Association of Costs and Days at Home With Transfer Hospital in Home

IMPORTANCE

New Centers for Medicare & Medicaid Services waivers created a payment mechanism for hospital at home services. Although it is well established that direct admission to hospital at home from the community as a substitute for hospital care provides superior outcomes and lower cost, the effectiveness of transfer hospital at home-that is, completing hospitalization at home-is unclear.

OBJECTIVE

To evaluate the outcomes of the transfer component of a Veterans Affairs (VA) Hospital in Home program (T-HIH), taking advantage of natural geographical limitations in a program's service area.

DESIGN, SETTING, AND PARTICIPANTS

In this quality improvement study, T-HIH was offered to veterans residing in Philadelphia, Pennsylvania, and their outcomes were compared with those of propensity-matched veterans residing in adjacent Camden, New Jersey, who were admitted to the VA hospital from 2012 to 2018. Data analysis was performed from October 2019 to May 2020.

INTERVENTION

Enrollment in the T-HIH program.

MAIN OUTCOMES AND MEASURES

The main outcomes were hospital length of stay, 30-day and 90-day readmissions, VA direct costs, combined VA and Medicare costs, mortality, 90-day nursing home use, and days at home after hospital discharge. An intent-to-treat analysis of cost and utilization was performed.

RESULTS

A total of 405 veterans (mean [SD] age, 66.7 [0.83] years; 399 men [98.5%]) with medically complex conditions, primarily congestive heart failure and chronic obstructive pulmonary disease exacerbations (mean [SD] hierarchical condition categories score, 3.54 [0.16]), were enrolled. Ten participants could not be matched, so analyses were performed for 395 veterans (all of whom were men), 98 in the T-HIH group and 297 in the control group. For patients in the T-HIH group compared with the control group, length of stay was 20% lower (6.1 vs 7.7 days; difference, 1.6 days; 95% CI, -3.77 to 0.61 days), VA costs were 20% lower (-$5910; 95% CI, -$13 049 to $1229), combined VA and Medicare costs were 22% lower (-$7002; 95% CI, -$14 314 to $309), readmission rates were similar (23.7% vs 23.0%), the numbers of nursing home days were significantly fewer (0.92 vs 7.45 days; difference, -6.5 days; 95% CI, -12.1 to -0.96 days; P = .02), and the number of days at home was 18% higher (81.4 vs 68.8 days; difference, 12.6 days; 95% CI, 3.12 to 22.08 days; P = .01).

CONCLUSIONS AND RELEVANCE

In this study, T-HIH was significantly associated with increased days at home and less nursing home use but was not associated with increased health care system costs.

Directed, Elliptic, and Higher Order Flow Harmonics of Protons, Deuterons, and Tritons in Au+Au Collisions at sqrt[s_{NN}]=2.4 GeV

Flow coefficients v_{n} of the orders n=1-6 are measured with the High-Acceptance DiElectron Spectrometer (HADES) at GSI for protons, deuterons, and tritons as a function of centrality, transverse momentum, and rapidity in Au+Au collisions at sqrt[s_{NN}]=2.4  GeV. Combining the information from the flow coefficients of all orders allows us to construct for the first time, at collision energies of a few GeV, a multidifferential picture of the angular emission pattern of these particles. It reflects the complicated interplay between the effect of the central fireball pressure on the emission of particles and their subsequent interaction with spectator matter. The high precision information on higher order flow coefficients is a major step forward in constraining the equation of state of dense baryonic matter.

Strong Absorption of Hadrons with Hidden and Open Strangeness in Nuclear Matter

We present the first observation of K^{-} and ϕ absorption within nuclear matter by means of π^{-}-induced reactions on C and W targets at an incident beam momentum of 1.7  GeV/c studied with HADES at SIS18/GSI. The double ratio (K^{-}/K^{+})_{W}/(K^{-}/K^{+})_{C} is found to be 0.319±0.009(stat)_{-0.012}^{+0.014}(syst) indicating a larger absorption of K^{-} in heavier targets as compared to lighter ones. The measured ϕ/K^{-} ratios in π^{-}+C and π^{-}+W reactions within the HADES acceptance are found to be equal to 0.55±0.04(stat)_{-0.07}^{+0.06}(syst) and to 0.63±0.06(stat)_{-0.11}^{+0.11}(syst), respectively. The similar ratios measured in the two different reactions demonstrate for the first time experimentally that the dynamics of the ϕ meson in nuclear medium is strongly coupled to the K^{-} dynamics. The large difference in the ϕ production off C and W nuclei is discussed in terms of a strong ϕN in-medium coupling. These results are relevant for the description of heavy-ion collisions and the structure of neutron stars.

Time-Like Baryon Transitions studies with HADES

The HADES collaboration uses the e+e− production as a probe of the resonance matter produced in collisions at incident energies of 1-3.5 GeV/nucleon at GSI. Elementary reactions provide useful references for these studies and give information on resonance Dalitz decays (R→Ne+e−). Such processes are sensitive to the structure of time-like electromagnetic baryon transitions in a kinematic range where (off-shell) vector mesons play a crucial role. Results obtained in proton-proton reactions and in a commissioning pion-beam experiment are reported and prospects for future pion beam experiments and for first hyperon Dalitz decay measurements are described. The connection with the investigations of medium effects to be continued with HADES in the next years at SIS18 and SIS100 is also discussed.

