Abstract TP385: Using a Learning Collaborative Model in Metro Chicago to Identify Best Practice Strategies for Emerging Topics: E-Cigarette Use in Stroke Patients

Background: While learning collaborative models have been shown to aid implementation of published national guidelines, less is known about their role in informing health care providers about emerging topics not yet written into guidelines. National guidelines state that stroke patients who have a history of smoking should receive smoking cessation intervention prior to hospital discharge. However, guidelines do not include recommendations related to e-cigarette use. Launched July 2018, the Metro Chicago Smoking Cessation Initiative was a one-year pilot aimed at improving understanding of smoking cessation interventions provided at discharge, smoking behavior post-discharge, and best practices for reducing smoking rates at 20 Chicago area hospitals. While hospital practices and patient behavior around e-cigarettes was not an aim, the learning collaborative model enabled hospital participants to report their experiences and enact practice changes related to e-cigarettes.

Methods: The pilot used a Learning Collaborative model that included a quality improvement leader, health behavior content experts, reporting of experiences and data, and sharing of best practices. Pilot participating hospitals were required to attend quarterly online learning sessions and use Get With The Guidelines® Stroke for data entry. Hospitals documented smoking cessation intervention provided at time of discharge and contacted patients via phone at 30 days post-discharge to gather data on current smoking use, quit attempts, and therapies used. Hospitals completed a baseline questionnaire reporting current smoking cessation practices and a mid-point questionnaire reporting changes to practice and experiences as a pilot participant. Responses were reviewed for themes related to e-cigarettes.

Results: See Table 1

Conclusions: A Learning Collaborative Model may be a method for identifying strategies for practice changes prior to guideline recommendations.

Abstract TP313: A Metro Chicago Learning Collaborative Model to Improve Smoking Cessation Rates in Stroke Patients

Background: National guidelines for stroke care recommend that patients discharged with a stroke who have a history of smoking receive smoking cessation intervention prior to hospital discharge. However, less is known about the types of intervention provided and subsequent outcomes post-discharge. The Metro Chicago Smoking Cessation Initiative Pilot aimed to improve understanding of smoking cessation interventions provided at discharge, smoking behavior at 30 days post-discharge, and best practices and barriers for reducing smoking rates in stroke patients discharged from 20 Chicago area hospitals.

Methods: A review of smoking cessation interventions provided at discharge and smoking cessation outcomes post-discharge for stroke patients discharged between August 1, 2018 and July 31, 2019 at 20 Chicago area participating hospitals was conducted using Get With The Guidelines® Stroke. The pilot used a Learning Collaborative model that included a quality improvement leader, smoking cessation/health behavior content experts, reporting of experiences and data, and sharing of best practices. All hospitals were required to attend quarterly online learning sessions and use Get With The Guidelines® Stroke for data entry.

Results: Preliminary results from the 20 participating hospitals suggest smoking cessation counseling is the most commonly delivered intervention at discharge. Of the patients reached at 30 days post-discharge, 75% of those who reported at history of smoking at the time of their stroke were still using tobacco products. However, nearly 50% of those patients reported having made at least one attempt to quit.

Conclusions: Preliminary results from this pilot project highlight the need for improved tracking of smoking cessation interventions provided at discharge and associated smoking behavior post-discharge, as well as the benefits of regional collaboration for identifying and implementing best practices.

Comparing Point-of-care-ultrasound (POCUS) to MRI for the Diagnosis of Medial Compartment Knee Injuries

Background:

Ultrasound has become an increasingly utilized tool for the imaging of the musculoskeletal system, especially for imaging the components of the knee. Even though MRI is touted as being the golden standard for identifying knee pathologies, the use of ultrasound has gained popularity in this field given its ability for rapid diagnosis. This study aims to investigate the efficacy of point-of-care ultrasound (POCUS) to diagnose injuries to the medial knee compartment when compared to magnetic resonance imaging (MRI).

