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Despite increased attention to policy choices to support family and informal caregivers, relatively little is known about states' experiences in providing caregiver support services. This article reports on the first nationwide survey of all 50 states and the District of Columbia in providing caregiver services since the passage of the National Family Caregiver Support Program. State program administrators reported that their program differs from other home and community-based services because of the explicit focus on the family or informal caregiver. Results suggest that despite an increasing availability of caregiver supports in all 50 states, there is also a great unevenness in services and service options for family caregivers across the states and within states. [ABSTRACT FROM AUTHOR]

Mandibular malignancies are rare in the pediatric population and subsequently not well characterized. SEER 18 registry data was collected, applying age 0-18 years and ICD-O-3 code C41.1 ('mandible'). Univariate Cox regression analysis was conducted, and hazard ratios (HR) were calculated for overall survival (OS) and disease-specific survival (DSS) according to patient demographics, tumor characteristics, and treatment. Kaplan-Meier survival curves were generated for OS and DSS. Sixty-four patients met the inclusion criteria. The median age at diagnosis was 13.0 years, and median survival was 8.7 years. Osteosarcoma was the most common histological diagnosis (n = 22). Sex, race, age (<13 vs ≥13 years), histological type, odontogenic origin, and treatment modality were found not to be associated with OS or DSS. The SEER stage 'distant' was significantly associated with an elevated HR of 6.28 for DSS (P = 0.027) and 5.29 for OS (P = 0.025). Kaplan-Meier survival curves demonstrated significantly lower 5-year DSS (P<0.001) and OS (P<0.001) for SEER 'distant' stage. This study includes the analysis of a large number of pediatric mandibular malignancies when compared to previous studies. 'Distant' stage was associated with decreased survival. Early clinical suspicion and diagnosis are paramount for improved survival., Competing Interests: Competing interests None., (Copyright © 2024. Published by Elsevier Inc.)

When approaching complex abdominal wall hernias at either index operation or a subsequent reoperation for recurrent incarcerated abdominal wall hernias, a majority of surgeons consider mesh placement a key step in the prevention of a future recurrence. While the laparoscopic and open approaches show no significant difference in hernia recurrence, the laparoscopic approach to complex abdominal wall hernias does reduce surgical-site infection, postoperative ileus, improves short-term quality-of-life scores, and reduces hospital length of stay (Davies et al. in Am Surg 78(8):888-892, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3500604/ , 2012, McGreevy et al. in Surg Endosc 17(11):1778-1780, https://www.ncbi.nlm.nih.gov/pubmed/12958679 , 2003, Bittner et al. in Surg Endosc 33:3069-3139, https://doi.org/10.1007/s00464-019-06907-7 , 2019). In this paper, we describe a robotic approach with a pulley technique to the fixation of polypropylene mesh in complex abdominal wall reconstruction. Our primary aim is to offer a new perspective to the re-creation of challenging abdominal walls and to encourage other surgeons to gain proficiency in the robotic approach. Additionally, the material cost to the technique is lower than that of self-expanding or deployable mesh reinforcements used in other laparoscopic approaches. Over time, as an institution breaks even on the cost of a robot with their return on investment, this technique offers potential cost-saving., (© 2020. Springer-Verlag London Ltd., part of Springer Nature.)

Roles of hospital risk managers have grown over the last 30 years. Once largely focused on hospital liability risk management, risk managers today have a broader set of enterprise risk management responsibilities. The following commentary about a surprise billing case considers roles of risk managers in promoting cost and price transparency., (© 2020 American Medical Association. All Rights Reserved.)

Objective: Stark health inequalities exist in the present day between the North and South of England, with people in the South, overall, experiencing better health across a range of parameters (e.g., life expectancy and number of years spent in good health). Bioarchaeological studies of skeletal remains from cemeteries across this geographical divide have the ability to provide a temporal perspective on the etiology, longevity, and nature of this disparity., Methods: In total 574 non-adults (0-17 years) from six urban sites (c. AD 1711-1856) were analyzed from the North and South of England. Measurements of long bone length, cortical thickness, and vertebral dimensions were analyzed alongside both skeletal and dental palaeopathological data to assess patterns of disease and growth disruption between skeletal samples., Results: There were few significant differences in growth parameters between the six sites in relation to geographical location. However, the northern-based sample Coach Lane (North Shields) demonstrated some of the highest rates of pathology, with metabolic disease being particularly prevalent., Discussion: Northern and southern populations suffered alike from the detrimental environmental conditions associated with urban centers of the 18th-19th centuries. However, the elevated prevalence of vitamin D deficiency seen within the Coach Lane sample is indicative of a regionally specific risk that may be related to latitude, and/or the influence of particular industries operating in the North-East., (© 2019 Wiley Periodicals, Inc.)

Introduction: Unplanned office visits due to cast-related problems in the pediatric orthopedic office are common. Decreasing problems associated with the use of a cast would improve patient safety, increase office productivity, and decrease inconvenience to the child and family., Methods: Pediatric patients treated with a cast in our office were included in the study if they returned for an unplanned office visit due to a cast-related problem. Group 1 received verbal cast care instruction. Group 2 had the same verbal instruction in addition to a written handout identical to the verbal instructions. Group 3 was provided the same verbal instructions and a revised handout limiting the number of instructions and focused on keeping the cast away from water., Results: The study included 550 patients with 146 in group 1, 124 in group 2, and 280 in group 3. Comparing group 1 (10.3%) and group 2 (10.5%), there was almost no difference in the rate of unplanned office visits due to cast-related problems. Combining the revised handout with verbal instructions in group 3, the percentage of patients returning for an unplanned visit was 6%. There was a relative decrease in office visits by 55% and an absolute decrease of 4.5% when comparing group 2 and group 3., Conclusions: There was a decrease in the number of unplanned office visits due to cast problems utilizing a handout focused on keeping the cast dry in collaboration with verbal cast care instructions. However, the decrease was not statistically significant.

