Co-managed care for fragility hip fractures (Rochester model)

Hip fractures in older adults are a common event with a high risk of morbidity and mortality. Patients who sustain a hip fracture often present with multiple co-morbid conditions that can benefit from co-management by orthopedic surgeons and geriatricians. This manuscript describes a co-managed model of care for patients with hip fractures. This model of care will be explained, and the benefits and results will be described. Retrospective review of the care of all native non-pathological hip fracture patients aged 60 years and older admitted between April 2005 and March 2009 to a 261-bed community teaching hospital. The outcome measures include patient characteristics, length of stay, mortality, 30-day readmission, re-operation, and costs of care. Seven hundred fifty-eight patients were identified with an average age of 84.8 (SD 8.4); 77.8% of the patients were female, 94.7% Caucasian, and 37.3% from nursing homes, and the mean Charlson score is 2.9 (SD 2.1). The length of stay was 4.3 days, 30-day readmission rate was 10.4%, 17-month re-operation rate was 1.9%, and costs of care to the system were $15,188. The 1-year mortality rate was 21.2%. This model of care resulted in improvements in all measures studied. Previous studies have shown reduction in in-hospital complications. Additional studies are needed to show if this model of care can be translated to other systems or to other surgical conditions. Wide application of this model care could substantially improve the quality of care and cost of caring for frail elders with hip fractures.

Ortho-geriatric service--a literature review comparing different models

In the fast-growing geriatric population, we are confronted with both osteoporosis, which makes fixation of fractures more and more challenging, and several comorbidities, which are most likely to cause postoperative complications. Several models of shared care for these patients are described, and the goal of our systematic literature research was to point out the differences of the individual models. A systematic electronic database search was performed, identifying articles that evaluate in a multidisciplinary approach the elderly hip fracture patients, including at least a geriatrician and an orthopedic surgeon focused on in-hospital treatment. The different investigations were categorized into four groups defined by the type of intervention. The main outcome parameters were pooled across the studies and weighted by sample size. Out of 656 potentially relevant citations, 21 could be extracted and categorized into four groups. Regarding the main outcome parameters, the group with integrated care could show the lowest in-hospital mortality rate (1.14%), the lowest length of stay (7.39 days), and the lowest mean time to surgery (1.43 days). No clear statement could be found for the medical complication rates and the activities of daily living due to their inhomogeneity when comparing the models. The review of these investigations cannot tell us the best model, but there is a trend toward more recent models using an integrated approach. Integrated care summarizes all the positive features reported in the various investigations like integration of a Geriatrician in the trauma unit, having a multidisciplinary team, prioritizing the geriatric fracture patients, and developing guidelines for the patients' treatment. Each hospital implementing a special model for geriatric hip fracture patients should collect detailed data about the patients, process of care, and outcomes to be able to participate in audit processes and avoid peerlessness.

Indoleamine 2,3-dioxygenase, an emerging target for anti-cancer therapy

The inability of the host immune system to control tumor growth appears to result from dominant mechanisms of immune suppression that prevent the immune system from effectively responding in a way that consistently results in tumor rejection. Among the many possible mediators of tumoral immune escape, the immunoregulatory enzyme, indoleamine 2,3-dioxygenase (IDO), has recently gained considerable attention. IDO is a heme-containing, monomeric oxidoreductase that catalyzes the first and rate-limiting step in the degradation of the essential amino acid tryptophan to N formyl-kynurenine. Tryptophan depletion as well as the accumulation of its metabolites results in a strongly inhibitory effect on the development of immune responses by blocking T cell activation, inducing T cell apoptosis and promoting the differentiation of naïve T cells into cells with a regulatory phenotype (T(regs)). Recent data obtained from preclinical tumor models demonstrate that IDO inhibition can significantly enhance the antitumor activity of various chemotherapeutic and immunotherapeutic agents. These results, coupled with data showing that increased IDO expression is an independent prognostic variable for reduced overall survival in cancer patients, suggest that IDO inhibition may represent an effective strategy to treat malignancies, either alone or in combination with chemotherapeutics or other immune based therapies. This review will focus on the role of IDO as a mediator of peripheral immune tolerance, evidence that IDO becomes dysregulated in human cancers, and the latest progress on the development of IDO inhibitors as a novel anti-cancer therapy.

Bone growth in nonorganic nutritional dwarfing rats

Since no data are available to characterize mandibular growth in nonorganic nutritional dwarfing (ND), the purpose of the present study was to describe the effects of a diet on mandible and femur growth in a nutritional dwarfish animal model. Male Wistar rats were divided into two groups of 10 animals each: Control (C) and Experimental (E80: diet-restricted group). C rats were fed a standard diet ad libitum. E80 rats received 80% of the amount of standard diet eaten by group C. Food intake and body weight (Wt) and length (Lt) were recorded periodically. Growth data (Wt and Lt) were expressed as a Z-score of weight-for-length (WLZ) ratio, an index of body size. Five animals of each group were selected at random at 4 and 8 weeks and sacrificed. Additionally at t = 0, 5 animals were sacrificed for baseline measurements. Mandibular growth was estimated directly on the right mandible by measuring ten dimensions. Femur growth was estimated from Wt and Lt measurements of the bone. Mandibular weight, area, length and height were negatively affected by dietary restriction during the first 4 weeks of the experimental period. Mandibular growth ceased after this point. Dimensions corresponding to the alveolar unit did not change with time. However, all other dimensions were negatively influenced but not to the same extent. Femur rather than mandibular weight was severely affected. Therefore, the negative effects of the nutritional stress that occurs after weaning would be stronger for the femur, than for the mandible. Femur length was also negatively affected by suboptimal nutrition. In summary, the results of the present study showed that mandible and femur growth respond differently to mild chronic food restriction. These observations could be explained in terms of the different critical bone growth periods and of the time at which nutritional stress was imposed.

Role of crevice in the occurrence of hemoglobin in saliva

The aim of the present study was to analyze the role of the gingival-periodontal component in the presence of blood in saliva. We studied a population of 184 adult patients composed of 101 totally edentulous patients with no oral mucosa lesions and 83 dentulous patients with clinically healthy gums. Saliva samples obtained by spontaneous salivation were collected in sterile containers. Qualitative and quantitative evaluation of each of the samples was performed. 67% of the dentulous patients tested positive for hemoglobin in saliva. None of the patients in the totally edentulous group exhibited hemoglobin in saliva. These data suggest that the periodontal condition is an essential factor for the presence of hemoglobin in saliva.

