E. coli promotes human Vγ9Vδ2 T cell transition from cytokine-producing bactericidal effectors to professional phagocytic killers in a TCR-dependent manner.

γδT cells provide immune-surveillance and host defense against infection and cancer. Surprisingly, functional details of γδT cell antimicrobial immunity to infection remain largely unexplored. Limited data suggests that γδT cells can phagocytose particles and act as professional antigen-presenting cells (pAPC). These potential functions, however, remain controversial. To better understand γδT cell-bacterial interactions, an ex vivo co-culture model of human peripheral blood mononuclear cell (PBMC) responses to Escherichia coli was employed. Vγ9Vδ2 cells underwent rapid T cell receptor (TCR)-dependent proliferation and functional transition from cytotoxic, inflammatory cytokine immunity, to cell expansion with diminished cytokine but increased costimulatory molecule expression, and capacity for professional phagocytosis. Phagocytosis was augmented by IgG opsonization, and inhibited by TCR-blockade, suggesting a licensing interaction involving the TCR and FcγR. Vγ9Vδ2 cells displayed potent cytotoxicity through TCR-dependent and independent mechanisms. We conclude that γδT cells transition from early inflammatory cytotoxic killers to myeloid-like APC in response to infectious stimuli.

Critical patch size generated by Allee effect in gypsy moth, Lymantria dispar (L.).

Allee effects are important dynamical mechanisms in small-density populations in which per capita population growth rate increases with density. When positive density dependence is sufficiently severe (a 'strong' Allee effect), a critical density arises below which populations do not persist. For spatially distributed populations subject to dispersal, theory predicts that the occupied area also exhibits a critical threshold for population persistence, but this result has not been confirmed in nature. We tested this prediction in patterns of population persistence across the invasion front of the European gypsy moth (Lymantria dispar) in the United States in data collected between 1996 and 2008. Our analysis consistently provided evidence for effects of both population area and density on persistence, as predicted by the general theory, and confirmed here using a mechanistic model developed for the gypsy moth system. We believe this study to be the first empirical documentation of critical patch size induced by an Allee effect.

Prospective payment for nursing homes increased therapy provision without improving community discharge rates.

OBJECTIVES: To determine the impact of the prospective payment system (PPS) for skilled nursing facilities (SNFs) on therapy use and community discharge rates. DESIGN: Quasi-experimental study examining the predemonstration (1994) to demonstration (1997) change in amount of therapy provided, and in community discharge rates at PPS participating and nonparticipating facilities. SETTING: Eighteen PPS participating and 17 nonparticipating SNFs in five states. PARTICIPANTS: Two thousand sixty-seven admissions to 18 PPS participating and 17 nonparticipating SNFs in five states. MEASUREMENTS: We compared changes in number of physical and occupational therapy visits per stay for patients receiving therapy and likelihood of being located in the community 60 days after admission between 1994 and 1997. Analyses were stratified by functional category and risk adjusted using multivariate methods. RESULTS: Demographics and percentage of patients in each stratum were similar in participating and nonparticipating sites and between 1994 and 1997. Amount of therapy received by the highest-functioning patients increased in participating sites (19.3 to 26.5 visits per stay, P = .005), but not in nonparticipating sites (23.3 to 18.2, P = .98). After adjusting for covariates, likelihood of community discharge for the highest-functioning patients did not change between participating and nonparticipating sites. CONCLUSIONS: The highest-functioning patients treated under the SNF PPS demonstration experienced great increases in therapy, without any improvement in rate of community discharge.

Reducing emergency visits in older adults with chronic illness. A randomized, controlled trial of group visits.