Subthreshold Ξ^{-} production in collisions of p(3.5 GeV)+Nb

Results on the production of the double strange cascade hyperon Ξ^{-} are reported for collisions of p(3.5  GeV)+Nb, studied with the High Acceptance Di-Electron Spectrometer (HADES) at SIS18 at GSI Helmholtzzentrum for Heavy-Ion Research, Darmstadt. For the first time, subthreshold Ξ^{-} production is observed in proton-nucleus interactions. Assuming a Ξ^{-} phase-space distribution similar to that of Λ hyperons, the production probability amounts to P_{Ξ^{-}}=[2.0±0.4(stat)±0.3(norm)±0.6(syst)]×10^{-4} resulting in a Ξ^{-}/(Λ+Σ^{0}) ratio of P_{Ξ^{-}}/P_{Λ+Σ^{0}}=[1.2±0.3(stat)±0.4(syst)]×10^{-2}. Available model predictions are significantly lower than the measured Ξ^{-} yield.

A re-evaluation of modelling of the current flow between electrodes: consideration of blood flow and wounds

Electrical stimulation has been used for exercise, healing wounds, relieving pain, and strengthening muscle. The assumption is that current will flow predictably between electrodes and, therefore, there will be predictability in the clinical response to electrical stimulation. This may not be the case. The present investigation shows that considerable channelling of current occurs when the skin is heated or when there is a wound between the electrodes. By studying current movement in nutrient agar (a homogenous medium), blood agar and layered blood and nutrient agar to simulate areas of increased blood flow, it was found that areas of high or low resistance, especially in the surface layer, caused significant current movement toward (low resistance area) or away (high resistance area) from those areas. When a resister model was used to measure dispersion characteristics of current in a three-dimensional array, it was shown that if even a single resister value was lowered by 20% in the upper layer, current sinking occurred in all three layers of the array. The results seem to imply that where the tissue is non homogeneous due to injury or inflammation, electrode design or current delivery systems need to be modified appropriately to have the intended effect of the electrical stimulation.

Current distribution under electrodes in relation to stimulation current and skin blood flow: are modern electrodes really providing the current distribution during stimulation we believe they are?

Carbonized rubber electrodes were tested extensively when they were first developed 30 years ago, but modern carbonized rubber electrodes have not received the type of scrutiny that the first electrodes received. Modern electrodes differ from the original electrodes in that they come with a self-adhesive electrode gel called hydrogel as part of their composition. The present study was undertaken to examine the current distribution and impedance characteristics of five brands of carbonized rubber electrodes and to examine the current distribution between electrodes during electrical stimulation in six subjects. Several different electrode sizes were tested between 3 and 10 cm. The current flow between the electrodes was determined by measuring the voltage across the skin on human subjects in 15 discrete locations between the electrodes. Blood flow was also measured between the electrodes with a laser Doppler flow meter to assess the physiological effect of current distribution on the skin at several skin temperatures. The results of these studies showed that at low currents, such as is used in TENS, very little current is actually applied through the skin due to the high impedance of the electrodes. At current levels normally used for electrical stimulation for functional movement, while current flow is better in most electrodes, it is very uneven, resulting in high current density in the centre of the electrodes and a fall off of at least 50% in current intensity at the edges of the electrode. There was very little difference in current density between small and large electrodes due to the high current density in the centre. Skin blood flow altered the movement of current between the electrodes and also may contribute to electrode performance. The implication of these studies is that electrode design needs to be altered for better current distribution, especially at low stimulation currents.

Functional outcome after restorative proctocolectomy in pigs: comparing a novel transverse ileal pouch to the J-pouch and straight ileoanal anastomosis

BACKGROUND

Restorative proctocolectomy followed by an ileoanal J-pouch procedure is the therapy of choice for patients with familial adenomatous polyposis and ulcerative colitis. After low anterior rectal resection, the authors have reported on a novel, less complex pouch configuration, a transverse coloplasty pouch. The aim of the present work was to apply this new design to the ileal pouch construction, to evaluate feasibility, and to measure functional results in comparison with the J-pouch and the straight ileoanal anastomosis using the pig as an animal model.

METHODS

Twenty-three pigs underwent restorative proctocolectomy followed by reconstruction with straight ileoanal anastomosis (IAA; n = 5), J-pouch (n = 7), and a transverse ileal pouch (TIP; n = 11). Pigs were followed for 6 days postoperatively. Peristaltic function was assessed by manometry proximal to the pouch, in the reservoir, and at the level of the ileoanal anastomosis. Functional outcome was monitored by semiquantitative assessment of the general condition of the animals, postoperative feeding habits, and stool frequency and consistency. A Fourier analysis was performed in order to compare peristalsis in the ileal reservoirs. The reservoir volume was measured in situ by triple contrast computed tomography scan with 3D reconstruction.

RESULTS

Seventeen animals survived for 1 week. There was no difference in the general condition or the feeding habits of the groups. A significant number of pigs with the TIP pouch (7/10) had semisolid or formed stools as opposed to liquid stools after J-pouch (6/6) and IAA (4/5; p = 0.01). TIP animals had a lower stool frequency (3.2 +/- 1.14 per day) on day 6 after the operation than pigs with J-pouch, 5.33 +/- 1,03, and IAA, 4.6 +/- 1.82 (p = 0.0036). The in situ volume of the pouches did not differ significantly. The Fourier analysis demonstrated a disruption of peristalsis by the J-pouch and the TIP reconstruction but not after IAA.

