Injury-related emergency department use among people with intellectual and developmental disabilities insured by Medicaid from 2010 to 2016

OBJECTIVES

Data on non-fatal injuries and visits to the emergency department (ED) for injuries are not readily available. The objective of this paper is to describe injury-related ED visits for people with intellectual and developmental disabilities who are covered by the Medicaid insurance programme.

METHODS

We aggregated 2010-2016 Medicaid claims data from eight states. Using these data, we identified individuals with intellectual and developmental disabilities and then determined an all-cause ED visit rate, ED visit due to injury rate and admission from ED due to injury rate. Data were stratified by sex and age group. Results were compared with national rates.

RESULTS

Medicaid members with intellectual and developmental disabilities visited EDs at approximately 1.8 times the rate of the general population. The ED visit rate due to injury was approximately 1.5 times that observed in the population overall. When ED visits due to injury data were stratified by age and sex, the largest discrepancy was observed in women ages 45-64, who visited EDs due to injury at a rate 2.1 times that of women of the same age in the general population. The admission rate from ED due to injury increased over the study period most notably in the older age groups.

CONCLUSIONS

While rates and patterns of ED utilisation among Medicaid members with intellectual and developmental disabilities vary by age and gender, our findings suggest this group visits the ED due to injury at rates well above the general population.

Valosin-containing-protein pathogenic variant p.R487H in Parkinson's disease

We describe a 66-year-old woman with Parkinson's disease, carrying a known pathogenic missense variant in the Valosin-containing-protein (VCP) gene. She responded excellently to L-dopa, had no cognitive or motoneuronal dysfunction. Laboratory analyses and MRI were unremarkable. Genetic testing revealed a heterozygous variant in VCP(NM_007126.5), chr9 (GRCh3 7):g.35060820C > T, c.1460G > A p.Arg487His (p.R487H).

Sibling Support Program: A Novel Peer Support Intervention for Parents, Caregivers and Siblings of Youth Experiencing Mental Illness

Caregivers and siblings of youth with mental illness often experience role-related psychological challenges, and it is important to focus on the needs of these family members. Existing literature demonstrates that caregivers and affected children benefit from participation in peer support and family-centered programs. This paper describes the Sibling Support Program: A Family-Centered Mental Health Initiative (SSP), a novel intervention for families of youth with mental illness. The SSP distinguishes itself from existing family-centered programs in that it utilizes a unique combination of peer support, parent mentor guidance, and clinician-led group therapy. The paper details the structure of the treatment model and presents preliminary data from participant surveys. Results show preliminary indications that the program provides both emotional and practical benefits. Along with high satisfaction ratings, family members report decreased feelings of isolation, gains in knowledge, and more positive thinking after program participation. Caregivers report that the SSP helped improve their understanding about the impact of a child’s mental illness on family members, and that they learned about effective family management strategies and access to resources. Siblings report learning coping strategies and feeling better after meeting peers with shared experiences.

Time trends in emergency department use among adults with intellectual and developmental disabilities

BACKGROUND

Emergency Department (ED) visits are common among adults with intellectual and developmental disabilities (IDD). However, little is known about how ED use has varied over time in this population, or how it has been affected by recent Medicaid policy changes.

OBJECTIVE

To examine temporal trends in ED use among adult Medicaid members with IDD in eight states that ranged in the extent to which they had implemented state-level Medicaid policy changes that might affect ED use.

METHODS

We conducted repeated cross-sectional analyses of 2010-2016 Medicaid claims data. Quarterly analyses included adults ages 18-64 years with IDD (identified by diagnosis codes) who were continuously enrolled in Medicaid for the past 12 months. We assessed change in number of ED visits per 1000 member months from 2010 to 2016 overall and interacted with state level policy changes such as Medicaid expansion.

RESULTS

States with no Medicaid expansion experienced an increase in ED visits (linear trend coefficient: 1.13, p < 0.01), while states operating expansion via waiver had a much smaller (non-significant) increase, and states with ACA-governed expansion had a decrease in ED visits (linear trend coefficient: 1.17, p < 0.01). Other policy changes had limited or no association with ED visits.

CONCLUSIONS

Medicaid expansion was associated with modest reduction or limited increase in ED visits compared to no expansion. We found no consistent decrease in ED visits in association with other Medicaid policy changes.