Biology of TACE inhibition

Studies conducted over the past decade have demonstrated a central role for tumour necrosis factor alpha (TNFalpha) in inflammatory diseases. As a result of this work, a number of biological agents that neutralise the activity of this cytokine have entered the clinic. The recent clinical data obtained with etanercept and infliximab highlight the relevance of this strategy. TNFalpha converting enzyme (TACE) is the metalloproteinase that processes the 26 kDa membrane bound precursor of TNFalpha (proTNFalpha) to the 17 kDa soluble component. Although a number of proteases have been shown to process proTNFalpha, none do so with the efficiency of TACE. A series of orally bioavailable, selective, and potent TACE inhibitors are currently in clinical development. These inhibitors effectively block TACE mediated processing of proTNFalpha and can reduce TNF production by lipopolysaccharide stimulated whole blood by >95%. Through a series of studies it is shown here that >80% of the unprocessed proTNFalpha is degraded intracellularly. The remainder appears to be transiently expressed on the cell surface. Although, in vitro, TACE inhibition has also been implicated in shedding of p55 and p75 surface TNFalpha receptors, the in vivo data cast doubt on the consequences of this finding. In a mouse model of collagen-induced arthritis, the inhibitors are efficacious both prophylactically and therapeutically. The efficacy seen is equivalent to strategies that neutralise TNFalpha. In many studies greater efficacy is observed with the TACE inhibitors, presumably owing to greater penetration to the site of TNFalpha production.

Photochemically enhanced binding of small molecules to the tumor necrosis factor receptor-1 inhibits the binding of TNF-alpha

The binding of tumor necrosis factor alpha (TNF-alpha) to the type-1 TNF receptor (TNFRc1) plays an important role in inflammation. Despite the clinical success of biologics (antibodies, soluble receptors) for treating TNF-based autoimmune conditions, no potent small molecule antagonists have been developed. Our screening of chemical libraries revealed that N-alkyl 5-arylidene-2-thioxo-1,3-thiazolidin-4-ones were antagonists of this protein-protein interaction. After chemical optimization, we discovered IW927, which potently disrupted the binding of TNF-alpha to TNFRc1 (IC(50) = 50 nM) and also blocked TNF-stimulated phosphorylation of Ikappa-B in Ramos cells (IC(50) = 600 nM). This compound did not bind detectably to the related cytokine receptors TNFRc2 or CD40, and did not display any cytotoxicity at concentrations as high as 100 microM. Detailed evaluation of this and related molecules revealed that compounds in this class are "photochemically enhanced" inhibitors, in that they bind reversibly to the TNFRc1 with weak affinity (ca. 40-100 microM) and then covalently modify the receptor via a photochemical reaction. We obtained a crystal structure of IV703 (a close analog of IW927) bound to the TNFRc1. This structure clearly revealed that one of the aromatic rings of the inhibitor was covalently linked to the receptor through the main-chain nitrogen of Ala-62, a residue that has already been implicated in the binding of TNF-alpha to the TNFRc1. When combined with the fact that our inhibitors are reversible binders in light-excluded conditions, the results of the crystallography provide the basis for the rational design of nonphotoreactive inhibitors of the TNF-alpha-TNFRc1 interaction.

Differential regulation of IL-1beta and TNF-alpha RNA expression by MEK1 inhibitor after focal cerebral ischemia in mice

Activation of the extracellular-signal-responsive kinase (ERK 1/2) by MAP kinase/ERK kinase (MEK1/2) following ischemia/reperfusion in the brain has been associated with cell death since inhibition of MEK1/2 provides neuroprotection in cerebral ischemia injury. Since inflammation has been implicated in ischemic brain injury, the present study investigated whether MEK1/2 modifies expression of two key inflammatory cytokines, IL-1beta and TNFalpha, that have been shown to exacerbate ischemic brain injury. A mouse model of transient cerebral ischemia was deployed to test the effect of selective MEK1/2 inhibitor (SL327) on infarct size and cytokine expression. SL327 (100 mg/kg, i.p.) administered 15 min prior to ischemia resulted in 64% reduction in infarct size over controls (n = 8, P < 0.01). Under the same condition, SL327 significantly reduced peak expression of IL-1beta mRNA (59% reduction compared to vehicle, P < 0.01, n = 4) but not TNF-alpha mRNA. A parallel reduction in IL-1beta protein (67%, P < 0.05, n = 6) was also observed using ELISA analysis. These data suggest that the neuroprotective effect of MEK1/2 inhibition may be mediated by suppression of IL-1beta. The study also demonstrates for the first time that these two cytokines are differentially regulated by kinase mediated signaling pathways.

Mutation in the DNA gyrase A Gene of Escherichia coli that expands the quinolone resistance-determining region

In three Escherichia coli mutants, a change (Ala-51 to Val) in the gyrase A protein outside the standard quinolone resistance-determining region (QRDR) lowered the level of quinolone susceptibility more than changes at amino acids 67, 82, 84, and 106 did. Revision of the QRDR to include amino acid 51 is indicated.

Growth deceleration and bone metabolism in nutritional dwarfing rats

Nutritional status as well as energy and protein intake are critical regulators of IGF-1 and IGFBP-3 and contribute to the modulation of bone remodeling and formation. The purpose of this study was to investigate on an experimental model with nutritional dwarfing (ND), whether the alterations on body growth velocity, energy metabolism and body composition could affect serum concentrations of IGF-1 and IGFBP-3 and bone (tibiae and mandible) histology and histomorphometry. Twenty-one male weanling Wistar rats (body weight = 38.20 +/- 0.94 g) were randomized to three groups: seven of them were killed at day = 0 (CO, n = 7); control (C, n = 7); and experimental 80 (E80, n = 7). During 4 weeks, C was fed ad libitum with a 1:1 carbohydrate to fat diet. E80 was being underfed with the same diet by 80% and the following parameters were measured: weight (Wt) for length (L) ratio z-score; oxygen consumption (VO2); body composition (BC) by EM-SCAN SA 3000. At t = 28, E80 and C were killed. Serum IGF-1 and IGFBP-3 and bone histology and histomorphometry were performed on C0, E80 and C. E80 showed Wt for L z-score between lean and adequate, a decrease in VO2 according to body proportions, a BC of a delayed puberty individual, IGF-1 and IGFBP-3 decreased by 56 and 53%, respectively. Tibiae's hematopoyetic and adipose bone marrow areas were combined, with sealing trabeculae on metaphyseal areas. This study suggests that there is a relationship among growth deceleration in ND rats and structural alterations on tibiae.

