Program activity in the second year of the Rural Telemedicine Grant Program Part 2.

Part 1, in our last issue, detailed the activity levels, number and types of consults, and transmission costs of the 13 telemedicine networks funded in 1994 by the Office of Rural Health Policy's Rural Telemedicine Grant Program. This concluding section presents the authors' conclusions drawn from the objective data in Part 1.

Rural telemedicine: a national snapshot.

OBJECTIVES: To estimate the use of telemedicine in rural hospitals in the U.S. and to identify and describe those rural hospitals that are active in telemedicine. MATERIALS AND METHODS: Nationwide mailed survey, with telephone follow-up, to all hospitals not located in a Metropolitan Statistical Area. RESULTS: The overall response rate was 95% of all rural hospitals. Of these, 416 (17.55%) reported having telemedicine, and more than 530 more have plans to begin telemedicine programs during the next few years. Rural hospitals of all sizes and in all regions of the country are initiating telemedicine programs, but there is significant variation by region. Specifically, hospitals located in more populous rural counties near metropolitan areas are less likely to have telemedicine than are hospitals located in less populous rural counties in more remote areas. Conservatively, more than 4000 teleconsults per month are estimated among rural hospitals nationwide in 1995, including all forms of telemedicine. CONCLUSIONS: Telemedicine is becoming an important means of providing specialty medical services in rural areas. This screening survey generated information about the extent of telemedicine use in rural communities, but it also raised many new questions. These questions are being pursued through a detailed follow-up survey.

Protein malnutrition alters the distribution of Fc gamma R+ (T gamma) and Fc mu R+ (T mu) T lymphocytes in experimental pulmonary tuberculosis.

Inbred, strain 2 guinea pigs were given isocaloric diets containing either 30% (control diet) or 10% (low-protein diet) ovalbumin and infected 4 weeks later by the respiratory route with virulent Mycobacterium tuberculosis. By using an Fc receptor rosette assay, the proportions of T lymphocytes bearing Fc receptors for immunoglobulin G (T gamma cells) or immunoglobulin M (T mu cells) were quantified in blood and lymphoid tissues taken postinfection. A significant elevation in the proportion of the putative suppressor T subset (T gamma) in the blood of protein-deprived guinea pigs was observed at all intervals postinfection. Conversely, the levels of the putative helper T subset (T mu) in the bronchotracheal lymph nodes draining the site of virulent infection in malnourished animals were significantly reduced. Diet did not influence T gamma or T mu cells in the spleens. Diet-induced loss of purified protein derivative-specific T-cell functions in tuberculosis may be associated with alterations in the proportions of or the balances between T gamma and T mu subsets.

Micronutrient status and immune function in tuberculosis.

Both macro- and micronutrients have been shown to affect resistance to tuberculosis, which is mediated by macrophages activated by T lymphocytes. Others have demonstrated inhibition of mycobacterial replication in macrophage cultures treated with vitamin D or retinoic acid. We examined the influence of dietary zinc and vitamin D on resistance to tuberculosis. Guinea pigs were fed diets containing varying levels of zinc or vitamin D, and infected 6 weeks later by the respiratory route with virulent Mycobacterium tuberculosis. Zinc-deficient guinea pigs had fewer circulating T cells and reduced tuberculin (PPD) hypersensitivity. The response of peritoneal exudate macrophages to the lymphokine MIF was impaired. Zinc deprivation did not influence disease resistance in BCG-vaccinated or nonvaccinated animals. Vitamin D deficiency adversely affected the tuberculin reaction and ability to control the infection. Lymphocytes from vitamin D-deprived animals did not proliferate normally when cultured with PPD. A diet supplemented with vitamin D enhanced T cell responses to PPD in vivo. These results suggest that zinc and vitamin D status affect immunity to tuberculosis.

Dietary protein deficiency and Mycobacterium bovis BCG affect interleukin-2 activity in experimental pulmonary tuberculosis.

