Trauma malpractice claims related to trauma level designation

The purpose of the present study was to review a one-state experience (Arizona) with trauma malpractice claims as a function of hospital trauma level designation. A total of 191 cases covering 7 years was reviewed and analyzed. Three categories of treatment facilities were compared: American College of Surgeons-categorized Level I hospitals, all other hospitals, and outpatient treatment facilities. Only 22 percent of the malpractice claims were found in Level I facilities, whereas 58 percent were found in other hospitals and 20 percent came from outpatient facilities. Not surprisingly, the indemnity awards were more than two times higher in other hospitals than in Level I hospitals. However, the legal dollars spent in defense per claim were two times higher in Level I than either outpatient hospitals or outpatient treatment facilities, suggesting that Level I malpractice claims are more defensible. We have identified six areas of high potential liability and have made some suggestions for the reduction of risk management in those areas.

Cat eye syndrome associated with aganglionosis of the small and large intestine

A newborn male infant is presented with the characteristic phenotype of the cat eye syndrome and a small supernumerary chromosome shorter than a 22. He also had complete absence of parasympathetic ganglion cells throughout the small and large intestine.

Novel human MHC class I genes are expressed by tumour cell lines representing embryonic and extraembryonic tissues

The expression of HLA class I(-like) genes was studied in two human developmental tumour cell lines representing embryonic (Tera-2) and extraembryonic (Jeg-3) origins. Neither cell line expresses polymorphic HLA-A, -B, -C antigens as determined by standard serological typing. Tera-2 cells express the HLA class I-like T cell system A (TCA) determinants; Jeg-3 cells are TCA negative. Northern blot analysis using an HLA class I alpha 3 domain specific probe revealed markedly reduced levels of HLA class I(-like) transcripts in both cell lines, which can be upregulated in Tera-2 cells by incubation with gamma interferon (gamma IFN). Immunoprecipitation studies with a large panel of HLA class I/beta-2 microglobulin (beta 2m) monoclonal antibodies (mAbs), detect low quantities of regular HLA class I heavy chains that are not associated with beta 2m on the surface of Tera-2 cells. In contrast, Jeg-3 cells express significant amounts of cell membrane beta 2m associated molecules of 41 and 45 kilodalton (kD). Screening of a Tera-2 cDNA library, yielded 30 clones that hybridize to a full length HLA class I cDNA probe. Sixteen have been characterized and represent HLA class I sequences, consistent with the haplotype of Tera-2. A similar screening of a Jeg-3 cDNA library isolated clones representing a single novel HLA-C-like sequence; this probably codes for the 45 kD cell surface molecules of Jeg-3. The 41 kD molecule may be encoded by the HLA-6.0 gene since this is constitutively expressed in Jeg-3 cells.

Self perceived standards of care in women's health. An illustrative case

This article compares the reality of cervical cancer screening rates in general practice with doctors' self perceived standards of care. It also examines other aspects of women's health care as revealed in a random sample of New South Wales general practitioners. The implications for continuing medical education and quality assurance are discussed.

Fusimotor mechanisms determining the afferent output of muscle spindles

There is both direct and indirect evidence that stretch activation occurs in the dynamic bag1 fibres of the mammalian muscle spindle and that it is responsible for maintaining the high sensitivity of primary sensory endings in stretches great enough to break the resting actomyosin bonds responsible for the short-range stiffness of muscle fibres. However the direct observations of dynamic bag1 fibre behaviour during stretching were made on damaged fibres and during very slow stretches. Preliminary results of experiments employing faster stretches of intact muscle spindles are reported here. An image processing system is being developed to automate and facilitate analysis of sarcomere movements during stretch, release and activation of intrafusal fibres. Unequivocal evidence confirming the development of stretch activation has not yet been found. Boyd (1986a) believed that static bag2 and chain fibres are controlled by separate populations of static gamma motoneurones, while accepting that there is some degree of common innervation. His evidence and the functional implications are discussed.