Respiratory support strategies in the prevention of bronchopulmonary dysplasia: A single center quality improvement initiative

BACKGROUND AND OBJECTIVES

Bronchopulmonary dysplasia (BPD) continues to be a significant morbidity affecting very preterm infants, despite multiple advancements in therapies to treat respiratory distress syndrome and prevent BPD. Local quality improvement (QI) efforts have shown promise in reducing unit or system-wide rates of BPD. In preterm infants born between 23- and 32-weeks' gestation, our aim was to decrease the rate of BPD at 36 weeks corrected gestational age from 43% to 28% by January 2019.

METHODS

Directed by a multidisciplinary respiratory QI team, we gradually implemented the following interventions to reach our aim: (1) early initiation of non-invasive ventilation in the delivery room, (2) initiation of caffeine prior to 24 h of life, (3) administration of early selective surfactant per a well-defined guideline, (4) continuation of non-invasive ventilation until 32 and 0/7 weeks corrected gestational age (CGA), and (5) a revision of the early selective surfactant guideline. Outcome measures included rates of BPD, and process measures included compliance with the above interventions.

RESULTS

A total of 509 infants with an average gestational age of 29 1/7 weeks and birth weight of 1,254 (SD±401) grams were included. The rate of BPD in our unit decreased from a baseline of 43% to 19% from the start of the project in October 2016 until the first quarter of 2022 (p < 0.00001). The greatest reductions in BPD rates were seen after the initiation of the guideline to extend non-invasive ventilation until 32 0/7 weeks CGA. The rate of severe BPD decreased from 22% to 9%.

CONCLUSIONS

In preterm infants born between 23- and 32-weeks' gestation, our local QI interventions to reduce rates of BPD were associated with a reduction in rates by 56%. Increased use of antenatal steroids and higher birth weights post- vs. pre-intervention may have contributed to this successes.

Health Service Utilization Patterns Among Medicaid-Insured Adults With Intellectual and Developmental Disabilities: Implications for Access Needs in Outpatient Community-Based Medical Services

Limited existing evidence suggests that adults with intellectual and developmental disabilities (IDD) experience substantial disparities in numerous areas of health care, including quality ambulatory care. A multistate cohort of adults with IDD was analyzed for patterns of inpatient admissions and emergency department utilization. Utilization was higher (inpatient [RR = 3.2], emergency department visits [RR = 2.6]) for adults with IDD, particularly for ambulatory care-sensitive conditions (eg, urinary tract [RR = 6.6] and respiratory infections [RRs = 5.5-24.7]), and psychiatric conditions (RRs = 5.8-15). Findings underscore the importance of access to ambulatory care skilled in IDD-related needs to recognize and treat ambulatory care-sensitive conditions and to manage chronic medical and mental health conditions.

Disability, Hospital Care, and Cost: Utilization of Emergency and Inpatient Care by a Cohort of Children with Intellectual and Developmental Disabilities

OBJECTIVE

To use medical claims data to determine patterns of healthcare utilization in children with intellectual and developmental disabilities, including frequency of service utilization, conditions that require hospital care, and costs.

STUDY DESIGN

Medicaid administrative claims from 4 states (Iowa, Massachusetts, New York, and South Carolina) from years 2008-2013 were analyzed, including 108 789 children (75 417 male; 33 372 female) under age 18 years with intellectual and developmental disabilities. Diagnoses included cerebral palsy, autism, fetal alcohol syndrome, Down syndrome/trisomy/autosomal deletions, other genetic conditions, and intellectual disability. Utilization of emergency department (ED) and inpatient hospital services were analyzed for 2012.

RESULTS

Children with intellectual and developmental disabilities used both inpatient and ED care at 1.8 times that of the general population. Epilepsy/convulsions was the most frequent reason for hospitalization at 20 times the relative risk of the general population. Other frequent diagnoses requiring hospitalization were mood disorders, pneumonia, paralysis, and asthma. Annual per capita expenses for hospitalization and ED care were 100% higher for children with intellectual and developmental disabilities, compared with the general population ($153 348 562 and $76 654 361, respectively).

CONCLUSIONS

Children with intellectual and developmental disabilities utilize significantly more ED and inpatient care than other children, which results in higher annual costs. Recognizing chronic conditions that increase risk for hospital care can provide guidance for developing outpatient care strategies that anticipate common clinical problems in intellectual and developmental disabilities and ensure responsive management before hospital care is needed.

