[Potential of fMRI for the Functional Assessment of the Pathological Visual System]. / Potenzial von fMRT für die Funktionsüberprüfung des pathologischen Sehsystems.

Current developments in functional magnetic resonance imaging (fMRI) of the human visual system have generated a set of powerful approaches that are of great promise for modern ophthalmology. These make it possible to perform an objective spatially resolved test of visual function in patients with strong visual impairment and even to investigate the functional organisation of the visual cortex in the blind. As a consequence, they open a broad field of applications for functional assessment in ophthalmology and provide fundamental insights into the interplay of pathology and plasticity in the human visual system. This is highlighted by current studies investigating patients with acquired or congenital defects of the macula, or with visual pathway abnormalities, extended retinal damage, and complete blindness. Therapeutic approaches targeting the restoration of visual input are expected to benefit from these fMRI applications, either for the estimation of the success rate of a planned retinal therapy or as an objective high-level biomarker for the readout of therapy success.

[Deficits of routine occupational therapy services in rheumatic diseases: results of the RheumaDat study]. / Defizite der ergotherapeutischen Routineversorgung bei rheumatischen Erkrankungen: Ergebnisse einer Auswertung der RheumaDat-Panel-Befragung.

The purpose of the present study is to describe the frequency and potential determinants of occupational therapy routine services in patients with rheumatic diseases. The study is based on a secondary analysis of the RheumaDat database. The results of the survey on 907 patients were analyzed regarding frequency of occupational therapy routine services and related sociodemographic and disease-specific variables. Approximately 8% of the study population received occupational therapy, patients with rheumatoid arthritis representing the largest proportion of these at 13%. Only patients with osteoarthritis showed a clear treatment pattern. Patients from this group receiving occupational therapy were older, had a longer duration of disease and were more affected. No clear appraisal of the therapy status in the rheumatoid arthritis or fibromyalgia group could be made. The results indicate shortages and the lack of a clear system in occupational therapy routine services in patients with different rheumatic diseases.

[Painless acanthamoeba keratitis]. / Schmerzlose Akanthamöbenkeratitis.

A 37-year-old contact lens wearer was treated for herpes simplex keratitis. After an initial improvement the keratitis became much worse. An annular infiltrate gave rise to the suspicion of acanthamoeba keratitis even though the patient was not in pain. This diagnosis was confirmed by histological and microbiological examination of the corneal disc after keratoplasty. Acanthamoeba keratitis should be considered even in the absence of pain, especially when the patients are contact lens wearers.

[Ophthalmological health care of the institutionalized elderly : The OVIS study]. / Ophthalmologische Versorgung in Seniorenheimen : Die OVIS-Studie.

BACKGROUND: Due to demographic change and societal transformation the number of elderly persons living in retirement homes is growing in Germany. Access to health care is more complicated in the setting of nursing homes. Different regional studies suggest unmet ophthalmological health care needs in institutionalized elderly people. This study assessed the current ophthalmological health care structure and supply status in nursing homes in Germany. METHODS: This prospective, multicenter cross-sectional study was conducted by 14 study centers in Germany. Elderly people living in 32 nursing homes were included after approval by the local institutional review boards. A standardized examination was performed which included a detailed medical and ocular history, refraction, visual acuity testing, tonometry, biomicroscopy and dilated funduscopy. Unmet ophthalmological health care needs were documented and the data were analyzed descriptively and via logistic regression modelling. RESULTS: A total of 600 participants (434 women and 166 men) aged 50-104 years were examined of which 368 (61%) had ophthalmological conditions requiring treatment. The most prevalent findings were cataracts (315; 53%), disorders of the eyelids (127; 21%), dry eye disease (57; 10%) and posterior capsule opacification (43; 7%). In 63 (11%) of the participants glaucoma was suspected and 55 (9%) of the examined population had a known diagnosis of glaucoma, of whom one third was not on any or on insufficient anti-glaucomatous therapy. 236 (39%) showed signs of age-related macular degeneration (AMD). Only 52% of the examined cohort had been examined by an ophthalmologist within the last 5 years and 39% stated that they would currently not be able to consult an ophthalmologist. Reported barriers were mainly transport and lack of support. CONCLUSION: This study demonstrates considerable unmet ophthalmological health care needs of the institutionalized elderly in Germany. Novel and reformed models of specialist care provision have to be developed.

