Hospital Facility Prices Declined As A Result Of Oregon's Hospital Payment Cap

Hospital prices for commercially insured people are high and vary widely, prompting states to seek ways to control hospital price growth. In October 2019, the Oregon state employee health insurance plan instituted a cap on hospital payments. Using 2014-21 data from the Oregon All Payer All Claims Reporting Program database, we performed a difference-in-differences analysis to test the impact of the cap on hospital facility prices for Oregon's state employee plan enrollees. We found that the cap was not associated with a significant reduction in inpatient facility prices across the post period (-$901.9 per admission) but was associated with a significant reduction in the second year after implementation (-$2,774.20). The cap was associated with a significant reduction in outpatient facility prices over the course of the first twenty-seven months of the policy (-$130.50 per procedure). We estimated $107.5 million (or 4 percent of total plan spending) in savings to the state employee plan during the first two years. The hospital payment cap successfully reduced hospital prices for enrollees in that plan.

Association Between the Medicare Advantage Quartile Adjustment System and Plan Behavior and Enrollment

Importance

Medicare Advantage (MA) has grown in popularity, but critics believe that insurers are overpaid, partially due to the quartile adjustment system that determines plan benchmarks. However, elimination of the quartile adjustments may be associated with less generous benefits and fewer plan offerings, which could slow MA enrollment growth.

Objective

To examine whether the quartile adjustment system is associated with differences in county-level benefits, insurer offerings, and MA enrollment.

Design, Setting, and Participants

The quartile adjustments create discontinuous jumps in county-level base payments based on historical traditional Medicare spending. Data from January 2017 to December 2021 and a regression discontinuity design were used to examine changes in insurer behavior and MA enrollment between quartiles. The analytic sample included 1557 county observations.

Main Outcomes and Measures

Study outcomes included monthly premiums, the share of plans charging premiums, primary care copayments, the share of plans using rebates to reduce Part B premiums, supplemental benefits, plan and contract availability, and MA enrollment.

Results

Discontinuities were found in the quartile adjustments and benchmarks. A 1-percentage point (pp) increase in the quartile adjustment was associated with a $6.36 increase in monthly benchmarks (95% CI, 5.10-7.62), a $0.51 decrease in monthly premiums (95% CI, -0.96 to -0.07), and a 0.68 pp decrease in the share of plans charging premiums (95% CI, -1.25 to -0.10). Significant changes were not found in primary care copayments (-$0.04; 95% CI, -0.17 to 0.09), the share of plans using rebates to reduce Part B premiums (-0.17 pp; 95% CI, -0.34 to 0.01), supplemental benefits (eg, preventive dental coverage; 0.17 pp; 95% CI, -0.25 to 0.0), the number of plans (1.06; 95% CI, -3.44 to 5.57) or contracts (0.31; 95% CI, -0.18 to 0.81), or the MA enrollment rate (0.16 pp; 95% CI, -0.61 to 0.94).

Conclusions and Relevance

The study results suggest that MA plans are not very sensitive to modest changes in payment rates. Modifications to the quartile adjustment system may generate savings without substantially affecting MA beneficiaries.

Legislative and Regulatory Options for Improving Medicare Advantage

The Medicare Advantage program was created to expand beneficiary choice and to reduce spending through capitated payment to private insurers. However, many stakeholders now argue that Medicare Advantage is failing to deliver on its promise to reduce spending. Three problematic design features in Medicare Advantage payment policy have received particular scrutiny: (1) how baseline payments to insurers are determined, (2) how variation in patient risk affects insurer payment, and (3) how payments to insurers are adjusted for quality performance. The authors analyze the statute underlying these three design features and explore legislative and regulatory strategies for improving Medicare Advantage. They conclude that regulatory approaches for improving risk adjustment and for recouping overpayments from risk-score gaming have the highest potential impact and are the most feasible improvement measures to implement.

Estimated Fiscal Effects of Medicare Advantage's Quartile Payment System

This economic analysis estimates fiscal effects of the quartile adjustments made to Medicare Advantage payments as part of the Patient Protection and Affordable Care Act.

Effect of speed and water depth on limb and back kinematics in Thoroughbred horses walking on a water treadmill

Water treadmill (WT) exercise may induce limb and back kinematics that meet specific training and rehabilitation goals. The study aimed to investigate the effects of walk speed, at different water depths (WDs), on limb and back kinematics of six Thoroughbreds exercising on a WT. Horses walked at 2.8/4.3/5.5/6.0 km/h (i.e. 0.8/1.2/1.5/1.7 m/s) at dry, metacarpophalangeal and carpal WD. Videography captured limb movement in the sagittal plane. Motion-capture measured thoracolumbosacral flexion-extension (FE), and lateral bend (LB) ranges of movement (ROM) using skin surface markers on the sixth, tenth, thirteenth, eighteenth thoracic, third and fifth lumbar, and third sacral spinous processes. Inertial-motion-sensors measured poll, withers and pelvic displacements. Following preliminary univariable analyses, multivariable mixed-effects linear-regression analyses were used to examine the relationship between speed, WD and each outcome variable (P < 0.05). Peak metacarpophalangeal, carpal and tarsal joint flexion increased with speed (P ≤ 0.002) and depth combined (P 0.001) while peak metatarsophalangeal flexion increased with WD only (P 0.001). Thoracolumbar FE-ROM between T10 and L3 and hindlimb retraction was increased by speed and WD combined (P 0.001). Hindlimb protraction was increased by speed (P 0.001) while hindlimb retraction was increased by speed and WD combined (P 0.001). Dorsoventral poll displacement was increased by speed (P 0.001) and carpal WD (P = 0.013), craniocaudal poll displacement was increased by speed and WD combined (P 0.001). Pelvic (tubera coxae and sacrum) dorsoventral displacements increased with speed and WD combined (P 0.001). Understanding the effects of speed and WD on limb, back and pelvic kinematics will improve decision making relating to dry and WT exercise within training.

Favorable Selection In Medicare Advantage Is Linked To Inflated Benchmarks And Billions In Overpayments To Plans

Increases in Medicare Advantage (MA) enrollment, coupled with concerns about overpayment to plans, have prompted calls for change. Benchmark setting in MA, which determines plan payment, has received relatively little attention as an avenue for reform. In this study we used national data from the period 2010-20 to examine the relationships among unobserved favorable selection, benchmark setting, and payments to plans in MA. We found that unobserved favorable selection in MA led to underpayment to counties with lower MA penetration and overpayment to counties with higher MA penetration. Because the distribution of MA beneficiaries has shifted over time toward counties that were overpaid, we estimate that plans were overpaid by an average of $9.3 billion per year between 2017 and 2020. Changes to risk adjustment in benchmark setting could likely mitigate the impact of favorable selection in MA.