Functional activities of human antibody induced by the capsular polysaccharide or polysaccharide-conjugate vaccines against Haemophilus influenzae type b

To determine the in vitro and in vivo activity of human antibody induced by different Haemophilus influenzae type b (Hib) vaccines, pooled human antisera obtained from adults immunized with either polyribosyl ribitol phosphate (PRP) or PRP-conjugated with diphtheria toxoid (PRP-D) vaccines were evaluated for opsonic and protective activity against Hib. In vitro, opsonophagocytic studies revealed that PRP-D induced antisera were approximately 2.5-fold more effective than PRP-induced antisera in supporting neutrophil-mediated killing of an Hib strain. In vivo studies using the infant rat model or Hib disease revealed that the decay of PRP antibody was similar with PRP or PRP-D induced antisera in unchallenged rats. However, in infant rats challenged with Hib, the PRP induced antibody decayed more rapidly than the PRP-D induced antibody as shown by significantly shorter half-life of the former. The protective efficacy was significantly greater with the PRP-D induced antisera than with the PRP induced antisera. This finding was shown by the significantly lower incidence of bacteraemia and the 5-fold lower dose of antibody required for 50% protection against bacteraemia in rats receiving the PRP-D induced antisera. The findings suggest that antibody to PRP induced by PRP-D vaccine is more opsonic and protective against Hib, and also decays more slowly in infant rats challenged with Hib than does antibody induced by PRP vaccine. Further studies are needed to elucidate the reason(s) for this difference in functional activity and in half-life of PRP antibody induced by PRP or by PRP-D vaccines.

Multi-centre general practitioner comparative study of controlled-release ('Valrelease') and conventional ('Valium') forms of diazepam in patients suffering from anxiety

A multi-centre, double-blind, parallel group study was carried out in 114 patients with an anxiety disorder to compare the effectiveness of diazepam given as 5 mg 3-times daily or as a once-daily 10 mg dose of a controlled-release formulation designed to provide smooth drug concentrations over about 24 hours, without the heavy sedation caused by a high initial peak. Patients were allocated at random to receive one or other dosage regimen for 1 week and treatment could be continued for a further week if necessary. Clinical assessments of response to treatment showed that whilst both formulations were equally effective in providing symptomatic improvement, a much higher proportion of patients on controlled-release diazepam were ready to terminate treatment after 1 week, having attained the desired relief of symptoms. Moreover, as indicated by patient diary records, significantly fewer patients on the controlled-release formulation complained of drowsiness in the morning and evening.

Safety and immunogenicity of Haemophilus influenzae type b polysaccharide-diphtheria toxoid conjugate vaccine (PRP-D) in infants

Safety and immunogenicity of a Haemophilus influenzae type b polysaccharide-diphtheria toxoid conjugate vaccine (PRP-D) was evaluated in infants seven to 14 months of age. PRP-D (80% of subjects) or saline placebo (20%) was randomly and blindly administered (two doses separated by two months). Incidence of mild reactions lasting less than 48 hr did not differ significantly between the placebo and vaccine recipients. Preimmunization levels of antibody to PRP were less than or equal to 0.15 micrograms/ml in 97% of subjects. A twofold increase in antibody concentration occurred in 88% of subjects following the first dose and in 99% following the second dose of vaccine. No change occurred in placebo recipients. Mean level of antibody and percentage of subjects with levels of antibody greater than or equal to 1 microgram/ml after vaccination increased with increasing age. Responses were related to vaccine lot but not to sex, race, or geographic location. Two doses of PRP-D in infants seven months of age and older induced antibody levels equal to or greater than levels in infants 24 months of age given the polysaccharide alone.

Immediate breast reconstruction with tissue expansion

Between October of 1983 and June of 1985, 31 patients underwent primary breast reconstruction with tissue expansion. Tissue expansion was utilized for breast reconstruction when the remaining muscle and skin following modified radical mastectomy was insufficient to accommodate a prosthesis that matched in size and shape the opposite breast. All expanders were placed beneath an investing muscular pocket created by elevating the pectoralis major and serratus anterior. Postoperative expansion began within 1 week, and the breast was expanded to double the volume of the opposite breast. Twenty-two patients have completed their reconstruction with a mean follow-up in 7 months. There were nine complications, including five deflations and four infections. All patients have remained Baker I or Baker II. Creating ptosis to match the breast was accomplished by placing the expander below the rectus fascia and superiorly advancing this expanded tissue at the time of prosthesis placement. Primary breast reconstruction with tissue expansion following modified radical mastectomy is safe, simple, and produces a breast with excellent shape, size, texture, and patient satisfaction.