Effect of elevated glucose concentration on membrane voltage regulation in retinal capillary pericytes.

The influence of elevated glucose concentration on resting membrane voltage, electrogenic Na(+)-K(+)-ATPase, and ATP-sensitive potassium channels (KATP channels) was studied in cultured bovine retinal capillary pericytes using conventional microelectrodes. The resting membrane voltage in cells grown in medium containing 5 mM glucose (control) averaged -27 +/- 1.2 mV (mean +/- SE, n = 26) and was not different from cells grown in medium containing 22.5 mM glucose (-26 1.2 mV, n = 26). Addition of ouabain (10(-4) M), a specific inhibitor of the Na(+)-K(+)-ATPase, depolarized the membrane potential by 3.6 +/- 0.4 mV (n = 10) in cells grown under control conditions and 0.7 +/- 0.2 mV (n = 6) in cells grown under elevated glucose conditions. Thus, electrogenic activity of the Na(+)-K(+)-ATPase was significantly (P < 0.0001) reduced to 19% compared with control conditions. Electrogenic Na(+)-K(+)-ATPase activity could be partially restored (ouabain-induced depolarization delta V = 2.0 +/- 0.2 mV, n = 6) in cells grown with high glucose in the presence of the aldose reductase inhibitor tolrestat (10(-5) M). The potassium channel opener Hoe 234 (10(-6) M) induced membrane potential hyperpolarization in control cells (delta V = 7.3 +/- 1.2 mV, n = 13), which could be completely inhibited by the KATP channel blocker glibenclamide (10(-7) M, n = 5). This indicates that pericytes possess KATP channels. The effect of KATP channels on membrane voltage was not significantly changed (P = 0.16) in cells cultured under high-glucose conditions (delta V = 9.6 +/- 2.0 mV, n = 6).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative analysis of vascular endothelial growth factor receptors on retinal and aortic vascular endothelial cells.

Ischemic eye disease often results in ocular neovascularization, presumably due to the elaboration of growth factors. Diabetic retinopathy is a classic example in which dramatic retinal neovascularization arises after ischemic retinal damage. The characterization of vascular endothelial growth factor (VEGF) as an angiogenic molecule whose expression is markedly induced by hypoxia makes it a promising candidate for mediating ischemic retinal neovascularization. Thus, we have characterized the structure, binding, and regulation of VEGF receptors in bovine retinal (BREC) and aortic endothelial cells (BAEC). VEGF stimulated a 2.1-fold increase in BREC number and DNA content at 0.6 nmol/l VEGF (P < 1 x 10(-7)). Scatchard binding analysis demonstrated specific high-affinity VEGF receptors on BREC with a Kd of 4.9 +/- 0.6 x 10(-11) mmol/l, similar to that observed for BAEC at 5.1 +/- 0.4 x 10(-11) mmol/l. BREC, however, possess 1.5 x 10(5) high-affinity receptors/cell, threefold more than BAEC (P < 0.003) and more than any cell type reported previously. 125I-VEGF affinity cross-linking revealed complexes at 220 and 170 kDa in BREC, but only a 220-kDa band of lesser intensity in BAEC. Cross-linking was displaceable in a dose-dependent manner by VEGF (P < 0.01) but not by other hormones. Hypoxia increased VEGF receptor number 50% in BREC without altering affinity. Antiphosphotyrosine immunoblotting showed VEGF-stimulated tyrosine autophosphorylation of VEGF receptor bands at 225 and 220 kDa and another band at 80 kDa within 1 min.(ABSTRACT TRUNCATED AT 250 WORDS)

The regulation of trabecular meshwork and ciliary muscle contractility.

