[Development and implementation of an outpatient clinic at an initial reception centre for asylum seekers in the German federal state of Baden-Wuerttemberg]. / Entwicklung und Implementierung einer Medizinischen Ambulanz in einer Erstaufnahmeeinrichtung für Asylsuchende des Landes Baden-Württemberg.

In 2015, more than 890,000 asylum seekers were registered in Germany. The provision of medical and psychosocial care for asylum seekers is facing numerous obstacles. Access to health care is mostly insufficient, particularly in initial reception centres. The present article describes the development and implementation of an interdisciplinary outpatient clinic for asylum seekers at the main registration authority in the state of Baden-Wuerttemberg operated by physicians of the University Hospital of Heidelberg and the local Medical Association in Heidelberg. A steering committee was appointed to plan and implement the interdisciplinary outpatient clinic. Semi-structured interviews with nine steering committee members were conducted to elucidate perceived barriers during the planning and implementation phase. The steering committee's strong personal commitment and the health authorities' impartial management were cited as the main contributing factors to the success of the implementation process. Significant barriers were seen in the funding of personnel, equipment, and language mediation as well as in legal liability and billing-related aspects. Results are discussed with a focus on financing, administrative and legal framework as well as language mediation, documentation and further matters that are essential to ensure high-quality care.

Characterization of the inflammatory phenotype of Mycobacterium avium subspecies paratuberculosis using a novel cell culture passage model.

Understanding the pathogenic mechanisms of Mycobacterium avium subspecies paratuberculosis (MAP) and the host responses to Johne's disease is complicated by the multi-faceted disease progression, late-onset host reaction and the lack of available ex vivo infection models. We describe a novel cell culture passage model that mimics the course of infection in vivo. The developed model simulates the interaction of MAP with the intestinal epithelial cells, followed by infection of macrophages and return to the intestinal epithelium. MAP internalization triggers a minimal inflammatory response. After passage through a macrophage phase, bacterial reinfection of MDBK epithelial cells, representing the late phase of intestinal mucosal infection, is associated with increased synthesis of the pro-inflammatory transcripts of IL-6, CCL5, IL-8 and IL-18, paired with decreased levels of TGFß. Transcriptome analysis of MAP from each stage of epithelial cell infection identified increased expression of lipid biosynthesis and lipopeptide modification genes in the inflammatory phenotype of MAP. Total lipid analysis by HPLC-ES/MS indicates different lipidomic profiles between the two phenotypes and a unique set of lipids composing the inflammatory MAP phenotype. The presence of selected upregulated lipid-modification gene transcripts in samples of ileal tissue from cows diagnosed with Johne's disease supports and validates the model. By using the relatively simple cell culture passage model, we show that MAP alters its lipid composition during intracellular infection and acquires a pro-inflammatory phenotype, which likely is associated with the inflammatory phase of Johne's disease.

Resolution of Crohn's disease and complex regional pain syndrome following treatment of paratuberculosis.

A cohort of family members with various chronic diseases including Crohn's disease, asthma, complex regional pain syndrome, hypothyroidism, type 1 diabetes mellitus, and lymphangiomatosis and/or evidence of infection by Mycobacterium avium subsp. paratuberculosis (MAP) are described in this series of case reports. MAP was cultured from the blood of three members affected by the first five diseases and there was accompanying elevated anti-MAP IgG in two members. The patient affected by the sixth disease has a markedly elevated anti-MAP titer. The two patients affected by the first four diseases have been treated with a combination of anti-MAP antibiotics and ultraviolet blood irradiation therapy with resolution of the disease symptomatology and inability to culture MAP in post treatment blood samples. These case reports of patients with MAP infections provide supportive evidence of a pathogenic role of MAP in humans.

Mannosylated lipoarabinomannans from Mycobacterium avium subsp. paratuberculosis alters the inflammatory response by bovine macrophages and suppresses killing of Mycobacterium avium subsp. avium organisms.