Ampicillin-chloramphenicol-resistant Haemophilus influenzae: plasmid-mediated resistance in bacterial meningitis

A 4-month-old infant with congenital heart disease and sepsis and arthritis, and subsequently meningitis, caused by an antibiotic-resistant strain of Haemophilus influenzae type b, failed to respond to sequential therapy with ampicillin and trimethoprim/sulfamethoxazole. Following treatment with ceftizoxime, the infant was well for 42 days, until he returned to the hospital and died. A total of 10 Haemophilus influenzae type b isolates, all outer membrane protein subtype 51, was isolated from the pretreatment blood and synovium, cerebrospinal fluid and subdural fluids, and the petrous pyramids at autopsy. Pretreatment isolates had no detectable plasmid DNA, chloramphenicol acetyltransferase or beta-lactamase; the minimal inhibitory concentration for ampicillin (AM) and chloramphenicol (CM) was 0.2 and 0.8 microgram/ml, respectively. However, all cerebrospinal fluid isolates had a 42-44 mD plasmid and produced chloramphenicol acetyltransferase and beta-lactamase; the minimal inhibitory concentration of these isolates to AM and CM were 12.5 and 25 micrograms/ml, respectively, and were also resistant to tetracycline and sulfonamide. Resistance to AM and CM was cotransferred by filter-mating conjugation at a frequency of one to two transconjugants per 10(5) to an Rd haemophilus recipient. Posttreatment isolates from the petrous pyramids also were resistant to AM and CM and produced chloramphenicol acetyltransferase and beta-lactamase activity, but had no plasmid DNA. These findings and data from genetic studies suggested that plasmid-bearing antibiotic-resistant Haemophilus influenzae type b was selected from a heterogenous population, and that the AM/CM resistance transposons were incorporated into the bacterial chromosome.

Newer Haemophilus influenzae type b vaccines and passive prophylaxis

PRP-protein conjugate vaccines may prove to be a prototype of a new generation of bacterial vaccines for the prevention of diseases caused by encapsulated bacteria, such as pneumococci, meningococci and Group B streptococci, as well as Hib. These diseases often strike the very young, the very old and individuals with compromised immunity. These vaccines have been "engineered" to maximize immune recognition and response. It is hoped that these vaccines will be adequate to control or possibly eradicate Hib and other invasive bacterial diseases. For high risk populations unable to respond to the vaccines, passive prophylaxis may have a role.

Sensory perception threshold measurement: an evaluation of semiobjective testing devices

Five semiobjective devices for testing sensory perception thresholds were concomitantly used on 36 normal subjects to determine normal threshold values, intersubject variability, and their correlation with age. The five devices include the Semmes-Weinstein monofilament (touch); three-point esthesiometer (two-point discrimination); Pfizer thermal tester (temperature); biothesiometer (vibration); and Optacon tactile tester (vibration). Each subject was tested at 12 upper extremity (UE) and ten lower extremity (LE) sites. The threshold was determined by the two-alternative forced choice method. Results showed that the mean threshold for each sensory perception modality in the UE sites was significantly lower than in the LE sites. The means of distally located sites for two-point discrimination and vibration thresholds were significantly lower than the means of the proximal sites in the UE. In the LE, touch perception threshold was significantly higher distally than proximally. Distally located nerves (median and ulnar) showed lower mean threshold values than proximally located nerves for two-point discrimination. There were also similar findings for the other sensory modalities in the UE and LE. The mean threshold of dermatomes showed significant variation across the trials for two-point discrimination and vibration sensation. Distally located dermatomes showed lower threshold values than those located proximally. The means of most sites tested for each sensory modality (except vibration tested by the Optacon) showed correlation with age. There was no difference in threshold values between men and women for any sensory modality. The mean values of standard deviation were provided for each peripheral sensory nerve and dermatome.(ABSTRACT TRUNCATED AT 250 WORDS)

Candida parapsilosis fungemia associated with parenteral nutrition and contaminated blood pressure transducers

During the period September 1983 through May 1985, Candida parapsilosis was isolated from intravascular sites (blood or vascular catheter tips) in 12 patients at a pediatric hospital. Of 205 patients with cultures of any site positive for Candida species, 32 (16%) had cultures positive for C. parapsilosis. In contrast, of 23 patients with intravascular cultures positive for Candida species, 12 (51%) had cultures positive for C. parapsilosis (P less than 0.001, Fisher's exact test). The 12 patients with intravascular cultures positive for C. parapsilosis were more likely to have received central venous nutrition therapy (10 of 12 versus 7 of 23; P less than 0.01, Mantel-Haenzel chi-square test) and had a longer duration of exposure to blood pressure transducers (P less than 0.08, paired t test) than the 23 ward- and age-matched controls. C. parapsilosis was isolated from 11 (32%) of 34 in-use and stored blood pressure transducers. After ethylene oxide sterilization of blood pressure transducers was begun, in-use pressure transducers showed no growth of C. parapsilosis. This study emphasizes the role of C. parapsilosis as a nosocomial pathogen associated with invasive devices and parenteral nutrition; it also emphasizes the importance of adhering to recommended procedures for sterilizing blood pressure transducers.