Mental Health Trainee Facilitation of Sibling Support Groups: Understanding its Influence on Views and Skills of Family-Centered Care

OBJECTIVES

Prior research suggests family-centered interventions are among the least taught yet most needed skills for practicing psychiatry. In this study, we evaluated whether having mental health trainees lead a sibling support group could serve as a method to promote family-centered care among trainees.

METHODS

All trainees in psychiatry, psychology, and social work were invited to participate as sibling support group facilitators. Both facilitator and non-facilitator trainees were then surveyed using a questionnaire inquiring about exposure to family-centered care, comfort level in providing family-centered care, attitudes regarding the importance of family-centered care, and desire to provide family-centered care in the future. A second survey was administered to the facilitator trainees to assess their perceptions of the sibling group leader experience.

RESULTS

Facilitator trainees reported increased engagement in family-centered activities during training (p < 0.05), expressed greater confidence in their family-centered care skills (p < 0.05), and reported stronger intentions to practice in a family-centered way (p < 0.05). Facilitator trainees were overwhelmingly positive about their experience with the sibling support program and reported it strengthened their commitment to addressing the needs of siblings as a part of family-centered care.

CONCLUSIONS

Facilitating a sibling support group may be an effective way for mental health trainees to gain skills and confidence in delivering family-centered care. Mental health training programs aiming to imbue trainees with the importance of family-centered care may consider creating opportunities for trainees to facilitate sibling support groups.

Disparities in diabetes management among medicaid recipients with intellectual and developmental disabilities (IDD): Evidence from five U.S. states

BACKGROUND

Diabetes is one of the most common chronic conditions among adults. Little is known about the quality of diabetes care received by adults with intellectual and developmental disabilities (IDD).

OBJECTIVE

To determine the extent to which the diabetes care needs are met for a population with both IDD and diabetes who are solely insured by Medicaid in five states (Iowa, Massachusetts, New York, Oregon and South Carolina).

METHODS

Medicaid administrative data in 2012 were used to identify Medicaid members (excluding dual eligibles) with diabetes and IDD in five states. Four diabetes care measures were compared between members with and without IDD using bivariate analyses. For those with diabetes and IDD, a logistic regression model was fitted for each state with the following predictors: age, sex, IDD subgroup, and occurrence of a specialist visit in the current or past year. A meta-analysis was then conducted to synthesize cross-state results.

RESULTS

Across the five states, 6229 (2%) of the 308,804 non-dual adult Medicaid members 18-64 years old with diabetes in 2012 also had IDD. Comparing those with IDD to their non-IDD peers on receipt of all four diabetes care measures showed differences by state, but state rates of overall adherence were very low, ranging from 16.6% to 28.5% of the population.

CONCLUSIONS

Meta-analysis results identified specialist visits as a strong predictor of adults with diabetes and IDD receiving all four components of diabetes care. This important information should be considered in efforts to improve quality care for this population.

Unlocking the Potential of State Level Data: Opportunities to Monitor Health and Related Outcomes in People With Intellectual and Developmental Disabilities

No single U.S. health surveillance system adequately describes the health of people with intellectual and developmental disabilities (IDD). Researchers and policy makers have sought to understand the potential of state and local administrative and survey data to produce a local as well as a national picture of the health of the population with IDD. Analyses of these secondary data sources have significant appeal because of the potential to derive new information without the burden and expense of new data collection. The authors examined the potential for data collected by states and territories to inform health surveillance in the population with IDD, including data from the administration of eligibility-based supports, health insurance claims, and surveys administered for monitoring and quality improvement. Although there are opportunities to align and harmonize datasets to enhance the available information, there is no simple path to use state and local data to assess and report on the health of the population with IDD. Recommendations for policy, practice, and research include the development and use of consistent operational definitions in data collection, and research to fill knowledge gaps.