Methods:

This was a prospective, observational study conducted at an orthopedic outpatient clinic. Prospective patients with medial knee pain scheduled for an MRI of the knee were evaluated by POCUS prior to the MRI. Sonographic findings were then compared to MRI results to assess correlation.

Results:

Nine patients were enrolled in the study. Median age was 53 years and eight were male (89%). POCUS demonstrated 100% sensitivity and 50% specificity for medial meniscus tear and 67% sensitivity and 83% specificity for medial collateral ligament (MCL) tear.

Conclusion:

Ultrasound may have a role as the initial rapid imaging modality in patients with suspected medial meniscus or MCL tears as it is highly sensitive, and it may serve as an effective screening tool for patients with both acute and chronic knee pain.

Psychometric properties of three instruments to measure fatigue with myocardial infarction

The purpose of this study was to evaluate the psychometric properties of three questionnaires to measure fatigue with myocardial infarction. The Fatigue Symptom Inventory Interference Scale, Profile of Moods States Fatigue subscale (POMS-F), and Short Form 36 (SF-36) Vitality Scale were completed during hospitalization (n = 116) and 30 days after hospital admission (n = 49). Moderate to strong correlations were found among each of these fatigue scales and between each fatigue scale and measures of other variables to include vigor, depressed mood, anxiety, and physical functioning. POMS-F scores decreased significantly at Time 2, but this decline in fatigue was not validated on the other fatigue scales. Patients' Time 1 scores reflected significantly more fatigue compared to published scores for healthy adults. The ability to discriminate between groups suggests that the instruments may be useful for identifying patients with cardiovascular risk factors who report clinically significant fatigue.

Self-synchronization and dissipation-induced threshold in collective atomic recoil lasing

Networks of globally coupled oscillators exhibit phase transitions from incoherent to coherent states. Atoms interacting with the counterpropagating modes of a unidirectionally pumped high-finesse ring cavity form such a globally coupled network. The coupling mechanism is provided by collective atomic recoil lasing, i.e., cooperative Bragg scattering of laser light at an atomic density grating, which is self-induced by the laser light. Under the rule of an additional friction force, the atomic ensemble is expected to undergo a phase transition to a state of synchronized atomic motion. We present the experimental investigation of this phase transition by studying the threshold behavior of this lasing process.

Observation of lasing mediated by collective atomic recoil

We observe the buildup of a frequency-shifted reverse light field in a unidirectionally pumped high-Q optical ring cavity serving as a dipole trap for cold atoms. This effect is enhanced and a steady state is reached, if via an optical molasses an additional friction force is applied to the atoms. We observe the displacement of the atoms accelerated by momentum transfer in the backscattering process and interpret our observations in terms of the collective atomic recoil laser. Numerical simulations are in good agreement with the experimental results.

Influence of threonine exporters on threonine production in Escherichia coli

Threonine production in Escherichia coli threonine producer strains is enhanced by overexpression of the E. coli rhtB and rhtC genes or by heterologous overexpression of the gene encoding the Corynebacterium glutamicum threonine excretion carrier, thrE. Both E. coli genes give rise to a threonine-resistant phenotype when overexpressed, and they decrease the accumulation of radioactive metabolites derived from [(14)C] L-threonine. The evidence presented supports the conclusion that both RhtB and RhtC catalyze efflux of L-threonine and other structurally related neutral amino acids, but that the specificities of these two carriers differ substantially.

Treatment of psychogenic polydipsia: comparison of risperidone and olanzapine, and the effects of an adjunctive angiotensin-II receptor blocking drug (irbesartan)

OBJECTIVE

Our objective was to determine the outcome of novel strategies in managing a case of severe polydipsia.

CLINICAL PICTURE

The patient was a 39-year-old male with a 20-year history of paranoid schizophrenia who, despite only mild residual psychotic symptoms, had been hospitalized for the previous 10 years because of severe polydipsic behaviour complicated by water intoxication.