Integration of horizontally acquired genes into transcriptional networks is essential for the regulated expression of virulence in bacterial pathogens. In Salmonella enterica, expression of such genes is repressed by the nucleoid-associated protein H-NS, which recognizes and binds to AT-rich DNA. H-NS-mediated silencing must be countered by other DNA-binding proteins to allow expression under appropriate conditions. Some genes that can be transcribed by RNA polymerase (RNAP) associated with the alternative sigma factor σ S or the housekeeping sigma factor σ 70 in vitro appear to be preferentially transcribed by σ S in the presence of H-NS, suggesting that σ S may act as a counter-silencer. To determine whether σ S directly counters H-NS-mediated silencing and whether co-regulation by H-NS accounts for the σ S selectivity of certain promoters, we examined the csgBA operon, which is required for curli fimbriae expression and is known to be regulated by both H-NS and σ S . Using genetics and in vitro biochemical analyses, we found that σ S is not directly required for csgBA transcription, but rather up-regulates csgBA via an indirect upstream mechanism. Instead, the biofilm master regulator CsgD directly counter-silences the csgBA promoter by altering the DNA-protein complex structure to disrupt H-NS-mediated silencing in addition to directing the binding of RNAP., (© 2018 John Wiley & Sons Ltd.)

The 18th and 19th centuries in England were characterised by a period of increasing industrialisation of its urban centres. It was also one of widening social and health inequalities between the rich and the poor. Childhood is well-documented as being a stage in the life course during which the body is particularly sensitive to adverse socio-economic environments. This study therefore aims to examine the relationship between health and wealth through a comprehensive skeletal analysis of a sample of 403 children (0-17 years), of varying socio-economic status, from four cemetery sites in London (c.1712-1854). Measurements of long bone diaphyseal length, cortical thickness, vertebral neural canal size, and the prevalence of a range of pathological indicators of health stress were recorded from the Chelsea Old Church (high status), St Benet Sherehog (middle status), Bow Baptist (middle status), and Cross Bones (low status) skeletal collections. Children from the low status Cross Bones site demonstrated deficient growth values, as expected. However, those from the high status site of Chelsea Old Church also demonstrated poor growth values during infancy. Fashionable child-care practices (e.g. the use of artificial infant feeds and keeping children indoors) may have contributed to poor infant health amongst high status groups. However, differing health risks in the lower status group revealed the existence of substantial health inequality in London at this time., (© 2016 The Authors International Journal of Osteoarchaeology Published by John Wiley & Sons Ltd.)

Objective: Family meals are associated with a healthier diet among children and adolescents, but how family meal frequency varies in the U.S. population overall by household food availability and sociodemographic characteristics is not well characterized., Design: The U.S. National Health and Nutrition Examination Survey 2007-2010 assessed the frequency of family meals eaten at home in the past week and the household availability of fruits, dark green vegetables, salty snacks, and sugar-sweetened beverages., Setting: Computer-assisted face-to-face interviews with a selected adult (≥18 years) who owned or rented the home (i.e., the household reference person)., Subjects: We analyzed information on family meal frequency for 18,031 participants living in multi-person households in relation to sociodemographic characteristics and food availability., Results: Among the U.S. population living in households of two or more individuals, the prevalence (95% confidence interval) of having 0-2, 3-6 and ≥7 family meals/week was 18.0% (16.6-19.3), 32.4% (31.0-33.9), and 49.6% (47.8-51.4), respectively. Greater household availability of fruits and dark green vegetables and less availability of salty snacks and sugar-sweetened beverages was associated with more frequent family meals. Family meals were more prevalent in low-income households and those in which the reference person was ≥65 years, married, or had less than high school education., Conclusions: About half of the US population living in households of 2 or more people shares meals frequently with their family at home. Family meal frequency was positively associated with a healthier pattern of household food availability.

Objective: Traditional methods of detecting growth disruption have focused on deficiencies in the diaphyseal length of the long bones. This study proposes the implementation of vertebral measurements (body height and transverse diameter of the neural canal) from non-adults (0-17 years) as a new methodology for the identification of growth disruption., Methods: Measurements of vertebral body height and transverse diameter were taken from 96 non-adult skeletons and 40 adult skeletons from two post-medieval sites in England (Bow Baptist, London and Coronation Street, South Shields). Non-adult measurements were plotted against dental age to construct vertebral growth profiles through which inter-population comparisons could be made., Results: Results demonstrated that both sites experienced some growth retardation in infancy, evident as deficiencies in transverse diameter. However, analysis of vertebral body height revealed different chronologies of growth disruption between the sites, with a later age of attainment of skeletal maturity recorded in the Bow Baptist sample., Discussion: These vertebral dimensions undergo cessation of growth at different ages, with transverse diameter being "locked-in" by ∼1-2 years of age, while vertebral body height may continue to grow into early adulthood. These measurements can therefore provide complementary information regarding the timing of growth disruption within archaeological populations. Non-adult vertebral measurements can increase our osteobiographical understanding of the timings of episodes of health stress, and allow for the analysis of growth when other skeletal elements are fragmentary., (© 2015 The Authors American Journal of Physical Anthropology Published by Wiley Periodicals, Inc.)

