Standardized total knee arthroplasty pathway improves outcomes in minority patients.

OBJECTIVES: Inferior total knee arthroplasty (TKA) outcomes are reported in minority populations. Standardized TKA pathways improve outcomes but have not been studied extensively in minority populations. This study evaluated the impact of TKA pathway standardization at an urban teaching hospital that predominantly treats minority patients. STUDY DESIGN: Retrospective cohort study. METHODS: This study compared primary TKA outcomes before and after implementation of a standardized multidisciplinary pathway that emphasized preoperative education and discharge planning, preemptive multimodal pain control, and early rehabilitation. Patients were grouped as "nonpathway" (n = 144) or "pathway" (n = 182) based on whether they underwent TKA before or after pathway implementation. Outcomes included length of stay (LOS), patient-controlled analgesia (PCA) use, blood transfusion, postoperative hemoglobin, complications, and discharge disposition. Analysis involved negative binomial and multiple logistic regression models, t tests, and Fisher's exact tests. RESULTS: Mean (SD) age was 61.6 (8.7) years, and 36.5% were men. Ethnicity of the patients included Hispanic (44.5%), African American (27.9%), Asian (14.1%), and White (12.9%). Pathway and nonpathway patients were similar demographically and racially. Pathway patients had shorter LOS (P = .04), less PCA use (P < .001), more frequent discharge home (P = .03), fewer transfusions (P = .002), and higher postoperative hemoglobin (P < .001). Overall incidence of complications was similar (P = .61). Nonpathway patients developed more cardiopulmonary complications (P = .02), whereas pathway patients had more wound dehiscence (P = .01). CONCLUSIONS: Compared with nonpathway patients, standardized TKA pathway patients had shorter LOS, decreased PCA use, increased discharge to home, fewer blood transfusions, and higher postoperative hemoglobin, with no difference in total incidence of complication.

Mapping of angiogenic markers for targeting of vectors to tumor vascular endothelial cells.

The vasculature of mouse breast tumor spheroids grown on mammary fat pad tissue in an intravital microscopy (IVM) viewing chamber was shown to derive from infiltrating angiogenic mammary vessels. The receptors tissue factor (TF), alpha V beta 3 integrin and Tie-2 were expressed on the vascular endothelium in the periphery but not in the center of the tumor spheroids nor in the mammary tissue nor in smooth muscle tissue, whereas Tie-1 and PCAM-1 were expressed extensively in the entire tumor and in the vascular endothelium of the entire tumor nodule and in normal mammary tissue. TF is a specific target for adenoviral vector-mediated cancer immunotherapy. Subcutaneous injection of the AdfVII/IgG(1)Fc vector leads to the release into the system circulation of a fVII/IgG(1)Fc immunoconjugate molecule that binds specifically and tightly to TF on vascular endothelial cells and tumor cells, activating a cytolytic immune response against the targeted cells. We show that a single administration of the AdfVII/IgG(1)Fc vector destroys the peripheral but not the central vasculature of a tumor spheroid, causing partial tumor regression; additional administrations prevent regeneration of the peripheral vasculature and regrowth of the tumor. These findings indicate that a critical parameter for optimizing tumor damage is the schedule for successive administrations of the AdfVII/IgG(1)Fc, which should coincide with the regeneration of the peripheral vasculature and continue until the tumor is destroyed.

Molecular organization and expression of the genetic locus glued in Drosophila melanogaster.

The Glued locus of Drosophila melanogaster is genetically defined as the functional unit which is affected by the dominant Glued mutation Gl. Genomic DNA was cloned from the region of the Glued locus, at 70C2 on chromosome 3, by using a P element insertion in the region as a molecular marker. Three genes encoding polyadenylated transcripts were detected within a 30-kilobase span of the cloned DNA. The gene nearest the P element insertion site was identified as a Glued gene on the basis of alterations in its DNA and encoded transcript associated with the Gl mutation and with reversions of Gl which eliminate the dominant effect by inactivation of the mutant allele. Expression of the wild-type Gl+ gene is temporally regulated during development; the amount of the encoded transcript is highest in the embryonic stage, decreasing in the first and second larval instars, and then increasing in the third instar and pupal stages. There is a maternal contribution of the Gl+ transcript to the embryo, which probably accounts for the maternal lethal effect of Glued mutations on early development. In situ hybridizations of Gl+ DNA to RNA in tissue sections showed that the Gl+ transcript is present in virtually all tissues of the embryo, late larva, and pupa. The general distribution of this transcript is consistent with genetic evidence indicating that the Glued locus controls a generally essential cell function (P. J. Harte and D. R. Kankel, Genetics 101:477-501, 1982). Different Glued mutations produce distinct phenotypic effects, including adults with severe visual defects, larvae lacking imaginal discs, and early lethality. These diverse mutant phenotypes are discussed in terms of quantitative changes in the Glued function. Closely adjacent to Gl+ is another gene which is transcribed in a divergent direction and expressed coordinately with Gl+ throughout Drosophila development. It remains to be determined whether this gene is also involved with the Glued function.

