Protein-only nanocapsules induce cross-presentation in dendritic cells, demonstrating potential as an antigen delivery system.

Templating has been demonstrated to be an efficient method of nanocapsule preparation. However, there have been no reports of using protein-only nanocapsules as an antigen delivery system. Such a system would enable the delivery of antigen without additional polymers. This study focused on defining the structural and cellular characteristics of nanocapsules consisting of antigen (ovalbumin) alone, synthesized by the templating method using highly monodispersed solid core mesoporous shell (SC/MS) and mesoporous (MS) silica nanoparticles of 410 nm and 41 nm in diameter, respectively. The synthesized ovalbumin nanocapsules were homogeneous in structure, and cellular uptake was observed in DC2.4 murine immature dendritic cells with minimal cytotoxicity. The nanocapsules were localized intracellularly and induced antigen presentation by the cross-presentation pathway. The templating system, using SC/MS and MS silica nanoparticles, was demonstrated to be an effective nanocapsule synthesis method for a new antigen delivery system.

Seafood allergy: A comprehensive review of fish and shellfish allergens.

Seafood refers to several distinct groups of edible aquatic animals including fish, crustacean, and mollusc. The two invertebrate groups of crustacean and mollusc are, for culinary reasons, often combined as shellfish but belong to two very different phyla. The evolutionary and taxonomic diversity of the various consumed seafood species poses a challenge in the identification and characterisation of the major and minor allergens critical for reliable diagnostics and therapeutic treatments. Many allergenic proteins are very different between these groups; however, some pan-allergens, including parvalbumin, tropomyosin and arginine kinase, seem to induce immunological and clinical cross-reactivity. This extensive review details the advances in the bio-molecular characterisation of 20 allergenic proteins within the three distinct seafood groups; fish, crustacean and molluscs. Furthermore, the structural and biochemical properties of the major allergens are described to highlight the immunological and subsequent clinical cross-reactivities. A comprehensive list of purified and recombinant allergens is provided, and the applications of component-resolved diagnostics and current therapeutic developments are discussed.

Evolution of thyroid hormone distributor proteins.

Thyroid hormones (THs) are evolutionarily old hormones, having effects on metabolism in bacteria, invertebrates and vertebrates. THs bind specific distributor proteins (THDPs) to ensure their efficient distribution through the blood and cerebrospinal fluid in vertebrates. Albumin is a THDP in the blood of all studied species of vertebrates, so may be the original vertebrate THDP. However, albumin has weak affinity for THs. Transthyretin (TTR) has been identified in the blood across different lineages in adults vs juveniles. TTR has intermediate affinity for THs. Thyroxine-binding globulin has only been identified in mammals and has high affinity for THs. Of these THDPs, TTR is the only one known to be synthesised in the brain and is involved in moving THs from the blood into the cerebrospinal fluid. We analysed the rates of evolution of these three THDPs: TTR has been most highly conserved and albumin has had the highest rate of divergence.

Risk management observations from litigation involving laparoscopic cholecystectomy.

HYPOTHESIS: Limited information exists on the outcome of laparoscopic cholecystectomy (LC) litigation. DESIGN: A retrospective review of a public malpractice database was compared with previously published reviews of LC litigation by K. A. Kern, MD, and the Physician Insurers Association of America. SETTING: Private surgery practice. Selection The database was searched for cases containing the terms laparoscopy, bile, or gall between August 1, 1999, and August 31, 2004. Identified cases were further reviewed to select only the unique cases that concerned elective biliary surgery. MAIN OUTCOME MEASURES: Surgical technique, injuries, and incidence of conversion to open procedures. RESULTS: In Kern's study, injuries triggering litigation involved the bile duct in 61%, bowel in 16%, vascular system in 9%, and miscellaneous events in 14%; in the present study, injuries involved the bile duct in 78%, bowel in 2%, vascular injury in 7%, and miscellaneous injuries in 13%. Missed injuries occurred in 86% in the present study and 83% of the Physician Insurers Association of America cases. Although 15% of cases in the present study were converted to open procedures, in 53% of these cases conversion was performed to repair an injury. CONCLUSIONS: Despite residency training, injuries triggering litigation after LC remain largely unchanged. The nature of the bile duct injuries suggests that routine intraoperative cholangiography is unlikely to make LC safer. To minimize the risk of litigation after LC, it is recommended that the threshold for conversion to open procedures be lowered.