CONCLUSION

The function of ileoanal reservoirs after proctocolectomy may result from the disruption of properistaltic waves after pouch formation. The mechanism of peristalsis disruption is independent of the in situ volume of the pouch.

Dielectron production in 12C+12C collisions at 2A GeV with the HADES spectrometer

The invariant-mass spectrum of e+e- pairs produced in 12C+12C collisions at an incident energy of 2 GeV per nucleon has been measured for the first time. The measured pair production probabilities span over 5 orders of magnitude from the pi(0)-Dalitz to the rho/omega invariant-mass region. Dalitz decays of pi(0) and eta account for all the yield up to 0.15 GeV/c(2), but for only about 50% above this mass. A comparison with model calculations shows that the excess pair yield is likely due to baryon-resonance and vector-meson decays. Transport calculations based on vacuum spectral functions fail, however, to describe the entire mass region.

In-medium effects on phase space distributions of antikaons measured in proton-nucleus collisions

Differential production cross sections of K+/- mesons have been measured in p + C and p + Au collisions at 1.6, 2.5, and 3.5 GeV proton beam energy. At beam energies close to the production threshold, the K- multiplicity is strongly enhanced with respect to proton-proton collisions. According to microscopic transport calculations, this enhancement is caused by two effects: the strangeness exchange reaction NY --> K- NN and an attractive in-medium K- N potential at saturation density.

A norovirus outbreak at a long-term-care facility: the role of environmental surface contamination

BACKGROUND

The role of environmental surface contamination in the propagation of norovirus outbreaks is unclear. An outbreak of acute gastroenteritis was reported among residents of a 240-bed veterans long-term-care facility.

OBJECTIVES

To identify the likely mode of transmission, to characterize risk factors for illness, and to evaluate for environmental contamination in this norovirus outbreak.

METHODS

An outbreak investigation was conducted to identify risk factors for illness among residents and employees. Stool and vomitus samples were tested for norovirus by reverse transcription polymerase chain reaction (RT-PCR). Fourteen days after outbreak detection, ongoing cases among the residents prompted environmental surface testing for norovirus by RT-PCR.

RESULTS

One hundred twenty-seven (52%) of 246 residents and 84 (46%) of 181 surveyed employees had gastroenteritis. Case-residents did not differ from non-case-residents by comorbidities, diet, room type, or level of mobility. Index cases were among the nursing staff. Eight of 11 resident stool or vomitus samples tested positive for genogroup II norovirus. The all-cause mortality rate during the month of the outbreak peak was significantly higher than the expected rate. Environmental surface swabs from case-resident rooms, a dining room table, and an elevator button used only by employees were positive for norovirus. Environmental and clinical norovirus sequences were identical.

CONCLUSION

Extensive contamination of environmental surfaces may play a role in prolonged norovirus outbreaks and should be addressed in control interventions.

Observation of different azimuthal emission patterns of K+ and of K- mesons in heavy-ion collisions at 1-2 A GeV

Azimuthal distributions of pi+, K+, and K- mesons have been measured in Au+Au reactions at 1.5A GeV and Ni+Ni reactions at 1.93 A GeV. In semicentral collisions at midrapidity, pi+ and K+ mesons are emitted preferentially perpendicular to the reaction plane in both collision systems. In contrast for K- mesons in Ni+Ni reactions, an in-plane elliptic flow was observed for the first time at these incident energies.

First evidence for different freeze-out conditions for kaons and antikaons observed in heavy-ion collisions

Differential production cross sections of K- and K+ mesons have been measured in Ni+Ni and Au+Au collisions at a beam energy of 1.5 A GeV. The K(-)/K(+) ratio is found to be nearly constant as a function of the collision centrality and system size. The spectral slopes and the polar emission pattern differ for K- and K+ mesons. These observations indicate that K+ mesons decouple earlier from the fireball than K- mesons.

Coulomb dissociation of 8B and the low-energy cross section of the 7Be(p,gamma)8B solar fusion reaction

An exclusive measurement of the Coulomb breakup of 8B into 7Be+p at 254A MeV allowed the study of the angular correlations of the breakup particles. These correlations demonstrate clearly that E1 multipolarity dominates and that E2 multipolarity can be neglected. By using a simple single-particle model for 8B and treating the breakup in first-order perturbation theory, we extract a zero-energy S factor of S17(0)=18.6+/-1.2+/-1.0 eV b, where the first error is experimental and the second one reflects the theoretical uncertainty in the extrapolation.

[Stabilization in treatment of per- and subtrochanteric fractures of the proximal femur]

The incidence of fractures in the trochanteric region is high in the elderly, and early stabilization is required that allows immediate weight bearing. Older patients with low bone quality, limited compliance and strength, and the inability for partial weight-bearing, benefit from intramedullary stabilization of these fractures. The choice of implant and the operative technique depends on the degree of instability in the individual fracture type. Intertrochanteric fractures are frequently combined with subtrochanteric fracture types. Their treatment is still a challenge because of the high degree of instability.