Ocular findings in aplastic anemia

OBJECTIVE

To analyze the ocular findings in aplastic anemia.

DESIGN

Eighteen patients with aplastic anemia were examined.

RESULTS

Ocular findings included cotton wool spots (38%), nerve fiber layer or preretinal hemorrhages (67%), vitreous hemorrhages (13%), a picture resembling central retinal vein occlusion (13%) and optic disk edema (6%). Preretinal hemorrhages were the presenting sign of aplastic anemia in 2 patients (13%).

CONCLUSIONS

A blood profile is needed in patients with unexplained retinal hemorrhages. Patients with aplastic anemia need to avoid ocular massage and Valsalva maneuvers to decrease ocular morbidity.

The development of the inventory of countertransference behavior

A measure was developed to assess supervisor-perceived countertransference (CT) behavior during counseling sessions. Eleven experts provided face validity for the items, indicating that each item was at least somewhat an expression of countertransference. Exploratory factor analysis of ratings of 126 supervisors of supervisee counseling sessions revealed, as expected, the existence of two factors. However, rather than reflecting the dimensions of overinvolvement and underinvolvement as hypothesized, the factors were better captured by the terms Negative Countertransference and Positive Countertransference. The total scale and each subscale demonstrated high internal consistency. In addition, both positive and negative CT were found to relate positively with an existing one-item index of countertransference behavior and negatively with an existing measure of countertransference management ability. Research and clinical implications are discussed.

Choroidal neovascular membranes: reproducibility of angiographic interpretation

PURPOSE

To determine interobserver agreement for classifying choroidal neovascular membranes in age-related macular degeneration.

METHODS

Six fluorescein angiograms of choroidal neovascular membranes were interpreted by 21 retina specialists. Reliability was measured by percent agreement and kappa coefficient.

RESULTS

Interobserver agreement of membrane types ranged from perfect concordance for a small, classic membrane to near-random classification for a complex pattern. Mean kappa coefficient was.64. Interobserver agreement of membrane size was most variable for intermediate size lesions (mean kappa coefficient =.40).

CONCLUSION

Fluorescein angiographic interpretation of choroidal neovascular membrane type and size can vary considerably. Interobserver agreement is better for membrane type than for membrane size.

The development of the inventory of countertransference behavior

A measure was developed to assess supervisor-perceived countertransference (CT) behavior during counseling sessions. Eleven experts provided face validity for the items, indicating that each item was at least somewhat an expression of countertransference. Exploratory factor analysis of ratings of 126 supervisors of supervisee counseling sessions revealed, as expected, the existence of two factors. However, rather than reflecting the dimensions of overinvolvement and underinvolvement as hypothesized, the factors were better captured by the terms Negative Countertransference and Positive Countertransference. The total scale and each subscale demonstrated high internal consistency. In addition, both positive and negative CT were found to relate positively with an existing one-item index of countertransference behavior and negatively with an existing measure of countertransference management ability. Research and clinical implications are discussed.

Mixed lens opacities and subsequent mortality

BACKGROUND

Previous studies have found an association between cataract or lens opacity and increased risk of mortality. Further work on determining explanatory factors for this association is needed.

OBJECTIVES

To determine, in a population-based cohort of older persons, the 2-year risk of death associated with different types of lens opacities; whether an association of mortality and lens opacity is explained by confounding risk factors such as smoking, diabetes, age, race, and sex, which are known to be related to opacity and mortality; whether lens opacity is a marker for health status; and whether there are differences in cause-specific mortality for persons with and without lens opacity.

MAIN OUTCOME MEASURE

Two-year mortality rate.

METHODS

The Salisbury Eye Evaluation Project consists of a random sample of 2520 residents of Salisbury, Md, aged 65 to 84 years. At baseline, lens photographs were taken to document nuclear, cortical, posterior subcapsular cataract, and mixed opacities. Data on education, smoking, alcohol use, hypertension, diabetes and other comorbid conditions, handgrip strength, and body mass index were also collected. Two-year follow-up was conducted for mortality and cause of death.

RESULTS

Nuclear opacity, particularly severe nuclear opacity, and mixed opacities with nuclear were significant predictors of mortality independent of body mass index, comorbid conditions, smoking, age, race, and sex (mixed nuclear: odds ratio, 2.23; 95% confidence interval, 1.26-3.95).

CONCLUSION

Lens opacity status is an independent predictor of 2-year mortality, an association that could not be explained by potential confounders.

Overexpression of the cat-86 gene is associated with thermosensitivity in Bacillus subtilis

Bacillus subtilis harboring the cat-86 constitutive plasmid pPL708C2 with an ochre mutation at the 9th codon (terc 9) was sensitive to chloramphenicol (Cm(s)) and exhibited relative thermostability when heated at 47 degrees C. Reversion to chloramphenicol resistance (Cm(r)) occurred at a frequency of 5.4 x 10(-8). All of the plasmid Cm(r) revertants tested were thermosensitive. Similarly, wild-type pPL708C2 present in B. subtilis also rendered the bacterium thermosensitive. When a nonsense mutation is introduced at codon 141, however, this terc 141 variant of pPL708C2 failed to thermosensitize B. subtilis. Another variant of pPL708C2 that produces intact yet catalytically inactive CAT-86 has both His-16 and His-17 at the active site replaced by Pro. Nevertheless, cells of B. subtilis carrying this variant were thermosensitive. Plasmid-free and pPL708C2-bearing strains did not exhibit differences in major heat shock proteins. Electron micrographs revealed a threefold increase of inclusion bodies present in a strain harboring pPL708C2 when compared with those in an isogenic plasmid-free strain.