Current models of aqueous humor outflow no longer treat trabecular meshwork (TM) as an inert tissue passively distended by the ciliary muscle (CM). Instead, ample evidence supports the theory that trabecular meshwork possess smooth muscle-like properties and is actively involved in the regulation of aqueous humor outflow and intraocular pressure. In this model, trabecular meshwork and ciliary muscle appear as functional antagonists, with ciliary muscle contraction leading to a distension of trabecular meshwork with subsequent reduction in outflow. and with trabecular meshwork contraction leading to the opposite effect. Smooth-muscle relaxing substances would therefore appear to be ideal candidates for glaucoma therapy with the dual goal of reducing intraocular pressure via the trabecular meshwork and of improving vascular perfusion of the optic nerve head. However, for such substances to effectively lower intraocular pressure, the effect on the ciliary muscle would have to he minimal. For this reason, more information is needed on the signalling processes involved in regulating trabecular meshwork and ciliary muscle contractility. This review attempts to outline current knowledge of signal transduction pathways leading to relaxation and contraction of ciliary muscle and trabecular meshwork. Pathways can be classified as involving or not involving changes of membrane voltage and of requiring or not requiring external calcium: possibly, other pathways exist. These different pathways involve different ion channels and isoforms of PKC and are expressed to a differing degree in ciliary muscle and trabecular meshwork, leading to differential responses when exposed to relaxing or contracting pharmacological agents. Some of these agents. like tyrosine kinase inhibitors and inhibitors of PKC. have been shown to relax trabecular meshwork while leaving ciliary muscle comparatively unaffected. This profile makes these substances appear as ideal drugs for simultaneously improving ocular outflow and retinal circulation, parameters that determine the time course of visual deterioration in glaucoma.

Sepsis associated with urinary tract infection. Antibiotic treatment with piperacillin.

Urosepsis is mostly induced by nosocomial gram-negative organisms. It is an infection that is difficult to treat and has high mortality, especially when associated with septic shock. For obstructive urosepsis, which occurs mostly after an acute stone occlusion of the upper urinary tract in pyelonephritis, intensive systemic medical therapy and drainage (and sometimes removal) of the septic kidney are necessary. For non-obstructive urosepsis, which is mostly an iatrogenic complication of diagnostic or therapeutic procedures on the genito-urinary tract, the same intensive medical care and urinary drainage are adequate. Systemic therapy in the treatment of urosepsis encompasses several disorders. Specific pathogenic mechanisms of shock, including failure of the microcirculation, hemostatic disorders, and microbiological problems, have to be considered in the systemic treatment of urosepsis. Appropriate antibiotic therapy may triple chances of survival. In this connection, piperacillin was successfully used in 30 patients with urosepsis treated at our institution.

[The German Acanthamoeba keratitis register: Initial results of a multicenter study]. / Das Deutsche Akanthamöbenkeratitis-Register : Erste Ergebnisse einer multizentrischen Erhebung.

BACKGROUND AND PURPOSE: In September 2011 the cornea section of the German Ophthalmological Society (DOG) established the first German Acanthamoeba keratitis registry. The data of this multicenter survey are being collected, compiled and evaluated at the Department of Ophthalmology at the Saarland University. The aim of this article is to present an intermediate report. PATIENTS AND METHODS: Data from 172 eyes with Acanthamoeba keratitis were collected during the last 10 years. For this interim report we actually evaluated 121 eyes (60.2 % female patients, average age 41.3 years) and collected the following data: date of onset of symptoms, date and method of diagnosis, initial diagnosis, anamnestic data, clinical symptoms and signs at diagnosis and during follow-up, conservative and surgical therapy. Criteria for inclusion in the Acanthamoeba registry was the established diagnosis of an Acanthamoeba keratitis with at least one of the methods described in this article. RESULTS: Acanthamoeba keratitis could be histologically proven in 55.3 % of the cases, via PCR in 25.6 %, with confocal microscopy in 20.4 % and using in vitro cultivation in 15.5 %. Clinical symptoms and signs in Acanthamoeba keratitis were pain in 67.0 %, ring infiltrates in 53.4 %, pseudodendritiform epitheliopathy in 11.7 % and keratoneuritis in 5.8 %. In 47.6 % of the cases the initial diagnosis was herpes simplex virus keratitis followed by bacterial keratitis in 25.2 % and fungal keratitis in 3.9 %. Acanthamoeba keratitis was the correct initial diagnosis in only 23.2 % of cases. The average time period between first symptoms and diagnosis was 2.8 ± 4.0 months (range 0-23 months). A triple therapy with Brolene® Lavasept® and antibiotic eye drops at least 5 ×/day was used in 54.5 % of eyes (n = 66). Penetrating keratoplasty was performed in 40.4 %, in 18 cases in combination with cryotherapy of the cornea. The mean graft diameter was 7.9 ± 1.1 mm (range 3.5-11.0 mm). The final visual acuity (Snellen visual acuity chart at 5 m) was comparable in the two groups of eyes with (5/40 ± 5/25) and without (5/32 ± 5/25) keratoplasty. CONCLUSION: Acanthamoeba keratitis is a rare and often very late diagnosed disease and two thirds of the cases were initially misdiagnosed. The early recognition of the typical symptoms is crucial for the prognosis of the disease. All ophthalmological departments in Germany are invited to submit further data of all confirmed cases (berthold.seitz@uks.eu), whether retrospectively or prospectively in order to generate an adequate standardized diagnostic and therapeutic approach for this potentially devastating disease.