Role of Candida in antibiotic-associated diarrhea

To quantitatively assess the role of Candida species in antibiotic-associated diarrhea (AAD), stool samples from a total of 395 patients and control subjects were cultured in differential isolation medium: 98 patients had AAD, 93 patients were taking antibiotics but did not have diarrhea (A(+)D(-)), 97 patients were not taking antibiotics but had diarrhea (A(-)D(+)), and 107 patients were control subjects (A(-)D(-)). In addition, secreted aspartyl proteinase (Sap) production was tested. In AAD patients, Candida positivity (77/98) and Candida overgrowth (62/98) were not different from that among A(+)D(-) patients (75/93 [P= .860] and 52/93 [P= .375], respectively). Candida overgrowth among A(-)D(+) patients (40/97, P= .003) was less frequent than among AAD patients, but Candida positivity was not different (80/97, P= .612). In control subjects, Candida positivity and overgrowth were less common than in all other groups. Production of Sap did not differ between patients with AAD and control subjects (P= .568 and P= .590, respectively). Data indicate that elevated Candida counts are a result of antibiotic treatment or diarrhea rather than a cause of AAD.

Evidence for a Soft Nuclear Equation-of-State from Kaon Production in Heavy-Ion Collisions

The production of pions and kaons has been measured in 197Au+197Au collisions at beam energies from 0.6 to 1.5A GeV with the kaon spectrometer at SIS/GSI. The K+ meson multiplicity per nucleon is enhanced in Au+Au collisions by factors up to 6 relative to C+C reactions, whereas the corresponding pion ratio is reduced. The ratio of the K+ meson excitation functions for Au+Au and C+C collisions increases with decreasing beam energy. This behavior is expected for a soft nuclear equation-of-state.

Emission pattern of high-energy pions: A new probe for the early phase of heavy-Ion collisions

The emission pattern of charged pions has been measured in Au+Au collisions at 1 GeV/nucleon incident energy. In peripheral collisions and at target rapidities, high-energy pions are emitted preferentially towards the target spectator matter. In contrast, low-energy pions are emitted predominantly in the opposite direction. The corresponding azimuthal anisotropy is explained by the interaction of pions with projectile and target spectator matter. This interaction with the spectator matter causes an effective shadowing which varies with time during the reaction. Our observations show that high-energy pions stem from the early stage of the collision whereas low-energy pions freeze out later.

[Molecular and phenotypic characterization of methicillin-resistant Staphylococcus aureus isolates. Studies at a traumatic surgery clinic, 1994-1997]

Methicillin resistant Staphylococcus aureus-strains, isolated from 1994 to 1997 from patients of the traumatic surgery hospital Tübingen, were compared using lysotyping and pulsed-field gel electrophoresis. Both typing methods detected two clones causing an outbreak 1994 in 6 patients and a third endemic clone of MRSA, which was isolated from 5 patients (1995), 4 patients (1996), and 6 patients (1997). Additionally other MRSA-types were found in 6 cases of which transmissions occurred in up to three patients. An epidemiological connection to MRSA isolated from patients of the university hospital of Tübingen was made. Possible consequences for patient management and antibiotic strategies in MRSA-infections were discussed.

[Unreamed intramedullary nailing as minimal invasive palliative intervention in osteolysis and pathologic fractures of long tubular bones]

Pathological fractures and osteolyses with impending fractures of long bones impose a severe problem in patients with advanced cancer. For palliative treatment between June 1993 and October 1995 intramedullary nailing was performed in 19 patients with 13 femoral, 7 humeral and 1 tibial lesions; AO unreamed nails were used for this purpose (unreamed femur nail UFN with or with spiral blade for femoral lesions and unreamed tibia nail UTN for humeri and tibia). Stabilization was achieved without severe complications; full weight bearing of both femora and humeri (while using crutches) was allowed. Simultaneous and bilateral nailing was done. Follow-up until death due to advanced cancer demonstrated no implant failure and improved quality of life as well. Unreamed intramedullary nailing seems to be a minimally invasive procedure with a low complication rate for palliative treatment of (impending) pathological fractures in advanced cancer.

[Elbow injuries in childhood]

Fractures and dislocations of the elbow are some of the most common injuries in childhood and adolescence. The majority occur in sport and play activities, e.g., a fall from gymnastics apparatus or a bike, or from popular sports items, such as skateboards or in-line skates. The injuries can be divided into pure dislocations of the joint and fractures of the distal humerus, proximal radius and ulna, or combinations of both. In addition, extra- and intraarticular fracture types are defined, with the latter as partial or complete joint lesions. Dislocations of the elbow joint or the radial head can occur as single injuries or in combination with a fracture. Supracondylar fractures and avulsion fractures of the medial epicondyle are the most frequent extraarticular lesions of the distal humerus. Fractures of the lateral condyle prevail is incomplete intraarticular lesions. In the forearm, radial head and neck fractures are predominant while typical and atypical Monteggia injuries have a special status. The complex joint construction and the age-dependent appearance of the epiphyseal ossification centers sometimes make a correct radiological diagnosis difficult. The trauma history and an exact, clinical examination help to verify the injury, as do comparative X-ray studies of the uninjured side when necessary (but not routinely). Unlike other anatomical areas, most elbow injuries-even in the growing skeleton-are treated operatively. Hereby, the growth plates have to be respected using minimal amounts of small implants. Additional immobilization in a cast for 2-4 weeks is necessary in most cases but does not lead to a functional deficit-in contrast to adults. The implants should be removed as early as possible. Despite all therapeutic efforts, a significant number of late sequelae, such as malunions and functional impairment, can be seen. The rate of long-term complications increases in cases of untreated displacement of fragments or joint instability. Corrective measures are performed only in selected cases and after the growth plates are closed. Our own treatment regime is demonstrated using exemplary clinical cases of the different injuries and the results of a long-term follow-up study on sports injuries of the elbow in children. Errors in diagnosis and therapy, as well as possible complications, are pointed out.