Proliferative response of mantle cell lymphoma cells stimulated by CD40 ligation and IL-4

Mantle cell lymphoma (MCL) is a tumor of intermediate-size, IgM+, IgD+ B cells derived from the mantle zone of the germinal center. Little is known about its specific immunologic features or responsiveness to T cell-derived signals. In this work, we evaluated the proliferation and cell cycle properties of freshly isolated MCL cells after CD40 ligation, in the absence and presence of interleukin 4 (IL-4). In each MCL case examined, there was a marked growth-enhancing effect of these two stimuli characterized by improved viability, augmented expression of Ki-67, and induction of the proliferating cell nuclear antigen (PCNA). Cyclin D1 was expressed throughout the cell cycle in MCL cells induced to enter S phase. From these investigations, we conclude that the biology of MCL B lymphocytes is affected by CD154 (CD40 ligand) and IL-4, two signals usually provided by CD4+ T cells. The capacity to manipulate the activation and cell cycle state of MCL cells by these specific immunological stimuli may be exploited to confer susceptibility to chemotherapy agents and develop novel therapies in this disease.

Optic nerve avulsion secondary to a basketball injury

Optic nerve avulsion secondary to a basketball injury is a rare complication. The patient underwent a vitrectomy for a non-clearing vitreous hemorrhage. The nerve was partially avulsed with multiple choroidal ruptures in the fovea. It was concluded that optic nerve disorders rarely occur after basketball injuries. Patients with a dense vitreous hemorrhage may benefit from a vitrectomy although the vision will be limited by the optic nerve disorder.

A comparison of job satisfaction among nursing assistants in nursing homes and the Program of All-inclusive Care for the Elderly (PACE)

Three hundred forty-nine full-time nursing assistants (NAs) in 5 PACE programs and their neighboring nursing homes were surveyed to assess job satisfaction. There were no significant differences between NAs in the two models of care with respect to demographics, job description, or importance placed on job elements. Job satisfaction, however, was higher among the PACE NAs. PACE NAs reported a significantly higher prevalence of the chance to form close relationships with patients, variety, respect for suggestions by people who make decisions about patient care, the chance to use one's own judgment, the chance to discuss patients with other team members, and respect for choices in assignment type.

[Assessment of normal growth patterns in rats by Z score]

Malnutrition is one of the most important causes of normal growth disruption. Anthropometric methods are highly valuable in clinic pediatric diagnosis to determine the nutritional status of children and as recovery monitoring. In previous studies, we have demonstrated that the standards weight-age, height-age and weight-height of growing rats had similar distribution to those in normal children. However, to improve the diagnostic effectiveness of anthropometric information, statistical analysis to normally and non-normally distributed variables should be applied. One hundred Wistar rats (50 male and 50 female rats) from weaning (day = 25, weight = 35-40 g) to 70 days of age were fed with a commercial diet. Water and diet were offered "ad libitum". Body weight and height were recorded every two or four days, respectively. Percentiles of weight vs age, height vs age and weight vs height were plotted for male and female rats. The statistical criterion for classifying the anthropometric measurements into nutritional categories was based on percentiles cutoff and Z-score. The Z-score was calculated according to: Z = (standard mean value-subject value/standard deviation of standard). The statistical anthropometric categories of growing rats were similar to those obtained in children. This evidence suggest that the rat can be used as an experimental model to infer and predict the nutritional response in children.

Impact of community volunteers on immunization rates of children younger than 2 years

OBJECTIVE

To assess the effectiveness of a volunteer-driven outreach program on immunization rates in children younger than 2 years.

DESIGN

Randomized controlled trial.

SETTING

Pediatric ambulatory clinics in New York, NY.

PATIENTS

A total of 163 children were randomly assigned to receive services from the volunteer-driven outreach program or to serve as control subjects. All children were (1) younger than 2 years, (2) no-shows for a scheduled appointment in the pediatric clinic, and (3) due or overdue for a vaccine.

INTERVENTION

Immunization outreach, tracking, and follow-up were provided by community volunteers throughout follow-up (mean, 6.5 months). Control children were notified of immunization status at enrollment but received no further contact until the conclusion of follow-up (mean, 6.4 months).

MAIN OUTCOME MEASURE

Immunization status 6 months after enrollment.

RESULTS

Significantly more intervention children were up-to-date with their vaccination series than controls (75% vs. 54%; P = .03). Children in the control group were 2.8 times more likely to be late for a vaccine than intervention children (odds ratio = 2.8; P = .02). In addition, an immunization delay of longer than 30 days at enrollment was a significant predictor of final immunization delay (odds ratio = 2.6; P = .02).

CONCLUSIONS

This volunteer-driven program significantly improved immunization rates among intervention children compared with controls. Results confirm previous findings that indicate an increased risk of an incomplete immunization series by 2 years of age among children who fall behind early in their primary vaccination series. However, control children were almost 3 times more likely to be late (for > or =1 vaccines) than intervention children, regardless of whether an earlier immunization delay was present.

Characteristics of discrepancies between self-reported visual function and measured reading speed. Salisbury Eye Evaluation Project Team

PURPOSE

Visual impairment is a risk factor for morbidity in the elderly and is often screened for by self-report. This study evaluates whether there are subsets for whom there is a discrepancy between self-reported and measured function.

METHODS

The prevalence of a discrepancy between self-reported difficulty reading a newspaper and measured reading speed was determined in 2520 community-based men and women, aged 65 to 84 years, and the discrepant group characterized by polychotomous regression.

RESULTS

Of subjects who reported minimal difficulty reading a newspaper, 10.8% (227/2107) read newsprint-sized text (0.21 degrees) more slowly than 80 words/min, a level previously shown to be necessary for sustained reading. Poor visual acuity, presence of psychiatric symptoms, and less satisfaction with vision were associated with being in the group that read slowly and reported difficulty with reading. Better cognition, better visual acuity, more years of education, white race, and fewer psychiatric symptoms were associated with being in the group that read more quickly and reported minimal difficulty. When reading the text size at which subjects read their fastest, only 2.6% of those with minimal difficulty remained discrepant. These individuals were more likely to have less education, be male, be African American, and have poorer cognitive status than those who did not remain discrepant.

CONCLUSIONS

A subset of the elderly population have a substantial discrepancy between self-reported reading difficulty and measured reading speed. In some, this discrepancy may be based on underlying expectations and experiences, and in others it may represent a transition from no visual impairment to visual impairment.

