and HifD, forming HifB-HifA and HifB-HifD complexes, which were purified from periplasmic extracts by ion-exchange chromatography. Continued investigation of the biogenesis of H. influenzae pili should provide general insights into organelle development and may suggest novel strategies for disease prevention.

T-cell alpha beta + and gamma delta + deficient mice display abnormal but distinct phenotypes toward a natural, widespread infection of the intestinal epithelium

Vertebrate immune systems contain T cells bearing either alpha beta or gamma delta T-cell antigen receptors (TCRs). alpha beta T cells perform all well-characterized T-cell effector functions, while the biological functions of gamma delta + cells remain unclear. Of particular interest is the role of gamma delta + cells during epithelial infections, since gamma delta + cells are commonly abundant within epithelia. Eimeria spp. are intracellular protozoa that infect epithelia of most vertebrates, causing coccidiosis. This study shows that in response to Eimeria vermiformis, mice lacking alpha beta T cells display defects in protective immunity, while mice lacking gamma delta + cells display exaggerated intestinal damage, apparently due to a failure to regulate the consequences of the alpha beta T cell response. An immuno-downregulatory role during infection, and during autoimmune disease, may be a general one for gamma delta + cells.

Gamma delta T cell help of B cells is induced by repeated parasitic infection, in the absence of other T cells

BACKGROUND

gamma delta T cells, like alpha beta T cells, are components of all well-studied vertebrate immune systems. Yet, the contribution of gamma delta T cells to immune responses is poorly characterized. In particular, it has not been resolved whether gamma delta cells, independent of any other T cells, can help B cells produce immunoglobulin and form germinal centers, anatomical foci of specialized T cell-B cell collaboration.

RESULTS

TCR beta-/- mice, which lack all T cells except gamma delta T cells, routinely displayed higher levels of antibody than fully T cell-deficient mice. Repeated parasitic infection of TCR beta-/- mice, but not of T cell-deficient mice, increased antibody levels and induced germinal centers that contained B cells and monoclonal gamma delta cells in close juxtaposition. However, antibody specificities were more commonly against self than against the challenging pathogen. gamma delta T cell-B cell help was not induced by repeated inoculation of TCR beta-/- mice with mycobacterial antigens.

CONCLUSIONS

In the absence of any other T cells, gamma delta T cell-B cell collaboration can be significantly enhanced by repeated infection. However, the lack of obvious enrichment for antibodies against the challenging pathogen distinguishes gamma delta T cell help from alpha beta T cell help induced under analogous circumstances. The increased production of generalized antibodies may be particularly relevant to the development of autoimmunity, which commonly occurs in patients suffering from alpha beta T cell deficiencies, such as AIDS.

Genetic characterization of trimethoprim resistance in Haemophilus influenzae

We previously demonstrated that trimethoprim (Tmp) resistance in Haemophilus influenzae is mediated by chromosomally encoded dihydrofolate reductase (DHFR) with a modified primary structure and distinct kinetic properties. To gain insight into the relationship of the DHFR structure and the level of Tmp resistance that it confers on the host bacterium, we cloned and characterized the folH genes of one Tmp-susceptible and two Tmp-resistant H. influenzae strains. Differences were observed between Tmp-susceptible and Tmp-resistant isolates both in the promoter region and in the coding sequences. The effect of differences between H. influenzae folH genes on Tmp susceptibility was investigated in Escherichia coli. Various folH gene hybrids were constructed, and their influence on Tmp susceptibility was determined. Resistance in E. coli mediated by folH from H. influenzae strain R1047 was associated with alterations in the promoter and the central part of folH. In contrast, the E. coli Tmp resistance phenotype associated with the folH gene of H. influenzae R1042 was characterized by alterations in one or more of three amino acid residues at the C-terminal part of the protein. These data indicate that Tmp resistance is not only related to alterations in the promoter region of the folH gene and the Tmp binding domains at the N-terminal and central part of DHFR. Alterations in the C-terminal part may also cause Tmp resistance, probably as a result of a change in secondary structure and the subsequent loss of Tmp binding affinity.

Efficient induction of persistent and prenatal parvovirus infection in rats

Parvoviruses are prevalent and disruptive infectious agents of laboratory rats. Risks to rat-based research from infection are increased by the persistence of virus in immune rats and by prenatal transmission of infection. The mechanisms leading to viral persistence and prenatal infection are poorly understood and have been difficult to study for lack of reliable and humane induction methods. We report here protocols for inducing persistent and prenatal infection without causing clinical disease using the UMass strain of rat virus (RV), a common rat parvovirus. Infant rats inoculated by the oronasal route at 6 days of age had greater than 90% prevalence of persistent infection. RV-UMass also induced intrauterine infection in pregnant rats inoculated by the oronasal route. Inoculation of dams at gestation day 9 frequently caused severe disease in the fetuses whereas inoculation at gestation day 12 caused primarily asymptomatic fetal infection that persisted post partum RV-UMass infection facilitates study of parvoviralhost interactions that are relevant to laboratory rats and which also may improve understanding of persistent and prenatal human parvovirus infection.