A mentor-based laboratory management elective for residents.

With the evolution of health care delivery systems, laboratories are being viewed as cost centers, and their value is being continually challenged. This requires pathologists to be adequately trained as leaders and managers. New training curricula for pathology residents have been developed, including combined didactic and mentor-based training. At the University of Utah, Salt Lake City, the combination of a large academic pathology department with a wholly owned commercial laboratory has allowed the development of a comprehensive 1-month didactic management course for senior residents. This course is designed to develop a broad-based foundation in laboratory management principles. The reinforcement of many of these principles, however, requires additional hands-on effort. We describe our first experience with this 1-month, theory based-teaching followed by a 3-month "real-world" experience based on a one-on-one mentor relationship between the director of laboratories and a senior resident, who assumed the role of the assistant director of laboratories.

A tool to assess homebound status.

Although this specific instrument focuses solely on helping the home care nurse determine homebound status, this type of instrument can be developed for the other criteria used in assessing a client for Medicare-eligible home care services. For example, a similar instrument can be developed to assess whether a patient meets the criteria for part-time intermittent care or skilled care using the Medicare definitions as a guide to tool development. As we move into a time when there is more scrutiny of home care for compliance to Medicare regulations and increased productivity to assure cost effectiveness, instruments like this are essential for careful documentation that allows the agency to demonstrate accountability. In addition, home care agencies are expecting new home care nurses to know and be able to apply the Medicare regulations after a brief orientation. Instruments like this can shorten the orientation process and provide support for the home care nurse in the field.

Multiple forms of arginase are differentially expressed from a single locus in Neurospora crassa.

The Neurospora crassa catabolic enzyme, arginase (L-arginine amidinohydrolase, EC 3.5.3.1), exists in multiple forms. Multiple forms of arginase are found in many vertebrates, but this is the only reported example in a microbial organism. The two major forms are structurally similar with subunit sizes of 36 and 41 kDa, respectively. The larger form is produced by mycelia growing in arginine-supplemented medium. Both forms are localized in the cytosol. The structural gene for arginase, aga, has been cloned and sequenced; it contains a 358-codon open reading frame with three in-frame ATGs at the amino terminus. Mutagenesis of these ATGs revealed that the first ATG initiates the 41-kDa protein and the third ATG initiates the 36-kDa protein. Mutation of the second ATG has no effect on translation. Northern analysis demonstrated that a 1.4-kilobase (kb) transcript is synthesized in minimal medium and both a 1.4- and 1.7-kb transcript are produced in arginine-supplemented medium. Primer extension identified the 5' ends of each transcript and demonstrated that the first and third ATG of the open reading frame are the initial AUGs of the 1.7- and 1. 4-kb mRNA, respectively. The results suggest that a basal promoter produces the 1.4-kb transcript and an arginine "activated" promoter is responsible for the 1.7-kb transcript. Tandem promoters are rare in eukaryotic organisms, and they often regulate developmental or tissue-specific gene expression. The possibility that arginase has a role in differentiation in N. crassa is being investigated.

Processing and function of a polyprotein precursor of two mitochondrial proteins in neurospora crassa.

In Neurospora crassa, the mitochondrial arginine biosynthetic enzymes, N-acetylglutamate kinase (AGK) and N-acetyl-gamma-glutamyl-phosphate reductase (AGPR), are generated by processing of a 96-kDa cytosolic polyprotein precursor (pAGK-AGPR). The proximal kinase and distal reductase domains are separated by a short connector region. Substitutions of arginines at positions -2 and -3 upstream of the N terminus of the AGPR domain or replacement of threonine at position +3 in the mature AGPR domain revealed a second processing site at position -20. Substitution of arginine at position -22, in combination with changes at -2 and -3, prevented cleavage of the precursor and identified two proteolytic cleavage sites, Arg-Gly downward arrow Tyr-Leu-Thr at the N terminus of the AGPR domain and Arg-Gly-Tyr downward arrow Ser-Thr located 20 residues upstream. Inhibitors of metal-dependent peptidases blocked proteolytic cleavage at both sites. Amino acid residues required for proteolytic cleavage in the connector were identified, and processing was abolished by mutations changing these residues. The unprocessed AGK-AGPR fusion had both catalytic activities, including feedback inhibition of AGK, and complemented AGK-AGPR- mutants. These results indicate that cleavage of pAGK-AGPR is not required for functioning of these enzymes in the mitochondria.

Malignant transformation of recurrent respiratory papillomatosis associated with integrated human papillomavirus type 11 DNA and mutation of p53.