[Nutrition dwarfism: longitudinal analysis of anthropometric and metabolic parameters in rats]

Nutritional dwarfing (ND) is the result of nonorganic causes reflective of a voluntary or unintentional reduction in food intake, inappropriate eating behavior, dissatisfaction with body weight or unhealthy approaches toward weight control. Patients with ND have reached an equilibrium between their genetic growth potential and their nutritional intake. This study was undertaken to compare on a growing rat model the metabolic alterations in terms of substrate utilization (SU), oxygen consumption (VO2) and growth rate velocity. Twenty male weanling Wistar rats were randomized to 3 groups: control (C), experimental 4 (E4) and 8 (E8). C was fed "ad libitum" with a stock diet, E4 and E8 were underfed by 80% of the requirements during four or eight weeks, respectively. During the depletion phase the following measurements were performed: 1a) body weight (Wt), 1b) length, 1c) Weight for Length ratio z-score, 2) Body composition (BC) by EM-SCAN Tobec Model 3 000, Springfield. USA, 3) VO2 by indirect calorimetry, ECO-OXYMAX.

RESULTS

1) wt for length was -0.70 +/- 0.43 for E4 (t = 4 weeks) and 1.44 +/- 0.32 for E8 (t = 8 weeks), 2% of fat mass was within the normal range, 3) VO2 was not significantly different between groups. Chronic suboptimal nutrition (80%) decreased growth velocity which was the sole manifestation of nutritional inadequacy.

Chronic lymphocytic leukemia B cells can express CD40 ligand and demonstrate T-cell type costimulatory capacity

Chronic lymphocytic leukemia (CLL) is characterized by a clonal expansion of CD5(+) B cells in the peripheral blood. Associated immune aberrations include abnormal Th-cell function and pathogenic autoantibodies. Under most circumstances, CLL B cells do not proliferate in culture and express a limited repertoire of surface antigens, including CD19, CD20, CD23, CD27, CD40, and CD70. In this report, we demonstrate that freshly isolated B cells from a subset of CLL cases constitutively express CD40 ligand (CD40L, CD154), a member of the tumor necrosis factor family which is normally expressed by activated CD4(+) T cells and mediates T-cell-dependent B-cell proliferation and antibody production. The degree of CD40L expression varied considerably among the CLL cases examined. CD40L was detected in purified CLL B cells by immunofluorescence flow cytometry, by RT-PCR, and by immunoprecipitation. To demonstrate that CD40L in the CLL B cells is functional, we used irradiated CLL cells to stimulate IgG production by target, nonmalignant B cells in coculture. The CLL B cells induced IgG production by normal B cells to a similar degree as did purified T cells in a process which was partially inhibited by monoclonal antibody to CD40L. This is one of the first reports of CD40L expression in a B-cell tumor. The data suggest that CD40L in the tumor cells may be a factor in the generation of pathologic antibodies by normal B cells in some patients with CLL.

CD40 ligation impedes lymphoblastoid B cell proliferation and S-phase entry

The CD40 cell surface antigen and member of the tumor necrosis factor (TNF) receptor superfamily is expressed in many cell types, including normal and neoplastic B cells. Signaling through CD40 induces B cell proliferation, differentiation and, in some circumstances, protects the B cell from apoptosis. Lymphoblastoid cells (LCLs) resemble the malignant B cells that comprise the Epstein-Barr virus (EBV)-associated posttransplant lymphoproliferative disorders, in that the cells bear a highly activated phenotype and, unlike most other EBV positive tumor cells, express the majority of latent EBV genes. In this study, we use assays of cell viability, proliferation, cell cycle and apoptosis to demonstrate that ligation of the CD40 receptor in EBV-transformed LCLs inhibits their growth. The process does not involve apoptosis, but is characterized by reduced S-phase entry from G0/G1. A better understanding of the negative effects of CD40 ligation in these cells may offer clues for the development of novel therapies in EBV-related B cell disorders.

Influence of dietary calcium concentration on body size and bone composition in rats during recovery from malnutrition

OBJECTIVE

The purpose of our study was to assess the influence of different levels of calcium (Ca) in a diet containing 30% protein on the rehabilitated of the body size from protein-energy malnutrition (PEM) and to establish the optimal Ca/protein ratio for attaining a normal body composition.

METHODS

Weanling female Wistar rats were fed with protein-free diet up to a weight deficit of 20 +/- 1%. Then they were arranged in groups (TO) and fed diets with 30% protein and 0.0, 0.2, 0.4, 0.6, 0.9 or 1.2% Ca for 28 days (T28). Food and deionized water were given ad libitum. Body weight and length were recorded every 3 days. At T28, the animals were sacrificed to determine femur composition.

RESULTS

At T13, weight-for-age (W/A) was within the normal range for rats consuming > or = 0.6% Ca. At T28 all groups showed adequate W/A. Although length-for-age was adequate during rehabilitated period, rate of weight gain improved when Ca was > or = 0.6%. Femur length did not show significant difference between groups. Total femur Ca content and mg Ca/g of dry-weight tissue increased with increments in dietary Ca concentration and tended to plateau with 0.4% Ca. Ca/P ratio reached the highest value with 0.9% Ca.

CONCLUSIONS

Our findings indicate that at a dietary protein level of 30% the Ca/protein ratio is a limiting factor in attaining of normal body size; this is achievable when Ca concentration is 1.2% and the Ca/protein ratio is 0.04.