Insulin-induced hyperpolarization in retinal capillary pericytes.

PURPOSE: This study investigated the mechanism of insulin-induced membrane voltage hyperpolarization in retinal capillary pericytes, which possess electrical membrane properties typical for smooth muscle cells and are supposed to regulate retinal microcirculation by a contractile mechanism. METHODS: The mechanism of insulin-induced hyperpolarization was studied in cultured bovine retinal capillary pericytes using conventional microelectrodes. RESULTS: Resting voltage averaged -28 +/- 0.9 mV (mean +/- SEM, n = 45). Insulin (10(-9) to 10(-7) mol/l) induced a slow hyperpolarization in a dose-dependent fashion. Voltage change (delta V) was -3.1 +/- 0.4 mV (n = 14, P < 0.0001, = control) with an insulin concentration of 10(-8) mol/l. Blockade of potassium channels with Ba2+ (5 mmol/l) completely abolished the hyperpolarizing effect of insulin (n = 5). Apamin (10(-9) mol/l), a blocker of low-conductance Ca(2+)-activated potassium channels, also completely inhibited the insulin-induced hyperpolarization (n = 4). Blocking ATP-sensitive potassium channels with glibenclamide (10(-7) mol/l) did not reduce the hyperpolarizing action of insulin (delta V = -2.2 +/- 0.4 mV, n = 5, P = 0.29). Equivalent hyperpolarizations were recorded when insulin was added in the presence of ouabain (10(-4) mol/l) to inhibit the electrogenic Na+/-/K+/-ATPase (delta V = -3.5 +/- 1.0 mV, n = 4, P = 0.68). When pericytes were grown for 3 days in culture medium with elevated glucose concentrations (22.5 mmol/l), the resting membrane voltage and the insulin-induced hyperpolarization were not significantly altered. CONCLUSION: Insulin hyperpolarizes the membrane voltage of retinal pericytes probably mediated by activation of apamin-sensitive Ca(2+)-activated potassium channels. Therefore, hormonal modulation of membrane voltage by insulin might be an important factor in the regulation of pericyte contractility and retinal microcirculation under physiological conditions and in diabetes mellitus.

Mediation of calcium-independent contraction in trabecular meshwork through protein kinase C and rho-A.

PURPOSE: Inhibition of protein kinase C (PKC) and rho-kinase (ROCK) may represent a new way of influencing outflow facility through isolated relaxation of the trabecular meshwork (TM). This work was performed to investigate the existence of calcium-independent contraction in this smooth-muscle-like tissue and its modulation by targeting the rho-guanosine triphosphatase (GTPase)-mediated pathway. METHODS: Isometric tension measurements of bovine TM and ciliary muscle (CM) were performed. Intra- and extracellular calcium buffering was accomplished with EGTA and 1, 2-bis(2-aminophenoxy)-ethane-N,N:,N:,N:',N:'-tetra-acetic acid tetrakis/acetoxymethhyl ester (BAPTA-AM) followed by stimulation of PKC with phorbolester (PMA) or 4alpha-phorbol. Calcium-independent contraction was blocked using the highly specific ROCK inhibitor Y-27632. Western blot analysis and immunoprecipitation was performed using human TM cells. RESULTS: In TM, carbachol induced partial contraction under conditions of extracellular calcium depletion (22. 1% +/- 2.3% versus 100%, n = 9). The membrane-permeable calcium chelator BAPTA-AM completely blocked this response (1.1% +/- 1.4% versus 100%, n = 9). When calcium was completely blocked, PMA induced contraction in TM (16.7% +/- 5.9% versus 100%, n = 9) but not in CM (1.8% +/- 2.5% versus 100%, n = 6). The inactive PMA analogue 4alpha-phorbol did not induce contraction, indicating that activation of PKC is involved in this contractile response. The ROCK inhibitor Y-27632 completely blocked the calcium-independent PMA-induced contraction in TM. Western blot analysis and immunoprecipitation revealed the expression of the rho-A protein in human TM cells. CONCLUSIONS: The data indicate that contrary to CM, the TM features calcium-independent contractile mechanisms linked to rho-A and PKC isoforms that do not require calcium for activation. ROCK inhibitors may allow specific modulation of the TM to enhance outflow facility, thus lowering intraocular pressure.