Recurrent respiratory papillomatosis (RRP), usually confined to the nasopharynx, trachea, and larynx, occasionally can progress to extensive bronchopulmonary disease. Most cases of bronchopulmonary and laryngeal papillomatosis are cytologically benign and do not undergo malignant transformation; however, squamous cell carcinoma (SCC) can arise in RRP in the absence of known risk factors such as radiation and smoking. In this study, the authors investigated molecular genetic alterations occurring in a case of metastasizing SCC that arose in long-standing bronchopulmonary papillomatosis. Genomic DNA from tracheal papillomata, tracheobronchial papillomata, SCC of the lung, and a lymph node metastasis was extracted. The physical state of the human papillomavirus type 11 (HPV-11) DNA was investigated by two-dimensional gel electrophoresis. Molecular genetic alterations of the host genome were studied by direct sequencing of polymerase chain reaction-amplified gene fragments and restriction fragment length polymorphism (RFLP) analysis. Episomal and integrated forms of HPV-11 sequences were detected in histologically benign tumors, but only the integrated form of the viral DNA could be found in malignant tissue samples. Molecular genetic studies revealed that an allelic loss of the interferon-beta gene (IFNbeta-1) and an endogenous type of mutation of the p53 antioncogene were found only in the malignant lesions. Mutations were not observed in the ras, neu, or multiple tumor suppressor (MTS1/p16) genes in any specimens. The authors' data indicated that the p53 genetic mutation was associated with integration of HPV-11 in histologically malignant lesions. This association may promote a progressive genetic instability that can lead to the development and clonal expansion of malignant lesions in RRP.

Natural killer-like T-cell lymphoma in the small intestine of a child without evidence of enteropathy.

A previously healthy 6-year-old boy developed symptoms of small intestinal obstruction and was found to have a large intraabdominal mass. At laparotomy the mass involved the jejunum and adjacent mesenteric lymph nodes, requiring resection. Microscopic and immunohistochemical studies demonstrated a T-cell non-Hodgkin's lymphoma, confirmed by finding clonal T-cell receptor-beta and -gamma gene rearrangements by Southern blot analysis. The immunophenotype of this lymphoma-CD3+CD4-CD8-CD56+TIA-1+ beta F1(-)-suggests that the tumor cells are cytotoxic natural killer (NK)-like T cells, probably of CD3+CD4-CD8- intraepithelial cell origin. Examination of the adjacent and distal small intestinal mucosa failed to show any significant pathologic change. This case was unusual because intestinal lymphomas in children are usually of B-cell origin and most commonly have small noncleaved cell morphology. Childhood intestinal T-cell lymphomas have not been the focus of specific study but appear to be rare. In adults, intestinal T-cell lymphomas often arise in the background of gluten-sensitive enteropathy (celiac disease). In contrast, this child had peripheral T-cell lymphoma, with NK-like T-cell features, in the small intestine with no clinical or histologic evidence of enteropathy.

High jugular bulb and conductive hearing loss.

A high jugular bulb is often discovered as an incidental finding that is asymptomatic. Conductive hearing loss in association with this anomaly may occur, but has been reported infrequently in the literature. We report five cases of high jugular bulb and associated conductive hearing loss. Mechanisms to explain the conductive hearing loss include contact of the jugular bulb with the tympanic membrane, interference with the ossicular chain, and obstruction of the round window niche. The operative findings, radiographic and audiometric data that support these mechanisms of conductive hearing loss are presented.

Characterization of vacuolar arginine uptake and amino acid efflux in Neurospora crassa using cupric ion to permeabilize the plasma membrane.

Treatment of Neurospora crassa mycelia with cupric ion has been shown to permeabilize the plasma and mitochondrial membranes. Permeabilized mycelia were shown to take up arginine into the vacuoles. Uptake was ATP-independent and appeared to be driven by an existing K+-gradient. The kinetic characteristics of the observed uptake were similar to those observed using vacuolar membrane vesicles: the Km for arginine uptake was found to be 4.2-4.5 mM. Permeabilized mycelia were used to study the regulation of arginine uptake into vacuoles. The results suggest that uptake is relatively indifferent to the contents of the vacuoles and is not affected by growth of mycelia in amino acid-supplemented medium. Efflux of arginine, lysine, and ornithine from vacuoles was also measured using mycelia permeabilized with cupric ion. Arginine release was shown to be specifically enhanced by cytosolic ornithine and/or increases in the vacuolar pool of arginine or ornithine. Lysine efflux was shown be indifferent to the presence of other amino acids. These observations emphasize the importance of vacuolar compartmentation in controlling arginine and ornithine metabolism and suggest that vacuolar compartmentation may play an important role in nitrogen homeostasis of filamentous fungi.

Acetylglutamate synthase from Neurospora crassa: structure and regulation of expression.

A DNA clone which complemented an arg-14 mutation of Neurospora crassa was isolated by sib selection from a cosmid library (pMOcosX). Southern and restriction-fragment-length polymorphism (RFLP) analysis confirmed that the cloned DNA contained the arg-14 gene. The arg-14 gene was identified as the structural gene for acetylglutamate synthase by immunodepletion of enzyme activity with antibodies prepared against an arg-14 fusion protein and by the thermal instability of acetylglutamate synthase in a temperature-sensitive arg-14 mutant. The fungai acetylglutamate synthase has little sequence homology to its bacterial counterpart, unlike other arginine biosynthetic enzymes. Expression of the arg-14 gene is regulated by cross-pathway control similar to many amino acid biosynthetic genes. However, expression of acetylglutamate synthase occurs throughout the developmental growth cycle, unlike other arginine biosynthetic enzymes.

