The hospital-at-home care model is feasible, safe, and efficacious for certain older patients with selected acute medical illnesses who require acute hospital-level care.

A B S T R A C T The effects of cholera enterotoxin on intestinal ion transport were examined in vitro. Addition of dialyzed filtrate of Vibrio cholerae (crude toxin) to the luminal side of isolated rabbit ileal mucosa caused a delayed and gradually progressive increase in transmural electric potential difference (PD) and shortcircuit current (SCC). A similar pattern was observed upon addition of a highly purified preparation of cholera toxin, although the changes in PD and SCC were smaller. Na and C1 fluxes across the short-circuited mucosa were determined with radioisotopes 3-4 hr after addition of crude toxin or at a comparable time in control tissues. The toxin caused a net secretory flux of Cl and reduced to zero the net absorptive flux of Na. Similar flux changes were observed when either crude or purified toxin was added in vivo and tissues were mounted in vitro 3-4 hr later. Addition of D-glucose to the

Hospital at Home care was associated with greater satisfaction than acute hospital inpatient care for patients and their family members. These findings support further dissemination of the Hospital at Home care model.

A B S T R A C T A continuous-flow centrifuge was used to infuse sodium salts of oleic, linoleic, lauric, or palmitic acid into the pancreatic artery of anesthetized dogs. In these regional perfusion studies there was no increase in FFA levels in the general circulation. Elevation of pancreatic FFA levels produced an immediate increase in pancreatic venous immunoreactive insulin (IRI). After 10 min of FFA infusion, IRI levels declined somewhat from the initial peak response but soon rose again to high levels which were then sustained until the infusion was terminated. All four long-chain FFA tested produced a similar biphasic IRI response. Clearcut increases in IRI were associated with absolute FFA levels (measured in pancreaticoduodenal venous plasma) as low as 0.6-0.8 Aeq/ml and with increments over basal levels of as little as 0.4-0.5 geq/ml. At higher levels of FFA, absolute IRI levels in the pancreatic venous effluent exceeded 1,000 AU/ml in some experiments and 5-to 10-fold increases over basal values were observed.These studies indicate that long-chain FFA, in physiological concentrations, can markedly stimulate insulin secretion by a direct effect on the pancreas. The results lend support to the concept of insulin as a hormone that is importantly involved in regulating the metabolism of all three principal classes of metabolic substrates and whose release is in turn regulated by all of them. The relative importance and precise nature of its physiologic role in the regulation of lipolysis, lipid deposition, and ketone body formation remains to be established. INTRODUCTIONWe have previously reported that the acute elevation of plasma free fatty acid (FFA) levels by systemic infusion of sodium oleate into conscious dogs was accompanied by a marked increase in immunoreactive insulin (IRI) and a fall in glucose levels in plasma (1). Seyffert and Madison reported similar effects accompanying the elevation of FFA levels produced by infusion of a triglyceride emulsion and injection of heparin into anesthetized dogs with chronic portacaval shunts (2). Sanbar, Evans, Lin, and Hetenyi demonstrated a hypoglycemic effect of octanoate in dogs with increase in plasma insulin levels (3). These studies do not establish whether the elevated FFA levels stimulate insulin release in vivo by a direct effect on the pancreas or whether the effect is indirect (e.g., secondary to metabolic effects in the periphery, effects via other endocrine systems or effects on the nervous system). There is some evidence that FFA may stimulate insulin secretion directly in vitro (4, 5) but other investigators have reported negative results (6, 7). In any case in order to establish physiologic significance it is still necessary to demonstrate effectiveness of FFA in vivo. In the present study, we have examined the nature of the insulin response accompanying infusion of long-chain FFA directly into the pancreatic artery of anesthetized dogs. These infusions raised intrapancreatic FFA levels without significantly increasing plasma FFA concentrati...

A B S T R A C r The acute elevation of plasma free fatty acid (FFA) levels by direct infusion of sodium oleate into the plasma of conscious dogs was accompanied by the rapid onset of a 2-to 12-fold increase in plasma immunoreactive insulin, and, subsequently, a marked fall in plasma glucose, even in dogs receiving intravenous glucose throughout the infusion. The magnitude of both the insulin and glucose responses correlated with the mean FFA level during infusion. A large increase in plasma insulin and fall in glucose also occurred when glycerol was infused with oleate in order to simulate endogenous lipolysis more closely. Insulin levels in pancreaticoduodenal vein blood rose markedly during oleate infusion, while plasma ketone levels rose only slightly.In contrast to the effects of oleate infusion, elevation of plasma FFA to correspondingly high levels by triolein ingestion and intravenous heparin produced only small increases in plasma insulin, which did not correlate well with the FFA level reached, and small increases in plasma glucose.The results indicate that under certain conditions elevated FFA levels may be a potent stimulus of insulin secretion. This response is modified under other conditions such as during chylomicron removal under the influence of heparin. This effect may play a role in the regulation of lipolysis and ketone formation, but determination of the exact mechanism of FFA stimulation of the pancreas and its physiological significance will require further investigation.

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