Monetary lessons from litigation involving laparoscopic cholecystectomy.

Limited information exists on the relationship between adverse events associated with laparoscopic cholecystectomy (LC) and subsequent litigation. Out of 104 suits concerning LC, 18 cases were settled for 628,138 dollars; 48 cases resulted in a plaintiff's verdict with the plaintiff receiving 2,891,421 dollars; and 18 cases resulted in a surgeon's verdict. However, when multiple defendant cases were excluded, there was <20,000 dollars difference between a negotiated settlement and plaintiff's verdict. Given the minimal monetary differences between a settlement and a plaintiff's verdict, when a surgeon is the sole defendant in a malpractice case concerning LC, the surgeon should encourage their carriers not to settle before trial; as only a trial will exonerate the surgeon. However, this encouragement should be tempered when there are "red flags" that favor the plaintiff, including multiple defendants (especially a hospital), male plaintiffs, bile duct injuries, knowledgeable and well-financed plaintiff's attorneys, and certain plaintiff's venues.

Why the distribution of medical errors matters.

During the last decade, interventions to reduce the number of medical errors have been largely ineffective. Although it is widely assumed that medical errors follow a Gaussian distribution, they may actually follow a Power Rule distribution. This article presents the evidence in favor of a Power Rule distribution for medical errors and then examines the consequences of such a distribution for medical errors. As the distribution of medical errors has real-world implications, further research is needed to determine whether medical errors follow a Gaussian or Power Rule distribution.

Why do physicians who treat lung cancer get sued?

BACKGROUND: Minimal information exists on why malpractice actions are filed against physicians who treat lung cancer. OBJECTIVE: To review currently available data on lung cancer malpractice litigation to develop litigation-avoidance strategies. DESIGN: A retrospective review of a publicly available database containing verdicts and settlements of malpractice cases. Data were then compared to the Physician Insurers Association of America (PIAA) Lung Cancer Study, which was published in 1992. The PIAA report is considered the best available data on malpractice and lung cancer. RESULTS: There were 89 patients in the current study and 213 patients in the PIAA study. Physicians are most often sued by patients in their 50s (mean age, 58.9 years; range, 34 to 80 years [current study]; vs 55 years; range, 17 to 75 years [PIAA study]). Primary care physicians (60% cases in the current study vs 33% cases in the PIAA study) and radiologists (20% cases in the current study vs 55% cases in the PIAA study) were named as defendants in > 75% of suits. Failure to diagnosis lung cancer was the most common reason physicians were sued (80% case in the current study vs 23.3% cases in the PIAA series). Despite the similarity in litigation profiles, the mean award to plaintiffs, in constant dollars, increased from $172,271 in the PIAA study to $632,261 in the current study. CONCLUSIONS: (1) Recommended strategies to avoid litigation depend on physician subspecialties. While primary care physicians would benefit most from setting up a chest radiograph tracking system, radiologists would benefit most from initiating a continuous quality improvement system to substantially decrease the misinterpretation rate of chest radiographs. (2) Over the past 12 years, there appears to have been a substantial increase in awards to patients with lung cancer who sue their physicians. However, this finding may be artificial because of differing study design. Further investigation on this subject is recommended.

Medical rationing: the implicit result of Leadership by Example.