Contributions of Mental and Behavioral Health Conditions to Health Service Utilization Among People With Intellectual and Developmental Disabilities in Massachusetts

Although existing evidence suggests an increased prevalence mental and behavioral health conditions for people with intellectual and developmental disabilities (IDD), little is known about health service utilization patterns related to these conditions. This study provides population-based data on hospital service utilization. Medicaid claims for people under 65 years of age in Massachusetts were used (years 2008-2013) to identify a cohort of people with IDD. Utilization of inpatient hospitalizations and outpatient Emergency Department (ED) was compared with the U.S. and MA general population through risk ratios. Findings suggest mental and behavioral health conditions were major contributors to increased utilization of inpatient and outpatient ED services and underscore the need for community-based service options that understand how to treat these conditions in people with IDD and address the myriad of related factors to identify, treat, and minimize the potential adverse life impact of these conditions for people with IDD.

In-hospital mortality among adults with autism spectrum disorder in the United States: A retrospective analysis of US hospital discharge data

A retrospective data analysis using 2004-2014 Healthcare Cost and Utilization Project Nationwide Inpatient Sample was conducted to examine in-hospital mortality among adults with autism spectrum disorders in the United States compared to individuals in the general population. We modeled logistic regressions to compare inpatient hospital mortality between adults with autism spectrum disorders (n = 34,237) and age-matched and sex-matched controls (n = 102,711) in a 1:3 ratio. Adults with autism spectrum disorders had higher odds for inpatient hospital mortality than controls (odds ratio = 1.44, 95% confidence interval: 1.29-1.61, p < 0.001). This risk remained high even after adjustment for age, sex, race/ethnicity, income, number of comorbidities, epilepsy and psychiatric comorbidities, hospital bed size, hospital region, and hospitalization year (odds ratio = 1.51, 95% confidence interval: 1.33-1.72, p < 0.001). Adults with autism spectrum disorders who experienced in-hospital mortality had a higher risk for having 10 out of 27 observed Elixhauser-based medical comorbidities at the time of death, including psychoses, other neurological disorders, diabetes, hypothyroidism, rheumatoid arthritis collagen vascular disease, obesity, weight loss, fluid and electrolyte disorders, deficiency anemias, and paralysis. The results from the interaction of sex and autism spectrum disorders status suggest that women with autism spectrum disorders have almost two times higher odds for in-hospital mortality (odds ratio = 1.95, p < 0.001) than men with autism spectrum disorders. The results from the stratified analysis also showed that women with autism spectrum disorders had 3.17 times higher odds (95% confidence interval: 2.50-4.01, p < 0.001) of in-hospital mortality compared to women from the non-autism spectrum disorders matched control group; this difference persisted even after adjusting for socioeconomic, clinical, and hospital characteristics (odds ratio = 2.75, 95% confidence interval: 2.09-3.64, p < 0.001). Our findings underscore the need for more research to develop better strategies for healthcare and service delivery to people with autism spectrum disorders.

Monitoring black grouse Tetrao tetrix in Isère, northern French Alps: cofactors, population trends and potential biases

Wildlife management benefits from studies that verify or improve the reliability of monitoring protocols. In this study in Isère, France, we tested for potential links between the abundance of black grouse (Tetrao tetrix) in lek–count surveys and cofactors (procedural, geographical and meteorological cofactors) between 1989 and 2016. We also examined the effect of omitting or considering the important cofactors on the long–term population trend that can be inferred from lek–count data. Model selections for data at hand highlighted that the abundance of black grouse was mainly linked to procedural cofactors, such as the number of observers, the time of first observation of a displaying male, the day, and the year of the count. Some additional factors relating to the surface of the census sector, temperature, northing, altitude and wind conditions also appeared depending on the spatial or temporal scale of the analysis. The inclusion of the important cofactors in models modulated the estimates of population trends. The results of the larger dataset highlighted a mean increase of +17 % (+5.3 %; +29 %) of the abundance of black grouse from 1997 to 2001, and a mean increase in population of +47 % (+16 %; +87 %) throughout the study period (1989–2016). We discuss the hypothesis of plausible links between this past increase in the number of black grouse and the ecological impact of the winter storm ‘Vivian’. Findings from our study and the ecological phenomena that were concomitant with the observed population trend provide opportunities to strengthen the monitoring and management of black grouse in the Alps.

Assessing the association between mental health and disability indicators among adults living in the United States

BACKGROUND

Over 40 million people in the U.S. experience mental illness and/or disabilities. However, there has been limited characterization of the relationship between mental health and disability in national surveys.