Megakaryocytic cell line-specific hyperploidy by cytotoxic necrotizing factor bacterial toxins

Cytotoxic necrotizing factor (CNF) toxins, isolated from certain Escherichia coli strains known to cause intestinal and extra intestinal infections, induce reorganization of the actin cytoskeleton and generate hyperploidy in adherent cell lines. We have examined the effect of CNF toxin on one of the few cell types that naturally increase nuclear DNA content, megakaryocytes. Our studies show that only hematopoietic cells capable of differentiating along the megakaryocyte lineage responded to the CNF2 toxin by becoming polyploid and by reorganizing actin. The K562, HEL, and CHRF-288-11 cell lines can be induced with phorbol ester to differentiate along the megakaryocyte lineage, and these cells also respond to the toxin with increased DNA content and actin cytoskeletal rearrangements. Interestingly, treatment of the K562 and HEL cell lines with CNF2 does not result in an increase in production of the megakaryocytic marker glycoprotein IIIa, unlike phorbol ester treatment. Conversely, two T-cell leukemic cell lines, CEM and Molt4, and the promyelocytic HL-60 cell line, which do not differentiate along the megakaryocyte lineage in response to phorbol myristate acetate, do not respond to CNF2, by increased expression of gpIIIa, increased nuclear DNA content, or actin reorganization. A potential target of these toxins, RhoA, is expressed by both megakaryocytic and nonmegakaryocytic cell lines, as shown by reverse transcription-polymerase chain reaction and Western blot. Although it is clear that the CNF toxins can affect a wide variety of adherent nonhematopoietic cell lines, we propose that the response to CNF, in terms of reorganizing actin structure and increase in DNA content in hematologic suspension cells, correlates with the capability of these target cells to differentiate along the megakaryocytic lineage.

Sequence analysis of ospA genes shows homogeneity within Borrelia burgdorferi sensu stricto and Borrelia afzelii strains but reveals major subgroups within the Borrelia garinii species

The genes coding for the outer surface protein A (OspA) of 19 different Borrelia burgdorferi strains belonging to the seven OspA-serotypes 1-7, previously described [Wilske et al. (1993) J Clin Microbiol, 31: 340-350], have been investigated. B. burgdorferi sensu lato strains were chosen from various biological sources (ticks, human skin and cerebrospinal fluid) as well as different geographical origins (Germany, Slovenia, Austria, United States). The open reading frames of all ospA genes consist of 819-825 nucleotides corresponding to proteins of approximately 30 kDa. The ospA sequences obtained in this study and previous published studies were compared with the results from OspA serotyping with monoclonal antibodies. The classification into the seven OspA serotypes could be confirmed on a genetic basis (ospA genotypes 1-7) for all strains analyzed so far (n = 29). In addition, one strain without OspA expression could be assigned to ospA genotype 2. Genetic stability could be proven for the ospA gene of B. burgdorferi strain PWudI after inocculation and reisolation from a gerbil. However, we found evidence for intragenic recombination by cluster analysis of ospA sequence data. Accordance of ospA genotype 1 strains with B. burgdorferi sensu stricto and ospA genotype 2 strains with B. afzelii, as well as the ospA genotype strains 3-7 with B. garinii was confirmed by pulsed-field gel electrophoresis of MluI-digested genomic DNA. B. garinii is not only more heterogeneous in respect to the OspA-encoding genes, but shows moreover major subgroups formed by genotypes 4, 5 and 6 and genotypes 3 and 7, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Molecular analysis of genes encoding outer surface protein C (OspC) of Borrelia burgdorferi sensu lato: relationship to ospA genotype and evidence of lateral gene exchange of ospC

It has been shown by analysis with monoclonal and polyclonal antibodies that outer surface protein C (OspC) of Borrelia burgdorferi sensu lato is highly heterogeneous. To determine if the heterogeneity has a genetic basis, the genes of 18 different B. burgdorferi sensu lato strains have been amplified by PCR, cloned, and sequenced. The ospC genes could be amplified from all strains tested, even from two strains which did not express OspC in detectable amounts. Among the 18 strains, 16 significantly different types of ospC sequences have been found. The sequence identities of the deduced amino acid sequences of different ospC genotypes range between 62 and 80% (determined without the leader peptide). The sequences range between 62 and 80% (determined without the leader peptide). The sequences correspond to one of the 13 OspC types distinguishable by analysis with monoclonal antibodies (B. Wilske, S. Jauris-Heipke, R. Lobentanzer, I. Pradel, V. Preac-Mursic, D. Roessler, E. Soutschek, and R. C. Johnson, J. Clin. Microbiol. 33:103-109, 1995) or represent additional types. Two completely new types were found, and OspC type 8 (which was found in Borrelia afzelii and Borrelia garinii) could be divided into two groups with different sequences but the same antibody pattern. Thus, strains belonging to different species or OspA serotypes were always significantly different in their ospC sequences. This was also confirmed by ospA sequence analysis. Interestingly, some strains of the same OspA serotype or genotype were very heterogeneous with respect to OspC, while others had nearly identical OspC proteins. Such groups of strains were found among B. burgdorferi sensu stricto, B. afzelii, and B. garinii strains. Cluster analysis of 5'-terminal and 3'-terminal stretches of ospC suggested recent intragenic recombination events in the ospC gene at least one B. afzelii strain. In addition, other recombination events between ancestors of strains belonging to the same or different species were evidenced by this type of analysis.