CONTEXT: Emergency department utilization by chronically ill older adults may be an important sentinel event signifying a breakdown in care coordination. A primary care group visit (i.e., several patients meeting together with the provider at the same time) may reduce fragmentation of care and subsequent emergency department utilization. OBJECTIVE: To determine whether primary care group visits reduce emergency department utilization in chronically ill older adults. DESIGN: Randomized trial conducted over a 2-year period. SETTING: Group-model HMO in Denver, Colorado. PATIENTS: 295 older adults (> or = 60 years of age) with frequent utilization of outpatient services and one or more chronic illnesses. INTERVENTION: Monthly group visits (generally 8 to 12 patients) with a primary care physician, nurse, and pharmacist held in 19 physician practices. Visits emphasized self-management of chronic illness, peer support, and regular contact with the primary care team. MEASURES: Emergency department visits, hospitalizations, and primary care visits. RESULTS: On average, patients in the intervention group attended 10.6 group visits during the 2-year study period. These patients averaged fewer emergency department visits (0.65 vs. 1.08 visits; P = 0.005) and were less likely to have any emergency department visits (34.9% vs. 52.4%; P = 0.003) than controls. These differences remained statistically significant after controlling for demographic factors, comorbid conditions, functional status, and prior utilization. Adjusted mean difference in visits was -0.42 visits (95% CI, -0.13 to -0.72), and adjusted RR for any emergency department visit was 0.64 (CI, 0.44 to 0.86). CONCLUSION: Monthly group visits reduce emergency department utilization for chronically ill older adults.

Outcomes of older persons receiving rehabilitation for medical and surgical conditions compared with hip fracture and stroke.

OBJECTIVE: Older persons with general medical and surgical conditions increasingly receive posthospital rehabilitation care in nursing homes and rehabilitation hospitals. This study describes the characteristics of such patients, contrasted with patients with traditional rehabilitation diagnoses of hip fracture and stroke. DESIGN: Prospective cohort study. SETTING: Seventeen skilled nursing facilities and six rehabilitation hospitals in seven states. PARTICIPANTS: Medicare patients age 65 or older receiving posthospital rehabilitation. METHODS: A total of 290 medical/surgical patients were compared with 336 hip fracture and 429 stroke patients. Data were collected prospectively from charts, nursing assessments, and patient interviews. Patient characteristics associated with functional recovery and mortality were estimated using multivariate regression. RESULTS: Medical/surgical patients had greater premorbid activities of daily living (ADL) (P < .001) and instrumental activities of daily living (IADL) (P < .01) disability, but suffered less decline with the acute event than hip fracture or stroke patients (P < .001). Medical/surgical patients were more likely to recover premorbid ADL function (P < .05) but 1-year mortality was significantly greater (30% vs. 14% hip fracture; 18% stroke; P < .001). Predictors of functional recovery and mortality differed between the three groups. Among medical/surgical patients, premorbid ADL difficulty, cognitive impairment, a pressure ulcer at rehabilitation admission, and depression were associated with failure to recover premorbid function whereas increasing comorbidity and incontinence were associated with mortality. CONCLUSIONS: Medical/surgical patients represent a unique rehabilitation population. They experienced greater premorbid functional disability, less acute decline, but greater mortality than patients with traditional rehabilitation diagnoses. Further study of this distinct rehabilitation population may help identify patients most likely to benefit from rehabilitation.

[Clinical neosporosis in the dog: a review]. / Klinische neosporose bij de hond; een literatuuronderzoek.

Neospora caninum is an intracellular protozoan parasite that was first recognized in dogs in 1988. N. caninum may cause neuromuscular disease in dogs. Later, it was discovered that N. caninum has a wide host range and is an important cause of abortion in cattle. In this article, the literature on N. caninum in the dog is reviewed, with emphasis on clinical signs, pathology, diagnosis, treatment, and prognosis.

[The role of the dog in the epidemiology of neosporosis in cattle]. / De rol van de hond in de epidemiologie van neosporose bij het rund.

Neospora caninum is an intracellular protozoan parasite that was discovered in a dog in 1988. Since then, N. caninum has been demonstrated in a variety of animal species and it has been recognized as an important cause of abortion in cattle. An infection with N. caninum can be maintained in cattle herds for several generations by transplacental transmission from cow to calf. Recently, it was demonstrated that dogs can act as definitive hosts of N. caninum and therefore may be a source of infection for other species by shedding oocysts. Further evidence of a role of the dog in spreading the infection to cattle has been derived from epidemiological studies. The present state of knowledge is reviewed in this paper.

Outcome and utilization differences for older persons with stroke in HMO and fee-for-service systems.