Structural motifs in rheumatoid T-cell receptors

The linkage of rheumatoid arthritis (RA) to HLA-DR haplotypes, high levels of HLA-DR expression, and T-cell infiltration in the joints, indicate a central role for the interaction of T-cell receptors (TCR) with antigen (Ag) + major histocompatibility complex (MHC) complexes in pathogenesis. Receptor analysis in RA has uncovered a restricted heterogeneity of TCR transcripts, suggesting an antigen-driven response. We analyzed the sequence and structural features of RA-associated TCRs in light of the recently published TCR crystal structures. The surface-exposed residues of the third complementarity-determining region (CDR3s) showed preferential use of certain amino acid residues when sequences derived from synovial fluid or tissue were compared with those derived from peripheral blood, particularly for alpha chains. Sequence alignment of oligoclonal synovial TCR CDR3s revealed groupings with similar CDR3 lengths and amino acid compositions, which suggests shared antigen recognition. Given the limitations of analyzing TCR sequences without knowing their structures, we developed several in vivo-activated synovial-tissue Vbeta17 + RA T-cell clones. Two Vbeta17/V alpha7 clones with different CDR3 sequences were analyzed by molecular modeling. Although distinct topologic features were seen, a central patch of residues with similar chemical and geometric characteristics was present in both. Electrostatic maps revealed similar binding surfaces of both alpha domains and central patches, with differences in the beta domains. This suggests that an alpha-domain-focused binding trajectory would allow shared antigen recognition by these TCRs. These studies support recognition of a limited diversity of Ag + MHC complexes by synovial RA TCRs.

Rapidly progressive herpetic retinal necrosis: a blinding disease characteristic of advanced AIDS

Eleven patients with rapidly progressive herpetic retinal necrosis (RPHRN) complicating AIDS were investigated retrospectively to study the disease spectrum, systemic involvement, and therapy. The mean CD4 cell count was 24/microL. There was a characteristic disease pattern with rapid progression, 82% bilaterality, relative resistance to intravenous antiviral therapy, and 70% retinal detachment. Varicella-zoster virus was the probable cause in 10 patients (detected by polymerase chain reaction in two eyes investigated), and herpes simplex virus was the probable cause in one. Cutaneous zoster occurred previously in 73% but was not concurrent. Seventy-three percent had central nervous system disease, possibly virus-related. RPHRN may be a local herpetic recrudescence in an immune-privileged site with transneural spread. Only four of 20 affected eyes retained useful vision. Poor ocular bioavailability, retinal ischemia, acquired drug resistance, and strain pathogenicity may underlie treatment failure. Acyclovir therapy appears relatively ineffective. Combined intravenous and intravitreal therapy with foscarnet and ganciclovir may be the best current management. Research advances are needed urgently.

Bilateral subinternal limiting membrane hemorrhage with Terson syndrome

PURPOSE

To report the anatomic location of bilateral dome-shaped posterior pole hemorrhages in a patient with Terson syndrome.

METHODS

Case report. We performed bilateral vitrectomy for vitreous hemorrhage in a patient with Terson syndrome. After removal of vitreous hemorrhage, the tissue overlying a large discrete hemorrhage in the posterior pole was removed, and the tissue from one eye was examined histologically.

RESULT

The discrete dome-shaped hemorrhage in the posterior pole was confined to the retina anteriorly by the internal limiting membrane.

CONCLUSION

Large dome-shaped retinal hemorrhages with Terson syndrome can be located beneath the internal limiting membrane of the retina.

Fas ligand expression and function in systemic lupus erythematosus

Mutations in the Fas receptor or its ligand (FasL) lead to lupus-like systemic autoimmune diseases in mice and in some humans. To determine whether a significant number of patients with systemic lupus erythematosus (SLE) have impaired FasL function, we compared T cell effector function by superantigen-activated CD4+ T cell lines or by anti-CD3- and IL-2-generated cytotoxic T cells. No differences were observed between SLE and normal control superantigen-derived CD4+ T cells in either the ability of these cells to up-regulate Fas expression or to induce apoptosis of the Fas-sensitive target B cells. When anti-CD3/IL-2-activated T cells were examined, SLE T cells had a modest reduction (-8%) in T cell cytotoxicity compared with normal controls, but the reduction was similar to the rheumatoid arthritis disease controls. A modest reduction in cytotoxicity was evident in both the Fas and perforin/granzyme pathways as determined by testing Fas-positive and -negative targets as well as by selective blockade of the perforin/granzyme pathway with concanamycin. These results indicate that no specific defects in FasL function are evident in the majority of SLE patients under the in vitro conditions tested. The proportional reduction in FasL and perforin/granzyme function in SLE and rheumatoid arthritis patients following anti-CD3/IL-2 stimulation most likely reflects subtle differences in activation in patient-derived vs normal control T cells.

Fas ligand expression and function in systemic lupus erythematosus

Mutations in the Fas receptor or its ligand (FasL) lead to lupus-like systemic autoimmune diseases in mice and in some humans. To determine whether a significant number of patients with systemic lupus erythematosus (SLE) have impaired FasL function, we compared T cell effector function by superantigen-activated CD4+ T cell lines or by anti-CD3- and IL-2-generated cytotoxic T cells. No differences were observed between SLE and normal control superantigen-derived CD4+ T cells in either the ability of these cells to up-regulate Fas expression or to induce apoptosis of the Fas-sensitive target B cells. When anti-CD3/IL-2-activated T cells were examined, SLE T cells had a modest reduction (-8%) in T cell cytotoxicity compared with normal controls, but the reduction was similar to the rheumatoid arthritis disease controls. A modest reduction in cytotoxicity was evident in both the Fas and perforin/granzyme pathways as determined by testing Fas-positive and -negative targets as well as by selective blockade of the perforin/granzyme pathway with concanamycin. These results indicate that no specific defects in FasL function are evident in the majority of SLE patients under the in vitro conditions tested. The proportional reduction in FasL and perforin/granzyme function in SLE and rheumatoid arthritis patients following anti-CD3/IL-2 stimulation most likely reflects subtle differences in activation in patient-derived vs normal control T cells.

Positive vitreous cultures from eyes without signs of infectious endophthalmitis

BACKGROUND AND OBJECTIVE

There is little information on the rate of false-positive vitreous cultures, because cultures from presumably sterile vitreous are not routinely taken in clinical practice. The objective of this study was to determine the rate of positive vitreous cultures from patients who have no signs of endophthalmitis.

PATIENTS AND METHODS

Aerobic cultures from vitreous biopsies were taken from 36 consecutive eyes in which there was no clinical evidence of endophthalmitis. Effluent collected in cassettes during pars plana vitrectomies was processed and cultured in a standard manner. Balanced salt solution was processed intraoperatively through the vitrector and cultured as a negative control.

RESULTS

Positive cultures were obtained in 8 of 36 eyes (22.2%). Coagulase-negative Staphylococcus and Corynebacteria accounted for 7 of the 9 identified organisms. No organism was grown in more than one medium. None of the patients were treated for endophthalmitis after surgery, and none had signs of intraocular infection.