TREATMENT

Novel antipsychotic agents, risperidone and olanzapine, as well as the specific angiotensin-II receptor blocking drug, irbesartan were employed at selected intervals in a study lasting nearly 3 years. A strict behavioural management programme was ongoing, in which diurnal weight change and the number of breaches of weight limits, requiring management in a low-stimulus environment, were documented on a daily basis. Summary measures of diurnal weight change and behavioural intervention were charted against changes in treatment.

OUTCOME

Polydipsic behaviour improved on risperidone up to 4 mg daily, but was not sustained. Olanzapine was similarly successful in stabilizing polydipsia, and improvement was achieved with the addition of irbesartan.

CONCLUSION

We suggest that the D2-sparing profiles of receptor binding achieved with low-dose risperidone and olanzapine may account for this beneficial effect. The benefit derived with irbesartan implicates the involvement of brain angiotensin systems centrally in helping to regulate drinking behaviour.

Polyamine transport and role of potE in response to osmotic stress in Escherichia coli

When transport of polyamines in Escherichia coli was examined, putrescine excretion was observed under two different physiological conditions: (i) strictly correlated to growth and (ii) following a hyperosmotic shock. Spermidine was not excreted. Characterization of a deletion mutant showed that PotE is not involved in these transport processes.

Bronchiectasis in Alaska Native children: causes and clinical courses

Although bronchiectasis has become a rare condition in U.S. children, it is still commonly diagnosed in Alaska Native children in the Yukon Kuskokwim Delta. The prevalence of bronchiectasis has not decreased in persons born during the 1980s as compared with those born in the 1940s. We reviewed case histories of 46 children with bronchiectasis. We observed that recurrent pneumonia was the major preceding medical condition in 85% of patients. There was an association between the lobes affected by pneumonia and the lobes affected by bronchiectasis. Eight (17%) patients had surgical resection of involved lobes. We conclude that the continued high prevalence of bronchiectasis appears to be related to extremely high rates of infant and childhood pneumonia. Pediatr Pulmonol. 2000;29:182-187. Published 2000 Wiley-Liss, Inc.

Severe respiratory syncytial virus disease in Alaska native children. RSV Alaska Study Group

Hospitalization rates for respiratory syncytial virus (RSV) infection range from 1 to 20/1000 infants. To determine the rate and severity of RSV infections requiring hospitalization for infants in the Yukon-Kuskokwim (YK) Delta of Alaska, a 3-year prospective surveillance study was conducted. The annual rate of RSV hospitalization for YK Delta infants <1 year of age was 53-249/1000. RSV infection was the most frequent cause of infant hospitalization. RSV disease severity did not differ among non-high-risk infants in the YK Delta and at Johns Hopkins Hospital (JHH). On average, 1/125 infants born in the YK Delta required mechanical ventilation for RSV infection. During the peak season, approximately $1034/child <3 years of age was spent on RSV hospitalization in the YK Delta. In YK Delta infants </=6 months old, RSV microneutralizing antibody titers <1200 were associated with severe disease (odds ratio=6.2, P=.03). In the YK Delta and at JHH, newborns may be at greater risk for severe RSV illness than previously thought.

Somatic gene transfer to salivary glands

Recent developments in gene transfer technology have expanded the range of in vivo experimentation and provided new insights that might be applicable to the treatment of human diseases. Somatic gene transfer may complement conventional transgenic animal experiments by allowing for more restricted gene expression. Salivary glands of rats are readily transduced in vivo by adenovirus vectors. This model has been used to demonstrate the effects of transferring a water channel (aquaporin) gene to glands that have been damaged by radiation. Submandibular glands that receive the aquaporin vector increase the stimulated salivary flow close to normal levels. The possible role of E2F1 in promoting cell regeneration in vivo was also explored. A vector expressing E2F1 was capable of increasing DNA synthesis in rat salivary glands, though complete mitosis was not observed. Future generations of vectors must overcome current limitations of efficiency, immunogenicity, and transient expression.

