Physicians' willingness to participate in the process of lethal injection for capital punishment.

BACKGROUND: It has been found that physicians condone colleague involvement in capital punishment. Physicians' own willingness to participate has not been explored. OBJECTIVE: To examine physicians' willingness to be involved in cases of capital punishment. DESIGN: Survey exploring physicians' willingness to participate in 10 aspects of capital punishment by lethal injection, 8 of which are disallowed by the American Medical Association. SETTING: United States. PARTICIPANTS: 1000 randomly selected practicing physicians. MEASUREMENTS: Questions assessing willingness to be involved in and attitudes toward capital punishment. RESULTS: 41% of respondents indicated that they would perform at least one action disallowed by the American Medical Association; 25% would perform five or more disallowed actions. Perceived duty to society (P < 0.001), approval of the death penalty (P < 0.001), and approval of assisted suicide (P = 0.015) correlated with increased willingness to perform disallowed actions. Only 3% of respondents knew of any guidelines on this issue. CONCLUSIONS: Despite medical society policies, many physicians would be willing to be involved in the execution of adults. The medical profession needs to be better informed about the ethical issues involved in physician participation in capital punishment.

spe-29 encodes a small predicted membrane protein required for the initiation of sperm activation in Caenorhabditis elegans.

Caenorhabditis elegans spermatids complete a dramatic morphogenesis to crawling spermatozoa in the absence of an actin- or tubulin-based cytoskeleton and without synthesizing new gene products. Mutations in three genes (spe-8, spe-12, and spe-27) prevent the initiation of this morphogenesis, termed activation. Males with mutations in any of these genes are fertile. By contrast, mutant hermaphrodites are self-sterile when unmated due to a failure in spermatid activation. Intriguingly, mutant hermaphrodites form functional spermatozoa and become self-fertile upon mating, suggesting that spermatids can be activated by male seminal fluid. Here we describe a mutation in a fourth gene, spe-29, which mimics the phenotype of spe-8, spe-12, and spe-27 mutants. spe-29 sperm are defective in the initiation of hermaphrodite sperm activation, yet they maintain the ability to complete the morphogenetic rearrangements that follow. Mutant alleles of spe-12, spe-27, and spe-29 exhibit genetic interactions that suggest that the wild-type products of these genes function in a common signaling pathway to initiate sperm activation. We have identified the spe-29 gene, which is expressed specifically in the sperm-producing germ line and is predicted to encode a small, novel transmembrane protein.

Physicians' experiences with patients who transgress boundaries.

BACKGROUND: Boundary violations have been discussed in the literature, but most studies report on physician transgressions of boundaries or sexual transgressions by patients. We studied the incidence of all types of boundary transgressions by patients and physicians' responses to these transgressions. METHODS: We surveyed 1,000 members of the Society of General Internal Medicine (SGIM) for the number of patient transgressions of boundaries which had occurred in the previous year. Categories were created by the investigators based on the literature. Physicians picked the most important transgression, and then were asked about their response to the transgression and its effect on the patient-physician relationship. Attitudinal questions addressed the likelihood of discharging patients who transgressed boundaries. The impact of demographic variables on the incidence of transgressions was analyzed using analysis of variance. RESULTS: Three hundred thirty (37.5%) randomly selected SGIM members responded to the survey. Almost three quarters of the respondents had patients who used their first name, while 43% encountered verbal abuse, 39% had patients who asked personal questions, 31% had patients who were overly affectionate, and 27% encountered patients who attempted to socialize. All other transgressions, including physical abuse and attempts at sexual contact, were uncommon. Only gender affected the incidence of transgressions; female physicians encountered more personal questions (P = .001), inappropriate affection (P < .005), and sexually explicit language (P < .05) than male physicians and responded more negatively to boundary transgressions. Respondents dealt with transgressions by discussion with the patient or colleagues or by ignoring the incident, but such transgressions generally had a negative impact on the relationship. Most physicians would discharge patients who engaged in physical abuse or attempts at sexual contact, but were more tolerant of verbal abuse and overly affectionate patients. CONCLUSIONS: Boundary transgressions by patients is common, but usually involves more minor infractions. Female physicians are more likely to encounter certain types of transgressions. The incidence and outcomes of such transgressions are important in assisting physicians to deal effectively with this issue.