CONCLUSIONS

A substantial number of vitrectomy cultures from effluent specimens grow low-virulence organisms in the absence of clinical signs of endophthalmitis. The absence of inflammation at the time of surgery suggests that these positive cultures are contaminants.

Characterization of cartilage metabolic response to static and dynamic stress using a mechanical explant test system

A new mechanical explant test system was used to study the metabolic response (via proteoglycan biosynthesis) of mature, weight-bearing canine articular cartilage subjected to static and dynamic compressive stresses. Stresses ranging from 0.5 to 24 MPa were applied sinusoidally at 1 Hz for intervals of 2-24 h. The explants were loaded in unconfined compression and compared to age-matched unloaded explants. Both static and dynamic compressive stress significantly decreased proteoglycan biosynthesis (range 25-85%) for all loading time intervals. The inhibition was proportional to the applied stress but was independent of loading time. After rehydration upon load removal, the measured water content of the loaded explants was not different from the unloaded explants for all test variables. Autoradiographic and electron microscopic analysis of loaded explants showed viable chondrocytes throughout the matrix. Our results suggest that the decreased metabolic response of cyclically loaded explants may be dominated by the static component (RMS) of the dynamic load. Furthermore, the observed decreased metabolism may be more representative of the in situ tissue response than that of unloaded explants, in which we found an increasing rate of metabolism for up to 6 days after explant removal.

Fas expression and apoptosis in human B cells

Mechanisms of B cell apoptosis are critical in reducing aberrant B cell proliferations such as those that arise in autoimmune disease and in B cell malignancies. The physiologic interaction of CD4+ helper T cells and B lymphocytes has been extensively studied over the past two decades. Although CD4+ T cells are considered primarily to offer positive costimulatory signals for B cell differentiation into active immunoglobulin-secreting cells, recent studies have shown that CD4+ T cells are crucial in downregulating the humoral immune response. In the course of cognate interaction between CD40 ligand (CD40L)-bearing CD4+ T cells and CD40-expressing germinal center B cells, CD40 ligation results in augmented Fas expression at the B cell surface. Like CD40L, Fas ligand is expressed on activated CD4+ Th1 cells and when bound to Fas receptor on the B cell surface, initiates an apoptotic signal in that cell. Thus, CD4+ T cells limit the growth of autologous germinal center B cells by first inducing Fas expression and then instigating a death signal via Fas ligand. In this work, we will consider these observations about CD4+ T-cell-induced, Fas-mediated B cell death in the context of other factors that affect apoptosis in B cells, normal and malignant.

Allelic variants of human TCR BV17S1 defined by restriction fragment length polymorphism, single strand conformation polymorphism, and amplification refractory mutation system analyses

Several human TCR BV gene subfamilies, including BV3, BV14, and BV17S1, are single member genes but are overutilized among activated CD4+ synovial T cells in the rheumatoid arthritis (RA). To define the role of these TCR BV genes in the pathogenesis of disease, it is critical to characterize the genomic organization and the allelic variations of these genes. In this study we describe allelic variations of BV17S1 defined by restriction fragment length polymorphism (RFLP), single strand conformation polymorphism (SSCP), and amplification refractory mutation system (ARMS) analyses. A single nucleotide replacement (C/T) results in an amino acid substitution (F/L) in the leader and distinguishes BV17S1*1 from BV17S1*2. This nucleotide substitution was found to create a BsmAI restriction enzyme recognition site in BV17S1*2. Therefore genotypic analyses can be performed either by the SSCP or RFLP method. The analyses of 75 unrelated individuals show that the frequency for allele BV17S1*1 is 52.7% and for allele BV17S1*2 is 47.3%. Both alleles are functionally expressed and are distributed within CD4+/CD8+ T cell subsets. Another point mutation in the CDR2 region of BV17S1, which results in the amino acid replacement of Gln by His, originally identified form a cDNA clone, has now been confirmed as an allele by ARMS analysis using genomic DNA preparations and designated to as BV17S1*3. Screening of this CDR2 related variant among normal populations indicates that this is a rare allele (1 of 75). Although this variant may be of functional significance, the genotypic analysis and functional studies are difficult due to the low frequency of BV17S1*3. In an attempt to define a correlation between BV17S1 allelic usage and susceptibility to RA, the germline distribution of BV17S1 alleles *1 and *2 has been examined in a small number of RA patients and no skewed usage has been identified.

CD4+ T-cell induction of Fas-mediated apoptosis in Burkitt's lymphoma B cells

Cytotoxic function of CD4+ Th1 cells is mediated by Fas (CD95, APO-1) and its ligand (Fas ligand). Recent studies using nontransformed B cells and the Ramos Burkitt's lymphoma (BL) B-cell line cells show that CD40 ligation at the B-cell surface by activated, CD40 ligand (CD40L)-bearing, CD4+ T cells upregulates Fas expression on B cells and primes B cells for Fas-mediated death signals. In this work, we examine whether this CD4+ T-cell-dependent molecular pathway for Fas upregulation and B-cell apoptosis reflects a peculiarity of the Ramos B-cell line or is applicable to other Burkitt's tumors as well. In 5 of the 6 Epstein-Barr virus-negative BL cell lines examined, the cells constitutively express undetectable or low levels of Fas and are resistant to Fas-mediated signals induced by monoclonal anti-Fas antibody. All 6 of the BL cell line B cells upregulate Fas in response to CD40 ligation, and in 4 of the cases they become sensitive to Fas-mediated death signals. In one BL cell line, the cells are constitutively sensitive to Fas-mediated cytolysis and are unaffected by CD40 signals. Next, we applied these immunologic manipulations to cells from a refractory clinical sample and observed that the tumor cells could be induced to express Fas and undergo apoptosis in our system. These results establish CD4+ T cells and the Fas-Fas ligand system as important immune regulators of Burkitt's lymphoma B cells and indicate that the susceptibility of tumor cells to Fas-mediated death signals can be modulated by specific activation events at the cell surface.