OBJECTIVE

To examine associations between current indicators for psychological distress, serious mental illness, and disability in the National Health Interview Survey (NHIS).

METHODS

Secondary analysis (univariate and multivariate log-binomial estimation of relative risk) of non-specific psychological distress, duration of serious mental illness, disability types, and demographic factors in adults from the NHIS.

RESULTS

Strong associations between psychological distress, serious mental illness, and disability types were found. After demographic stratifications and adjustment, associations were strongest for cognitive disabilities, compared to other disability types. Adults reporting serious psychological distress or more than 10 years of serious mental illness were 19.7 (17.8, 21.7) and 11.0 (10.2, 12.0) times more likely to report cognitive disabilities, compared to adults reporting no psychological distress or serious mental illness. After sex and race/ethnicity adjustment, individuals ages 35-54 years reporting serious psychological distress or more than 10 years of serious mental illness were 8.6 (6.9, 10.6) and 3.7 (3.3, 4.2) times more likely to report cognitive disabilities, compared to individuals ages 35-54 years reporting no psychological distress or serious mental illness.

CONCLUSIONS

There is a robust association between mental health and cognitive disabilities among adults. Our results suggest health agencies and public policy consider addressing the concurrent nature of mental illness and cognitive disabilities in services and programs for adults with disabilities.

Using Medicaid Data to Characterize Persons With Intellectual and Developmental Disabilities in Five U.S. States

This project sought to identify Medicaid members with intellectual and developmental disabilities (IDD) in five states (Delaware, Iowa, Massachusetts, New York, and South Carolina) to develop a cohort for subsequent analyses of medical conditions and service utilization. We estimated that over 300,000 Medicaid members in these states had IDD. All members with diagnostic codes for IDD were identified and the three most frequent diagnoses were unspecified intellectual disability, autism or pervasive developmental disorder, and cerebral palsy. The percentage of Medicaid members with IDD ranged from 2.3% in New York to 4.2% in South Carolina. Identifying and characterizing people with IDD is a first step that could guide public health promotion efforts for this population.

Robust Vaccine Responses in Adult and Pediatric Cord Blood Transplantation Recipients Treated for Hematologic Malignancies

Because cord blood (CB) lacks memory T and B cells and recent decreases in herd immunity to vaccine-preventable diseases in many developed countries have been documented, vaccine responses in CB transplantation (CBT) survivors are of great interest. We analyzed vaccine responses in double-unit CBT recipients transplanted for hematologic malignancies. In 103 vaccine-eligible patients, graft-versus-host disease (GVHD) most commonly precluded vaccination. Sixty-five patients (63%; engrafting units median HLA-allele match 5/8; range, 2 to 7/8) received protein conjugated vaccines, and 63 patients (median age, 34 years; range, .9 to 64) were evaluated for responses. Median vaccination time was 17 months (range, 7 to 45) post-CBT. GVHD (n = 42) and prior rituximab (n = 13) delayed vaccination. Responses to Prevnar 7 and/or 13 vaccines (serotypes 14, 19F, 23F) were seen in children and adults (60% versus 49%, P = .555). Responses to tetanus, diphtheria, pertussis, Haemophilus influenzae, and polio were observed in children (86% to 100%) and adults (53% to 89%) even if patients had prior GVHD or rituximab. CD4(+)CD45RA(+) and CD19(+) cell recovery significantly influenced tetanus and polio responses. In a smaller cohort responses were seen to measles (65%), mumps (50%), and rubella (100%) vaccines. No vaccine side effects were identified, and all vaccinated patients survived (median follow-up, 57 months). Although GVHD and rituximab can delay vaccination, CBT recipients (including adults and those with prior GVHD) have similar vaccine response rates to adult donor allograft recipients supporting vaccination in CBT recipients.