Bladder autoaugmentation in adult patients with neurogenic voiding dysfunction

Bladder autoaugmentation offers an alternative to enterocystoplasties for patients with low capacity high pressure bladders caused by non-malignant pathology. In particular for patients with neuropathic hyperreflexive bladders, refractory to less invasive therapy, bladder autoaugmentation will attain comparable results with less impact on life quality compared to other bladder augmentation procedures. The procedure does not preclude later enterocystoplasty or deafferentations. Over the last 7 years, 50 patients were treated by this method, some of them for other than neurogenic voiding dysfunction. Substantial increase of bladder capacity and compliance resulted, at the cost of increased residual urine and the need for intermittent catheterisation in most patients. Some patients are able to perform complete voiding at will. The time lapse between surgery and functional rehabilitation of the bladder (substantial increase of capacity and detrusor compliance) cannot be predicted yet. In most patients this amelioration was observed 1-6 months after surgery, but in some the effect was equivocal for a year or longer. Low-dose anticholinergics appear to speed up the therapeutic effect. One patient had enterocystoplasty and one deafferentation later, one had rupture of the bladder, probably from the use of an artificial sphincter, and two are rated as failures because of psychogenic bladder-centred problems. Bladder autoaugmentation is a favourable treatment for patients who are motivated to wait possibly longer for functional changes to occur and are willing to perform intermittent catheterisation afterwards.

Pervasive occult gastrointestinal bleeding in an Alaska native population with prevalent iron deficiency. Role of Helicobacter pylori gastritis

OBJECTIVE

To confirm prevalent iron deficiency among Yupik Eskimos living in Alaska and to explore the frequency of and potential lesions accounting for occult gastrointestinal bleeding.

DESIGN

Descriptive survey.

SETTING

Rural Arctic community.

SUBJECTS

A total of 140 adult volunteers from 3 villages in the Yukon-Kuskokwim Delta region of western Alaska.

MAIN OUTCOME MEASURES

Daily iron intake, hematologic and biochemical indexes of iron status, fecal hemoglobin levels, stool parasites, and endoscopic findings.

RESULTS

While dietary iron intake by Yupiks was similar to that of a reference population, iron deficiency prevalence was increased 13-fold in Yupik men and 4-fold in Yupik women. Fecal hemoglobin levels were elevated in 90% of subjects contrasted with only 4% of a reference group; median levels were 5.9 and 0.5 mg of hemoglobin per gram of stool, respectively. Among 70 Yupik subjects with elevated fecal hemoglobin levels who had endoscopy performed, 68 (97%) had an abnormal gastric appearance consisting of erythema, mucosal thickening, diffuse mucosal hemorrhages, erosions, or ulcerations. Gastric biopsies revealed chronic active gastritis with associated Helicobacter pylori in 68 (99%) of 69. No other hemorrhagic gastrointestinal disease was detected.

CONCLUSIONS

Based on this study sample, occult gastrointestinal bleeding appears to be pervasive in the Yupik population and likely underlies the prevalent iron deficiency. An atypical hemorrhagic gastritis associated with H pylori infection is present almost universally and may represent the bleeding source.

Computer use, computer training, and employment. Outcomes among people with spinal cord injuries

Computer use and training may be of special benefit to people with spinal cord injuries (SCIs) because computer technology may help lessen the impact of mobility limitations that are inherent with this disability. This article summarizes several findings from a 1994 survey conducted of New Jersey residents who suffered SCIs within the previous 10 years. The results indicate that, among people with SCIs, 46% currently use a computer in some capacity and 22% received computer training since the date of their injury. Perhaps surprisingly, both corresponding percentages are higher in the general population. People with SCIs appear to have less access to computers because most people learn how to use computers at work, and only a minority of people with SCIs work. The lower rate of use of computers among people with SCIs is unfortunate because the steep employment and earnings declines often experienced after an SCI are partially mitigated for those who have computer skills. The results suggest the importance of policies and programs aimed at increasing access to computers and computer training for people with severe disabilities.