Alar and apples: newspapers, risk and media responsibility

During 1989, a major environmental and health risk issue, the spraying of Alar on apples, created a furor among the American people. After hearing charges from the Natural Resources Defense Council (NRDC) that eating Alar-laden apples significantly increased a child's risk of developing cancer, numbers of school districts dropped apples from their menus and parents poured apple juice down the drains. Apple sales plummeted. The NRDC's charges, which were disseminated by a well-planned and effective public relations campaign, brought counter-charges from the US environmental Protection Agency, which accused the NRDC of basing its study on poor data, among other things. The core of the dispute was in the risk figures and risk interpretations being used by each organization.

T helper cell-dependent, microbial superantigen-mediated B cell activation in vivo

We have utilized a severe combined immune-deficient (SCID) mouse adoptive transfer model to explore the in vivo immunostimulatory effects of bacterial superantigens (SAg). B cell reconstituted SCID recipients were treated with the Staphylococcus aureus-derived toxic shock syndrome toxin (TSST-1) alone or in conjunction with syngeneic L3T4+ TSST-1-reactive Th cells. Over several months of study, the repetitive administration of TSST-1 resulted in a prompt, transient increase in serum IgG levels. This response required both biologically active TSST-1 and Th cells. These findings demonstrate that certain bacterial SAgs can promote Th cell-dependent B cell activation and differentiation in vivo. These studies strengthen the analogy between SAg-mediated and allospecific Th-B cell interactions responsible for the autoimmune sequelae of graft-versus-host disease.

Th1 CD4+ lymphocytes delete activated macrophages through the Fas/APO-1 antigen pathway

The Fas/APO-1 cytotoxic pathway plays an important role in the regulation of peripheral immunity. Recent evidence indicates that this regulatory function operates through deletion of activated T and B lymphocytes by CD4+ T cells expressing the Fas ligand. Because macrophages play a key role in peripheral immunity, we asked whether Fas was involved in T-cell-macrophage interactions. Two-color flow cytometry revealed that Fas receptor (FasR) was expressed on resting murine peritoneal macrophages. FasR expression was upregulated after activation of macrophages with cytokines or lipopolysaccharide, although only tumor necrosis factor-alpha rendered macrophages sensitive to anti-FasR antibody-mediated death. To determine the consequence of antigen presentation by macrophages to CD4+ T cells, macrophages were pulsed with antigen and then incubated with either Th1 or Th2 cell lines or clones. Th1, but not Th2, T cells induced lysis of 60-80% of normal macrophages, whereas macrophages obtained from mice with mutations in the FasR were totally resistant to Th1-mediated cytotoxicity. Macrophage cytotoxicity depended upon specific antigen recognition by T cells and was major histocompatibility complex restricted. These findings indicate that, in addition to deletion of activated lymphocytes, Fas plays an important role in deletion of activated macrophages after antigen presentation to Th1 CD4+ T cells. Failure to delete macrophages that constitutively present self-antigens may contribute to the expression of autoimmunity in mice deficient in FasR (lpr) or Fas ligand (gld).

CD40 ligation induces Apo-1/Fas expression on human B lymphocytes and facilitates apoptosis through the Apo-1/Fas pathway

The Apo-1/Fas antigen (CD95) mediates programmed cell death of lymphocytes when bound by Fas ligand or anti-Apo-1/Fas antibody. In contrast, the CD40 antigen provides a potent activation and survival signal to B lymphocytes when it is engaged by its T cell ligand (CD40L, gp39) or cross-linked by anti-CD40 antibody. In this study, we use human tonsillar B cells and the Ramos Burkitt's lymphoma B cell line, which serves as a model for human germinal center B lymphocytes, to study the effectors of Apo-1/Fas expression and apoptosis of human B cells. We found that Apo-1/Fas expression was upregulated on both malignant and normal human B lymphocytes after CD40 ligation induced by (a) cognate T helper-B cell interaction mediated by microbial superantigen (SAg); (b) contact-dependent interaction with CD40L+, but not CD40L- Jurkat mutant T cell clones; and (c) monoclonal anti-CD40, but not any of a panel of control antibodies. Enhanced B cell Fas/Apo-1 expression is functionally significant. Coculture of Ramos Burkitt's lymphoma line cells with irradiated SAg-reactive CD4+ T cells with SAg or CD40L+ Jurkat T cells results in B cell apoptosis, evidenced by reduced cell viability and DNA laddering. This process is augmented by the addition of anti-Apo-1/Fas monoclonal antibody, consistent with an acquired susceptibility to Apo-1/Fas-mediated apoptosis. These data support an immunoregulatory pathway in which seemingly contradictory signals involving the B cell proliferation/survival antigen CD40, as well as the Apo-1/Fas molecule, which mediates programmed cell death of lymphocytes, are linked in the process of human B cell activation.

Increased fall rates in nursing home residents after relocation to a new facility

OBJECTIVE

To examine the change in fall rates after relocation of nursing home residents from one facility to another and to identify resident risk factors for changes in falls following relocation.

DESIGN

Retrospective review of incident reports to identify falls, followed by chart review of a longitudinal cohort.

SETTING

An academic nursing home whose residents and programs moved from a 125-year-old, 233-bed facility to a newly constructed 255-bed facility.

PATIENTS

A total of 210 nursing home residents were moved from one facility to the other. Of these, 133 individuals who lived in the old facility for 9 months before the move and in the new facility for 6 months after the move formed the longitudinal cohort.

RESULTS

In the 3 months after the move, the fall rate increased from 0.34 to 0.70 falls per resident per quarter in the entire nursing home population (P < .001) and subsequently returned to baseline. In the longitudinal subgroup the fall rate went from 0.26 to 0.60 (P < .005). Fall-related injuries in the longitudinal subgroup went from 0.058 injuries per resident per quarter at baseline to 0.15 (P < .001). However, the injury rate per fall did not change. There were no characteristics associated with being a faller in the quarter before the move. Dementia and not being bedbound were associated with being a faller after the move. Individuals who were ambulatory or wheelchair mobile had a significant risk of increasing the number of falls after the move, and individuals with dementia had a strong but insignificant trend in this direction.

CONCLUSIONS

The incidence of falling doubled after relocation of nursing home residents to a new facility. An increase in falls was seen in individuals who were not bedbound. Although nursing home relocation may be a relatively uncommon occurrence, it is reasonable to infer that older individuals who change their living environments are at increased risk for falls and fall-related injuries.