OBJECTIVES: To compare treatment and outcomes for older persons with stroke in Medicare health maintenance organizations (HMOs) and fee-for-service (FFS) systems. DESIGN: Inception cohort stratified by payer and followed for 1 year. SETTING: Six HMOs and five FFS systems with large Medicare populations in the West, Midwest, and Eastern United States. PARTICIPANTS: A total of 429 randomly selected stroke patients receiving rehabilitation in nursing homes or rehabilitation hospitals (RHs) from June 1993 to June 1995. MEASUREMENTS: Improvement in activities of daily living (ADLs) during rehabilitation, and ADL recovery, community residence, and utilization until 12 months after stroke. Outcomes were adjusted for premorbid function, marital status, comorbid illness, posthospital function, cognition, psychological problems, and stroke deficits. RESULTS: At baseline, HMO patients were more likely to be married, and less likely to be blind or have psychiatric diagnoses. HMO patients had shorter hospitalizations (P < .001), were less likely to be admitted to RHs (13% vs 85%, P < .001), and received fewer therapy and physician specialist visits (P < .001) but more home health visits (P < .001). During rehabilitation, FFS patients made greater improvement in ADLs (difference, 0.73 ADLs; 95% CI, .37-1.09). At 1 year, there was no difference in ADL recovery (difference, -0.24 ADL; 95% CI, -0.64-0.16), but FFS patients were more likely to reside in the community (adjusted OR, 1.8; 95% CI, 1.1-3.1), and HMO patients were more likely to reside in nursing homes (adjusted OR, 2.4; 95% CI, 1.1-5.5). CONCLUSION: Study findings suggest that short-term functional outcomes and eventual community residence rates are poorer for Medicare HMO patients with stroke than for stroke patients receiving FFS care, consistent with the lower intensity of rehabilitation (in nursing homes vs RHs) and less specialty physician care.

Patients' perceptions of physicians' recommendations for comfort care differ by patient age and gender.

OBJECTIVE: To determine patient characteristics associated with patient and proxy perceptions of physicians' recommendations for life-prolonging care versus comfort care, and with acceptance of such recommendations. DESIGN: Cross-sectional. SETTING: Five teaching hospitals in Denver, Colo. PATIENTS: We studied 239 hospitalized adults believed by physicians to have a high likelihood of dying within 6 months. MEASUREMENTS AND MAIN RESULTS: Interviews with patients or proxies were conducted to determine perceptions of physicians' recommended goal of care and roles in decision making. RESULTS: Patients' mean age was 66.6 years; 44% were women. In adjusted analysis, age greater than 70 years and female gender were associated with a higher likelihood of believing that comfort care had been recommended by the physician (odds ratio [OR], 3.70; 95% confidence interval [CI], 1.89 to 7.24; OR, 1.99; 95% CI, 1.04 to 3. 84, respectively). Patients and proxies gave substantial decision-making authority to physicians: 29% responded that physicians dominate decision making, 55% that decision making is equally shared by physicians and patients, and only 16% that patients make decisions. Increasing age was associated with an increased likelihood of believing that physicians should dominate decision making (P <.005). CONCLUSIONS: Among patients with advanced illness, perceived comfort care recommendations were related to patient age and gender, raising concern about possible gender and age bias in physicians' recommendations. Although all patients and proxies gave significant decision-making authority to physicians, older individuals were more likely to give physicians decision-making authority, making them more vulnerable to possible physician bias.

A comparison of functional outcomes after hip fracture in group/staff HMOs and fee-for-service systems.