Inbred strain 2 guinea pigs were vaccinated with Mycobacterium bovis BCG or were left unvaccinated. They were maintained for 6 weeks on defined, isocaloric diets containing either 30% (control animals) or 10% (animals receiving low protein) ovalbumin as the sole protein source. Animals were challenged by the respiratory route with a low dose of virulent M. tuberculosis H37Rv and killed 4 weeks later. Protein-malnourished animals were not protected by previous vaccination with BCG. Lymphocytes isolated from various tissues were tested in vitro for proliferative responses to mitogen (concanavalin A) and antigen (purified protein derivative [PPD]), production of interleukin-2 (IL-2), and response to exogenous recombinant IL-2 (rIL-2). Protein-malnourished guinea pigs responded only weakly to PPD skin tests, and their blood and lymph node lymphocytes exhibited impaired proliferation when cultured with PPD in vitro. IL-2 levels were consistently low in cultures of stimulated blood and spleen lymphocytes from protein-deprived animals. BCG vaccination of nutritionally normal guinea pigs, on the other hand, induced significantly more IL-2 production by PPD- and concanavalin A-stimulated lymphocytes. The addition of exogenous mouse rIL-2 (40 and 80 U/ml) in vitro to PPD-stimulated blood and lymph node cells from nonvaccinated, protein-deprived guinea pigs resulted in no improvement of the proliferative response. Previous vaccination of malnourished guinea pigs did not consistently enhance the response of PPD-stimulated lymphocytes to added rIL-2. Dietary protein deficiency and BCG vaccination appear to modulate antigen-driven cellular immunity in animals with tuberculosis by altering the production of, and the response to, IL-2 by PPD-stimulated lymphocytes.

Impact of protein malnutrition on exogenous reinfection with Mycobacterium tuberculosis.

Malnutrition may be a predisposing host factor in the development of exogenous-reinfection tuberculosis. Outbred Hartley guinea pigs were given isocaloric diets containing either 30% ovalbumin (control animals) or 10% ovalbumin (low-protein-fed [LP] animals). Equal numbers of control and LP animals were assigned to one of three infection groups: (i) primary pulmonary infection with a low-virulence, streptomycin-resistant (LVsr) isolate of Mycobacterium tuberculosis and then reinfection 6 weeks later by the same route with a high-virulence (HV) isolate; (ii) only the primary infection (LVsr isolate); and (iii) only the secondary infection (HV isolate). Each infection resulted in the development of 4 to 12 pulmonary tubercles. Guinea pigs were skin tested with purified protein derivative and killed 6 weeks after the second infection. Protein deprivation suppressed the dermal responses to purified protein derivative in all infection groups. Primary infection of well-nourished animals with the LVsr isolate induced significant protection against infection with the HV isolate in the reinfected group, based upon the numbers of viable mycobacteria in the lung and spleen. Protein malnutrition did not exacerbate disease in the reinfected group beyond that observed in malnourished animals infected with the HV isolate only, but neither did the infection with the LVsr isolate protect the LP animals against reinfection with the HV isolate. We conclude that malnutrition interferes with the protection normally afforded by primary infection but does not result in more severe disease in reinfected individuals than would be observed in singly infected subjects.

Reduced parasitemia observed with erythrocytes containing inositol hexaphosphate.

Chemicals entrapped in erythrocytes by hypotonic hemolysis can be assessed for possible antiparasitic activity both in vivo and in vitro, regardless of whether they are able to diffuse into erythrocytes readily. Inositol hexaphosphate, a highly charged compound, produced a dramatic lowering of the percentage of cells infected by Babesia microti in vivo and both B. microti and Plasmodium falciparum in vitro. Several possible mechanisms for this observation are discussed.

Effects of diet and genetics on Mycobacterium bovis BCG vaccine efficacy in inbred guinea pigs.

Strain 2 and strain 13 guinea pigs were vaccinated with Mycobacterium bovis BCG and placed on low-protein or protein-adequate diets. Five weeks later all animals were infected by the respiratory route with virulent Mycobacterium tuberculosis H37Rv organisms. Four weeks postchallenge, guinea pigs were skin tested with purified protein derivative and sacrificed. Protein deficiency resulted in significant reductions in body weight and thymus weight and in an impairment in the ability to control the M. bovis BCG vaccine organisms and to mount delayed hypersensitivity reactions. Protein deficiency also adversely affected the efficacy of the BCG vaccine as demonstrated by the numbers of virulent organisms recovered in spleens and lungs. Strain differences were observed in the number of leukocytes, thymus weight, and the responsiveness of blood lymphocytes to purified protein derivative stimulation. In general, strain 13 guinea pigs responded more dramatically to dietary insult than did their strain 2 counterparts. Protein deprivation completely abolished BCG vaccine protection in the lungs and spleens of strain 13 animals and significantly reduced the protection afforded to strain 2 animals. In both strains, the BCG vaccine protected normally nourished guinea pigs. There was no significant difference between strains with respect to susceptibility to pulmonary infection with virulent mycobacteria. Thus, diet and genetic pedigree each had a significant influence on BCG vaccine efficacy.