Reconstruction of craniofacial bone defects with individual alloplastic implants based on CAD/CAM-manipulated CT-data

Reconstruction of craniofacial bone defects by intraoperative modelling of autogenous or alloplastic materials may cause undesirable results concerning the implant shape or the long-term maintenance of this shape. Furthermore, the use of alloplastic materials to be modelled intraoperatively may result in an inflammatory tissue response. Therefore the question is raised whether CAD/CAM-techniques may be used for the pre-operative geometric modelling of the implant based on helical computed tomography data. A numerically based 3-dimensional model of the skull defect serves as the basis for a freeform-surfaces design of the implant shape, position and thickness, using modelling tools and programmes developed for industrial CAD/CAM. The precise and individual fit of the implant results from generating its margins by the borders of the defect, whereas the implant surface is generated by the geometry of the non-affected neighbouring bone contours. The implant data run a numerically controlled milling machine to fabricate the individual implant. The reconstruction of post-traumatic defects of the forehead, of post-surgical temporal defects after intracranial haemorrhage, and of a parieto-occipital defect due to ablative tumour surgery are presented as the first clinical experiences of this new method.

CAD by processing of computed tomography data and CAM of individually designed prostheses

In the past an economic fabrication of individual prostheses used in reconstructive cranio-maxillo-facial surgery was not possible due to technical deficiencies. Now, through the consistent use of the most modern computer-based techniques developed in the field of industrial engineering, these costs can be reduced to an economic level. Mathematical freeform surfaces models are first created from helical computed tomography data. These serve as the basis for an efficient and idealized construction of prostheses geometries, and provide control-data for a computerized numerical control-fabrication. In 4 clinical cases this new processing technique has successfully been utilized in the fabrication of individually designed prostheses for the reconstruction of skull defects. The range of opportunities offered is reflected not only in the great variety of possible geometric details, but also in the fact that the prostheses may be manufactured--partly using indirect impression-taking techniques--from 3 different biocompatible materials so far and other applications are likely to turn up.

A seroreactive 120-kilodalton beta-1,3-glucanase of Coccidioides immitis which may participate in spherule morphogenesis

A beta-glucosidase of Coccidioides immitis was identified in electrophoresis gel separations of the concanavalin A-bound mycelial culture-filtrate-plus-lysate preparation. p-Nitrophenol-beta-D-glucopyranoside was used as the substrate to visualize the enzymatically active fraction in nonreducing gels. The gel-isolated, chromatographically purified enzyme has an optimal pH of 8.0 and cleaves beta-1,3-glycosyl linkages. The alkaline beta-glucosidase was further characterized by a pI of 3.8 to 4.0, optimal activity at 37 to 40 degrees C, and molecular size of 120 kDa as identified by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. The purified beta-glucosidase is identical to a previously reported 120-kDa antigen (Ag) which reacts with immunoglobulin M (IgM) tube precipitin (TP) antibody in sera from patients with coccidioidomycosis. The TP-Ag was described as a valuable serodiagnostic reagent for detection of specific IgM in patients with early coccidioidal infections. The beta-glucosidase, like the TP-Ag, was localized in the cell wall and cytoplasmic vesicles of parasitic cells (spherules) by immunofluorescence and immunoelectron microscopy with specific antiserum raised against the purified enzyme. The boiled cell wall fraction isolated from these same young (presegmented) spherules was partially digested by the beta-glucosidase. Addition of a potent beta-glucosidase inhibitor, 1-deoxynojirimycin, to the parasitic-phase culture medium at a concentration of 200 microM blocked or retarded conversion of arthroconidia to spherules. Antibody was raised in guinea pigs against chromatographically purified 1-deoxynojirimycin which was conjugated with bovine serum albumin. The inhibitor was localized by immunofluorescence in the wall of the 1-deoxynojirimycin-treated cells. We suggest that the spherule wall-associated, alkaline hydrolase functions as a beta-1,3-glucanase to provide for wall plasticity as well as intussusception of newly synthesized wall polymers during the period of rapid diametric growth of parasitic cells of C. immitis.