CONTEXT: Previous studies examining differences in the quality of care between capitated and fee-for-service payment systems have focused on the care delivered in a single setting. No study to date has compared outcomes over an entire episode of care delivered across multiple settings. OBJECTIVE: To compare outcomes of care for patients receiving institutional rehabilitation for hip fracture in fee-for-service and group/staff HMO delivery systems. DESIGN: One-year prospective inception cohort. SETTING: Six hospital-based, integrated care systems paid on a traditional fee-for-service model and five group/staff HMOs (paid fixed capitation rate by Medicare). The 11 delivery systems were selected because of their commitment to geriatric rehabilitation. PATIENTS: 196 fee-for-service and 140 group/staff HMO patients with acute hip fracture were identified on admission to inpatient rehabilitation. MEASURES: Four primary outcomes--recovery of activities of daily living, improvement in ambulation, return to community living, and mortality--were measured at 3, 6, 9, and 12 months. Service utilization was assessed in the acute-care hospital setting, rehabilitation setting, and at each 3-month follow-up interval. Risk adjustment was performed by using multiple and logistic regression. RESULTS: Overall, no differences were found between patients in group/staff HMOs and fee-for-service patients. Group/staff HMO patients experienced improved functional recovery at 6 months (P < 0.01) and improved ambulation at 12 months (P = 0.05) compared with fee-for-service patients, although these were isolated findings. With regard to utilization, group/staff HMO delivery systems used physician services less intensively and substituted less-skilled allied health personnel. CONCLUSION: Compared with fee-for-service delivery systems, with a similar commitment to excellence in geriatric rehabilitation, group/staff HMOs can achieve equivalent outcomes in older patients recovering from hip fracture with less-intense service utilization.

Seroepidemiological evidence for a relationship between Neospora caninum infections in dogs and cattle.

Dogs from dairy farms with a known prevalence of Neospora caninum antibodies in the cattle were examined for the presence of N. caninum antibodies using an ELISA. Data of farm dogs were compared with those of dogs examined at a university clinic, which originated mainly in urban areas. Of the 152 farm dogs, 36 (23.6%) were seropositive to N. caninum, which was significantly higher than the proportion of seropositives in the clinic dog population (19 of 344, 5.5%). Seroprevalence was significantly higher (P = 0.01) in female dogs than in male dogs. Seroprevalence in dogs increased with age, indicating postnatal infection. Seropositivity to N. caninum in farm dogs was strongly correlated with a high prevalence of N. caninum antibodies in the cattle. At farms where no dogs were present, the seroprevalence to N. caninum in the cattle was significantly lower (P = 0.0002) than in farms where dogs were present. These findings suggest that there is a relationship between N. caninum infection of farm dogs and cattle. Since dogs have been shown to be definitive hosts of N. caninum, cattle may be infected by exposure to canine oocysts. Further research is needed to find out whether and how dogs may acquire the infection from cattle.

Stroke rehabilitation in nursing homes: how do we measure quality?

Over one-third of Medicare stroke patients are admitted to nursing homes for rehabilitation. Patients with stroke who are admitted to nursing homes are extremely heterogeneous, including both those with minimal physical and cognitive impairment and those who are totally physically dependent. Quality measures that are appropriate for evaluating stroke care in nursing homes include outcome measures, particularly those that are patient-centered, such as self-reported functional recovery and return to the community; process measures involving essential services such as screening for depression and pain; and structural measures such as the availability of a psychologist or presence of an interdisciplinary team. In measuring quality, nursing home professionals must allow sufficient time for outcomes to unfold, such as 3 to 6 months, rather than measuring outcome at discharge from a setting. Nursing home professionals must also take into consideration patient heterogeneity in terms of risk factors for outcomes of interest.

[Capnocytophaga canimorsus infections: a possibly fatal complication of bite wounds]. / Capnocytophaga Canimorsus-infecties: een mogelijk dodelijke complicatie van bijtwonden.

Practising veterinarians and their assistants run the risk of being bitten by their patients, mostly cats and dogs, and many have experienced that bites and bite-wound infections can have unpleasant consequences. In recent years, more insight has been gained into a 'new' bacterial infection of bite wounds that not only has severe local effects but also potentially fatal systemic consequences. The bacterium involved is Capnocytophaga canimorsus. All bite wounds should be treated adequately, but this is especially so when wounds are infected with C. canimorsus. In this article, dog and cat bites are briefly described and then an overview is given of current knowledge of C. canimorsus and appropriate prophylactic measures.

Application of functional independence measure-function related groups and resource utilization groups-version III systems across post acute settings.