A comparison of learning activity packages and classroom instruction for diet management of patients with non-insulin-dependent diabetes mellitus

Forty patients were randomly assigned to receive either the individualized learning activity packages or classroom instruction. Effectiveness was evaluated on the basis of fasting plasma glucose, glycosylated hemoglobin, percent of ideal body weight, and knowledge and behavior scores. No significant differences were found between the groups at entry or at the 2-month follow-up. At the 5-month follow-up, the group that received the learning activity packages scored significantly higher on knowledge assessment, significantly increased their behavior score, and decreased their percent of ideal body weight. Patients who received classroom instruction increased their behavior score and exhibited significantly decreased glycosylated hemoglobin levels. Behavior and blood glucose levels were significantly correlated. Although the learning activity packages proved effective in increasing knowledge, no significant improvement was observed in blood glucose levels.

Immunological and molecular polymorphisms of OspC, an immunodominant major outer surface protein of Borrelia burgdorferi

The gene of the immunodominant major protein pC of Borrelia burgdorferi was previously cloned and sequenced (R. Fuchs, S. Jauris, F. Lottspeich, V. Preac-Mursic, B. Wilske, and E. Soutschek, Mol. Microbiol. 6:503-509, 1992). pC is abundantly expressed on the outer surface of B. burgdorferi, as demonstrated by immunoelectron microscopy with monoclonal antibody L22 1F8. Accordingly, pC is renamed OspC, by analogy to the outer surface proteins OspA and OspB. Western immunoblot analysis of 45 B. burgdorferi isolates with monoclonal antibodies revealed that OspC is immunologically heterogeneous. Partial sequence analysis of the ospC gene confirmed the protein heterogeneity at the genetic level. We found that the degree of identity between the ospC partial sequences of five strains representing different OspA serotypes was only 63.3 to 85.4%. Immunological heterogeneity was also observed among representatives of the three newly designated genospecies of B. burgdorferi sensu lato, B. burgdorferi sensu stricto, B. garinii, and group VS461. Heterogeneity was confirmed for B. garinii at the genetic level. The ospC gene was also cloned from strains that did not express OspC, and antibody-reactive OspC was expressed in Escherichia coli. In addition, OspC-expressing variants were obtained from a nonexpressing strain by plating single colonies on solid medium. These findings confirm that the ospC gene is also present in nonexpressing strains. Because OspC is an immunodominant protein for the early immune response in Lyme borreliosis and was effective as a vaccine in an animal model, the immunological and molecular polymorphisms of ospC and OspC have important implications for the development of diagnostic reagents and vaccines.

Genetic heterogenity of the genes coding for the outer surface protein C (OspC) and the flagellin of Borrelia burgdorferi

The ospC gene coding for the outer surface protein OspC and the fla gene coding for the flagellin have been investigated in three different Borrelia burgdorferi sensu lato strains. These strains (the North American strain B31 and the European strains PKo and PBi) derive from various biological sources (lxodes dammini, human skin and human CSF) and belong to three different B. burgdorferi OspA serotypes and genospecies (OspA serotype 1, B. burgdorferi sensu stricto; OspA serotype 2, group VS461 and OspA serotype 4, B. garinii, respectively). The ospC and fla genes of the respective strains have been amplified by polymerase chain reaction, cloned in pUC8 and sequenced. The fla as well as the ospC genes were different among the three strains investigated. In general the fla genes are more conserved than the ospC genes. The fla genes have the same length of 1008 nucleotides coding for proteins of 336 amino acids, whereas the ospC genes differ in length. The ospC genes of strains B31, PKo and PBi have 630, 636 and 621 nucleotides encoding proteins of 210, 212 and 207 amino acids, respectively. The ospC genes exhibit sequence identities between 70% and 74% among each other, sequence identities of the fla genes are in the range 96-97%. The ospC genes could be expressed in Escherichia coli to obtain proteins with and without leader peptides. The expression of the fla gene and an internal gene fragment resulted in the complete flagellin protein and a truncated protein (amino acids 129-251). The different ospC and fla gene products were immunoreactive with monoclonal antibodies and human sera and, thus, enlarge the spectrum of recombinant antigens to improve antibody detection in patients with Lyme borreliosis.