Prevalence of Central Nervous System Polypharmacy and Associations with Overdose and Suicide-Related Behaviors in Iraq and Afghanistan War Veterans in VA Care 2010-2011.

BACKGROUND: The increase in the quantities of central nervous system (CNS)-acting medications prescribed has coincided with increases in overdose mortality, suicide-related behaviors, and unintentional deaths in military personnel deployed in support of the wars in Iraq and Afghanistan. Data on the extent and impact of prescribing multiple CNS drugs among Iraq and Afghanistan Veterans (IAVs) are sparse. OBJECTIVES: We sought to identify the characteristics of IAVs with CNS polypharmacy and examine the association of CNS polypharmacy with drug overdose and suicide-related behaviors controlling for known risk factors. METHODS: This cross-sectional cohort study examined national data of Iraq and Afghanistan Veterans (N = 311,400) who used the Veterans Health Administration (VHA) during the fiscal year 2011. CNS polypharmacy was defined as five or more CNS-acting medications; drug/alcohol overdose and suicide-related behaviors were identified using ICD-9-CM codes. Demographic and clinical characteristics associated with CNS polypharmacy were identified using a multivariable logistic regression model. RESULTS: We found that 25,546 (8.4 %) of Iraq and Afghanistan Veterans had CNS polypharmacy. Those with only post-traumatic stress disorder (PTSD) (adjusted odds ratio (AOR) 6.50, 99 % confidence interval (CI) 5.96-7.10), only depression (AOR 6.42, 99 % CI 5.86-7.04), co-morbid PTSD and depression (AOR 12.98, 99 % CI 11.97-14.07), and co-morbid traumatic brain injury (TBI), PTSD, and depression (AOR 15.30, 99 % CI 14.00-16.73) had the highest odds of CNS polypharmacy. After controlling for these co-morbid conditions, CNS polypharmacy was significantly associated with drug/alcohol overdose and suicide-related behavior. CONCLUSION: CNS polypharmacy was most strongly associated with PTSD, depression, and TBI, and independently associated with overdose and suicide-related behavior after controlling for known risk factors. These findings suggest that CNS polypharmacy may be used as an indicator of risk for adverse outcomes. Further research should evaluate whether CNS polypharmacy may be used as a trigger for evaluation of the current care provided to these individuals.

Mutations affecting functions of the Drosophila gene glued.

Glued mutations in Drosophila comprise an essential complementation group with complex developmental effects. The original Glued mutation (Gl) has dominant nonlethal effects in heterozygous flies, principally on the morphogenesis of the visual system. Gl also has a recessive lethal effect early in development. Mutations that reverse the dominant visual effects of Gl (GlR mutations) were induced by gamma-radiation or by insertions of the transposable P element. The GlR(G) mutations induced by gamma-radiation do not reverse the lethal effect of Gl; these appear to be null mutations, some of which (and possibly all) delete segments of the Glued region. The GlR(P) mutations induced by insertion of the P element also reverse concomitantly a recessive lethal effect of Gl, suggesting that both the recessive and dominant effects are controlled by the same gene. The reversal of a lethal effect of Gl by the P element is remarkable, since it indicates that an essential gene function can be restored by insertion of unrelated DNA. Another class of lethal Glued mutations was induced in the normal Gl+ strain by ethyl methanesulfonate (EMS). The EMS mutations belong to the same essential complementation group as Gl, but do not have the strong dominant effects of Gl on the visual system. The GlR(P) mutations provide a molecular marker for the Glued gene, which was used to map the gene to the 70C2 band of chromosome 3L by in situ hybridization of a P element probe to polytene chromosomes from the GlR(P) strains and also to isolate clones of Glued genomic DNA for molecular studies of the normal gene and the various Glued mutations.

DNA homology between the 3'-untranslated regions of a developmentally regulated Drosophila gene and a mouse alpha-interferon gene.