Comprehensive Primary Care Plus Did Not Improve Quality Or Lower Spending For The Privately Insured

Comprehensive Primary Care Plus (CPC+) was a multipayer payment reform model that provided incentives for primary care practices to lower spending and improve quality performance. Although CPC+ has been evaluated in Medicare, little is known about its impact in the private sector. Using claims and enrollment data from the period 2013-20 from two large insurers in Michigan, we performed difference-in-differences analyses and found that CPC+ was not associated with changes in total spending (-$44.70 per year) or overall quality performance (-0.1 percentage point). These changes did not vary systematically across CPC+ cohorts, tracks, regions, or participation in prior primary care innovations. We conclude that CPC+ did not improve spending or quality for private-plan enrollees in Michigan, even before accounting for payouts to providers. This analysis adds to existing evidence that CPC+ may cost payers money in the short term, without concomitant improvements to care quality.

Value-Based Payment Models In The Commercial Insurance Sector: A Systematic Review

Value-based payment models are a prominent strategy in health reform. Although Medicare payment models have been extensively evaluated, much less is known about value-based payment models in the commercial insurance sector. We performed the first systematic review of the quality, spending, and utilization effects of commercial models, extracting results from fifty-nine studies. Forty-one of these studies evaluated outcomes. More studies had positive results for quality outcomes (81 percent of studies) than for spending (56 percent) and utilization (58 percent). Less rigorous studies were more likely to find positive results. Given the mixed nature of the findings, commercial insurers should identify ways to strengthen value-based payment programs or leverage other strategies to improve health care value.

Days-lost to training and competition in relation to workload in 263 elite show-jumping horses in four European countries

Orthopaedic, or other, injuries in sports medicine can be quantified using the 'days-lost to training' concept. Both the training regimen and the surface used in training and racing can affect the health of racehorses. Our aim was to associate 'days-lost to training' in elite-level show-jumpers to horse characteristics, training and management strategies, and the time spent working on various training and competition surfaces. We designed a longitudinal study of professional riders in four European countries. Data were recorded using training diaries. Reasons for days-lost were classified into non-acute and acute orthopaedic, medical, hoof-related, and undefined. We produced descriptive statistics of training durations, relative to type of training, surfaces used, and days-lost. We created zero-inflated negative-binomial random-effects models using the overall days-lost as outcome. In the whole dataset, duration variables related to training surfaces were analysed as independent. The Swedish data only were also used to test whether duration variables were related to competition surfaces. Thirty-one riders with 263 horses provided data on 39,028 days at risk. Of these, 2357 (6.0%) were days-lost (55% and 22% of these were due to non-acute and acute orthopaedic injuries, respectively) in 126 horses. In the all-country model, controlling for season, a significant variable was country. Switzerland and the UK had lower incidence-rate ratios (IR) compared to Sweden (IRs 0.2 and 0.03, respectively). Horses with previous orthopaedic problems had almost a doubled IR (1.8) of days-lost due to orthopaedic injury, compared to baseline. If the horse had jumping training more than 1 min per day at risk the IRs were 6.9-7 (compared to less than this amount of time); this was, however, likely an effect of a small baseline. Variation in training was a protective factor with a dose-response relationship; the category with the highest variation had an IR of 0.1. In the Swedish model, controlling for season, there was an association of year (IR 2.8 year 2010). Further, if the horse rested >17-25% of the days at risk, or >33% of the DAR2, had IRs 3.5 and 3.0, compared to less time. Horses ≥ 6 years had IRs of 1.8-2.0, compared to younger horses. Limited training use of sand surface was a risk-factor (IR 2.2; >4 ≤ 12 min/day at risk), compared to not training on sand. Training/competing on sand-wood was a protective factor (IRs 0.4-0.5) compared to not using this surface.

Variation in training regimens in professional showjumping yards

REASONS FOR PERFORMING STUDY

Training regimens of showjumping horses under field conditions are largely undocumented.

OBJECTIVES

The aims of this study were to quantify and compare training regimens used in professional-level showjumping yards, with respect to time exercised and type of activity.

STUDY DESIGN

Prospective cohort study.

METHODS

A prospective 6-month cohort study of showjumping horses in 4 European countries (The Netherlands, Sweden, Switzerland, Great Britain) was designed to analyse training and health data, in yards with several horses in training and riders competing at professional level. Riders documented the daily frequency and duration of all physical activities of the horses. Variation in training routines were compared between riders, location and time. Mixed-models analysis was used to examine factors associated with total time exercised and time spent in flatwork.

RESULTS

In 4 countries, the 31 participating riders trained 263 European Warmbloods. The total days at risk (e.g. days in which the horses were considered fit for exercise) was 39,262. Mean time spent in daily exercise, including ridden work, lungeing and treadmill exercise, varied between riders from 19-52 min/day at risk. There was considerable variation in activities and level of heavy work and light exercise, i.e. turnout. Total time exercised and time spent in flatwork differed with month, country and proportion of days lost to training. Low variation of activities was associated with decreased total time trained and increased time spent in flatwork.

CONCLUSIONS

Riders at this elite professional level of showjumping used training regimens that vary substantially in time spent training and other physical activities and showjumping horses are challenged differently during training despite competing at the same level. Whether all training regimens prepare the horses equally for the demands of competition remains to be determined.

Chronic streptococcal and non-streptococcal pharyngitis

Pharyngitis is a common medical problem in the outpatient medical setting, resulting in more than seven million pediatric visits each year. Most types of pharyngitis are caused by infectious etiologies. The most common cause of pharyngitis is viral infection; however, some of the more serious types of pharyngitis are attributed to bacterial etiologies, such as group A β-hemolytic Streptococcus pyogenes (GAS). Complications from GAS pharyngitis include rheumatic fever, deep space abscesses, and toxic shock. Although most episodes of pharyngitis are acute in nature, a small percentage becomes recurrent or chronic. With regards to chronic pharyngitis, non-infectious etiologies, such as laryngopharyngeal reflux and periodic fever, aphthous ulcers, pharyngitis, and adenitis syndrome also need to be considered. Both medical and surgical therapies are effective in managing pharyngitis. First-line medical therapy includes antibiotic therapy. For certain indications, surgical management via adenotonsillectomy is recommended. Adenotonsillectomy has been shown to be effective in reducing disease burden and improving disease-specific and global quality of life. Several techniques for adenotonsillectomy exist, including traditional and intracapsular tonsillectomies.