OBJECTIVES: The present study evaluated alternative patient classification systems for skilled nursing facility and rehabilitation facility patients. METHODS: Medicare patients were selected from a random sample of 27 rehabilitation facilities and 65 skilled nursing facilities participating in a national longitudinal study of subacute care. Detailed casemix and resource use data was obtained on 513 patients with hip fracture and 483 stroke patients. The Functional Independence Measure-Function Related Groups (FIM-FRGs) classification system for rehabilitation facilities was replicated on length of stay and tested on resource use for rehabilitation facility patients as well as for skilled nursing facility patients. Modifications to the FIM-FRGs also were tested. The Resource Utilization Groups-Version III classification was tested on rehabilitation facility patients. RESULTS: The FIM-FRGs explained the same amount of variance in length of stay as in the original FIM-FRGs development sample (R2 hip fracture = 0.14, R2 stroke = 0.28), and similar variance in resource use. A modified version of the FIM-FRGs explained more variance in length of stay (R2 hip fracture = 0.19, R2 stroke = 0.39) and resource use (R2 hip fracture = 0.20, R2 stroke = 0.41). Neither model adequately predicted length of stay or resource use in skilled nursing facility patients. The Resource Utilization Groups-Version III rehabilitation groups accounted for little variance in rehabilitation facility patients' per-diem resource use (R2 = 0.11). CONCLUSIONS: The FIM-FRGs are valid for resource use as well as length of stay for rehabilitation facility patients, but are not valid for skilled nursing facility patients. Similarly, the Resource Utilization Groups-Version III system does not apply to rehabilitation facility patients. Related work, however, suggests that development of a single episode-based patient classification system for skilled nursing facility and rehabilitation facility patients is possible and should be pursued.

Development and validation of a clinical prediction rule for prolonged nursing home residence after hip fracture.

OBJECTIVES: To develop and validate a clinical prediction rule for nursing home residence 6 months after a hip fracture. DESIGN: Two prospective cohort studies, a development study (DS) and a validation study (VS). SETTING: The DS included hip fracture patients admitted to 92 rehabilitation units or skilled nursing facilities; the VS included hip fracture patients from 11 integrated healthcare systems. PARTICIPANTS: A total of 344 community-dwelling hip fracture patients aged 65 and older participated in the DS; 239 similar patients were enrolled in the VS. INTERVENTION: None. MEASUREMENTS: The acute hospital record, nursing evaluations, and patient questionnaires provided information about demographics, physical and neuropsychological function, and comorbidity. Residence 6 months after fracture was determined by phone interview. Multivariate analysis identified predictors for a risk score to assess the likelihood of nursing home residence. RESULTS: 18.7% of patients in the DS resided in nursing homes 6 months after hip fracture. The four independent risk factors for institutionalization were (1) being unmarried (OR = 6.7 [95% CI 2.4 to 19]), (2) incontinence (OR = 2.3 [CI 1.2 to 4.7]), (3) dependence in ambulation (OR = 5.0 [CI 2.1 to 12.3]), and (4) cognitive impairment (OR = 6.6 [CI 3.3 to 13.2]). Of patients with all four risk factors, 73.2% were institutionalized at 6 months, compared with 0% of patients with no risk factors. In the VS, 6.1% of patients resided in nursing homes after 6 months, with a range from 50.0% of patients with four risk factors to 0% of those with no risk factors. Areas under receiver-operating characteristic curves for the prediction rule were 0.84 +/- .03 in the DS, and 0.81 +/- .06 in the VS. CONCLUSION: A clinical prediction rule using four easily measurable characteristics can identify individuals at high or low risk of nursing home residence 6 months after hip fracture.

Rehabilitation costs: implications for prospective payment.