Physicians' attitudes about involvement in lethal injection for capital punishment.

BACKGROUND: Physicians could play various roles in carrying out capital punishment via lethal injection. Medical societies like the American Medical Association (AMA) and American College of Physicians have established which roles are acceptable and which are disallowed. No one has explored physicians' attitudes toward their potential roles in this process. METHODS: We surveyed physicians about how acceptable it was for physicians to engage in 8 actions disallowed by the AMA and 4 allowed actions involving lethal injection. Questions assessing attitudes toward capital punishment and assisted suicide were included. The impact of attitudinal and demographic variables on the number of disallowed actions deemed acceptable was analyzed via analysis of variance and multiple logistic regression analysis. RESULTS: Four hundred eighty-two physicians (51%) returned questionnaires. Eighty percent indicated that at least 1 of the disallowed actions was acceptable, 53% indicated that 5 or more were acceptable, and 34% approved all 8 disallowed actions. The percentage of respondents approving of disallowed actions varied from 43% for injecting lethal drugs to 74% for determining when death occurred. All 4 allowed actions were deemed acceptable by the majority of respondents. Favoring the death penalty (P<.001) and the acceptance of assisted suicide (P<.001) were associated with an increased number of disallowed actions that were deemed acceptable. CONCLUSIONS: Despite medical society policies, the majority of physicians surveyed approved of most disallowed actions involving capital punishment, indicating that they believed it is acceptable in some circumstances for physicians to kill individuals against their wishes. It is possible that the lack of stigmatization by colleagues allows physicians to engage in such practices. Arch Intern Med. 2000;160:2912-2916

A global profile of germline gene expression in C. elegans.

We used DNA microarrays to profile gene expression patterns in the C. elegans germline and identified 1416 germline-enriched transcripts that define three groups. The sperm-enriched group contains an unusually large number of protein kinases and phosphatases. The oocyte-enriched group includes potentially new components of embryonic signaling pathways. The germline-intrinsic group, defined as genes expressed similarly in germlines making only sperm or only oocytes, contains a family of piwi-related genes that may be important for stem cell proliferation. Finally, examination of the chromosomal location of germline transcripts revealed that sperm-enriched and germline-intrinsic genes are nearly absent from the X chromosome, but oocyte-enriched genes are not.

Mast cell tryptase release and asthmatic responses to allergen increase with regular use of salbutamol.

BACKGROUND: Increased asthmatic responses to allergen, both early and late, have been demonstrated after regular use of beta(2)-agonists in as few as 7 days. Desensitization of beta(2)-adrenergic receptors on airway mast cells may contribute to this effect by allowing greater release of mast cell mediator on allergen-induced degranulation. Tryptase released from lung mast cells can be measured in serum 1 hour after allergen challenge and serves as a marker of mast cell degranulation. OBJECTIVE: To examine the effect of regular treatment with salbutamol, a beta(2)-agonist, on mast cell mediator release after allergen challenge and its influence on the early asthmatic response (EAR) and the late allergic response, we measured the EAR, serum tryptase levels, the 7-hour FEV(1), and sputum tryptase levels and cell profiles. METHODS: We conducted a placebo-controlled, double-blind, randomized cross-over comparison of treatments for 10 days with either a salbutamol metered-dose inhaler (100 microgram, 2 puffs 4 times daily) or a matched placebo inhaler with at least a 7-day washout between treatments. Atopic subjects (n = 14) with mild-to-moderate asthma performed same-dose allergen inhalation tests after both treatments 12 to 15 hours after the last dose of study inhaler. Baseline and 7-hour FEV(1) and the EAR to allergen were measured by using spirometry; venous blood was drawn at 1 hour for analysis of serum tryptase; and sputum was induced and collected at 1 and 7 hours. RESULTS: Salbutamol treatment resulted in a significantly greater EAR (20% +/- 1.6% [SEM] vs 15% +/- 2.1%; P =.047); increased 1-hour serum tryptase levels (9.09 +/- 1.57 vs 7.52 +/- 1.12 microgram/L; P =. 011); increased proportions of eosinophils in the 7-hour sputum sample (39.1% +/- 5.1% vs 28.4% +/- 4.4%; P <.05); increased proportion of metachromatic cells in the 7-hour sputum sample (4.4% +/- 1.1% vs 2.2% +/- 0.6%; P =.032); and lower 7-hour FEV(1) (2.77 +/- 0.18 vs 2.97 +/- 0.20 L; P =.014). Baseline FEV(1) was not significantly different after salbutamol treatment compared with values after placebo treatment (2.90 +/- 0.20 vs 3.00 +/- 0.19 L; P =.11). CONCLUSION: Regular 10-day treatment with salbutamol increases the allergen-induced release of mediator from airway mast cells, and this is reflected in an increased EAR to allergen. Late-phase responses to allergen were also enhanced, as demonstrated by decreased 7-hour FEV(1) and increased eosinophilia and percentage of metachromatic cells in the 7-hour sputum sample. Increased allergen-induced mast cell degranulation could, in part, explain the increased asthmatic responses to allergen after beta(2)-agonist treatment and could contribute to the deterioration of asthma control that is associated with regular use of beta(2)-agonist by potentiating allergic inflammation.