Evaluating representativeness and cancer screening outcomes in a state department of developmental services database

Though it is widely recognized that people with intellectual and developmental disabilities (IDD) face significant health disparities, the comprehensive data sets needed for population-level health surveillance of people with IDD are lacking. This paucity of data makes it difficult to track and accurately describe health differences, improvements, and changes in access. Many states maintain administrative health databases that, to date, have not been widely used for research purposes. In order to evaluate the feasibility of using administrative databases for research purposes, the authors attempted to validate Massachusetts' administrative health database by comparing it to a large safety net hospital system's patient data regarding cancer screening, and to the state's service enrollment tables. The authors found variable representativeness overall; the sub-population of adults who live in 24-hr supported residences were better represented than adults who live independently or with family members. They also found a fairly low false negative rate for cancer screening data as compared with the "gold standard" of hospital records. Despite some limitations, these results suggest that state-level administrative databases may represent an exciting new avenue for health research. These results should lend context to efforts to study cancer and health screening variables using administrative databases. The present study methods may also have utility to researchers in other states for critically evaluating other state IDD service databases. This type of evaluation can assist researchers in contextualizing their data, and in tailoring their research questions to the abilities and limitations of this kind of database.

Stressful nurses: the effect on patient outcomes

The article describes a study that measured, over a 3-month period, staffing problems, including turnover rates; nurse incidents, including absenteeism, back injuries, and needle sticks; and patient incidents, including falls and medication errors. The self-reported stress of the nurses caring for these patients was recorded over the same 3-month period. Data showed that a relatively strong relationship exists between a hospital unit's Stress Continuum Scale (SCS) and the occurrence of patient incidents. The relationship between the SCS and personal incidents and nurse injuries appears weak, as does the relationship between staff turnover and stress. Lagging staff turnover by 1 month resulted in a moderate association with the SCS, however.

Reclassification of Lactobacillus casei subsp. casei ATCC 393 and Lactobacillus rhamnosus ATCC 15820 as Lactobacillus zeae nom. rev., designation of ATCC 334 as the neotype of L. casei subsp. casei, and rejection of the name Lactobacillus paracasei

The type strain of Lactobacillus casei subsp. casei (ATCC 393) exhibits low levels of DNA homology with other strains of L. casei subsp. casei (8 to 46%) and strains of Lactobacillus paracasei (30 to 50%), but exhibits a level of DNA similarity of 80% with Lactobacillus rhamnosus ATCC 15820, the original type strain of "Lactobacterium zeae" Kuznetsov 1959. Strains ATCC 393T (T = type strain) and ATCC 15820T are members of one protein profile cluster that is separate from the other Lactobacillus spp. The randomly amplified polymorphic DNA PCR profile of strain ATCC 393T is also different from the profiles obtained for the other species. L. casei ATCC 334T is genetically closely related to L. casei subsp. casei strains (71 to 97%) and L. paracasei strains (71 to 91%), is a member of the same protein profile cluster as these organisms, and shares several DNA amplicons with L. paracasei strains. On the basis of these results, we propose that L. casei subsp. casei ATCC 393T and L. rhamnosus ATCC 15820 should be reclassified as members of Lactobacillus zeae nom. rev. (type strain, ATCC 15820), that strain ATCC 334 should be designated the neotype strain of L. casei subsp. casei, and that the name L. paracasei should be rejected.

Active autoimmune gastritis without total atrophy of the glands

To date, autoimmune gastritis has been diagnosed for the most part only when total atrophy of the oxyntic glands is detected. On the basis of 40 patients without total atrophy of the glands, and with parietal cell antibodies in the serum, we show that the diagnosis of type A gastritis is also possible in the pre-atrophic stage. The histological criteria for the diagnosis of active autoimmune gastritis without total atrophy of the glands are 1. usually dense, diffuse locally emphasized lymphocytic infiltration of the lamina propria between the glands in the oxyntic mucosa, 2. focal destruction of individual glands in the corpus of the stomach by lymphocytes, and 3. reactive pseudohypertrophy of the parietal cells. A comparison with a group of patients with autoimmune gastritis and total atrophy of the glands shows that in active autoimmune gastritis, too, women are more frequently affected than men (in both groups, the sex ratio is approximately 3:1). Patients without atrophy of the glands are, on average, about 12 years younger than those with "burnt out" type A gastritis (average age 69.98:57.80 years). While in the case of burnt out type A gastritis, no colonisation with Helicobacter pylori was to be found, such colonisation was demonstrated for the corpus mucosa in 22.5%, and for the antral mucosa in 15.0%. In 27.5% a minimal or low-grade inactive superficial gastritis, as may be seen after eradication of Helicobacter pylori, was additionally diagnosed in the antrum. A knowledge of the histological appearance of the pre-atrophic stage of type A gastritis might be of importance for the possible prevention of pernicious anaemia.(ABSTRACT TRUNCATED AT 250 WORDS)