Isolation and expression of a gene which encodes a wall-associated proteinase of Coccidioides immitis

A chymotrypsinlike serine proteinase of Coccidioides immitis with an estimated molecular size of 34 kDa has been shown by immunoelectron microscopy to be associated with the walls of the parasitic cells of this human respiratory pathogen. The proteinase has been suggested to play a role in spherule development. We report the isolation of a 1.2-kb cDNA from an expression library of C. immitis constructed in the lambda ZAP II phage vector. The cDNA is suggested to encode the 34-kDa protein. We demonstrate identity between segments of the deduced amino acid sequence of the open reading frame of the 1.2-kb cDNA and three distinct sequences obtained from cyanogen bromide cleavage peptides of the purified proteinase. The occurrence of N-glycosyl linkage sites in the deduced sequence of 309 amino acids of the open reading frame (ORF) correlates with our identification of such linkage sites in the native glycosylated proteinase. A protein encoded by an 800-bp fragment of the 1.2-kb cDNA, which was produced by transformed Escherichia coli XL1-Blue, was recognized by the anti-34-kDa protein antibody in a Western blot (immunoblot). Northern (RNA) hybridization of total poly(A)-containing RNA of C. immitis with the labeled 1.2-kb cDNA clone revealed a single band of approximately 1.75 kb. Partial homology was demonstrated between the deduced amino acid sequence of the ORF (927 bp) and reported sequences of alpha-chymotrypsin and chymotrypsinogens. Expression of the proteinase gene was examined by Northern dot blot analysis of total RNA from different stages of parasitic cell development in C. immitis. Maximum levels of specific mRNA were detected during early endospore wall differentiation. The 34-kDa proteinase appears to be concentrated in walls of the parasitic cells at stages of active growth. We suggest that the enzyme may participate in wall plasticization and/or intussusception or in cell wall turnover.

Coccidioides immitis fractions which are antigenic for immune T lymphocytes

The principal mechanism of resistance to coccidioidomycosis in experimental animals has been reported to be T-cell-mediated immunity. We have generated a Coccidioides immitis antigen-specific murine T-cell line to identify specific macromolecules capable of eliciting an immune mouse T-cell proliferative response. The murine T cells were stimulated in vitro with a soluble conidial wall fraction (SCWF), which has been previously characterized by humoral and cellular immunoassays. The SCWF was separated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and electrotransferred to a nitrocellulose membrane, and the stained blot was cut into seven pieces based on the molecular size of the SCWF components. The nitrocellulose membrane strips were converted into antigen-bearing particles and tested in a T-cell proliferation assay. Antigenic components of the SCWF in the molecular size range of 43 to 66 kDa were identified as the most immunoreactive. In a parallel study, we used a cDNA expression library derived from mRNA of the mycelial phase of C. immitis, which was constructed in lambda gt11 to identify clones that encoded T-cell-reactive fusion proteins (FPs). The cDNA library was screened by using anti-SCWF rabbit serum, and the FPs expressed in Escherichia coli were isolated and tested for T-cell response in the same manner as the SCWF components. The nucleotide sequence of a 0.2-kb cDNA insert encoding a protein which elicited vigorous T-cell response was determined. The isolated cDNA insert hybridized to a single 1.9-kb mRNA band in a Northern blot of the total RNA fraction of the mycelial phase of C. immitis. Antibody with affinity for the T-cell-reactive FP was isolated from anti-SCWF rabbit serum by solid-phase immunoadsorption. The FP-specific antibody reacted with a 47-kDa polypeptide in Western blots (immunoblots) of the SCWF. The same antibody preparation was used for immunoelectron microscopy to show that the FP was localized in the walls of arthroconidia and spherules of C. immitis. Attempts to clone and sequence the entire gene which encodes the T-cell-reactive protein are under way. The results of this study should lead to the determination of the complete structure of an important T-cell-stimulating antigen of C. immitis.