Background: Recruitment into large, preconception randomised clinical trials (RCT) is challenging. We describe clinic and community-based preconception recruitment strategies for the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial and highlight approaches that were and were not successful. This longitudinal RCT was conducted at four major sites in the US. Eligible women had one to two prior pregnancy losses and were actively trying to become pregnant., Methods: Provider/clinic and community-based outreach strategies were utilised, and the recruitment rate and costs of methods were assessed., Results: A screening questionnaire was completed by 5485 women; 42.4% (n = 2323) screened were initially eligible, of whom 50.7% (n = 1228) were randomised. Provider/clinic-based recruitment yielded the highest number eligible of those screened (30.1%) and also the most randomised participants overall (40.3%). The next highest yield came from direct mail and brochures/flyers at 13.1% and 12.5% of women randomised, respectively. However, direct mailings cost $720 per participant randomised. Other than word of mouth, provider/clinic-based recruitment was the most cost effective method, costing an average of $60 per randomised participant. Web-based recruitment yielded 4.7% of participants at a cost of $278 per randomised participant., Conclusions: Provider and clinic-based recruitment was the most effective and cost-efficient method of recruitment in a preconception intervention study of reproduction among women., (© 2015 John Wiley & Sons Ltd.)

Histoplasma capsulatum (Hc) is the causative organism of a spectrum of disease affecting both the immunocompetent and the immunocompromised host. Hc is a dimporhic fungus that converts from conidia to the pathogenic yeast phase after entry into the mammalian host. Despite rapid ingestion by macrophages, it survives intracellularly within the macrophage. The intracellular survival strategy of Hc yeasts focuses on regulating the phagosomal compartment by modulating the intraphagosomal pH to 6.5. As an intracellular pathogen of MΦ, Hc obtains iron from Fe-transferrin, ferritin, or both, via the production of hydroxamate siderophores, and the production of ferric reductases. A better understanding of the mechanisms by which Hc yeasts acquire iron from the host may lead to novel therapeutics for histoplasmosis., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Endoplasmic reticulum (ER) stress is a condition in which the protein folding capacity of the ER becomes overwhelmed by an increased demand for secretion or by exposure to compounds that disrupt ER homeostasis. In yeast and other fungi, the accumulation of unfolded proteins is detected by the ER-transmembrane sensor IreA/Ire1, which responds by cleaving an intron from the downstream cytoplasmic mRNA HacA/Hac1, allowing for the translation of a transcription factor that coordinates a series of adaptive responses that are collectively known as the unfolded protein response (UPR). Here, we examined the contribution of IreA to growth and virulence in the human fungal pathogen Aspergillus fumigatus. Gene expression profiling revealed that A. fumigatus IreA signals predominantly through the canonical IreA-HacA pathway under conditions of severe ER stress. However, in the absence of ER stress IreA controls dual signaling circuits that are both HacA-dependent and HacA-independent. We found that a ΔireA mutant was avirulent in a mouse model of invasive aspergillosis, which contrasts the partial virulence of a ΔhacA mutant, suggesting that IreA contributes to pathogenesis independently of HacA. In support of this conclusion, we found that the ΔireA mutant had more severe defects in the expression of multiple virulence-related traits relative to ΔhacA, including reduced thermotolerance, decreased nutritional versatility, impaired growth under hypoxia, altered cell wall and membrane composition, and increased susceptibility to azole antifungals. In addition, full or partial virulence could be restored to the ΔireA mutant by complementation with either the induced form of the hacA mRNA, hacA(i), or an ireA deletion mutant that was incapable of processing the hacA mRNA, ireA(Δ10). Together, these findings demonstrate that IreA has both HacA-dependent and HacA-independent functions that contribute to the expression of traits that are essential for virulence in A. fumigatus.

Histoplasma capsulatum is a dimorphic fungal pathogen that survives and replicates within macrophages (MΦ). Studies in human and murine MΦ demonstrate that the intracellular growth of H. capsulatum yeasts is exquisitely sensitive to the availability of iron. As H. capsulatum produces hydroxamate siderophores, we sought to determine if siderophores were required for intracellular survival in MΦ, and in a murine model of pulmonary histoplasmosis. The expression of SID1 (coding for L-ornithine-N(5)-monooxygenase) was silenced by RNA interference (RNAi) in H. capsulatum strain G217B, and abolished by gene targeting in strain G186AR. G217B SID1-silenced yeasts grew normally in rich medium, did not synthesize siderophores, and were unable to grow on apotransferrin-chelated medium. Their intracellular growth in human and murine MΦ was significantly decreased compared to wild type (WT) yeasts, but growth was restored to WT levels by the addition of exogenous iron, or restoration of SID1 expression. Similar results were obtained with G186AR Δsid1 yeasts. Compared to WT yeasts, G217B SID1-silenced yeasts demonstrated in C57BL/6 mice significantly reduced growth in the lungs and spleens seven days after infection, and 40% of the mice given a normally lethal inoculum of G217B SID1-silenced yeasts survived. These experiments demonstrate that: (1) SID1 expression is required for siderophore biosynthesis by H. capsulatum strain G217B, (2) SID1 expression is required for optimum intracellular growth in MΦ, and (3) inhibition of SID1 expression in vivo reduces the virulence of H. capsulatum yeasts., (© 2011 ISHAM)

Infections due to Histoplasma capsulatum occur as a result of the inhalation of airborne microconidia of the mold into the alveoli of the lungs. In this study we quantified the transformation over time of conidia into yeast-like cells within macrophages (MΦ) and dendritic cells (DC). Conidia from strain G217B which had been surface labeled with carboxy-fluorescein succinimidyl ester (CFSE), or conidia from strain G217B that expresses green fluorescent protein (GFP) only in the yeast phase, were used to infect MΦ and DC. At various time points, numbers of intracellular conidia or yeasts were quantified via phase-contrast and fluorescent microscopy. Transformation of conidia from non-GFP-expressing G217B also was quantified by their incorporation of ³H-leucine. In both human and murine MΦ, numerous yeast-like cells appeared by day 3 post-infection. The time course of conidia transformation into yeasts in culture medium was the same as in MΦ. However, transformation of conidia to yeasts was significantly restricted in human DC and murine lung DC. In DC, significant numbers of yeasts did not appear until 5 days post-infection. Further, MΦ monolayers were destroyed by day 6-7 post-infection, whereas DC monolayers remained intact throughout the study period. These data suggest that in vivo, conidia may transform into yeast-like cells efficiently whether or not they are phagocytosed by MΦ, but not when ingested by DC.