An OspA serotyping system for Borrelia burgdorferi based on reactivity with monoclonal antibodies and OspA sequence analysis

A total of 136 Borrelia burgdorferi sensu latu strains from various biological sources (ticks, human skin, and cerebrospinal fluid) and geographical sources (Europe and North America) were investigated by Western blot (immunoblot) with eight monoclonal antibodies against different epitopes of the outer surface protein A (OspA). On the basis of the differential reactivities of these monoclonal antibodies, seven OspA serotypes were defined. As determined by 16S rRNA sequence analysis, these serotypes correlated well with recently delineated genospecies: serotype 1 corresponds to B. burgdorferi sensu strictu, serotype 2 corresponds to group VS461, and serotypes 3 to 7 correspond to Borrelia garinii sp. nov. (G. Baranton, D. Postic, I. Saint Girons, P. Boerlin, J.-C. Piffaretti, M. Assous, and P. A. D. Grimont, Int. J. Syst. Bacteriol. 42:378-383, 1992). Antigenic differences were confirmed by partial sequence analysis of OspA of representatives of each serotype. Comparative sequence analysis suggested that serotype 5 OspA resulted from genetic recombination of serotype 4 and 6 ospA genes. Serotype 2 (group VS461) was most prevalent among European skin isolates (49 of 62 isolates). Among all B. garinii strains included in this study, serotype 6 was most frequently found in ticks and only rarely in human skin and cerebrospinal fluid, whereas serotypes 4 and 5 were isolated from patients but never from ticks. Our data suggest different pathogenic potentials and organotropisms of distinct OspA serotypes and raise the question of true antigenic variation among B. garinii strains.

Low dose streptozotocin-induced diabetes in mice: reduced IL-2 production and modulation of streptozotocin-induced hyperglycemia by IL-2

The possible role of interleukin 2(IL-2) in the pathogenesis of multiple low dose streptozotocin (Sz)-induced diabetes in mice was analysed. Spleen cells from diabetic male C57Bl/6 mice showed diminished mitogen-induced IL-2 production as determined by bioassay using the IL-2-dependent T-cell line CTLL-2. In parallel the proliferative response was reduced. Systemic daily administration of human recombinant IL-2 for 3 weeks had dose-dependent effects on the development of hyperglycemia in Sz-treated (5 x 40 mg) mice: while IL-2 at doses of 1 x 2, 1 x 10, 2 x 10 micrograms/kg body weight caused partial suppression of hyperglycemia, higher doses (2 x 20, 2 x 40 micrograms/kg) had an enhancing effect. Treatment with the lowest dose (1 x 1 micrograms/kg) or with a control preparation from bacteria (2 x 10 micrograms/kg) did not significantly alter the course of diabetes. Effects of IL-2 were similar when treatment was started concomitantly with or only after streptozotocin injections. This observation argues against the direct interaction between IL-2 and streptozotocin but suggests modulation of immune reactivity by IL-2. Our findings of decreased mitogen-stimulated IL-2 production by splenic lymphocytes, and the disease-modulating effect of IL-2 in the low-dose streptozotocin diabetes extend our previous observations in spontaneously diabetic BB rats and further support the notion of an involvement of IL-2 in the control of autoimmune diseases.

Composition of fluids obtained from human epididymal cysts

The fluid composition of five epididymal spermatocoeles, one epididymal cyst and a hydrocoele was examined. The fluid obtained from the spermatocoeles was a dilute suspension of mainly immotile spermatozoa. The sperm-free fluid contained less protein, phosphate, glucose, triglyceride and cholesterol than serum but more testosterone and chloride than peripheral blood. It contained no epididymal secretion products. Proteins in the fluid differed from those in serum. From the fluid composition these cysts appeared to be continuous with the rete testis, either dilatations of efferent ducts or Haller's superior aberrant duct (vas aberrans of the rete testis). Fluid from an epididymal cyst containing no spermatozoa was mainly of similar composition. In contrast, hydrocoele fluid resembles blood serum.

Application of time-resolved infrared spectral photography to chemical kinetics

We discuss the application of time-resolved infrared spectral photography to the determination of the time-dependent reactant and product concentrations in the simple chain reaction of chlorine atoms, generated by pulsed photolysis, with ethane-Cl(2) mixtures. The technique and experimental results are discussed in terms of the limitations and advantages of the method for general kinetic studies in the microsecond and submicrosecond time domain.

Analysis of 22 immunomodulatory substances for efficacy in low-dose streptozotocin-induced diabetes

Of 22 immunomodulatory substances screened 12 were effective in modulating the course of hyperglycemia following low dose streptozotocin treatment. In this animal model diabetes is induced by administration of low doses of streptozotocin (30-40 mg/kg) body weight to male C57BL/6J/Bom, C57BL/KsJ and C3H/He/Bom mice on 5 consecutive days. Conventional immunosuppressants (azathioprine, cyclophosphamide) largely protected from diabetes development. Partial suppression of hyperglycemia was also seen after administration of B. pertussis, fetal tissue extracts, FTS, inosine pranobex, metronidazole and ADA 202-718. The majority of these substances, when applied with another regimen, and TP5 caused enhancement of diabetes. In conclusion, several substances with a therapeutic potential in experimental diabetes have been identified. Those with little risk of side-effects may deserve further analysis.