Analysis of the mechanisms through which pathogenic mycobacteria interfere with macrophage activation and phagosome maturation have shown that engagement of specific membrane receptors with bacterial ligands is the initiating event. Mannosylated lipoarabinomannan (Man-LAM) has been identified as one of the ligands that modulates macrophage function. We evaluated the effects of Man-LAM derived from Mycobacterium avium subsp. paratuberculosis (MAP) on bovine macrophages. Man-LAM induced a rapid and prolonged expression of IL-10 message as well as transient expression of TNF-α. Preincubation with Man-LAM for up to 16 h did not suppress expression of IL-12 in response to interferon-γ. Evaluation of the effect of Man-LAM on phagosome acidification, phagosome maturation, and killing of Mycobacterium avium subsp. avium (MAA) showed that preincubation of macrophages with Man-LAM before addition of MAA inhibited phagosome acidification, phagolysosome fusion, and reduced killing. Analysis of signaling pathways provided indirect evidence that inhibition of killing was associated with activation of the MAPK-p38 signaling pathway but not the pathway involved in regulation of expression of IL-10. These results support the hypothesis that MAP Man-LAM is one of the virulence factors facilitating survival of MAP in macrophages.

Cellular and humoral immunogenicity of Mycobacterium avium subsp. paratuberculosis specific lipopentapeptide antigens.

Paratuberculosis caused by Mycobacterium avium subsp. paratuberculosis (MAP) is a chronic infectious disease affecting domestic and wild ruminants. Antigens currently used for the diagnosis of paratuberculosis are whole-cell derived crude preparations. The identification of MAP-specific antigens for the specific and early diagnosis of this infection is strongly needed. This study assessed the ability of the MAP-specific synthetic lipopeptide antigen Para-LP-01 to invoke specific serum antibody (Ab) and cell-mediated immune (CMI) responses in sheep experimentally exposed to MAP S strain. Responses were compared to those elicited by the crude whole-cell derived MAP 316v antigen (316v). Para-LP-01 induced a significant serum Ab response in MAP-infected sheep in comparison with unexposed or uninfected sheep, but failed to induce detectable CMI responses including production of IFN-γ, IL-10 and lymphoproliferation, unlike 316v which invoked both CMI and serum Ab responses in MAP-exposed sheep. Para-LP-01 is a suitable antigen for serodiagnosis of MAP-infection in sheep. The differential induction of humoral and CMI responses by lipid based antigens could enhance current understanding of the role played by cell-wall associated lipid antigens in the pathogenesis of MAP-infection.

A Mycobacterium avium subsp. paratuberculosis LuxR regulates cell envelope and virulence.

Mycobacterium avium subsp. paratuberculosis adapts to the environment via the regulation of genes affecting its envelope's composition. Bacteria grown in milk (in vivo conditions) presented differences in the cell wall-associated lipids and in the expression of genes involved in lipid metabolism (FadE8, FadE6 and MAP1420) and host cell invasion (MAP1203, LprL). A different lipid profile was also observed in the envelope of intracellular bacteria after 1 h of infection. Intracellular bacteria showed up-regulation of a LuxR regulator which controls the envelope's composition by up-regulation of FadE8, MAP1420, MAP1203 and LprL and by down-regulation of pks12, mmpL2 and MAP2594. A LuxR-overexpressing strain with a lipid-deficient envelope phenotype, infected epithelial cells more efficiently than the wild-type bacteria; however, it was not more resistant than the wild-type strain to the action of bactericidal proteins. Here we show that LuxR regulates virulence determinants and is involved in mycobacteria adaptation to the host.

A major cell wall lipopeptide of Mycobacterium avium subspecies paratuberculosis.

Mycobacterium avium subspecies paratuberculosis (MAP), the causative agent of Johne disease in cattle and other ruminants, is proposed to be at least one of the causes of Crohn disease in humans. MAP and Mycobacterium avium subspecies avium, a closely related opportunistic environmental bacterium, share 95% of their genes and exhibit homologies of more than 99% between these genes. The identification of molecules specific for MAP is essential for understanding its pathogenicity and for development of useful diagnostic tools. The application of gas chromatography, mass spectrometry, and nuclear magnetic resonance led to the structural identification of a major cell wall lipopeptide of MAP, termed Para-LP-01, defined as C20 fatty acyl-D-Phe-N-Me-L-Val-L-Ile-L-Phe-L-Ala methyl ester. Variations of this lipopeptide with different fatty acyl moieties (C16 fatty acyl through C17, C18, C19, C21 to C22) were also identified. Besides the specificity of this lipopeptide for MAP, the presence of an N-Me-L-valine represents the first reported N-methylated amino acid within an immunogenic lipopeptide of mycobacteria. Sera from animals with Johne disease, but not sera from uninfected cattle, reacted with this lipopeptide, indicating potential biological importance.