An investigation of the relationships between angles and shapes of the hoof capsule and the distal phalanx

REASONS FOR PERFORMING STUDY

There is little scientific evidence to support the premise that poor foot conformation predisposes to foot pain and lameness.

OBJECTIVES

To determine relationships between external characteristics of the hoof capsule and angles of the distal phalanx; to determine variability in shape of the distal phalanx; and to investigate association between distal phalanx angles and the injury causing lameness.

MATERIALS AND METHODS

Feet were documented photographically and radiographically. Linear and angle measurements were obtained for the hoof capsule and distal phalanx and compared statistically. Horses were categorised according to injury group, and angles and linear ratios were compared between groups.

RESULTS

There was modest correlation between hoof wall and heel angles and angles of the distal phalanx. There was variation in shape of the distal phalanx. There was no significant association between injury type and angles of the distal phalanx, although there was a trend for the angle of the dorsal aspect of the distal phalanx with the horizontal to be smaller in horses with injuries of the podotrochlear apparatus or deep digital flexor tendon compared with other groups.

CONCLUSIONS

There are variations in shape of the distal phalanx largely due to differences in orientation of the concave solar border and the solar border to the horizontal. Variations in shape of the distal phalanx were not accurately correlated with external characteristics of the hoof capsule. There were weak associations between injury groups and angles of the distal phalanx.

CLINICAL RELEVANCE

Further work is required to elucidate risk factors for foot-related lameness.

Is there a characteristic distal tarsal subchondral bone plate thickness pattern in horses with no history of hindlimb lameness?

REASONS FOR PERFORMING STUDY

Osteoarthritis (OA) is a common cause of distal tarsal pain, but disease development is poorly understood. Awareness of normal tarsal structure and function is important in order to understand the pathogenesis of OA. Thickening of the subchondral bone (SCB) plate has been related to the development of OA, but SCB plate patterns in the equine tarsus have not been documented.

HYPOTHESES

There is a repeatable pattern of SCB thickness across the distal tarsal joints, and specifically that thickness would be greatest dorsally and laterally.

METHODS

Twenty cadaver tarsi were collected from mature horses that had undertaken low-level exercise only with no history of hindlimb lameness. Magnetic resonance images were acquired using a high-resolution sagittal 3-dimensional T1-weighted spoiled gradient echo sequence. Subchondral bone thickness was measured on sagittal images at dorsal and plantar locations on the proximal and distal aspects of the central (CT) and third (T3) tarsal bones and proximal aspect of the third metatarsal bone (Mt3).

RESULTS

On the proximal aspect of CT, medial and lateral SCB thickness were significantly greater than midline. On the distal aspect of CT and T3 and proximal Mt3, lateral SCB thickness was significantly greater than medial and midline sites. Dorsal SCB thickness was greatest on the proximal and distal aspects of CT and proximal Mt3. Subchondral bone accounted for a greater proportion of CT and T3 on the dorsal aspect than the plantar.

CONCLUSIONS

There is a repeatable pattern of SCB thickness in the distal tarsal bones of horses with no history of hindlimb lameness. This reflects the pattern of loading across the joints.

POTENTIAL RELEVANCE

This study provides evidence of a consistent osteochondral pattern in the equine tarsus for reference in identification of osteoarticular pathologies.

Alteration of distal tarsal subchondral bone thickness pattern in horses with tarsal pain

REASONS FOR PERFORMING STUDY

Understanding of the development of pathology and source of pain in distal tarsal osteoarthritis is poorly understood. Magnetic resonance imaging is often used in the analysis of human osteoarthritis (OA) because it is sensitive to early changes.

HYPOTHESIS

In association with distal tarsal joint (DTJ) pain, there will be an alteration in the characteristic subchondral bone (SCB) thickness pattern of horses with no history of pain when subjected to low-level exercise.

METHODS

Sixteen cadaver tarsal joints were collected from 9 mature horses with a history of tarsal pain and radiographic evidence of OA; 3 cadaver tarsi were collected from 2 mature horses with a history of tarsal pain and no radiographic abnormality. Magnetic resonance images were acquired using high-resolution sagittal 3D T1 weighted spoiled gradient echo sequence. Subchondral bone thickness was measured on sagittal images at dorsal and plantar locations on the proximal and distal aspects of the central (CT) and third (T3) tarsal bones and proximal aspect of the third metatarsal bone (MT3).

RESULTS

In tarsi with radiographic evidence of OA medial and lateral SCB thicknesses were greater than midline on the proximal and distal aspects of CT and T3. Lateral SCB thickness was greater than medial on the proximal aspect of MT3. There was an increase in SCB thickness at the majority of sites compared with normal horses. There were too few joints in the group without radiographic changes to analyse statistically. In painful tarsi SCB thickness was greater medially than laterally at all sites. In horses without tarsal pain all lateral sites had greater SCB thickness, except the proximal aspect of CT.

CONCLUSIONS

There is alteration of normal SCB thickness patterns in painful tarsi. Different thickness patterns could represent different types of pathological processes.

POTENTIAL CLINICAL RELEVANCE

Further work is required to elucidate the pathological processes leading to OA of the DTJs.

Comparison of high-field and low-field magnetic resonance images of cadaver limbs of horses

Eleven limbs taken postmortem from 10 lame horses were examined by MRI in a low-field 0.27T system designed for standing horses and a high-field 1.5T system used to examine anaesthetised horses. Nine limbs were examined in the foot/pastern region and two in the fetlock region, and the results were compared with gross pathological examinations and histological examinations of selected tissues. The appearance of normal tissues was similar between the two systems, but the anatomical arrangement of the structures was different due to differences in positioning, and a magic angle artefact was observed at different sites in some imaging sequences. Articular cartilage could be differentiated into two articular surfaces in most joints in the high-field images but could generally be separated only at the joint margins in the low-field images. Abnormalities of tendon, ligament and bone detected by gross examination were detected by both forms of MRI, but some details were clearer on the high-field images. Articular cartilage found to be normal on pathological examination was also classified as normal on MRI, but lesions in articular cartilage detected on pathological examination were identified only by high-field MRI. An abnormality was detected on MRI of all the limbs that had abnormal navicular flexor fibrocartilage on pathological examination.