Histoplasma capsulatum (Hc) is a pathogenic fungus that replicates in macrophages (Mphi). In dendritic cells (DC), Hc is killed and fungal Ags are processed and presented to T cells. DC recognize Hc yeasts via the VLA-5 receptor, whereas Mphi recognize yeasts via CD18. To identify ligand(s) on Hc recognized by DC, VLA-5 was used to probe a Far Western blot of a yeast freeze/thaw extract (F/TE) that inhibited Hc binding to DC. VLA-5 recognized a 20-kDa protein, identified as cyclophilin A (CypA), and CypA was present on the surface of Hc yeasts. rCypA inhibited the attachment of Hc to DC, but not to Mphi. Silencing of Hc CypA by RNA interference reduced yeast binding to DC by 65-85%, but had no effect on binding to Mphi. However, F/TE from CypA-silenced yeasts still inhibited binding of wild-type Hc to DC, and F/TE from wild-type yeasts depleted of CypA also inhibited yeast binding to DC. rCypA did not further inhibit the binding of CypA-silenced yeasts to DC. Polystyrene beads coated with rCypA or fibronectin bound to DC and Mphi and to Chinese hamster ovary cells transfected with VLA-5. Binding of rCypA-coated beads, but not fibronectin-coated beads, was inhibited by rCypA. These data demonstrate that CypA serves as a ligand for DC VLA-5, that binding of CypA to VLA-5 is at a site different from FN, and that there is at least one other ligand on the surface of Hc yeasts that mediates binding of Hc to DC.

Histoplasma capsulatum is a dimorphic fungal pathogen that survives and replicates within macrophages (Mphi). To identify specific genes required for intracellular survival, we utilized Agrobacterium tumefaciens-mediated mutagenesis, and screened for H. capsulatum insertional mutants that were unable to survive in human Mphi. One colony was identified that had an insertion within VMA1, the catalytic subunit A of the vacuolar ATPase (V-ATPase). The vma1 mutant (vma1::HPH) grew normally on iron-replete medium, but not on iron-deficient media. On iron-deficient medium, the growth of the vma1 mutant was restored in the presence of wild-type (WT) H. capsulatum yeasts, or the hydroxamate siderophore, rhodotorulic acid. However, the inability to replicate within Mphi was only partially restored by the addition of exogenous iron. The vma1::HPH mutant also did not grow as a mold at 28 degrees C. Complementation of the mutant (vma/VMA1) restored its ability to replicate in Mphi, grow on iron-poor medium and grow as a mold at 28 degrees C. The vma1::HPH mutant was avirulent in a mouse model of histoplasmosis, whereas the vma1/VMA1 strain was as pathogenic as WT yeasts. These studies demonstrate the importance of V-ATPase function in the pathogenicity of H. capsulatum, in iron homeostasis and in fungal dimorphism.

750 mg per day of acetazolamide in the prevention of acute mountain sickness (AMS), as recommended in the meta-analysis published in 2000 in the British Medical Journal, may be excessive and is controversial. To determine if the efficacy of low-dose acetazolamide 125 mg bd (250 mg), as currently used in the Himalayas, is significantly different from 375 mg bd (750 mg) of acetazolamide in the prevention of AMS, we designed a prospective, double-blind, randomized, placebo-controlled trial. The participants were sampled from a diverse population of (non-Nepali) trekkers at Namche Bazaar (3440 m) in Nepal on the Everest trekking route as they ascended to study midpoints (4280 m/4358 m) and the endpoint, Lobuje (4928 m), where data were collected. Participants were randomly assigned to receive 375 mg bd of acetazolamide (82 participants), 125 mg bd of acetazolamide (74 participants), or a placebo (66 participants), beginning at 3440 m for up to 6 days as they ascended to 4928 m. The results revealed that composite AMS incidence for 125 mg bd was similar to the incidence for 375 mg bd (24% vs. 21%, 95% confidence interval, -12.6%, 19.8%), in contrast to significantly greater AMS (51%) observed in the placebo group (95% confidence interval for differences: 8%, 46%; 12%, 49% for low and high comparisons, respectively). Both doses of acetazolamide improved oxygenation equally (82.9% for 250 mg daily and 82.8% for 750 mg daily), while placebo endpoint oxygen saturation was significantly less at 80.7% (95% confidence interval for differences: 0.5%, 3.9% and 0.4%, 3.7% for low and high comparisons, respectively). There was also more paresthesia in the 375-mg bd group (p < 0.02). We conclude that 125 mg bd of acetazolamide is not significantly different from 375 mg bd in the prevention of AMS; 125 mg bd should be considered the preferred dosage when indicated for persons ascending to altitudes above 2500 m.