Effects of protein deprivation and BCG vaccination on alveolar macrophage function in pulmonary tuberculosis.

Alveolar macrophages were isolated from lung lavage fluids taken from BCG-vaccinated and nonvaccinated guinea pigs 2 and 4 wk after challenge with virulent Mycobacterium tuberculosis H37Rv by the respiratory route. Animals had been maintained on either purified, protein-adequate (30%) or protein-deficient (10%) isocaloric diets for 6 wk prior to respiratory challenge. Protein deficiency was accompanied by loss of dermal tuberculin reactivity, even in animals with extensive tuberculosis. Vaccination with BCG failed to protect guinea pigs on the low protein diet. Based on phagocytosis of heterologous erythrocytes with time in vitro, the percentage of actively phagocytic alveolar macrophages remained relatively constant, but the rate of erythrocyte uptake was significantly depressed as the disease progressed, especially in nonvaccinated guinea pigs. However, neither measure of alveolar phagocyte activity was affected by dietary treatment. Protein deficiency does not appear to alter the initial host-parasite interaction in the lungs of tuberculous guinea pigs but exerts a deleterious effect on anamnestic responses, including tuberculin reactivity and antimycobacterial resistance, in BCG-vaccinated animals.

The influence of dietary protein on the protective effect of BCG in guinea pigs.

Specific pathogen-free, Hartley guinea pigs were vaccinated with viable Bacille Calmette-Guerin (BCG) and given isocaloric diets identical in every nutrient except protein (control = 30%; low protein = 10%). A non-vaccinated group was maintained on the control diet. Five weeks later, all animals were infected with an aerosol containing virulent M. tuberculosis H37Rv. On the same day, half of the protein-deficient guinea pigs were transferred to the control diet, while the remainder were maintained on the low protein (10%) diet. Animals from each diet treatment were tuberculin tested and sacrificed 1,2,3 and 4 weeks post-challenge. Protein-deficient guinea pigs exhibited diminished tuberculin reactions and loss of BCG-induced protection against virulent challenge as measured by the number of viable M. tuberculosis recovered from the lung and spleen. Renourished animals expressed normal levels of delayed hypersensitivity within 1 week of initiating the normal diet and were protected as well as vaccinated control guinea pigs against virulent respiratory challenge.

Mycobacterium bovis BCG vaccine fails to protect protein-deficient guinea pigs against respiratory challenge with virulent Mycobacterium tuberculosis.

Specific-pathogen-free Hartley guinea pigs were maintained on isocaloric-purified diets either adequate (30%) or moderately deficient (10%) in protein. Half of each diet group was vaccinated with viable Mycobacterium bovis BCG. Six weeks later, all animals were challenged by the respiratory route with virulent Mycobacterium tuberculosis H37Rv. At intervals of 1, 2, and 3 weeks postchallenge, guinea pigs from each diet and vaccination group were skin tested with tuberculin and sacrificed. Protein deficiency resulted in loss of tuberculin hypersensitivity. Vaccination with M. bovis BCG protected control animals, as determined by significant reductions in the number of M. tuberculosis H37Rv organisms recovered from lungs, spleen, and bronchotracheal lymph nodes 2 and 3 weeks postchallenge. Based upon the same criteria, the degree of protection afforded protein-deficient animals by M. bovis BCG vaccine ranged from partial (spleen and lymph nodes) to none at all (lungs). Approximately the same numbers of tubercle bacilli were recovered from nonvaccinated guinea pigs in both diet groups. Protein deficiency appears to impair M. bovis BCG-induced immunity while not affecting primary pulmonary infection with virulent M. tuberculosis.