[General practice of colorectal cancer surgery: often still inadequate resection]

With the aim of investigated the question as to whether surgery for colorectal carcinoma is being carried out in a standardised tumor-oriented manner, 777 surgical specimens containing colorectal carcinomas obtained from 33 hospitals were analysed. Only 4.76% of these carcinomas were pT 1 early carcinomas, the largest portion of the tumors (63.96%) was classified as pT 3. The pN stages were distributed as follows: pN 0 53.4%, pN 1 22.0%, pN 2 13.77%, pN 3 9.39%, and pN X 1.41%. The surgeons indicated an R-classification in only 24% of the specimens. Measurements of the length of the resected material, the width of the mesocoli or perirectal tissue, the distal margin of clearance, the number of lymph nodes on the vessel trunk, and the number of pericolic or perirectal lymph nodes revealed a considerable degree of fluctuation in the measurements, and thus in the operative methodology applied to colorectal carcinoma surgery. Analysis of the four hospitals with the highest operating rates taking sigmoidorectal specimens as an example, showed that some abdominal surgeons are still not performing this operation in accordance with the oncological rules for tumor-oriented surgery.

Cryptosporidiosis of the appendix vermiformis: a case report

The present case report describes a 30-year-old man with AIDS who developed cryptosporidiosis of the appendix vermiformis. The patient had been admitted to hospital with all the symptoms of appendicitis, and an appendectomy was performed. The histological work-up of the surgical specimen revealed an acute phlegmonous appendicitis, and also a welldeveloped cryptosporidiosis, which was confirmed by electron-microscopic examination. Two years later, the patient died of pneumonia contracted during a generalised CMV infection. The postmortem examination revealed cryptosporidial organisms in the biliary tract. As far as we know, this is the first ever report of cryptosporidiosis of the appendix vermiformis.

[Malignant somatostatinoma--diagnosis after 6 years]

Early symptoms of malignant somatostatinoma with dyspeptic complaints, moderate diabetes mellitus and cholecystolithiasis are the reason of primary treatment of these patients by surgeons.

CASE REPORT

In a 34-year old patient with typical anamnesis of cholecystitis and moderate diabetes mellitus liver metastases were seen during laparotomy. In the beginning the metastases were mistaken for hepatocellular carcinoma histologically. There was no deterioration until June 1988 when a high-grade stenosis of the duodenum has developed. Now a malignant somatostatinoma was diagnosed histologically and confirmed by immunohistology. Somatostatinomas are generally diagnosed by repeated measures of increased plasma SLI associated with decreased insulin, glucagon, pancreatic-polypeptide (PP) and vasoactive-intestinal-peptide (VIP). In normally or moderately increased plasma SLI concentrations provocation with tolbutamid may be helpful. Treatment should remove most of the tumor by surgical intervention, while chemotherapy must be less pronounced.

Bifidobacterium gallicum sp. nov. isolated from human feces

A bifidobacterial isolate from human feces was found to have very low genetic relatedness to any previously described species of the genus. This strain, which also contained a unique type of peptidoglycan, L-lysine-L-alanine-L-serine (A3 alpha), is considered to represent a new species, which is designated Bifidobacterium gallicum. Its description is presented. The type strain is strain DSM 20093. gallicum. Its description is presented. The type strain is strain DSM 20093.

["Brown bowel" syndrome--lipofuscinosis of the intestine as a cause of atonia]

We report on a 42 year old male patient having been ill with pseudo-pobstruction and gastroinstestinal atonid for 24 years. He was thought to suffer from Crohn's disease and was treated conservatively. Since the therapy proved to be insufficient, explorative laparatomie was performed and parts of the small and large intestine which were thought to be inflamed, were removed. The histologic examination revealed the deposition of a significant amount of lipofuscin in the muscularis propria. This so-called brown bowel syndrome is known to be responsible for the development of gastrointestinal atonia. It is generally believed that this syndrome is caused by a vitamin E deficiency which may occur due to malabsorption. The brown bowel syndrome is treated sympomatically, and until now only one case achieving a remission of the disease has been reported.