How does exercise intensity and type affect equine distal tarsal subchondral bone thickness?

Adaptation of osteochondral tissues is based on the strains experienced during exercise at each location within the joint. Different exercise intensities and types may induce particular site-specific strains, influencing osteochondral adaptation and potentially predisposing to injury. Our hypotheses were that patterns of equine distal tarsal subchondral bone (SCB) thickness relate to the type and intensity of exercise, and that high-intensity exercise leads to site-specific increases in thickness. SCB thickness was measured at defined dorsal and plantar locations on magnetic resonance images of cadaver tarsi collected from horses with a history of low [general purpose ( n = 20) and horse walker ( n = 6)] or high [elite competition ( n = 12), race training ( n = 15), and treadmill training ( n = 4)] exercise intensity. SCB thickness was compared between sites within each exercise group and between exercise groups. SCB thickness in elite competition and race training, but not treadmill training, was greater than low-intensity exercise. For general purpose horses, lateral SCB thickness was greater than medial throughout. Horse walker exercise led to relatively thicker lateral and medial SCB compared with the midline. Elite competition was associated with increased SCB thickness of the proximal small tarsal bones medially and the distal bones laterally. For race training and treadmill training, there were minimal differences between sites overall, although the lateral aspect was greater than medial, and medial greater than midline at a few sites for race training. In conclusion, different types of high-intensity exercise were associated with different patterns of SCB thickness across the joints from medial to lateral and proximal to distal, indicating that both exercise intensity and type of exercise affect the SCB response at any particular site within the equine distal tarsal joints.

Association of type of sport and performance level with anatomical site of orthopaedic injury diagnosis

REASON FOR PERFORMING STUDY

Although anecdotal reports of increased orthopaedic injury risk in equine sports exist, there is little scientific evidence to support this.

OBJECTIVES

To test whether horses undertaking a single competitive sport have increased risk of specific injuries compared to those used for general purpose riding (GP); and whether injury type varies with sport category and performance level.

METHODS

Data from 1069 records of horses undergoing orthopaedic evaluation (1998-2003) and meeting inclusion criteria were reviewed. Sport category (GP, showjumping, dressage, eventing, racing), level (nonelite or elite) and diagnosis were recorded. Effects of sport category and level on probability of a specific diagnosis were assessed using chi-squared tests. Logistic regression was used to determine which competitive sports and levels increased risk of injury compared with GP.

RESULTS

Overall there was a significant effect of sport category and level on diagnosis (P<0.0001). There was significant difference between anatomical site injured and sport category (P<0.0001); a high risk of forelimb superficial digital flexor tendon injury in elite eventing (P<0.0001) and elite showjumping (P = 0.02); distal deep digital flexor tendon (DDFT) injury in elite showjumping (P = 0.002); and hindlimb suspensory ligament injury in elite (P<0.0001) and nonelite (P = 0.001) dressage. There was a low risk of tarsal injury in elite eventing (P = 0.01) and proximal DDFT injury in dressage (P = 0.01).

CONCLUSIONS

Horses competing in different sports are predisposed to specific injuries; particular sports may increase the risk of injury at certain anatomical sites; and the type and site of injury may reflect the type and level of performance.

POTENTIAL RELEVANCE

These findings could guide clinicians in the diagnosis of sport related injuries.

Do the matrix degrading enzymes cathepsins B and D increase following a high intensity exercise regime?

OBJECTIVE

It has been shown by others that levels of matrix degrading enzymes are increased in osteoarthritis (OA) and so are proposed to be involved in the aetiopathogenesis of the disease, including exercise-associated OA. Therefore we hypothesised that cathepsin B and cathepsin D were increased in cartilage samples previously shown to have early stage OA from 2-year-old Thoroughbred horses, euthanased for reasons other than this study, that had a history of 19-week high intensity exercise (n=6) compared to age and sex-matched horses with a history of low intensity exercise (n=6).

METHODS

Cartilage samples were used from four specific sites within the carpal joints. Standard immunolocalisation protocols and blind counting of positive and negative cells within the articular surface, mid-zone and deep zone (DZ) were used to test our hypothesis.

RESULTS

A high intensity exercise regime did not significantly alter the number of chondrocytes positive for cathepsin B, whereas a significant decrease was found for cathepsin D in the DZ, indicating that these enzymes are regulated differently by mechanical loading. Furthermore, cathepsin D varied according to the topographical location within the joint, reflecting biomechanical differences experienced during a high compared to a low intensity exercise regime.

CONCLUSION

This study disproves our hypothesis that cathepsins B and D are increased following a high intensity exercise regime unlike that reported for other matrix enzymes.

The effect of intra-articular methylprednisolone acetate and exercise on equine carpal subchondral and cancellous bone microhardness

Dorsal carpal osteochondral injury is a major cause of lameness in horses undergoing high intensity training. Intra-articular corticosteroid treatment is used commonly to manage exercise-associated articular pain, but its use remains highly controversial in the equine athlete. This project, therefore, aimed to compare the mechanical properties of intra-articular MPA and diluent-treated middle carpal subchondral and cancellous bone in horses undergoing a short-term treadmill exercise programme. It was hypothesised that subchondral and cancellous bone mechanical properties are influenced by intra-articular administration of methylprednisolone acetate (MPA). Eight 2-year-old female horses had MPA or diluent administered into contralateral middle carpal joints at 14 day intervals, for a total of 4 treatments per horse. Horses underwent a standard treadmill exercise protocol until euthanasia (Day 70). Standard sites were located on the dorsal aspect of third, radial and intermediate carpal bones. Osteochondral samples from each test site were divided into subchondral bone and cancellous bone portions. These were dried, resin-embedded and gold-coated. Microhardness measurements were obtained at each test site. No significant effect of intra-articular treatment was detected. At each site, cancellous bone trabecular struts had an 18-19% higher microhardness value than the overlying subchondral bone. These findings indicate that intra-articular administration of MPA at this dose has no effect on subchondral or cancellous bone adaptation to short-term exercise and, therefore, on the propensity of carpal bones to injury. Further investigation into the calcified cartilage layer, effect of different corticosteroid preparations and diffusion of medication are required.

