Pulmonary embolism and malpractice claims

BACKGROUND: Deep venous thrombosis (DVT) with pulmonary embolization (PE) often occurs as an unexpected event with fatal consequences. This provides a setting for malpractice claims. METHODS: We reviewed 160 consecutive malpractice claims submitted by attorneys for medical expert review during the 11-year period ending in 1997. Seven cases involved DVT with PE. RESULTS: Alleged failure to anticipate and reduce the chance of PE was the basis for six of the claims. All six patients were at risk for lower extremity DVT, and one had a history of DVT 6 months earlier. The PE was manifested by sudden death in three cases. The seventh case represented a complication of heparin therapy for PE. CONCLUSIONS: We conclude that risk management for PE should focus primarily on DVT. Physicians should perform and document an examination for DVT whenever there is a history of lower extremity stasis or it is likely to occur. They should also consider documenting a concurring second opinion when making anticoagulant-related decisions.     

Occupational exposure to HIV, hepatitis B, hepatitis C, and tuberculosis

This article reviews risk of occupational exposure to bloodborne pathogens, specifically HIV, hepatitis B, and hepatitis C to healthcare workers. Information regarding assessing the risk of exposure, appropriate actions to take if an exposure occurs, the most recent recommendations for treatment and follow-up postexposure, and prevention strategies for avoiding exposure are presented. Additionally, current recommendations for the prevention of the transmission of tuberculosis in healthcare workers and the regulatory guidelines governing this topic are discussed.     

Essential role of the disulfide-bonded loop of chromogranin B for sorting to secretory granules is revealed by expression of a deletion mutant in the absence of endogenous granin synthesis

Sorting of regulated secretory proteins in the TGN to immature secretory granules (ISG) is thought to involve at least two steps: their selective aggregation and their interaction with membrane components destined to ISG. Here, we have investigated the sorting of chromogranin B (CgB), a member of the granin family present in the secretory granules of many endocrine cells and neurons. Specifically, we have studied the role of a candidate structural motif implicated in the sorting of CgB, the highly conserved NH2-terminal disulfide- bonded loop. Sorting to ISG of full-length human CgB and a deletion mutant of human CgB (Deltacys-hCgB) lacking the 22-amino acid residues comprising the disulfide-bonded loop was compared in the rat neuroendocrine cell line PC12. Upon transfection, i.e., with ongoing synthesis of endogenous granins, the sorting of the deletion mutant was only slightly impaired compared to full-length CgB. To investigate whether this sorting was due to coaggregation of the deletion mutant with endogenous granins, we expressed human CgB using recombinant vaccinia viruses, under conditions in which the synthesis of endogenous granins in the infected PC12 cells was shut off. In these conditions, Deltacys-hCgB, in contrast to full-length hCgB, was no longer sorted to ISG, but exited from the TGN in constitutive secretory vesicles. Coexpression of full-length hCgB together with Deltacys-hCgB by double infection, using the respective recombinant vaccinia viruses, rescued the sorting of the deletion mutant to ISG. In conclusion, our data show that (a) the disulfide-bonded loop is essential for sorting of CgB to ISG and (b) the lack of this structural motif can be compensated by coexpression of loop-bearing CgB. Furthermore, comparison of the two expression systems, transfection and vaccinia virus-mediated expression, reveals that analyses under conditions in which host cell secretory protein synthesis is blocked greatly facilitate the identification of sequence motifs required for sorting of regulated secretory proteins to secretory granules.     

TNF-alpha released by comigrating monocytes promotes transendothelial migration of activated lymphocytes

We investigated mechanisms that increase motility and transendothelial trafficking of activated lymphocytes. Freshly isolated lymphocytes stimulated with immobilized anti-CD3 for 2 h migrate into polymerized collagen in 1.99+/-0.25-fold greater numbers and across confluent endothelial monolayers in 4.8+/-0.5-fold greater numbers compared with leukocytes incubated with non-specific IgG. Activated lymphocytes form clusters with monocytes, and their increased motility was dependent on the presence of comigrating monocytes. Five lines of evidence support the idea that monocytes modulate lymphocyte motility through the release of TNF-alpha: 1) flow-cytometric analyses, using highly specific and avid mAbs to probe permeabilized whole blood leukocytes, showed that >80% of circulating monocytes contain intracellular TNF-alpha, whereas <5% contain IL-1 and none contain IL-6; 2) stimulation with immobilized anti-CD3 that was intended to activate lymphocytes also induced monocytes to release increased quantities of TNF-alpha; 3) rTNF-alpha, added in doses of 1 to 20 pg/ml to purified anti-CD3-stimulated lymphocytes, reproduced, in a dose-dependent manner, the motility-enhancing effect of adding monocytes; 4) the transient increase in the expression of TNF R-I on CD3-activated T lymphocytes parallels their transiently increased motility; and 5) addition of anti-TNF-alpha, anti-TNF R-I, anti-TNF R-II, or soluble TNF R-I decreased the motility of stimulated lymphocytes. These results suggest that T lymphocyte stimulation via the CD3-TCR complex signals nearby monocytes to release TNF-alpha, which feeds back on the lymphocytes to increase their locomotor activity.     