Ultrastructure of the islets of Langerhans after long-term occlusion of the pancreatic duct system

The long-term effect of surgically induced atrophy and fribrosis of the exocrine parenchyma of the pancreas on the islets of Langerhans was examined electron-microscopically in animal experiments in mini-pigs. Ligature of the pancreatic duct, occlusion of the pancreatic duct system with an alcoholic solution of amino acids and the combination of this occlusion with ligature of the pancreatic duct were compared. A largely similar result was found in all three experimental groups 9 months post-operatively: The islets of Langerhans are mostly subdivided into predominantly small and apparently intact islet cell complexes by peri- and intra-insular fibrosis, and, where larger islet cell complexes are found, these are, in places, also destroyed in the peripheral region. The diffusion distance between the capillaries and the endocrine cells is, in part, considerably dilated by the interposition of collagen fibres. In the capillaries, thickenings and duplications of the basement membrane, as well as swelling of the endothelial cells can be found. There are rarely signs of atrophy in the islet cells lying in clusters. Only the granular structure of the B-cells diverges from the norm. From our morphological findings a delayed and diminished hormone output after pancreatic duct occlusion can be deduced, whereby, compared to earlier short-term experiments of our own, no significant progression of the peri- and intra-insular fibrosis can be determined.

Partial purification and properties of neuraminidase from Bifidobacterium lactentis

Bifidobacterium lactentis 659 a gram-positive, nonsporeforming anaerobic bacterium originally isolated from the feces of breast-fed infants produces neuraminidase after enzyme induction with 2mM N-acetylmannosamine added to the culture medium. Bacteria were transferred and grown in a medium containing casein hydrolysate, lactose, sodium acetate, amino acids, vitamins, salts and 2% human milk for 48 h at 37 degrees C under N2/CO2 atmosphere. Two subcultures derived from the original strain B. lactentis 659 were investigated separately because of different growth characteristics. However, their taxonomic identity was not doubtful. Neuraminidase was liberated from the bacterial sediments by ultrasonic treatment in 0.15M NaCl and was isolated by 60% ammonium sulfate precipitation, dialysis, concentration, and column chromatography on Sepharose CL-6B and Sephadex G-100. The enzyme exhibits a molecular weight of 38000 and a pH optimum in the range of pH 5--6 in barbital/acetate buffers. Starch gel electrophoresis and neuraminidase-specific staining with NeuAc alpha 2 leads to (3-methoxyphenyl) glycoside revealed two major and three minor enzyme bands. Michaelis constants (Km) were determined to be 7.1 mM for the (alpha 2 leads to 3) linkage of II3NeuAc-Lac, 7.5mM for the (alpha 2 leads to 6) linkage of II6Neu-Ac-Lac and 15mM for the (alpha 2 leads to 8) linkage in II3(leads from 2NeuAc8)2-Lac. Among the different groups of naturally occurring NeuAc-containing substrates, i.e. glycoproteins, gangliosides and oligosaccharides, B. lactentis neuraminidase cleaves oligosaccharides preferentially without remarkable differences between (alpha 2 leads to 3) and (alpha 2 leads to 6) linkages. Globular glycoproteins and mucins are poor substrates and gangliosides are practically not affected. In contrast, enzyme activity towards synthetic NeuAc glycosides is very high. The enzyme is activated by 50% with 50mM Ca2 and inhibited by 20mM EDTA accordingly. In general, B. lactentis neuraminidase shows a substrate specificity pattern similar to those found in other non-pathogenic and non-invasive representatives of the human bacterial flora. The potential biological role of intestinal Bifidobacteria will be discussed.

[Mechanism of the variation of the acetate/lactate/ratio during glucose fermentation by bifidobacteria (author's transl)]

It is demonstrated that most strains of bifidobacteria form much more acetate and less lactic acid from glucose than is to be expected according to the breakdown of glucose via the "bifidoshunt". The analysis of isotope distribution among the fermentation products of glucose labeled in different positions showed that the excess of acetate is the result of the phosphoroclastic splitting of a part of the pyruvate arising from carbons 4, 5, and 6 of glucose. In addition to acetate (carbons 5 and 6), formate is formed from carbon 4 and some acetate is reduced to ethanol. The formation of "extra" acetate occurs mainly during the log phase and is less pronounced in resting cells. The extent of the phosphoroclastic splitting of pyruvate varies considerably among different strains even among those from the same species.