Subchondral bone thickness, hardness and remodelling are influenced by short-term exercise in a site-specific manner

It was hypothesised that subchondral bone thickness, hardness and remodelling are influenced by exercise intensity, and by location within a joint. Dorsal carpal osteochondral injury is a major cause of lameness in horses undergoing high intensity training. This project aimed to determine the subchondral bone thickness, formation, resorption and hardness at sites with high and low incidence of pathology in 2 year-old horses undergoing 19 weeks high intensity treadmill training or low intensity exercise, and to compare these factors between exercise groups. Dorsal and palmar test sites were identified on radial, intermediate and third carpal articular surfaces after euthanasia. Adjacent osteochondral samples from each test site underwent histomorphometric analysis (for subchondral bone thickness, osteoid perimeter, osteoid seam width, eroded cavity area and eroded cement line surface length) and microhardness testing. Bone from horses undergoing high intensity training was thicker with a greater osteoid perimeter, and at individual sites had a smaller osteoid seam width and eroded cavity. Exercise-related differences were most marked at dorsal locations. Maximal differences in bone formation indices were observed at dorsal radial and medial third carpal locations. Overall subchondral bone from dorsal sites was thicker with a greater osteoid perimeter. Subchondral bone from dorsal sites was approximately 35% harder than bone from palmar sites. These results show topographical variations in subchondral bone structure, formation, resorption and material properties and a site-specific response to exercise. The maximal response to exercise was at high load sites with a clinical predisposition to injury. These findings indicate that the combined effect of exercise and local load variations within a joint may lead to maximal adaptive responses or overload of these responses at sites predisposed to injury.

Biochemical composition of equine carpal articular cartilage is influenced by short-term exercise in a site-specific manner

It was hypothesized that cartilage macro-molecular characteristics are influenced by exercise intensity and by location within a joint.

OBJECTIVE

To determine the macromolecular characteristics of carpal articular cartilage at common and uncommon sites of pathology in horses undergoing high or low intensity exercise, and to compare this composition between exercise groups.

DESIGN

Twelve horses (19.3+/-0.9 years) were assigned to exercise groups. Each group underwent 19 weeks high-intensity treadmill training (N=6) or low-intensity exercise (N=6). Dorsal and palmar test sites were identified on radial, intermediate and third carpal articular surfaces after euthanasia. Cartilage was collected from each site, freeze-dried and assessed for water content. Hydroxyproline, glycosaminoglycan and DNA analyses were performed on cartilage from each test site. Adjacent cartilage underwent histological preparation and assessment for chondrocyte numerical density at each site and proteoglycan distribution through the depth of cartilage.

RESULTS

Dorsal cartilage had a higher collagen content, DNA content, and chondrocyte numerical density, but lower glycosaminoglycan content than palmar cartilage. Cartilage from horses undergoing high-intensity training had a significantly higher glycosaminoglycan content than cartilage from horses undergoing low-intensity exercise, with maximal difference being observed in cartilage from dorsal radial and dorsal intermediate carpal articular surfaces. Overall no effect of exercise on collagen was observed, but at sites predisposed to clinical lesions cartilage from horses undergoing high-intensity training contained significantly less collagen than from horses undergoing low-intensity exercise. Distribution of proteoglycan was non-uniform in 52% of the sections examined, with superficial loss of toluidine blue staining primarily at dorsal sites and in the high-intensity exercise group.

CONCLUSIONS

These results indicate that topographical and exercise related differences exist in carpal cartilage composition, and that the effect of exercise on overall composition and distribution within the cartilage was maximal at sites predisposed to clinical lesions. These findings could indicate that the combined effect of exercise and local load variations within a joint may lead to a risk of exceeding the physiologic threshold at high load sites that are predisposed to clinical injury.

The distribution of cartilage oligomeric matrix protein (COMP) in equine carpal articular cartilage and its variation with exercise and cartilage deterioration

Based on previous studies where tendons receiving the most load have been shown to have the highest levels of cartilage oligomeric matrix protein (COMP), we hypothesized that COMP distribution in articular cartilage may be influenced by mechanical loading. This investigation aimed (a) to describe the pattern of COMP immunoreactivity in middle carpal joint cartilage of two-year-old Thoroughbred horses; (b) to determine topographical variations; (c) to compare high (group 1) and low (group 2) intensity training and (d) to describe COMP immunoreactivity at sites with early osteoarthritis. Group 1 (n =6) underwent a 19 week high-intensity treadmill training programme and group 2 (n =6) were given daily walking until euthanasia. Dorsal and palmar sites on radial and third carpal articular surfaces were prepared. Immunohistochemistry was performed with polyclonal rabbit anti-equine COMP antiserum using a biotin-streptavidin/peroxidase method. Results showed: (a) intracellular immunoreactivity was present in all cartilage zones, but the distribution of COMP staining within the matrix varied between cartilage zones; (b) differences in distribution between sites were not observed, but total COMP levels in exercised horses (n =2) did vary between sites with dorsal sites containing less COMP than palmar sites on the radial, intermediate and third carpal lateral facet; (c) group 1 cartilage showed marked interterritorial distribution in the deep layer compared to group 2 where staining was more generalized throughout the matrix and (d) fibrillated cartilage showed increased local immunoreactivity in the matrix. These findings demonstrate zonal variations in equine COMP distribution which may be influenced by loading.

Opposing effects of bone morphogenetic proteins on neuron production and survival in the olfactory receptor neuron lineage

In olfactory epithelium (OE) cultures, bone morphogenetic proteins (BMPs) can strongly inhibit neurogenesis. Here we provide evidence that BMPs also promote, and indeed are required, for OE neurogenesis. Addition of the BMP antagonist noggin inhibited neurogenesis in OE-stromal cell co-cultures. Bmp2, Bmp4 and Bmp7 were expressed by OE stroma, and low concentrations of BMP4 (below the threshold for inhibition of neurogenesis) stimulated neurogenesis; BMP7 did not exhibit a stimulatory effect at any concentration tested. Stromal cell conditioned medium also stimulated neurogenesis; part of this effect was due to the presence within it of a noggin-binding factor or factors. Studies of the pro-neurogenic effect of BMP4 indicated that it did not increase progenitor cell proliferation, but rather promoted survival of newly generated olfactory receptor neurons. These findings indicate that BMPs exert both positive and negative effects on neurogenesis, depending on ligand identity, ligand concentration and the particular cell in the lineage that is responding. In addition, they reveal the presence of a factor or factors, produced by OE stroma, that can synergize with BMP4 to stimulate OE neurogenesis.