Suicide by pipe bomb: a case report.

While lying down, a 23-year-old man detonated an improvised explosive device placed behind his head. The posterior neck and shoulders were singed, and much of the brain was avulsed. Death was due to laceration and partial avulsion of the cerebrum, midbrain, and brain stem. The injuries had a directional nature. Facts derived from the scene investigation and gross dissection, including nature, distribution, and extent of the wounds, in conjunction with preceding medical and social history, allowed for a reasonable reconstruction of the circumstances.

Sequential chemotherapy and radiotherapy for squamous cell esophageal carcinoma.

A Phase II study of sequential chemotherapy with 5-fluorouracil and cisplatin followed by radiotherapy was initiated to see whether the use of two therapies sequentially could have an effect on response rate. Thirteen patients with advanced squamous cell carcinoma of the esophagus were treated with 1,000 mg/m2/day 5-fluorouracil days 1-5 continuously and 100 mg/m2 cisplatin on day 1. An average of four cycles (range, one to nine) were given every 28 days; 11 patients received more than three cycles. The radiation consisted of 60 Gy over 6-8 weeks. There was only one (8%) complete response (CR) and 11 (85%) partial responses (PRs). Restaging after radiation revealed no conversion of PR to CR. Median survival was 39 weeks (range, 6-208+). Chemotherapy alone or its use sequentially with radiotherapy is inadequate, and newer approaches are needed to to improve survival.

Confidentiality and health insurance fraud.

BACKGROUND: Health insurance fraud committed by patients may be an increasing problem given the number of underinsured and uninsured people in the United States. Physicians recognizing acts of health insurance fraud perpetrated by patients face an ethical dilemma: should they disclose the incident to the insurance company, or protect patient confidentiality? OBJECTIVE: To explore physicians' attitudes toward the reporting of patient-initiated health insurance fraud. METHODS: Three hundred seven physician members of the American College of Physicians returned a mailed questionnaire that presented 6 case vignettes (3 variables) of patients who used a relative's insurance to obtain health care in the past. For each vignette, respondents were asked whether the treating physician should report insurance fraud to the health insurance carrier. RESULTS: Sixty-three respondents (20.7%) indicated that physicians should report all the patients presented in the vignettes, while 45 (14.8%) indicated none should be reported; the rest indicated that the decisions to-report should be based on the characteristics presented, with acute vs terminal illness (P < .001), history of fraud (P < .001), and wealth of the patient (P < .001) all causing physicians to be more likely to report the patient to the health insurance carrier. Multivariate analysis demonstrated that type of practice (P = .04) and respondents' experiences with insurance fraud (P = .03) had significant effects on the willingness to report patients. CONCLUSIONS: Physicians are divided about whether to report patients who have committed insurance fraud. Their decisions to report insurance fraud are influenced by their attitudes and demographic features, as well as by patient factors.