Histoplasma capsulatum (Hc) is a facultative intracellular fungus that modulates the intraphagosomal environment to survive within macrophages (Mphi). In the present study, we sought to quantify the intraphagosomal pH under conditions in which Hc yeasts replicated or were killed. Human Mphi that had ingested both viable and heat-killed or fixed yeasts maintained an intraphagosomal pH of approximately 6.4-6.5 over a period of several hours. These results were obtained using a fluorescent ratio technique and by electron microscopy using the 3-(2,4-dinitroanilo)-3'-amino-N-methyldipropylamine reagent. Mphi that had ingested Saccharomyces cerevisae, a nonpathogenic yeast that is rapidly killed and degraded by Mphi, also maintained an intraphagosomal pH of approximately 6.5 over a period of several hours. Stimulation of human Mphi fungicidal activity by coculture with chloroquine or by adherence to type 1 collagen matrices was not reversed by bafilomycin, an inhibitor of the vacuolar ATPase. Human Mphi cultured in the presence of bafilomycin also completely degraded heat-killed Hc yeasts, whereas mouse peritoneal Mphi digestion of yeasts was completely reversed in the presence of bafilomycin. However, bafilomycin did not inhibit mouse Mphi fungistatic activity induced by IFN-gamma. Thus, human Mphi do not require phagosomal acidification to kill and degrade Hc yeasts, whereas mouse Mphi do require acidification for fungicidal but not fungistatic activity.

Histoplasma capsulatum is a fungal pathogen that requires the induction of cell-mediated immunity (CMI) for host survival. We have demonstrated that human dendritic cells (DC) phagocytose H. capsulatum yeasts and, unlike human macrophages (Mø) that are permissive for intracellular growth, DC killed and degraded the fungus. In the present study, we sought to determine whether the mechanism(s) by which DC kill Histoplasma is via lysosomal hydrolases, via the production of toxic oxygen metabolites, or both. Phagosome-lysosome fusion (PL-fusion) was quantified by using fluorescein isothiocyanate-dextran and phase and fluorescence microscopy and by electron microscopy with horseradish peroxidase colloidal gold to label lysosomes. Unlike Mphi, Histoplasma-infected DC exhibited marked PL-fusion. The addition of suramin to Histoplasma-infected DC inhibited PL-fusion and DC fungicidal activity. Incubation of Histoplasma-infected DC at 18 degrees C also concomitantly reduced PL-fusion and decreased the capacity of DC to kill and degrade H. capsulatum yeasts. Further, culture of Histoplasma-infected DC in the presence of bafilomycin, an inhibitor of the vacuolar ATPase, did not block DC anti-Histoplasma activity, indicating that phagosome acidification was not required for lysosome enzyme activity. In contrast, culture of Histoplasma-infected DC in the presence of inhibitors of the respiratory burst or inhibitors of NO synthase had little to no effect on DC fungicidal activity. These data suggest that the major mechanism by which human DC mediate anti-Histoplasma activity is through the exposure of yeasts to DC lysosomal hydrolases. Thus, DC can override one of the strategies used by H. capsulatum yeasts to survive intracellularly within Mø.

Candida albicans, a component of the normal flora of the alimentary tract and mucocutaneous membranes, is the leading cause of invasive fungal disease in premature infants, diabetics, and surgical patients and of oropharyngeal disease in AIDS patients. As little is known about the regulation of monocyte/macrophage anti-Candida activity, we sought to determine if fungicidal activity might be regulated by extracellular matrix proteins to which monocytes/macrophages are adherent in vivo. Compared to monocyte/macrophages that adhered to plastic, human monocytes and monocyte-derived macrophages that adhered to type 1 collagen matrices, but not to fibronectin, vitronectin, or laminin, demonstrated a significant increase in candidacidal activity. The enhancement of monocyte fungicidal activity was maintained over a 4-h period, whereas macrophage fungicidal activity was maximum at 1 h. Although adherence of monocytes and macrophages to collagen matrices concomitantly enhanced the production of superoxide anion, only the fungicidal activity of collagen-adherent monocytes was partially blocked by superoxide dismutase and catalase. Remarkably, we found that only 10% of the phagosomes in C. albicans-infected macrophages that adhered to plastic fused with lysosomes. In contrast, 80% of yeast-containing phagosomes of collagen-adherent macrophages fused with lysosomes. These data suggest that nonoxidative mechanisms are critical for human macrophage anti-Candida activity and that C. albicans pathogenicity is mediated, in part, by its ability to inhibit phagolysosomal fusion in macrophages.

Histoplasma capsulatum (Hc) is a dimorphic fungal pathogen indigenous to the Ohio and Mississippi River Valleys in the United States. Infection is initiated by inhalation of microconidia or small mycelial fragments into the terminal bronchioles of the lung. The conidia are taken up by alveolar macrophages (Mphi), in which they convert to the pathogenic yeast phase. The yeasts replicate in the alveolar Mphi and other Mphi recruited to the lung as part of the inflammatory response. Thus, the yeasts are able to disseminate from the lung to other organs, such as the liver and spleen. As a facultative intracellular parasite, the interaction of Hc yeasts with Mphi is a critical component of the host response to infection. In addition, Hc yeasts have critical interactions with inflammatory neutrophils, and with dendritic cells (DCs) in the lung and other organs. Indeed, recent new evidence suggests that DCs may be the key antigen-presenting cells that initiate cell-mediated immunity. Thus, the methods described in this chapter cover quantitation of the binding, ingestion, and intracellular replication of Hc yeasts in human Mphi, DCs, and neutrophils.

Purpose: This study describes the preliminary experiences of 10 states in providing support services to family or informal caregivers of elderly adults and adults with disabilities; it focuses on the newly created National Family Caregiver Support Program, state general funds, Medicaid-waiver programs, and other state-funding streams., Design and Methods: Case studies were conducted, between March and July 2002, through in-person interviews with state officials and stakeholders in Alabama, California, Florida, Hawaii, Indiana, Iowa, Maine, Pennsylvania, Texas, and Washington., Results: States were in the start-up phase of implementing the National Family Caregiver Support Program and varied greatly in program design and integration of caregiver support into their home- and community-based care system. Viewing family caregivers as a client population was a paradigm shift for many state officials., Implications: Heavy reliance is currently placed on family and informal caregivers in home- and community-based care, without adequate support services. Family support should be an explicit goal of long-term-care system reform.