A fragment of the Neurogenin1 gene confers regulated expression of a reporter gene in vitro and in vivo

The basic helix-loop-helix transcription factor neurogenin1 is required for proper nervous system development in vertebrates. It is expressed in neuronal precursors during embryonic development and is thought to play a role in specifying neuronal fate. To investigate the regulation of neurogenin1 expression, the transcriptional start site of the gene was identified and a 2.7-kb fragment ending in the first exon was shown to possess basal promoter activity. This 2.7-kb fragment was able to promote expression of reporter genes in P19 cells under conditions in which expression of endogenous neurogenin1 was induced. Importantly, the 2.7-kb fragment was able to drive expression of a lacZ reporter gene in transgenic mice in most tissues in which neurogenin1 is normally expressed, including those peripheral ganglia that fail to develop in neurogenin1 "knockout" mice. These findings identify a regulatory region containing elements responsible for appropriate expression of a gene with a crucial role in generating the vertebrate nervous system.

Mutations in the reduced-folate carrier affect protein localization and stability

The reduced-folate-carrier (rfc) gene has been shown to be functionally important for reduced-folate transport in mammalian cells. In the present paper we describe the identification of alterations in both alleles of the rfc gene in a mutant Chinese-hamster ovary cell line deficient in methotrexate transport. One allele of the rfc gene contains a point mutation resulting in a Gly(345)-->Arg substitution in the predicted amino acid sequence. In this case, a protein of similar size to the wild-type protein is produced, although it remains as an immature, core-glycosylated, form. The second allele contains a point mutation in the last base of intron 5 that results in the utilization of a cryptic splice site leading to a seven-base deletion in the mRNA. The use of an alternate splice site changes the reading frame to yield a truncated protein with 68 different C-terminal amino acids as compared with the wild-type. Both of these altered gene products were monitored by fusion with green fluorescent protein and found to be non-functional with an increased rate of turnover. The protein with the point mutation is trapped in the endoplasmic reticulum with subsequent degradation, whereas the product of the splice mutation is not membrane-associated and is partially degraded. Thus mutations in both alleles of the rfc gene in this resistant cell line account for the loss of reduced-folate transport. The observations made regarding the degradation of these mutant gene products also provide support for putative checkpoints in the endoplasmic reticulum.

Equine carpal articular cartilage fibronectin distribution associated with training, joint location and cartilage deterioration

Processes involved in equine carpal osteochondral injury have not been established. In other species, fibronectin appears important in chondrocyte-matrix interactions, and levels are increased in osteoarthritis. This investigation aimed to (a) describe fibronectin immunoreactivity in the middle carpal joint of 2-year-old Thoroughbreds, (b) determine topographical variations, (c) compare strenuously trained (Group 1) or gently exercised horses (Group 2) and (d) describe sites with early osteoarthritis. Group 1 (n = 6) underwent a 19 week high intensity treadmill training programme. Group 2 (n = 6) underwent 40 min walking until euthanasia. Dorsal and palmar sites on radial, intermediate and third carpal articular surfaces were prepared. Immunohistochemistry was performed using a biotin-streptavidin/peroxidase method. Cross-reactivity of rabbit antihuman fibronectin antiserum with equine fibronectin was confirmed using Western blotting. Results showed: (a) fibronectin was present primarily in pericellular and interterritorial matrix locations, (b) dorsal sites had zonal immunoreactivity compared to palmar sites, (c) Group 1 dorsal radial carpal cartilage had increased superficial staining compared to Group 2 and (d) fibrillated cartilage showed increased intracellular and local matrical immunoreactivity (superficial zone). These findings suggest topographical and exercise-related variations in fibronectin distribution, and indicate equine fibronectin is localised at sites of cartilage degeneration and released into the matrix by chondrocytes in the local area.

Exercise affects the mechanical properties and histological appearance of equine articular cartilage

Dorsal carpal osteochondral injury is a major cause of reduced performance in horses undergoing high-intensity training. It was hypothesised that the mechanical behaviour and histology of cartilage are influenced by the intensity of exercise and by location within a joint. Relationships between histology and mechanical behaviour were identified in 2-year-old horses undergoing 19 weeks of high-intensity treadmill training or low-intensity exercise and then compared between groups. Dorsal and palmar test sites were identified on radial, intermediate, and third carpal articular surfaces after euthanasia. The mechanical properties of cartilage were determined with an automated creep indentation apparatus as previously described for equine cartilage. Cartilage morphology was assessed with use of sections stained with haematoxylin and eosin and toluidine blue. Dorsal cartilage was less permeable, thinner, and had a loss of chondrocyte alignment compared with palmar cartilage. Cartilage from strenuously trained horses showed more fibrillation and chondrocyte clusters than did cartilage from gently exercised animals. Dorsal radial carpal cartilage and third carpal cartilage of strenuously trained animals were significantly less stiff than that from gently exercised animals, and the former had reduced superficial toluidine blue staining compared with that from the gently exercised group. These results indicate that topographical and exercise-related differences exist in the morphology and mechanical properties of carpal cartilage and suggest that strenuous training may lead to deterioration of cartilage at sites with a high clinical incidence of lesions.

An MRI study of the effect of treadmill training on bone morphology of the central and third tarsal bones of young thoroughbred horses

Training results in marked modelling of the subchondral bone of the carpus, but the effect of training on the subchondral bone of the distal tarsal joints is unknown. The aim of this study was to determine whether training influenced modelling of the third and central tarsal bones in Thoroughbred horses. Twelve untrained Thoroughbred horses were divided into 2 groups. Group 1 underwent a 19 week progressive training regimen on a high speed treadmill. Group 2 were walked for 40 min daily. Images of left tarsi were obtained by magnetic resonance imaging (MRI) with a 0.5 Tesla superconducting magnet using a spin echo sequence. Sagittal and oblique sagittal slices were made perpendicular to the articular surfaces of the intertarsal joints and were analysed using image analysis software to measure the proportion of dense subchondral bone in the dorsal facet of each bone. Mean +/- s.d. percentage area of dense subchondral bone in the dorsal facet of the central tarsal bone in Group 1 was 47 +/- 8 medially, 46 +/- 4 sagitally and 50 +/- 11 dorsolaterally, whereas in Group 2 it was 39 +/- 16 medially, 43 +/- 8 sagitally and 53 +/- 7 dorsolaterally. For the third tarsal bone mean +/- s.d. percentage area of dense subchondral bone in Group 1 was 32 +/- 10 medially, 39 +/- 11 sagitally and 44 +/- 8 dorsolaterally, whereas in Group 2 it was 28 +/- 8 medially, 37 +/- 6 sagitally and 41 +/- 9 dorsolaterally. There was no significant difference in percentage area of dense subchondral bone between the trained and untrained horses. An effect of treadmill training of Thoroughbred horses on modelling of the central and third tarsal bones could not be demonstrated.