Telling patients about the diagnosis of HIV infection.

This study used a questionnaire to examine how patients in the HIV/AIDS Clinic at a Department of Veterans Affairs hospital were told of their diagnosis, by whom, and to what degree they were given emotional and educational support. Nearly 17% of patients were informed by someone not in the health professions (often military personnel), and 27% of patients were notified in a nonprivate setting. Forty-seven percent indicated they received little or no educational support at the time of diagnosis, while 39% received little or no emotional support. Educational and emotional support for patients at the time of HIV diagnosis may be lacking.

Glaucoma, capillaries and pericytes. 2. Identification and characterization of retinal pericytes in culture.

As cell cultures of pericytes derived from bovine retina are in regular use by a number of investigators, we decided to confirm the identity of these cells, to show them different from other cells that might contaminate cultures derived from retinal tissue, to characterize the properties they share with pericytes in situ and to establish a practical and effective means for confirmation of the cell type of each batch of cultured cells used in scientific studies. Cultured pericytes differed in immunocytochemical reactions and phagocytic properties from vascular smooth muscle, vascular endothelial cells, astroglia, conjunctival fibroblasts or retinal pigment epithelium. Like vascular smooth muscle, pericytes in situ and those in culture have the contractile proteins actin and myosin, which implies a potential role in blood flow control. In routine studies of cultured pericytes, they can be identified by their unique reaction in situ and in vitro with the antiganglioside monoclonal antibody 3G5. The presence of any contaminating endothelial cells can be recognized by their ability to take up acetylated low-density lipoprotein.

Glaucoma, capillaries and pericytes. 3. Peptide hormone binding and influence on pericytes.

To test the potential for vasoactive neuropeptide receptors to affect capillary resistance, we have begun to study the plausibility that pericytes might be equipped to respond to a representative peptide vasoconstrictor and a representative peptide vasodilator. Pericytes cultured from the bovine retinal vasculature specifically bind the angiotensin II (Ang II) antagonist saralasin (1 nM125I-saralasin bound at 2.2 +/- 0.41 fmol/mg protein) and 125I-vasoactive intestinal peptide (VIP; Kd of 0.5 nM with a population of 30 fmol/mg protein). Incubation with 100 microM Ang II induced minimal cAMP synthesis, while VIP (1 microM, 10 microM) did not induce any change in cAMP concentration. Ang II (10 microM and 100 microM) caused contraction of pericytes cultured on an elastic silicone surface. Circulating or locally produced vasoactive neuropeptides might affect pericyte contractile tone via several intracellular pathways, moderated by indirect effects of these peptides through endothelial stimulation, with the net effect on local blood flow resulting from the effects on arteries and veins as well as capillaries.

Glaucoma, capillaries and pericytes. 4. Beta-adrenergic activation of cultured retinal pericytes.

To characterize the relaxation of pericytes induced by beta-adrenergic stimulation, changes in the contractile tone of pericytes were quantified as a change in the wrinkling of an elastic silicone surface on which they were cultured. Isoproterenol produced relaxation of pericytes in a dose-dependent manner over a range of 5 nM to 1 microM. Low concentrations of the nonselective beta-blockers propanolol and timolol blocked the relaxation produced by isoproterenol. The specific beta 2-adrenergic component of isoproterenol-induced relaxation was shown by blockage with bromoacetyl alprenolol menthane. In contrast, atenolol and betaxolol, as relatively selective beta 1-adrenergic blockers, had no effect on the isoproterenol-induced relaxation.

Glaucoma, capillaries and pericytes. 5. Preliminary evidence that carbon dioxide relaxes pericyte contractile tone.

