National Alliance for Oral Health Consensus Conference on Medically Necessary Oral Health Care: Legal issues

This paper examines medical malpractice law as it applies to medically necessary oral health care. The basic legal concepts and reported cases involving medically necessary oral health care are reviewed. It is concluded that dental professionals and consumer advocates must advance their educational and legislative advocacy efforts so that health professional colleagues and the public will become aware of the importance of these services and insurers will routinely include coverage of medically necessary oral health care in their medical and dental policies. While failure to provide medically necessary oral health care can be violative of patient rights and legally actionable, medical malpractice litigation should always be the behavior modifier of last resort.     

Maisonneuve fracture dislocation of the ankle

Ligamentous injuries of the ankle are usually benign and may be managed satisfactorily by nonoperative measures. This is not true, however, of the Maisonneuve variant. In this paper we present a case report of a high school athlete who sustained a Maisonneuve fracture dislocation of the ankle. The diagnosis was missed initially, because of an incomplete examination. The subsequent physical and radiographic examination revealed the proper diagnosis. Guidelines for the evaluation and appropriate treatment are discussed.     

Importance of the T cell receptor alpha-chain transmembrane distal region for assembly with cognate subunits

Antigen recognition by alphabeta T lymphocytes is mediated via the multisubunit TCR complex consisting of invariant CD3gamma,delta,epsilon and zeta chains associated with clonotypic TCRalpha and beta molecules. Charged amino acids located centrally within the TCRalpha transmembrane region are necessary and sufficient for assembly with the CD3deltaepsilon heterodimer. Previously, we have shown that deletion of 6-12 amino acids from the carboxy terminus of the TCRalpha-chain dramatically abrogates surface TCR expression, suggesting that the distal portion of the TCRalpha transmembrane region contains information that regulates the assembly and/or intracellular transport of TCR complexes. We have examined in more detail the molecular basis for reduced TCR expression in T cells bearing truncated TCRalpha chains. We found that in contrast to wild-type (wt), variant TCRalpha proteins missing the last nine C-terminal amino acids did not associate with core CD3gamma,delta,epsilon chains and were not assembled into disulphide-linked alphabeta heterodimers. The stability of newly synthesised wt and variant TCRalpha molecules was similar, showing that the abrogated surface TCR expression was not a consequence of impaired protein survival. Nevertheless, truncated TCRalpha chains still assembled with the chaperon protein calnexin in the endoplasmic reticulum, indicating that the distal portion of the TCRalpha transmembrane region is not essential for calnexin interaction. These data document a role for the distal portion of the TCRalpha transmembrane region in the assembly of TCR complexes and provide a molecular basis for reduced TCR expression in cells bearing truncated TCRalpha chains.     

Use of a repetitive DNA probe to type clinical and environmental isolates of Aspergillus flavus from a cluster of cutaneous infections in a neonatal intensive care unit

Aspergillus flavus is second to A. fumigatus as a cause of invasive aspergillosis, but no standard method exists for molecular typing of strains from human sources. A repetitive DNA sequence cloned from A. flavus and subcloned into a pUC19 vector, pAF28, was used to type 18 isolates from diverse clinical, environmental, and geographic sources. The restriction fragment length polymorphisms generated with EcoRI- or PstI-digested genomic DNA and probed with digoxigenin-labeled pAF28 revealed complete concordance between patterns. Eighteen distinct fingerprints were observed. The probe was used to investigate two cases of cutaneous A. flavus infection in low-birth-weight infants in a neonatal intensive care unit (NICU). Both infants were transported by the same ambulance and crew to the NICU on the same day. A. flavus strains of the same genotype were isolated from both infants, from a roll of tape used to fasten their umbilical catheters, from a canvas bag used to store the tape in the ambulance, and from the tape tray in the ambulance isolette. These cases highlight the need to consider exposures in critically ill neonates that might occur during their transport to the NICU and for stringent infection control practices. The hybridization profiles of strains from a second cluster of invasive A. flavus infections in two pediatric hematology-oncology patients revealed a genotype common to strains from a definite case patient and a health care worker. A probable case patient was infected with a strain with a genotype different from that of the strain from the definite case patient but highly related to that of an environmental isolate. The high degree of discrimination and reproducibility obtained with the pAF28 probe underscores its utility for typing clinical and environmental isolates of A. flavus.     

Comorbid psychiatric disorders in depressed outpatients: demographic and clinical features

BACKGROUND: This study evaluated the clinical and sociodemographic features associated with various degrees of concurrent comorbidity in adult outpatients with nonpsychotic major depressive disorder (MDD). METHODS: Outpatients enrolled in the STAR*D trial completed the Psychiatric Diagnostic Screening Questionnaire (PDSQ). An a priori 90% specificity threshold was set for PDSQ responses to ascertain the presence of 11 different concurrent DSM-IV Axis I disorders. RESULTS: Of 1376 outpatients, 38.2% had no concurrent comorbidities, while 25.6% suffered one, 16.1% suffered two, and 20.2% suffered three or more comorbid conditions. Altogether, 29.3% met threshold for social anxiety disorder, 20.8% for generalized anxiety disorder, 18.8% for posttraumatic stress disorder, 12.4% for bulimia, 11.9% for alcohol abuse/dependence, 13.4% for obsessive-compulsive disorder, 11.1% for panic disorder, 9.4% for agoraphobia, 7.3% for drug abuse/dependence, 3.7% for hypochondriasis, and 2.2% for somatoform disorder. Those with more concurrent Axis I conditions had earlier ages at first onset of MDD, longer histories of MDD, greater depressive symptom severity, more general medical comorbidity (even though they were younger than those with fewer comorbid conditions), poorer physical and mental function, health perceptions, and life satisfaction; and were more likely to be seen in primary care settings. LIMITATIONS: Participants had to meet entry criteria for STAR*D. Ascertainment of comorbid conditions was not based on a structured interview. CONCLUSIONS: Concurrent Axis I conditions (most often anxiety disorders) are very common with MDD. Greater numbers of concurrent comorbid conditions were associated with increased severity, morbidity, and chronicity of their MDD.     

The consistency of peer and parent influences on tobacco,alcohol, and marijuana use among young adolescents

The purpose of this study was to determine the degree to which the use of tobacco, alcohol, and marijuana by young adolescents can be described using a common theoretical model. Structural models were created in which psychosocial variables hierarchically predicted the use of each substance. The fit of a model in which paths from predictor variables were constrained to be equal was not inferior in any meaningful way to that of a model in which all path coefficients were freely estimated, thus suggesting that use of tobacco, alcohol, and marijuana by young adolescents may be considered to be a unitary phenomenon. A simplified model, in which these substances were combined into a single latent variable, showed a good fit. The results of these analyses suggest that it may be beneficial to consider adolescent substance use to be a unitary phenomenon.This research was supported by National Institute on Drug Abuse Grant 1-R18-DA-003406.