Antigen complex of Coccidioides immitis which elicits a precipitin antibody response in patients

The occurrence in patients of elevated levels of immunoglobulin M (IgM) precipitin antibody to Coccidioides immitis antigens, which are commonly detected by the immunodiffusion-tube precipitin (TP) assay, is suggestive of primary nondisseminating coccidioidomycosis. We previously demonstrated that the concanavalin A-bound mycelial culture filtrate plus lysate preparation is a source of at least two TP antibody-reactive antigens (TP-Ags), which were identified by sodium dodecyl sulfate-polyacrylamide gel electrophoresis as 120- and 110-kDa fractions. Evidence is presented here that the crude filtrate plus lysate preparation contains additional lectin-bound, TP antibody-reactive fractions as well as a component which elicits a complement fixation antibody response in patients. The 120- and 110-kDa fractions were isolated from the antigen complex and further characterized in this paper. Both TP-Ags are glycoproteins and have been shown by immunoelectron microscopy to be colocalized within cytoplasmic vesicles and the wall of spherules. Deglycosylation of these TP-Ags by sodium periodate treatment resulted in a loss in patients of 82 to 95% of IgM adsorption to the antigens as detected by the enzyme-linked immunosorbent assay (ELISA). Comparison of their carbohydrate compositions revealed that mannose and glucose are the predominant monosaccharides of both TP-Ags but only the 120-kDa fraction contained 3-O-methylmannose, a sugar which appears to be unique to C. immitis among the systemic fungal pathogens. We previously showed that 3-O-methylmannose is at least partly responsible for the reactivity of IgM antibody with the 120-kDa TP-Ag. Good correlation was shown between results of immunodiffusion-TP assays and ELISAs of IgM response to both the 120- and 110-kDa fractions by using 70 serum samples from patients with proved coccidioidomycosis. However, only 2.8% (3 of 109) of the serum samples from patients with other mycoses and nonmycotic infections showed IgM adsorption to the 120-kDa TP-Ag as detected by the ELISA, while 21.1% (23 of 109) showed IgM adsorption to the 110-kDa TP-Ag. The 120-kDa TP-Ag is a potentially valuable serodiagnostic reagent for detection of specific IgM by ELISA in patients with primary coccidioidomycosis.

Composition, serologic reactivity, and immunolocalization of a 120-kilodalton tube precipitin antigen of Coccidioides immitis

Diagnosis of coccidioidomycosis largely depends on serologic tests. In this investigation, the enzyme-linked immunosorbent assay (ELISA) was used to detect patient immunoglobulin M (IgM) precipitin antibody binding to a 120-kilodalton (kDa) fraction previously isolated from an alkali-soluble, water-soluble extract of the arthroconidial wall and mycelial culture filtrate plus toluene lysate of Coccidioides immitis. Results of the serologic response to this tube precipitin antigen (TP-Ag) in the ELISA correlated well with results of immunodiffusion assays of 30 serum samples from patients. Immunoelectron microscopic examinations of arthroconidia and spherules were performed with patient IgM precipitin antibodies isolated from sera eluted over a solid-phase immunosorbent column containing the purified 120-kDa TP-Ag. The antibody probe located the 120-kDa TP-Ag on the walls of in vitro-grown arthroconidia and spherules. Pronase digestion and heating (100 degrees C, 5 min) had no apparent effect on the activity of the 120-kDa TP-Ag, while periodate oxidation resulted in total loss of its immunodiffusion-TP activity. Analysis of the carbohydrate composition of the TP-Ag revealed xylose, 3-O-methylmannose (3-O-MM), mannose, galactose, and glucose. Competitive inhibition ELISAs were used to demonstrate that 3-O-MM is largely responsible for the reactivity of IgM precipitin antibodies with the 120-kDa TP-Ag. Synthetic 3-O-MM may be a useful probe for detection of anti-Coccidioides precipitin antibodies in the ELISA.