The effects of protein kinase C on trabecular meshwork and ciliary muscle contractility.

PURPOSE: The possible role of protein kinase C (PKC) inhibitors in novel pressure-lowering drugs is currently under investigation. To gain further insight into regulation of contractility by PKC in trabecular meshwork (TM) and ciliary muscle (CM), the effects of various PKC inhibitors and activators were tested. METHODS: Isometric tension measurements of bovine TM and CM strips were performed. PKC was stimulated by phorbol ester and by the diacylglycerol analogue diC8. PKC blockade was accomplished using H7 and myristoilated PKC substrate (mPKC). Western blot analysis was used to identify specific PKC isoforms in human trabecular meshwork (HTM), human ciliary muscle (HCM), and bovine TM and CM. RESULTS: In tissues precontracted by carbachol PKC antagonist H7 led to a relaxation of TM (25+/-7.2 versus 100%; n = 8) with no effect on CM. mPKC substrate selectively blocks PKC. This substance led to relaxation of TM (32.8+/-7.4 versus 100%, n = 7), whereas CM was not affected. PMA at concentrations of 10(-6) M led to a slow contraction of both tissues that was more marked in TM. DiC8 and 4alpha-phorbol had no effect on contractility. Western blot analysis revealed expression of calcium-dependent PKC-alpha and calcium-independent PKC-epsilon isoforms in HTM and HCM. PKC-epsilon expression was more pronounced in HTM than in HCM. Similar PKC isoform expression was found in native bovine tissue. CONCLUSIONS: PKC isoforms show different tissue distributions in human and bovine TM and CM. Contractility differences exist in both tissues in response to PKC antagonists and agonists. The data indicate that PKC may be involved in regulation of aqueous humor outflow by the TM. Thus, inhibition of PKC may represent a new way of influencing outflow facility through isolated relaxation of TM.

Mechanisms of action of unoprostone on trabecular meshwork contractility.

PURPOSE: This study was performed to clarify the possible mechanism behind the ocular hypotensive effect of unoprostone isopropyl (Rescula; Novartis Ophthalmics AG, Basel, Switzerland), a new docosanoid that has been shown to reduce intraocular pressure (IOP) in patients with ocular hypertension or primary open-angle glaucoma. To gain insight into the possible mode of action, the effects of unoprostone on ciliary muscle (CM) and trabecular meshwork (TM) contractility, intracellular calcium levels, and membrane channels were investigated. METHODS: The effects of unoprostone (M1 metabolite = free acid, 10(-5) M) and endothelin (ET)-1 (10(-9) M) on bovine TM (BTM) and ciliary muscle (CM) strips were investigated, by using a custom-made force-length transducer system. The effects of unoprostone and ET-1 (5 x 10(-8) M) on intracellular Ca(2+) mobilization in cultured human TM (HTM) were measured using fura-2AM as a fluorescent probe. Patch-clamp experiments were performed on HTM and BTM cells to investigate the unoprostone-dependent modulation of membrane currents. RESULTS: In isolated TM and CM strips, unoprostone almost completely inhibited ET-induced contractions (TM: 2.9% +/- 4.3% vs. 19.6% +/- 5.7%, P < 0.05, n = 6; CM: 1.4% +/- 1.6% vs. 30.1% +/- 5.3%, P < 0.01, n = 6; 100% = maximal carbachol-induced (10(-6) M) contraction). However, neither carbachol-induced contraction nor baseline tension was affected by unoprostone. Furthermore, unoprostone had no effect on baseline intracellular calcium levels (baseline: 126 +/- 45 nM versus unoprostone: 132 +/- 42 nM, n = 8) in HTM cells. The endothelin-induced increase (679 +/- 102 nM), however, was almost completely (P < 0.01) blocked by unoprostone (178 +/- 40 nM). In patch-clamp recordings, unoprostone could be shown to double the amplitude of outward current (HTM: 200% +/- 33%; n = 6; BTM: 179% +/- 20%; n = 8). This effect was blocked by the specific inhibitor of maxi-K channels, iberiotoxin. CONCLUSIONS: This study presents evidence for direct interaction of unoprostone with the contractility of the TM and CM. This compound may lower IOP by affecting aqueous outflow, most probably conventional outflow pathways (i.e., TM) through inhibition of ET-dependent mechanisms. In addition, unoprostone interacts with the maxi-K channel. Although primarily Ca(2+)-sensitive signal-transduction pathways seem to be involved, effects of unoprostone on Ca(2+)-independent pathways and uveoscleral outflow cannot be excluded.