The Institute of Medicine (IOM) has released the latest publication in its campaign to curtail medical error: Leadership by Example: Coordinating Government Roles in Improving Health Care Quality. In this publication, the IOM recommends that the government utilize its position as the country's largest purchaser of healthcare to institute unified performance standards, create appropriate incentives to improve quality of care, and develop a system to disseminate provider-specific quality information to the public. The author examines these recommendations and the contents of IOM's prior publications and concludes that necessary predicates of IOM's vision are rationing of care and a two-tiered system of healthcare. Thus, if the IOM's recommendations are carried out, the author envisions a healthcare system in which truly state-of-the-art care can only be purchased out of pocket. He concludes that, although Leadership by Example is a rational plan to address escalating healthcare costs, it is unclear both whether the American public would support it if the IOM were explicit about its ultimate impact, and whether the recommendations, in the long run, will prove to be a good thing.

The schizophrenia of physician extender utilization.

The Patient Protection and Affordable Care Act of 2010 provides incentives for healthcare to be delivered by Affordable Care Organizations (ACOs). The public face of many, if not most, ACOs is likely to be the Patient Centered Medical Home (PCMHs), a business structure that evolved from Retail Medical Clinics, which made greater use of physician extenders (PAs). Accordingly, this paper examines the evolution and structure of PCMHs as well as how the PCMH is regulated. As neither legal or market regulatory mechanisms are ideal for policing business structures that employ PAs, this paper concludes that the tort reform most appropriate for PCMHs is the introduction of either no-fault or enterprise liability coverage.

Investing in medical students: which ones are worth a surgeon's time?

BACKGROUND: Little information exists on which third-year medical students will become worthy protégés. METHODS: Performance and encounter metrics for 4 classes of medical students were correlated with the students who matched into a surgery residency. RESULTS: Overall, 68 of 422 (16%) graduating seniors matched into a surgery residency. Male students were twice as likely as female students to match in surgery were, and most (81%) matching students took their general surgery rotation at the university hospital. Students who took certain elective rotations (eg, urology and orthopedics) tended to enter those surgical professions. Grades, test scores, clinical performance, oral presentation skills, and encounter data were not predictive of which students would enter the surgical profession. CONCLUSION: For surgeons who are willing to mentor medical students, our data suggest that currently, the selection of medical students worthy of surgeon-mentor's time will remain an art.

The impact of provider-specific report cards on coronary artery bypass graft volume.

PURPOSE: Reporting states (RS) publish hospital-specific report cards for coronary artery bypass graft (CABG) (MS-DRG 235 and 236) surgery. When RS are compared with non-reporting states (NRS), do report cards influence the volume of CABG surgery performed? METHODS: Using publicly available Medicare data (hospitalcompare.hhs.gov) for CABG-only procedures, the volume of CABG procedures performed in RS (CA, MA, NJ, NYS, and PA) was compared with the volume of these procedures performed in NRS. RESULTS: In the continental US during the financial year 2008 a total of 41,589 Medicare patients underwent a CABG (33,318 CABGs in NRS versus 8,272 CABGs in RS). A similar percentage of states in each group regulated their markets with certificate-of need statutes (30% NRS versus 40% RS). Per million capita (pmc), the number of CABG providers in the two groups was similar with respect to hospitals (4.1±1.6 hospitals pmc in NRS versus 2.9±1.2 hospitals pmc in RS); cardiac surgeons (2.4±1.5 surgeons pmc in NRS versus 5.1±2.9 surgeons pmc in RS); and interventional cardiologists (ICs) (18.3±5.5 ICs pmc in NRS versus 21.2±5.0 ICs pmc in RS). However, pmc, NRS performed significantly more CABG procedures (152.0±62.6 CABGs pmc in NRS versus 113.8±31.6 CABG pmc in RS; p=0.05). CONCLUSIONS: States that publish hospital-specific report cards perform significantly fewer CABGs per capita than states without report cards. As the government's national hospital-specific report card becomes more popular, the per capita performance of CABGs in NRS could fall to the level found in RS due to the reputational incentives created by the use of hospital-specific report cards.