Histoplasma capsulatum (Hc), is a facultative intracellular fungus that binds to CD11/CD18 receptors on macrophages (Mphi). To identify the ligand(s) on Hc yeasts that is recognized by Mphi, purified human complement receptor type 3 (CR3, CD11b/CD18) was used to probe a Far Western blot of a detergent extract of Hc cell wall and cell membrane. CR3 recognized a single 60-kDa protein, which was identified as heat shock protein 60 (hsp60). Biotinylation of viable yeasts, followed by precipitation with streptavidin-coated beads, and Western blotting with anti-hsp60 demonstrated that hsp60 was on the surface of Hc yeasts. Electron and confocal microscopy revealed that hsp60 resided on the yeast cell wall in discrete clusters. Recombinant hsp60 (rhsp60) inhibited attachment of Hc yeasts to Mphi. Recombinant hsp60 and Abs to CD11b and CD18 inhibited binding of yeasts to Chinese hamster ovary cells transfected with CR3 (CHO3). Polystyrene beads coated with rhsp60 bound to Mphi, and attachment was inhibited by Abs to CD11 and CD18. Freeze/thaw extract (F/TE), a preparation of Hc yeast surface proteins that contained hsp60, inhibited the attachment of Hc yeasts to Mphi. Depletion of hsp60 from F/TE removed the capacity of F/TE to block binding of Hc to Mphi. Interestingly, rhsp60 did not inhibit binding of Hc yeasts to dendritic cells (DC), which recognize Hc via very late Ag 5. Moreover, F/TE inhibited attachment of Hc to DC even when depleted of hsp60. Thus, Hc hsp60 appears to be a major ligand that mediates attachment of Hc to Mphi CD11/CD18, whereas DC recognize Hc via a different ligand(s).

Objective: To report an unusual manifestation of metastatic papillary thyroid carcinoma with functional metastatic lesions demonstrated by radioiodine scanning and to discuss the relationship of Graves' disease and thyroid carcinoma., Methods: A case report is presented, and the current literature is reviewed., Results: An 82-year-old man had symptoms and laboratory results suggestive of thyrotoxicosis. 123I thyroid uptake scanning demonstrated lateral uptake, which directed attention to the lateral aspect of the neck and resulted in subsequent identification of previously overlooked lymphadenopathy. Total thyroidectomy, including excision of the central compartment and right jugular chain lymph nodes, was performed., Conclusion: In two previous reports of similar cases of metastatic thyroid carcinoma, imaging was done with use of a different scanning agent. To our knowledge, this is the first published case report of functional metastatic lesions imaged with 123I before thyroidectomy. This preoperative finding facilitated clinical management of the patient's thyroid cancer and thyrotoxicosis.

Candida albicans is a component of the normal flora of the alimentary tract and also is found on the mucocutaneous membranes of the healthy host. Candida is the leading cause of invasive fungal disease in premature infants, diabetics, and surgical patients, and of oropharyngeal disease in AIDS patients. As the induction of cell-mediated immunity to Candida is of critical importance in host defense, we sought to determine whether human dendritic cells (DC) could phagocytose and degrade Candida and subsequently present Candida antigens to T cells. Immature DC obtained by culture of human monocytes in the presence of granulocyte-macrophage colony-stimulating factor and interleukin-4 phagocytosed unopsonized Candida in a time-dependent manner, and phagocytosis was not enhanced by opsonization of Candida in serum. Like macrophages (Mphi), DC recognized Candida by the mannose-fucose receptor. Upon ingestion, DC killed Candida as efficiently as human Mphi, and fungicidal activity was not enhanced by the presence of fresh serum. Although phagocytosis of Candida by DC stimulated the production of superoxide anion, inhibitors of the respiratory burst (or NO production) did not inhibit killing of Candida, even when phagocytosis was blocked by preincubation of DC with cytochalasin D. Further, although apparently only modest phagolysosomal fusion occurred upon DC phagocytosis of Candida, killing of Candida under anaerobic conditions was almost equivalent to killing under aerobic conditions. Finally, DC stimulated Candida-specific lymphocyte proliferation in a concentration-dependent manner after phagocytosis of both viable and heat-killed Candida cells. These data suggest that, in vivo, such interactions between DC and C. albicans may facilitate the induction of cell-mediated immunity.

Histoplasma capsulatum (Hc) is a facultative, intracellular parasite of world-wide importance. As the induction of cell-mediated immunity to Hc is of critical importance in host defense, we sought to determine whether dendritic cells (DC) could function as a primary APC for this pathogenic fungus. DC obtained by culture of human monocytes in the presence of GM-CSF and IL-4 phagocytosed Hc yeasts in a time-dependent manner. Upon ingestion, the intracellular growth of yeasts within DC was completely inhibited compared with rapid growth within human macrophages. Electron microscopy of DC with ingested Hc revealed that many of the yeasts were degraded as early as 2 h postingestion. In contrast to macrophages, human DC recognized Hc yeasts via the fibronectin receptor, very late Ag-5, and not via CD18 receptors. DC stimulated Hc-specific lymphocyte proliferation in a concentration-dependent manner after phagocytosis of viable and heat-killed Hc yeasts, but greater proliferation was achieved after ingestion of viable yeasts. These data demonstrate that human DC can phagocytose and degrade a fungal pathogen and subsequently process the appropriate Ags for stimulation of lymphocyte proliferation. In vivo, such interactions between DC and Hc may facilitate the induction of cell-mediated immunity.