The Drosophila genome was screened for DNA sequences that have homology with the mouse alpha-interferon gene MuIFN alpha 2, by hybridizing a library of cloned Drosophila genomic DNA with an MuIFN alpha 2 cDNA probe under reduced stringency conditions. Several dispersed regions of homology were identified, one of which was mapped at position 67D8-10 on chromosome 3. The homology in this region occurs within a gene, called ect, which encodes a 2.9-kb poly(A)+RNA transcript. The principal homology between ect and MuIFN alpha 2 involves A + T-rich sequences with short repeats, which are located within the untranslated 3' end of the transcribed region of each gene. Since no homology between the translated regions of ect and MuIFN alpha 2 was detected by hybridization, there appears to be no significant structural or functional homology between the encoded proteins. The ect gene is temporally regulated during Drosophila development, with a major peak of expression during the second half of Drosophila embryogenesis. Expression of ect occurs selectively in ectodermal tissues of the embryo, suggesting a specialized role for the gene in the early development of ectodermal structures.

Role of tissue factor in metastasis: functions of the cytoplasmic and extracellular domains of the molecule.

Tissue factor (TF) is a transmembrane glycoprotein that complexes with factor VIIa to initiate blood coagulation. It was reported in an earlier study that expression of high levels of TF in a human melanoma cell line promotes metastasis, and that the cytoplasmic domain of TF is required for this metastatic effect. To analyze the functions of the cytoplasmic and extracellular domains of TF in metastasis, two TF mutants were constructed; in one mutant alanine was substituted for each of the three serine residues in the cytoplasmic domain, preventing phosphorylation; in the other mutant alanine was substituted for four key residues in the extracellular domain, preventing binding of factor VIIa and consequently eliminating the initiation of blood coagulation by the TF-VIIa complex. Melanoma lines expressing high levels of either mutant form of TF were weakly metastatic in SCID mice, indicating that phosphorylation of the cytoplasmic domain and formation of a complex with VIIa by the extracellular domain are required for the full metastatic effect of TF. It was also found that increasing TF expression in human melanoma cells does not increase expression of vascular endothelial growth factor or promote growth and vascularization of tumors derived from the melanoma cells, suggesting that TF acts by a mechanism other than angiogenesis to promote metastasis.

[General medicine malpractice cases]. / Allgemeinmedizinische Behandlungsdefizite.

During the last five years legal proceedings about alleged treatment mistakes in Germany more than doubled. Using a standardized questionnaire about legal proceedings in general medicine, involving liability, an anonymous survey with the members of the workgroup law medicine of the Deutsche Anwaltsverein (DAV) was carried out. The questions included among other things the number and reasons of legal proceedings involving liability. Of 322 questioned lawyers who focused on medicine law 122 (38%) answered. 69.9% of the lawyers think poor information is the main reason for legal proceedings involving liability in general medicine. Three disease groups were mentioned more frequently: diseases of the digestive system (22 mentions), diseases of the circulatory system (21) and diseases of the muscles, skeleton and connective tissue (15). 40 mentions of injections as treatment mistakes build the most frequent therapeutic reason for legal proceedings involving liability. Most of the lawyers think that guidelines do not reduce legal proceedings involving liability. The most common reasons for legal proceedings involving liability such as poor information and insufficient medical examination may point out that the budgetary standards for consultation cannot guarantee enough time for firstly giving a sufficient individual information to the patient and secondly for developing a decision satisfactory for both sides.

Comparison of fusion phage libraries displaying VH or single-chain Fv antibody fragments derived from the antibody repertoire of a vaccinated melanoma patient as a source of melanoma-specific targeting molecules.

A single-chain Fv (scFv) fusion phage library derived from random combinations of VH and VL (variable heavy and light chains) domains in the antibody repertoire of a vaccinated melanoma patient was previously used to isolate clones that bind specifically to melanoma cells. An unexpected finding was that one of the clones encoded a truncated scFv molecule with most of the VL domain deleted, indicating that a VH domain alone can exhibit tumor-specific binding. In this report a VH fusion phage library containing VH domains unassociated with VL domains was compared with a scFv fusion phage library as a source of melanoma-specific clones; both libraries contained the same VH domains from the vaccinated melanoma patient. The results demonstrate that the clones can be isolated from both libraries, and that both libraries should be used to optimize the chance of isolating clones binding to different epitopes. Although this strategy has been tested only for melanoma, it is also applicable to other cancers. Because of their small size, human origin and specificity for cell surface tumor antigens, the VH and scFv molecules have significant advantages as tumor-targeting molecules for diagnostic and therapeutic procedures and can also serve as probes for identifying the cognate tumor antigens.