Clinical implications of immunologic phenotyping in cutaneous T cell lymphoma

The composition of cutaneous lesions from 158 patients with confirmed cutaneous T cell lymphoma, 91 patients with suspected cutaneous T cell lymphoma, and 145 patients with lymphoid disorders other than cutaneous T cell lymphoma was quantitated in situ with the use of commercially available murine monoclonal antibodies that identify the Pan T, T-helper/inducer (Th), T cytotoxic/suppressor (Ts), and Pan B lymphocyte subsets. On average, cutaneous infiltrates of confirmed cutaneous T cell lymphoma were found to contain significantly more Th and less Ts or Pan B cells compared to benign lymphoid disorders. Moreover, when analyzed in terms of the type of lesion examined by biopsy, the absolute amount of Th cells progressively expands with increasing magnitudes of infiltrate in the dermis while the amount of Ts and Pan B cells remains relatively constant among lesions. A useful diagnostic criterion (anti-Leu 1/4 greater than or equal to 70% and anti-Leu 3a/anti-Leu 2a ratio greater than or equal to 6) correctly discriminated between cutaneous T cell lymphoma and non-cutaneous T cell lymphoma in 87.5% of cases. A positive immunodiagnostic result also may be useful for the prediction of subsequent histopathologic confirmation of cutaneous T cell lymphoma in patients who have suspect lymphoid infiltrates, such as alopecia mucinosis or idiopathic generalized erythroderma, when first seen. With the use of multivariate analysis, stage and possibly the percentage of Th cells within the T cell component in cutaneous infiltrates were covariates with significant relationships to survival in patients with confirmed cutaneous T cell lymphoma. In addition, Ts cells in infiltrates did not correlate significantly with observed responses to topical treatment and subsequent course in pretumorous mycosis fungoides. These results indicate that Ts cells play little biologic role in modifying the natural history of cutaneous T cell lymphoma.

Inhibition of immune-mediated low-dose streptozotocin diabetes by agents which reduce vascular permeability

Low-dose streptozotocin treatment in C57Bl/6J mice causes development of hyperglycemia within two weeks. Diabetes development is due to the specific loss of beta cells from pancreatic islets which can be blocked by immunosuppressive treatment. The role of vascular permeability in pancreatic islet destruction was studied by administration of methysergide or pargyline in addition to low-dose streptozotocin. Both drugs impair serotonin-enhanced vascular permeability. Administration of methysergide or pargyline during the first 11 days following streptozotocin treatment caused substantial suppression of diabetes development. These observations suggest a role of enhanced vascular permeability in immune-mediated beta cell destruction.

Administration of silica or monoclonal antibody to Thy-1 prevents low-dose streptozotocin-induced diabetes in mice

Multiple injections of low doses of streptozotocin induce an experimental diabetes in mice. We have analyzed in two inbred strains whether the development of hyperglycaemia can be influenced by administration of macrophage-toxic silica particles or by a monoclonal antibody to Thy-1.2. Mice received streptozotocin (30 or 40 mg/kg) on five consecutive days (day 0-day 4) and in addition either silica particles (starting at day 0) or anti-Thy-1.2 (starting at day -2 or -3). In both strains mice receiving streptozotocin alone became hyperglycaemic within two weeks. Additional treatment with silica almost fully prevented diabetes development. Anti-Thy-1.2 administration was similarly effective in C57B1/Ks and partially protective in C57BL/6 mice. Histological analysis of pancreatic islets showed that a large fraction of beta cells had been spared from destruction by this treatment. The data indicate a role for both macrophages and Thy-1 positive cells in the pathogenesis of low-dose streptozotocin-induced diabetes.

Suppression of low-dose streptozotocin-induced diabetes by immunomodulatory lectins

The effect of immunomodulatory lectins on diabetes development following low-dose streptozotocin treatment in inbred mice was studied. All lectins administered had been shown previously to suppress immune reactivity. Among plant lectins concanavalin A but not Lens culinaris or wheat germ agglutinin partially suppressed hyperglycaemia following low-dose streptozotocin. A similar inhibitory effect was found for the staphylococcal enterotoxin B. Finally, administration of an immunomodulatory lectin from vertebrates, electrolectin, also had a beneficial effect on the course of the disease. These findings indicate that some lectins have a suppressive effect on Type 1 diabetes in an animal model.

Effect of cyclosporin A on low-dose streptozotocin diabetes in mice

The effect of cyclosporin A administration on diabetes development following multiple low-dose streptozotocin treatment was determined in inbred mice. When given daily at a dose of 12 or 60 mg/kg body weight the drug induced an earlier development of hyperglycemia and led to persistently higher blood glucose levels. Enhancement of diabetes by cyclosporin A was also seen when the drug was given only after termination of treatment with streptozotocin.

Effect of food deprivation on rat gastric somatostatin and gastrin release

The influence of food deprivation on the release of somatostatin and gastrin from the rat stomach was investigated using an isolated, vascularly perfused rat stomach preparation. Basal and acetylcholine-stimulated gastrin release were significantly lower after a 3 day starvation, whereas the inhibitory effect of acetylcholine and the stimulatory effect of glucagon on somatostatin secretion were not influenced by fasting. In dose-response studies, isoproterenol dose-dependently stimulated somatostatin secretion. The increases were similar in both groups fasted for 12 and 72 h. Gastrin release remained at basal levels. Bombesin dose-dependently increased gastrin secretion; this stimulatory effect on the G cell was significantly reduced after a 72-h starvation. Somatostatin secretion was only weakly stimulated by high concentration of bombesin revealing no effect of fasting. Somatostatin content of the nonperfused stomach declined from 57 +/- 4 pmol/stomach in fed controls to 36 +/- 3 pmol/stomach after a 72-h fast. Antral gastrin concentration decreased by 42% in a 3-day fasting period. It is concluded that rat gastric somatostatin release in vitro is--in contrast to gastrin--not altered by food deprivation while the somatostatin content in gastric tissue declined during fasting.