We undertook this study to determine if pericytes respond to carbon dioxide in a manner such that they could help control capillary blood flow and that their physiologic responses to pCO2 might be worthy of detailed study. Pericytes were isolated from bovine retinas and grown in cell culture. Changes in the contractile tone of the pericytes upon changing the ambient pCO2 were observed by noting changes in the wrinkling of an elastic silicone surface on which they were grown. An increase in pCO2 caused acidosis of the medium and relaxation of the pericytes in a reversible, concentration-dependent manner. These findings suggest that the regulation of blood flow to meet local metabolic needs does not reside entirely in the arterioles and precapillary sphincters, but at least in part in the capillary bed through the contractile properties of pericytes. The local pCO2 is one of several potential indicators of whether or not local blood flow is adequate for local tissue needs. The response to local conditions may modulate or be modulated by the effect of neurotransmitters and hormones on the local rate of blood flow.

Intern candidates who withdraw from contracts: incidence and internal medicine program directors' attitudes.

OBJECTIVE: To study the prevalence of intern candidates accepted through the National Resident Matching Program (NRMP) or after the match who subsequently withdraw and the attitudes of program directors regarding this issue. DESIGN: Mailed survey. SETTING: Four hundred fifty-four internal medicine program directors. MEASUREMENTS: Questionnaires assessing program directors' attitudes toward interns who contract for positions after having verbal or written agreements elsewhere (and the program directors who accept them), the importance of this problem, and the incidence of this problem. MAIN RESULTS: Fifty-five programs (of the 221 responding) experienced intern withdrawals. Programs with larger numbers of open positions after the match had more intern withdrawals (p = 0.03). Eleven of the program directors knew of the prior commitment of the intern, and in all cases the other program director was called for permission to accept the intern. Program directors had negative feelings about both the interns who withdrew and the program directors who accepted them. Community, municipal, and Veterans Affairs hospital program directors were significantly less negative than those in university and university-affiliated hospitals toward interns who withdrew from written commitments (p = 0.001) and the program directors who accepted them (p < 0.05). CONCLUSION: Problems with intern candidate withdrawals from offered/matched programs affect a significant proportion of programs, especially those with larger numbers of unmatched positions. Program directors are generally disapproving.

Preparing for Medicare outpatient payment reform.

Orthopedic hospitals, institutions with a high volume of surgeries, and hospitals with high Medicare populations should learn from the experiences of eye and ear hospitals, some of which could have been put out of business by Medicare outpatient payment reforms proposed in 1986 and partially implemented since then. As the reforms are refined, hospitals should analyze their vulnerability to the proposed changes using the matrix proposed in this article. They should also take steps to counter any negative impact on revenues and try to influence the nature and scope of the reforms.

Effects of cholinergic and adrenergic agonists on adenylate cyclase activity of retinal microvascular pericytes in culture.

Pericytes are contractile cells that might help regulate microvascular blood flow. To understand their potential role in the regulatory responses of the retina and optic nerve head vessels, the response of pericytes isolated from bovine retinal microvessels was determined to oxotremorine, isoproterenol, phenylephrine, and clonidine. Isoproterenol doubled the basal levels of cyclic adenosine monophosphate (cAMP) specifically through beta-adrenergic receptors, because the effect was blocked by dl-propranolol. The alpha 1 agonist phenylephrine did not induce any major change in adenylate cyclase activity. The alpha 2 agonist clonidine decreased basal cAMP synthesis and reduced the effect of isoproterenol. The cholinergic agonist oxotremorine did not modify the basal activity of adenylate cyclase but was able to decrease by almost 50% the forskolin-induced increase of cAMP. These results suggest that pericytes have functional adrenergic and cholinergic receptors, and they might respond to autonomic vasoactive substances present in vivo.

Angiotensin II binding receptors in retinal and optic nerve head blood vessels. An autoradiographic approach.

Angiotensin II (AII) binding sites were identified in cross-sections of the cat retinal and optic nerve vasculatures. The authors used 3H-AII and 125I-saralasin, an agonist and a high-affinity antagonist of AII receptors, respectively, to generate light microscopy autoradiograms in resin-embedded tissues. With both radioligands the presence of AII binding sites was confirmed in retinal arterioles but not in the veins or capillaries of the retina. Additionally the presence of such binding sites in the capillaries of the optic nerve head was shown. These results support the hypothesis that microvascular tone and perhaps autoregulatory responses of optic nerve capillaries might be influenced by vasoactive substances, such as AII, either leaking from the choroid or locally synthetized.