Effects of nicotine and mecamylamine microinjections into the nucleus accumbens on ethanol and sucrose self-administration

Nicotine (NIC) and ethanol (ETOH) are both drugs of abuse that can affect similar pathways in the central nervous system. However, the role of nicotinic processes in ETOH's reinforcing actions is unclear. Although the mesolimbic dopamine systems are known to be involved in the reinforcing effects of ETOH, the role of nicotinic receptors within the nucleus accumbens (NAc) in ETOH reinforcement has not been studied. To address this issue, adult male Long-Evans rats were initiated to self-administer ETOH (10% v/v, n = 14) using the sucrose-substitution procedure or sucrose (5% w/v, n = 8) in a 30-min operant session. They were then surgically implanted with bilateral stainless-steel guide cannulae to allow for microinjection into the core of the NAc. After recovery from surgery, presession microinjections of NIC (0.3, 3.3, 10, 30, and 60 microg/1 microl/brain) or the antagonist mecamylamine (MEC) (1, 3, 10, 30, and 60 microg/1 microl/brain) were performed prior to an ETOH or sucrose self-administration session. NIC (3.3 and 60 microg/microl) and MEC (30 microg/microl) both reduced ETOH self-administration behavior, without affecting sucrose-reinforced behavior. A reduction in the total duration of ETOH responding (termination) was also observed after either 60 microg/microl of NIC and 30 microg/microl of MEC. The lack of a clear dose-response relationship for the agonist and the antagonist indicates that the interaction between the NAc nicotinic system and ETOH self-administration is complex.     

Environmental and genetic variance in children's observed and reported maladaptive behavior

The genetic and environmental contributions to children's maladaptive behavior are assessed in a sample of 154 twin pairs (77 MZ twin pairs and 77 DZ twin pairs), who range in age from 6 to 11 years. To bridge the strengths of behavioral genetic methods and environmental assessment techniques, we use a multimethod, multimeasure approach to data collection, and analyze the data using behavioral genetic modeling techniques. Results indicate that genetic variation accounts for a majority of the variance in parent-reported child maladaptive behavior (average = 62%). One parent-report measure also suggests a smaller, significant contribution of shared environmental variance. In contrast to the parental ratings, the observational coding and global impressions of parent-twin interactive behavior suggest that shared environment is the primary source of variance accounting for parent and child maladaptive behavior. This is due, in part, to the direct influence one's interactive partner has on the expression of maladaptive behavior in an interactive setting. When controlling for the co-participant's behavior, genetic variation increases and shared environmental variation decreases.     

OA1 mutations and deletions in X-linked ocular albinism

X-linked ocular albinism (OA1), Nettleship-Falls type, is characterized by decreased ocular pigmentation, foveal hypoplasia, nystagmus, photodysphoria, and reduced visual acuity. Affected males usually demonstrate melanin macroglobules on skin biopsy. We now report results of deletion and mutation screening of the full-length OA1 gene in 29 unrelated North American and Australian X-linked ocular albinism (OA) probands, including five with additional, nonocular phenotypic abnormalities (Schnur et al. 1994). We detected 13 intragenic gene deletions, including 3 of exon 1, 2 of exon 2, 2 of exon 4, and 6 others, which span exons 2-8. Eight new missense mutations were identified, which cluster within exons 1, 2, 3, and 6 in conserved and/or putative transmembrane domains of the protein. There was also a splice acceptor-site mutation, a nonsense mutation, a single base deletion, and a previously reported 17-bp exon 1 deletion. All patients with nonocular phenotypic abnormalities had detectable mutations. In summary, 26 (approximately 90%) of 29 probands had detectable alterations of OA1, thus confirming that OA1 is the major locus for X-linked OA.