Isolation of tube precipitin antibody-reactive fractions of Coccidioides immitis

Patients presenting with primary coccidioidal infection have been shown by earlier investigators to produce immunoglobulin M (IgM) precipitin antibodies to lysates of mycelial and spherule phases of Coccidioides immitis. This humoral response has been detected by tube precipitin (TP) and immunodiffusion (ID)-TP assays of patient sera, which are valuable aids in early diagnosis of coccidioidomycosis. Several reports of antigenic fractions which show reactivity with patient TP antibody have been published. However, confusion persists with respect to the nature of the specific serologically reactive macromolecule(s). In this study we isolated two TP antibody-reactive antigens (TP-Ags) from an alkali-soluble, water-soluble fraction of the inner conidial wall and a culture filtrate plus toluene lysate of the mycelial phase of C. immitis. The crude antigens were first separated by concanavalin A (ConA) chromatography. The TP-Ags were identified in ID-TP assays as 120- and 110-kilodalton (kDa) fractions which were electroeluted from reducing sodium dodecyl sulfate-polyacrylamide gel electrophoresis separations of the ConA-bound conidial wall extract and ConA-bound culture filtrate plus lysate preparation, respectively. Following electroelution, the 120-kDa fraction was subjected to gel filtration chromatography which yielded a major 240-kDa and minor 120-kDa component. The apparent dimer may be a product of disulfide bond formation resulting from reassociation of the reduced, monomeric components (120 kDa). The latter was suggested by the presence of cysteine in the isolated fraction. The electroeluted 110-kDa fraction was subjected to ion-exchange chromatography. The DEAE-isolated, TP antibody-reactive fraction was identified as antigen 2 in the coccidioidin-anti-coccidioidin reference system. Homogeneity of the TP-Ags was demonstrated in silver-stained sodium dodecyl sulfate-polyacrylamide gels of the respective chromatographically isolated fractions. The two purified TP-Ags showed reactivity in the TP and ID-TP assays and were capable of binding patient IgM but comparatively little IgG antibody, as determined by an enzyme-linked immunosorbent assay. It appears that the diagnostic TP reaction between sera from patients with coccidioidomycosis and the ID reference antigens examined in this study is a composite of IgM binding to both a 120-kDa and a 110-kDa antigen.

Isolation of antigens with proteolytic activity from Coccidioides immitis

Three antigens with proteolytic activity have been isolated from crude, water-soluble fractions of the saprobic phase of the fungal pathogen Coccidioides immitis. Two proteinases, identified in our immunoelectrophoresis reference system as Ag11 and AgCS, were isolated from the soluble conidial wall fraction (SCWF). Ag11 was previously shown to be a serine proteinase and was characterized in this study as a 60-kilodalton (kDa) fraction by gel filtration (GF). The purified proteinase demonstrated little or no reactivity with 21 serum samples from coccidioidomycosis patients in the enzyme-linked immunosorbent assay; this may be due to limited presentation of this antigen to the host during the course of coccidioidomycosis. AgCS was separated by GF chromatography into two fractions identified by molecular masses of 39 and 19 kDa. Most proteolytic activity was shown by substrate gel electrophoresis to be associated with the lower-molecular-mass fraction. AgCS was reactive with 18 of the 21 serum samples and shown to be the major component of a heat-stable antigen previously reported to be immunospecific for C. immitis. The third antigen with proteolytic activity was isolated from the 5-day mycelial culture filtrate and identified by GF as a 56-kDa fraction. Uniformly high levels of immunoreactivity between 18 of the 21 patient sera and the 56-kDa antigen were demonstrated. Antigens with proteolytic activity may play important roles in fungus-host interactions as well as morphogenesis of the pathogen.

Long-term follow-up of Perthes disease treated with spica casts

Forty adults with a history of Legg-Calve-Perthes disease treated with spica casts were clinically and radiographically evaluated an average of 30 years post-treatment (range 14 to 40 years). Clinical results were 85% good, 5% fair, and 10% poor. Five percent showed significant degenerative joint disease on follow-up radiographs and 7% had undergone prosthetic replacement. Fifteen percent of the patients had a positive family history of Perthes disease. Factors associated with a better result included: diagnosis before age 9, shorter length of follow-up, minimal femoral head and neck involvement, and a congruous joint.