Previously we demonstrated that human neutrophils mediate potent and long-lasting fungistasis against Histoplasma capsulatum yeasts and that all of the fungistatic activity resides in the azurophil granules. In the present study, specific azurophil granule constituents with fungistatic activity were identified by incubation with H. capsulatum yeasts for 24 h and by quantifying the subsequent growth of yeasts via the incorporation of [(3)H]leucine. Human neutrophil defensins HNP-1, HNP-2, and HNP-3 inhibited the growth of H. capsulatum yeasts in a concentration-dependent manner with maximum inhibition at 8 microg/ml. At a concentration of 4 microg/ml, all possible paired combinations of defensins exhibited additive fungistatic activity against H. capsulatum yeasts. Cathepsin G and bactericidal-permeability-increasing protein (BPI) also mediated fungistasis against H. capsulatum in a concentration-dependent manner. The fungistatic activities of combinations of cathepsin G and BPI were additive, as were those of combinations of cathepsin G or BPI with HNP-1, HNP-2, and HNP-3. Lysozyme and elastase exhibited modest antifungal activity, and azurocidin and proteinase 3 exhibited no significant fungistasis against H. capsulatum yeasts. Thus, defensins, cathepsin G, and BPI are the major anti-H. capsulatum effector molecules in the azurophil granules of human neutrophils.

Histoplasma capsulatum (Hc) maintains a phagosomal pH of about 6.5. This strategy allows Hc to obtain iron from transferrin, and minimize the activity of macrophage (Mo) lysosomal hydrolases. To determine the mechanism of pH regulation, we evaluated the function of the vacuolar ATPase (V-ATPase) in RAW264.7 Mo infected with Hc yeast or the nonpathogenic yeast Saccharomyces cerevisae (Sc). Incubation of Hc-infected Mo with bafilomycin, an inhibitor of the V-ATPase, did not affect the intracellular growth of Hc, nor did it affect the intraphagosomal pH. In contrast, upon addition of bafilomycin, phagosomes containing Sc rapidly changed their pH from 5 to 7. Hc-containing phagosomes had 5-fold less V-ATPase than Sc-containing phagosomes as quantified by immunoelectron microscopy. Furthermore, Hc-containing phagosomes inhibited phagolysosomal fusion as quantified by the presence of acid phosphatase, accumulation of LAMP2, and fusion with rhodamine B-isothiocyanate-labeled dextran-loaded lysosomes. Finally, in Hc-containing phagosomes, uptake of ferritin was equivalent to phagosomes containing Sc, indicating that Hc-containing phagosomes have full access to the early "bulk flow" endocytic pathway. Thus, Hc yeasts inhibit phagolysosomal fusion, inhibit accumulation of the V-ATPase in the phagosome, and actively acidify the phagosomal pH to 6.5 as part of their strategy to survive in Mo phagosomes.

Macrophages function in both innate and cell-mediated immunity in host defense against pathogenic fungi. They initially serve as a protected environment in which the primary fungal pathogen Histoplasma capsulatum multiplies and disseminates from the lung to other organs. Upon induction of cell-mediated immunity, cytokines activate macrophages to destroy the yeasts and thus remove them from the host.

We have demonstrated that monocyte-derived macrophages (Mphi) from HIV+ individuals are deficient in their capacity to phagocytose Histoplasma capsulatum (Hc) yeasts, and are more permissive for the intracellular growth of Hc. To determine whether these defects in Mphi function were caused by HIV infection of the Mphi and/or by pathological events associated with HIV infection, cultured normal human Mphi were infected with the HIV-1BaL strain. Virus production, quantified by reverse transcriptase activity and p24 antigen, was evident on day 8 after infection and peaked on day 16. On days 12, 16, and 20 after infection, HIV-1-infected Mphi were deficient in their capacity to recognize and bind Hc yeasts compared with control Mphi, and also were more permissive for the intracellular growth of Hc. Culture of normal Mphi with the envelope glycoprotein gp120 inhibited phagocytosis of Hc yeasts by Mphi in a concentration-dependent manner, but did not cause more rapid intracellular growth of Hc. Normal Mphi cultured in the serum of HIV+ individuals with impaired Mphi function subsequently were deficient in their capacity to phagocytose Hc yeasts, and were more permissive for the intracellular growth of yeasts compared with Mphi cultured in normal serum. Conversely, culture of normal Mphi in the serum of HIV+ patients with normal Mphi function did not affect the interaction of Hc yeasts with Mphi. Moreover, when Mphi from HIV+ individuals that were initially defective in host defense against Hc were cultured in normal HIV- serum, normal Mphi function was demonstrated. Adsorption of gp120 from the serum of two HIV+ patients removed the capacity of the serum to cause a Mphi defect in phagocytosis of Hc, but had no effect on the capacity of the serum to cause accelerated intracellular growth. These data demonstrate that observed defects in Mphi interaction with Hc yeasts may be caused by gp120 and other, as yet unknown serum component(s) probably released into serum by HIV-infected cells.