Flufenamic acid enhances current through maxi-K channels in the trabecular meshwork of the eye.

PURPOSE: Flufenamic acid relaxes trabecular meshwork, a smooth muscle-like tissue involved in the regulation of ocular outflow in the eye. In this study, we attempted to determine if ionic channels are involved in this response. METHODS: Cultured human (HTM) and bovine (BTM) trabecular meshwork cells were investigated using the patch-clamp technique. RESULTS: In trabecular meshwork, flufenamic acid (10(-5) M) reversibly stimulated outward current to 406 +/- 71% of initial outward current level in BTM (n = 10) and 294 +/- 75% of initial current level in HTM (n = 12) in all cells investigated; no significant differences emerged. The response was dosage-dependent. Replacement of potassium in all solutions eliminated the response to flufenamic acid (n = 4, BTM). Blocking K(ATP ) channels with glibenclamide (10(-5) M, n = 6) and small-conductance calcium-activated potassium channels with apamin (10(-6) M, n = 5) had no effect. A direct effect on calcium channels could also not be detected. Blockage of the large-conductance calcium-activated potassium channel (maxi-K) by iberiotoxin (10(-7) M) suppressed 87 +/- 9% (n = 6; HTM) and 91 +/- 10% (n = 6; BTM) of the response. Depleting the cells of calcium did not significantly alter the response to flufenamic acid. CONCLUSIONS: Flufenamic acid stimulates maxi-K channels in trabecular meshwork of both human and bovine origin. This should lead to hyperpolarization, closure of L-type channels and lowered cytosolic calcium levels, possibly explaining the relaxation observed in response to this substance.

Uniform persistence and permanence for non-autonomous semiflows in population biology.

Conditions are presented for uniform strong persistence of non-autonomous semiflows, taking uniform weak persistence for granted. Turning the idea of persistence upside down, conditions are derived for non-autonomous semiflows to be point-dissipative. These results are applied to time-heterogeneous models of S-I-R-S type for the spread of infectious childhood diseases. If some of the parameter functions are asymptotically almost periodic, an almost sharp threshold result is obtained for uniform strong endemicity versus extinction in terms of asymptotic time averages. Applications are also presented to scalar retarded functional differential equations modeling one species population growth.

Epidemic and demographic interaction in the spread of potentially fatal diseases in growing populations.

The spread of a potentially fatal infectious disease is considered in a host population that would increase exponentially in the absence of the disease. Taking into account how the effective contact rate C(N) depends on the population size N, the model demonstrates that demographic and epidemiological conclusions depend crucially on the properties of the contact function C. Conditions are given for the following scenarios to occur: (i) the disease spreads at a lower rate than the populations grows and does not modify the population growth rate: (ii) the disease initially spreads at a faster rate than the population grows and lowers the population growth rate in the long run and the following three subscenarios are possible: (iia) the population still grows exponentially, but at a slower rate; (iib) population growth is limited, but the population size does not decay; (iic) population increase is converted into population decrease.

How to estimate the efficacy of periodic control of an infectious plant disease.

Certain infectious plant diseases are controlled by inspection and subsequent hand removal of diseased parts. In this paper we give two sets of criteria from which one can conclude whether this control effort is adequate or not. These criteria do not require knowledge of the infection- or detection rate of the disease but only use the structure of the contact matrix. Computer experiments give a feeling of how many inspections are needed in order to draw a conclusion.

Recurrent outbreaks of childhood diseases revisited: the impact of isolation.

The recurrent outbreaks of measles and other childhood diseases have previously been explained by an interaction of intrinsic epidemiologic forces generating dampened oscillations and of seasonal and/or stochastic excitation. We show that isolation (i.e., sick individuals stay at home and have a reduced infective impact) can create self-sustained oscillations provided that the number of per capita contacts is largely independent of the number of individuals present. This means that the bilinear mass action term for disease incidence is modified by dividing it by the number of nonisolated individuals.