Clear plastic cups: a childhood choking hazard.

The disposable plastic beverage cup is not usually regarded as hazardous to young children. Certain varieties of these products however, are manufactured from a brittle, clear plastic that easily cracks and fragments. While most conscientious parents keep their children safe from peanuts, balloons, and other known choking hazards, a child can surreptitiously bite a cup edge and aspirate the fragment. We report two cases of foreign body aspiration involving clear plastic cups that went undetected one of which remained 21 months following a negative rigid bronchoscopy. Diagnostic difficulties are related to the transparency and radiolucency of these objects. When suspicious of foreign body aspiration in children, otolaryngologists should inquire about the availability of clear plastic cups in the household and be mindful of the diagnostic pitfalls. Further investigations including CT scanning and repeat bronchoscopy may be helpful in cases of suspected missed foreign bodies. An educational campaign aimed at prevention and placement of product package warning labels should be established.

The usefulness of transesophageal echocardiography in diagnosing cardiac contusions.

OBJECTIVES: To assess the usefulness of transesophageal echocardiography in diagnosing cardiac contusions in patients with blunt trauma. BACKGROUND: For more than a decade, noninvasive tests, including ECGs, cardiac enzymes, nuclear studies, and transthoracic echocardiography have been utilized in an attempt to identify trauma patients with cardiac injuries. These tests have been imperfect in identifying the patients at high risk for mortality. METHODS: We retrospectively reviewed the charts in 22 patients with transesophageal echocardiographically diagnosed cardiac contusions noting age, race, sex, transthoracic echocardiographic examinations, study quality, and outcome. We also noted the Injury Severity Score, which is a measure of the severity of illness in trauma patients. Higher scores correlate more severe injury and higher mortality. We defined cardiac contusions as presence of wall motion abnormality, including either or both ventricles, in the absence of transmural myocardial infarction on ECG following nonpenetrating chest trauma. RESULTS: Over a 30-month period, 81 transesophageal echocardiographic examinations were performed on trauma patients. Among this group, 22 patients were diagnosed as having cardiac contusions. There were 15 patients with right ventricular contusions, 7 patients with left ventricular contusions, and 2 patients with both ventricles involved. We compared this group with all ICU trauma patients admitted to the hospital during this time period. Overall, the contusion patients had an average Injury Severity Score of 27 and a mortality of 27% compared with the overall trauma group with an Injury Severity Score of 33 and a corresponding mortality of 9% (p < 0.001). Corresponding ECGs were nondiagnostic in 73% of patients with cardiac contusion. There were no complications related to the transesophageal examinations. CONCLUSIONS: Transesophageal echocardiographically diagnosed cardiac contusion in trauma patients carries a high mortality rate. Transesophageal examinations are safe and provide excellent quality images where transthoracic examinations were inadequate. Right ventricular contusions are approximately twice as common as left ventricular contusions.

Descending thoracic aortomyoplasty: a technique for clinical application.

BACKGROUND: Descending thoracic aortomyoplasty is a form of skeletal muscle-powered cardiac assistance. Its use in clinical settings has been limited by the ligation of intercostal arteries necessary to complete a circumferential wrap of the aorta with the latissimus dorsi. METHODS: This study assessed the feasibility and the efficacy of aortomyoplasty constructed with a modified latissimus dorsi. A pericardial patch was attached to the latissimus dorsi and divided around the preserved intercostal arteries. Nine alpine goats (37 +/- 2 kg) underwent descending aortomyoplasty using this technique. All intercostal arteries were preserved. After a 6-week recovery period, the animals underwent a 6-week, incremental electrical conditioning program. After 90 postoperative days, animals were examined under anesthesia with the myostimulator on and off. RESULTS: Aortomyoplasty activation resulted in augmentation of mean diastolic aortic pressure by 16.0 +/- 0.9 mm Hg (23%). Significant improvements in cardiac index (40%), stroke volume index (37%), left ventricular stroke work index (49%), and mean arterial pressure (19%) were noted. An intravascular sonographic probe placed in the descending aorta revealed circumferential compression of the aorta during counterpulsation. Mean cross-sectional aortic area was reduced by 51.8%, from 210.1 +/- 7.1 to 108.9 +/- 6.7 mm2 during aortomyoplasty activation (p < 0.05). Histologic analysis confirmed the long-term patency of intercostal arteries. CONCLUSIONS: Descending aortomyoplasty, modified with an interposing patch of pericardium, effectively transfers skeletal muscle force across the aortic wall and assists cardiac function. This technique allows preservation of all aortic branches, and with this novel approach, the clinical utility of aortomyoplasty can now be explored.