The effect of training on the calcified zone of equine middle carpal articular cartilage

Carpal osteochondral injury is frequently observed in strenuously trained horses. It is clear that the integrity of articular cartilage and subchondral bone are intimately related, although there is controversy about which component is the most important. Calcified cartilage provides the mechanical link between soft hyaline cartilage and stiff subchondral bone so it is essential to understand the tissue's response to exercise. Middle carpal calcified and uncalcified (hyaline) cartilage thickness was investigated in horses undergoing high- and low-intensity exercise. Twelve untrained horses (18-21 months) were paired, and randomly assigned to an exercise group. Group 1 underwent 19 weeks progressive high-intensity training on a high-speed treadmill. Group 2 underwent walking exercise only. Osteochondral specimens were obtained from 8 test sites per carpus immediately after euthanasia. Histomorphometric measurements of total cartilage, hyaline layer, and calcified zone thickness were obtained from decalcified and undecalcified samples. Mean +/- s.d. (micron) calcified cartilage thickness for dorsal cartilage from Group 1 was 271 +/- 73 and from Group 2 was 163 +/- 49; for palmar cartilage from Group 1 was 195 +/- 42 and Group 2 was 150 +/- 52. Group 1 horses had significantly thicker total cartilage (P < 0.0001) and calcified zone (P < 0.0001) than Group 2, but there was no difference in hyaline layer. Within each group all dorsal sites had thicker calcified cartilage (P < 0.003) than palmar sites, but no difference in hyaline or total cartilage. These findings indicate that high-intensity exercise leads to greater calcified zone depth without alteration in hyaline cartilage thickness, and that this response is maximal at sites that withstand high, intermittent loads. Increasing calcified cartilage thickness with exercise may maintain the articular surface stiffness gradient in the face of alterations in hyaline cartilage and/or subchondral bone stiffness.

The effects of intra-articular methylprednisolone and exercise on the mechanical properties of articular cartilage in the horse

INTRODUCTION

Intra-articular corticosteroids are widely used as anti-inflammatory agents for symptomatic management of arthritis, but their administration with concurrent exercise remains controversial. Biochemical and morphologic analysis of treated cartilage has revealed conflicting results, but previous biomechanical assessment has not been undertaken.

OBJECTIVE

To compare the biomechanical properties of intra-articular methylprednisolone acetate (MPA) and diluent treated cartilage in treadmill exercised horses.

METHODS

Eight 2-year-old female horses had MPA or diluent administered into contralateral middle carpal joints at 14 day intervals for a total of four treatments per horse. Horses underwent a standard treadmill exercise protocol until euthanasia (day 70). Standard sites were tested on the third, radial and intermediate carpal bones using an automated indentation apparatus to obtain the creep and recovery behavior of the articular cartilage. Using previously validated biphasic creep indentation methodology, aggregate modulus, Poisson's ratio, permeability, shear modulus, thickness, creep and recovery equilibrium times and percent recovery were obtained at each site. Results were analyzed using ANOVA and multiple comparisons of the means (P < 0.05).

RESULTS

Cartilage intrinsic material properties and thickness demonstrated significant differences between MPA and diluent treated joints. Diluent treated cartilage had a 97% increase in compressive stiffness modulus (P = 0.0001), was 121% more permeable (P = 0.0001), had 88% increase in shear modulus (P = 0.0001), and was 24% thicker (P = 0.0001) than MPA treated articular cartilage.

CONCLUSIONS

The findings indicate that repetitive intra-articular administration of MPA to exercising horses alters the mechanical integrity of articular cartilage, which could lead to early cartilage degeneration.

Biomechanical comparison of the Herbert and AO cortical bone screws for compression of an equine third carpal bone dorsal plane slab osteotomy

OBJECTIVE

To assess feasibility of insertion of 4.5-mm Herbert cannulated bone screws (HS) using fluoroscopic guidance and compare the mechanical shear strength of these HS and 4.5-mm AO cortical bone screws (AO) for fixation of dorsal plane slab osteotomies in equine cadaver third carpal bones (C3).

ANIMALS OR SAMPLE POPULATION

Eight equine cadavers.

METHODS

Bone mineral composition and density of contralateral C3 were confirmed to be equivalent using dual-energy x-ray absorptiometry. A standard 10-mm C3 slab osteotomy was reduced using HS or AO instrumentation under fluoroscopic guidance. Specimens were loaded in shear until failure, using a materials testing apparatus.

RESULTS

HS and AO instrumentation allowed accurate reconstruction of the osteotomy, but there was difficulty encountered seating the HS proximal self-tapping threads. There was no significant difference in maximal load to failure, stiffness, or mode of failure of constructs created with the HS and AO screws.

CONCLUSIONS

Use of 4.5-mm HS for repair of C3 radial facet, dorsal plane slab fractures may result in a mechanically comparable fixation to a repair using a 4.5-mm AO. Equine dorsal C3 may be too dense, however, to allow placement of the proximal self tapping threads of the HS without potentially excessive application of torque to the screw itself.

CLINICAL RELEVANCE

Dorsal plane, radial facet slab fractures of the equine C3 are a significant clinical problem. Accurate reconstruction and stabilization are necessary for return to athletic function.

Structural organization of the reduced folate carrier gene in Chinese hamster ovary cells

The reduced folate carrier gene (rfc) encodes a putative protein that is involved in the intracellular accumulation of folates. In this report, we describe the organization of the rfc gene from Chinese hamster ovary cells. The hamster rfc gene contains 7 exons and 6 introns, which span 15.3 kilobases. It codes for two alternatively spliced messenger RNAs, one that contains all 7 exons and one that lacks exon 2 but contains the remaining 6 exons. The transcriptional start of the gene has been mapped to six sites approximately 200 base pairs upstream of the putative ATG initiation codon. The promoter region has no TATA box-like sequence but contains a consensus Sp1 binding site. This is the first report of the genomic structure of the reduced folate carrier gene from any species.