OBJECTIVE: To obtain information relevant to development of prospective payment for Medicare rehabilitation facilities (RFs) and skilled nursing facilities (SNFs): compares service utilization, length of stay (LOS), case mix, and resource consumption for Medicare patients receiving postacute institutional rehabilitation care. DATA SOURCES/STUDY SETTING: Longitudinal patient-level and related facility-level data on Medicare hip fracture (n = 513) and stroke (n = 483) patients admitted in 1991-1994 to a sample of 27 RFs and 65 SNFs in urban areas in 17 states. STUDY DESIGN: For each condition, two-group RF-SNF comparisons were made. Regression analysis was used to adjust RF-SNF differences in resource consumption per stay for patient condition (case mix) and other factors, since random assignment was not possible. DATA COLLECTION/EXTRACTION METHODS: Providers at each facility were trained to collect patient case-mix and service utilization information. Secondary data also were obtained. PRINCIPAL FINDINGS: RF patients had shorter LOS, fewer total nursing hours (but more skilled nursing hours), and more ancillary hours than SNF patients. After adjustment, ancillary resource consumption per stay remained substantially higher for RF than SNF patients, particularly for stroke. The adjusted nursing resource consumption differences were smaller than the ancillary differences and not statistically significant for hip fracture. Supplemental outcome findings suggested minimal differences for hip fracture patients but better outcomes for RF than SNF stroke patients. CONCLUSIONS: Much can be gained from an integrated approach to developing prospective payment for RFs and SNFs. In that context, consideration of condition-specific per-stay payment methods applicable to both settings appears warranted.

Rehabilitation care and outcomes from the patient's perspective.

In the past, quality of health care was measured principally with reference to provider-established norms. More recently, increased attention has been paid to patients' views on care delivery and outcomes. However, in rehabilitation medicine, this trend has not been established: provider-assessed outcomes during short stays in specific settings are the focus of care. This article offers a theoretic framework for the assessment of rehabilitative care from the patient's perspective. Four domains of the patient's experience and the specific dimensions of each domain are discussed, and their influence on the measurement of quality from the patient's viewpoint is reviewed. A similar comparison is made between patient and provider perspectives on care outcomes. Examples are provided of patient-based outcome measures. Emphasis is placed on the importance of distinguishing between provider and patient perspectives and on giving the patient's views a primary role in evaluating care and outcomes.

Outcomes and costs after hip fracture and stroke. A comparison of rehabilitation settings.

OBJECTIVE: To assess whether outcomes and costs differ for elderly patients admitted to rehabilitation hospitals, subacute nursing homes, and traditional nursing homes. DESIGN: Inception cohort stratified by provider type and followed prospectively for 6 months. SETTING: A total of 92 hospital-based units and freestanding facilities from 17 states. PATIENTS: A total of 518 randomly selected patients with hip fracture and 485 stroke patients admitted from November 1991 to February 1994. MAIN OUTCOME MEASURES: At 6 months comparing community residence, recovery to premorbid levels in 5 activities of daily living (ADLs), Medicare costs, and the number of therapy and physician visits. Outcomes were adjusted for premorbid residence and function, caregiver availability, comorbid illness, admission function, cognition, depression, sensory deficits, and mobility impairments. RESULTS: On admission, rehabilitation hospital patients were more likely (P<.001) to have caregivers and better cognitive and physical function. Hip fracture patients admitted to rehabilitation hospitals did not differ from patients admitted to nursing homes in returning to the community (adjusted odds ratio [OR], 1.3; 95% confidence interval [CI], 0.6-2.6) or in the number of ADLs recovered to premorbid level (difference, 0.09 ADL; 95% CI, -0.27-0.44), but stroke patients admitted to rehabilitation hospitals were more likely to return to the community (adjusted OR, 3.3; 95% CI, 1.5-7.2) and recover ADLs (difference, 0.63 ADL; 95% CI, 0.20-1.07). Subacute nursing home patients with stroke were more likely than traditional nursing home patients to return to the community (adjusted OR, 6.8; 95% CI, 2.2-21.4), there was no difference in return to the community for patients with hip fracture (adjusted OR, 1.6; 95% CI, 0.7-3.6), and there were no differences in recovery of ADLs for either condition. Medicare costs were greater (P<.001) for rehabilitation hospital patients than for subacute nursing home patients, and the costs for subacute nursing home patients were greater (P=.03 for stroke and .009 for hip fracture) than for traditional nursing home patients. CONCLUSIONS: Study findings are consistent with enhanced outcomes for elderly patients with stroke treated in rehabilitation hospitals but not for patients with hip fracture. Subacute nursing homes were more effective than traditional nursing homes in returning patients with stroke to the community, despite comparable functional outcomes.