Human monocyte/macrophages (Mphi) were adhered to extracellular matrix proteins, and the intracellular growth of Histoplasma capsulatum (Hc) yeasts were quantified and compared with their growth in Mphi adhered to plastic. Freshly isolated monocytes and cultured monocyte/derived Mphi adhered to type 1 collagen gels, but not to nongelled collagen-, fibronectin-, laminin-, or vitronectin-coated surfaces, demonstrated significant fungistatic activity against Hc yeasts. Activation of Mphi developed immediately upon adherence to the collagen matrices (1 h) and did not require additional time in culture. In addition, many of the yeasts were digested by 24 h postinfection. Mphi adhered to collagen maintained their fungistatic activity for up to 4 days, during which time monolayers cultured on plastic were destroyed. Culture of Mphi in the presence of IFN-gamma or TNF-alpha for 24 h before infection did not augment the fungistatic activity of collagen-adherent Mphi. Likewise, culture of monocytes on collagen gels with IL-3, granulocyte-Mphi CSF (GM-CSF) or Mphi CSF (M-CSF) for 7 days did not enhance Mphi fungistatic activity above that obtained by monocytes cultured on collagen alone. The mechanism(s) of Mphi-mediated fungistasis was not associated with production of toxic oxygen radicals, nitric oxide, or the restriction of intracellular iron. However, experiments with horseradish peroxidase-labeled gold colloids and immunoelectron microscopy demonstrated that phagolysosomal fusion, which is minimal in Hc-infected Mphi adhered to plastic, is enhanced significantly at both 1 h and 24 h postinfection in Mphi adhered to collagen matrices. These data suggest that in vivo, matrix-bound Mphi may express a previously unrecognized antifungal activity that proceeds in the absence of exogenous cytokines and is mediated, in part, by overcoming the capacity of Hc yeasts to inhibit Mphi phagolysosomal fusion.

The fungal pathogen Blastomyces dermatitidis produces an adhesin (WI-1) in yeast stages, which contains repetitive regions that bind host-cell receptors. Adhesin and glucan may modulate fungal interactions with macrophages; their level of expression is altered in hypovirulent mutants. Adhesin is also involved in immune responses, and may be important in eliciting the clearance of the fungus.

Polymorphonuclear neutrophils (PMN) kill Cryptococcus neoformans (Cn) by oxidative mechanisms, but the roles of various reactive oxygen intermediates (ROIs) are not known. We used a mannitol low-producing Cn mutant (Cn MLP) and its wild-type parent (Cn H99) to examine the role of ROIs distal to H2O2 in PMN killing and to determine whether mannitol produced by Cn protects the fungus against ROIs. At PMN:Cn cell ratios of 1:1, 10:1, and 100:1, PMN killed significantly more Cn MLP than Cn H99 cells after 2 and 4 h (p less than 0.05). Superoxide dismutase and the hydroxyl radical (OH.) scavengers mannitol and DMSO inhibited killing of both strains (p less than 0.05), but catalase did not. Cn H99 and Cn MLP stimulated PMN to produce similar amounts of O2- and H2O2. In contrast, Cn MLP stimulated greater luminol-dependent chemiluminescence than did Cn H99 (p less than 0.05). Finally, H2O2 alone killed similar numbers of Cn H99 and Cn MLP cells, but oxidants generated by FeSO4 (1 microM), H2O2 (10 microM), and iodide (1 to 3 microM) killed significantly more Cn MLP than Cn H99 cells in 1 h (p less than 0.05). Mannitol, DMSO, and catalase completely inhibited killing of both Cn strains by this cellfree system, but superoxide dismutase did not. These results suggest that 1) distal ROIs such as OH. and HOCI are key effector molecules against Cn, and 2) mannitol produced by Cn may protect against oxidative killing by scavenging distal ROIs.

Histoplasma capsulatum requires intracellular iron to survive and multiply within human and murine macrophages (M phi). Thus, iron chelators may be useful compounds in the treatment of histoplasmosis. In the present study we compared the efficacies of five different iron chelators with deferoxamine (DEF) for their capacity to inhibit the growth of H. capsulatum yeast cells in culture medium and within human M phi. Of the agents tested, only one, VUF 8514, a 2,2'-bipyridyl analog, was found to be effective. VUF 8514 inhibited the growth of yeast cells in tissue culture medium and within M phi in a dose-response fashion. In tissue culture medium, the 50% effective dose (ED50) of VUF 8514 was 30 nM and the ED50 of DEF was 1 mM. In human M phi, the ED50 of VUF 8514 was 520 nM and the ED50 of DEF was 4 mM. Thus, VUF 8514 was effective at a concentration 7.7 x 10(3)-fold lower than DEF in inhibiting the growth of yeast cells in M phi. Inhibition of the intracellular growth of yeast cells by VUF 8514 was reversed by holotransferrin and iron nitriloacetate, an iron compound that is soluble at neutral to alkaline pH. Thus, VUF 8514 inhibits the intracellular growth of yeast cells by acting as an iron chelator rather than through its capacity as a weak base. These data suggest that the hydroxamic acid siderophore of H. capsulatum yeast cells competes successfully for iron against some iron chelators but not others and that VUF 8514 may be a potential therapeutic agent for the treatment of histoplasmosis.

The myelinogenic potential of an oligodendrocyte cell line (N20.1) immortalized by transformation with a temperature-sensitive retrovirus (Verity et al., J Neurochem 60:577-587, 1993) has been evaluated in a co-culture system utilizing dorsal root ganglion neurons. When N20.1 cells were placed in co-culture with dorsal root ganglion neurons at 39 degrees C, the temperature at which TAg expression is decreased relative to that in cells maintained at 34 degrees C, there was a dramatic decrease in the N20.1 proliferation rate compared to cells maintained in the absence of neurons at either temperature. This decrease in proliferation was observed within 3 days of co-culture and appeared to precede a further decrease in TAg expression that occurred with time in response to the neurons. In co-cultures the immunoreactivity of N20.1 cells for galactocerebroside increased with time, and the cells appeared to establish contact with neurites and initiate formation of membranous sheets. When the duration of co-culture was extended to 52 days, myelin-like figures were noted by electron microscopy. Thus, the extent of N20.1 differentiation is dependent on the presence of neurons and the duration of co-culture. This culture system represents a potentially powerful tool for the study of neuronal-glial interactions influencing myelinogenesis and remyelination.