Application of a hook plate for management of equine ulnar fractures

Closed fractures of the proximal aspect of the ulna were repaired in 10 horses younger than or equal to 6 months of age by application of a hook plate using a tension band principle. Ulnar fractures were classified as type 1A (2 horses), type 1B (4 horses), type 2 (1 horse), type 3 (1 horse), and type 4 (2 horses); all fractures had displacement of a proximal fragment. Complications were implant deformation (4 horses), screw pullout (1 horse), osseous sequestration (1 horse), ulnar fracture through a hole used to apply a tension device (1 horse), and metacarpophalangeal deformity associated with a displaced anconeal fragment (1 horse). Hook deformation was likely associated with failure to insert screws in all of the proximal holes of the plate and also in two horses, possibly with difficult recovery from anesthesia. Seven horses were discharged from the hospital and were being used for athletic activities. Insertion of the hook through the tendon of the triceps muscle and incorporation of the fragment within the hook can be used to effectively reduce and stabilize a fragment that might otherwise not hold screws.

A Modular Steel Freeway Bridge: Design Concept and Earthquake Resistance

A modular multilane steel freeway bridge has been constructed from surplus railroad flatcar decks. It can be erected on-site in a few days' time. It has been built and static-load tested for emergency freeway bridge repair. This inexpensive modular bridge may also have broad application around the world for low-cost bridges in areas where funds are limited. On the basis of static-load testing performed by the California Department of Transportation and computer dynamic analysis, this simple modular-design concept has the potential of providing a strong bridge that can withstand the severe aftershocks expected immediately after a major earthquake.

Primary pulmonary germ cell tumor with blastomatous differentiation

We describe the clinical and pathologic findings of a patient with mixed blastoma-germ cell malignancy primary in the lung. Serum alpha-fetoprotein levels were elevated at presentation, and normalized with anti-germ cell chemotherapy. The resection specimen contained massively necrotic germ cell tumor with viable mature neural tissue, plus viable biphasic blastoma with stromal bone and skeletal muscle differentiation. It is not clear whether the germ cell component represents unusual differentiation of a somatic cell line or whether the blastoma component represents an unusual pattern of teratomatous differentiation.

Acute effects of perineural administration of sodium hyaluronate on palmar digital neurectomy sites in horses

Biaxial palmar digital neurectomy of all limbs was performed on 6 mixed-breed castrated adult male horses, using a standard guillotine method. Using a Teflon catheter, 20 mg (2 ml) of sodium hyaluronate (group 1), 2 ml of phosphate-buffered saline solution (group 2), or catheter placement with no infusion (group 3) was applied to 4 (group 1) or 2 (groups 2 and 3) of 8 incisions/horse. Treatments were administered after closure of the neurectomy incision, and the catheter was removed. Horses were evaluated daily for 1 week, then weekly over a 9-week period for evidence of lameness, swelling, and ultrasonographic changes. On week 9, horses were euthanatized and neurectomy sites were removed en bloc for histologic evaluation of axonal regrowth, inflammation, and fibrosis. Neither lameness nor sign of painful neuroma was observed clinically in any of the horses. Neurectomy eliminated cutaneous heel sensation in all limbs for the duration of the study. Swelling was evident at all neurectomy sites. There were no significant differences between treatment sites for measurement of pastern circumference or ultrasonographic evaluation of incisional swelling. Foci of ultrasonographic hyperechogenicity increased over time, but there was no significant difference in hyperechogenicity between treatment groups. Histologic evidence of neuroma formation was observed at all sites. Morphometric assessment of neuroma cross-sectional areas revealed no significant difference between the groups, as did subjective histologic assessment of neuroma density and fibrous tissue content.(ABSTRACT TRUNCATED AT 250 WORDS)

Isolation of a hamster cDNA clone coding for a function involved in methotrexate uptake

A clone has been isolated from a Chinese hamster ovary cell cDNA expression library that complements mutant cells defective in the uptake of the folate analogue methotrexate. When transfected with this clone, the mutant cells regain the ability to bind and transport the drug and, as a consequence, become sensitive to its cytotoxic action. The clone is 2314 base pairs long and has an open reading frame of 1557 base pairs that codes for a putative protein of 58 kDa. This novel putative protein has a high content of hydrophobic residues and has a large part of its predicted secondary structure in the form of beta-sheets. In the wild-type cell line and in one of the mutant cell lines, this clone detects an mRNA of 2.5 kilobases, while in another mutant cell line, this message is absent. The data are consistent with this clone encoding either the reduced folate transporter or an auxiliary function that interacts with this transporter. This is the first report of a cDNA coding for a function, other than folate-binding protein, that is involved in the transport of methotrexate.

Incarceration of the jejunum in the epiploic foramen of a four month old foal

A 4-month Arabian filly presented for abdominal pain of 30 hours duration was found to have tachycardia, tachypnea, congested mucous membranes and gross abdominal distension. Further examination disclosed gastric reflux and small intestinal distension. Dehydration, prerenal azotemia, electrolyte abnormalities and metabolic alkalemia were observed. There was a progressive nonresponse to analgesic medication and deterioration in the foal's physiologic condition consistent with a small intestinal strangulating obstruction. Surgical exploration was declined. Necropsy examination revealed incarceration of the mid-jejunum in the epiploic foramen with proximal jejunal distension. This case is remarkable as the first report of entrapment of the jejunum in the epiploic foramen of a young foal.

Pulsion diverticulum of the cranial cervical esophagus in a horse

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Molecular cloning of a gene involved in methotrexate uptake by DNA-mediated gene transfer

A methotrexate-resistant Chinese hamster ovary cell line deficient in methotrexate uptake has been complemented to methotrexate sensitivity by transfection with DNA isolated from a wild-type Chinese hamster ovary genomic cosmid library. Primary and secondary transfectants, which contain a limited number of cosmid sequences, have been shown to regain methotrexate sensitivity and to take up methotrexate. Furthermore, the DNA from three cosmid clones, isolated from a primary methotrexate-sensitive transfectant, after transfection rescued the methotrexate-resistant phenotype at a high frequency. Restriction endonuclease analysis of the DNA of these cosmid clones indicated that they overlapped extensively and shared two regions of Chinese hamster ovary DNA of 6.6 kb and 20.6 kb. These observations indicate that a gene involved in methotrexate uptake is contained in its entirety within one of these regions. This is the first report of the functional molecular cloning of a gene involved in methotrexate uptake. A general strategy is also described for screening large cosmid libraries from primary transfectants.