Malpractice Woes: Here Is What You Should Do if You Get Sued.

This article relates the first-hand experience of a surgeon who faced 2 medical malpractice actions separated by 30 years and how each of those experiences affected him. The first episode occurred early in his career and caused anxiety, fear, and anger. The importance of getting support during a medical malpractice event, and the opportunities to do so, are discussed. The timeline of a typical medical malpractice lawsuit and phases of the litigation process are detailed. The authors provide guidance on how to make this process less stressful. The article summarizes medical malpractice lawsuits involving otolaryngologists.

[Evaluation of adherence to the regulations for declaration of notification of transfusion reactions with fever and chills. A study of the Association Inter-Régionale du Sud-Est d'Hémovigilance (AIRSEH)]. / Evaluation de la conformité à la réglementation des déclarations d'incidents transfusionnels pour frissons-hyperthermie dans des établissements de santé du sud-est de la France (groupe AIRSEH).

Febrile non-hemolytic transfusion reactions (FNHTR) are the most frequently reported acute adverse effects of blood products, and should be notified within 48 h according to the hemovigilance regulation. In order to study the conformity of these notifications and to search for factors associated with non-conformity, we retrospectively studied all FNHTR notified by voluntary centers of the AIRSEH group from 1st September 1994 to 31st December 1999. Seven hundred and sixty-one FNHTR were registered by 10 centers, most of them were benign (grade 1); 67.8% were non-conform. The non-conformity was associated with the number of biological investigations performed (median number, respectively, 4.24 and 2.94--P = 0.038--in non-conform and conform notifications--P = 0.038) in univariate analysis. Using a logistic regression model, center and severity were the only two factors significantly associated with non-conformity. Different center practices, and in particular the interface between the hospital and the blood bank, may be responsible for the effect center. Moreover, the non-conformity concerns first of all benign FNHTR. A stronger separation between alert and epidemiological surveillance is proposed in order to improve the notifications' conformity.

A new mutation of E-cadherin gene in familial gastric linitis plastica cancer with extra-digestive dissemination.

Over a 12-month period, we diagnosed poorly differentiated infiltrative independent-cell gastric adenocarcinoma in two brothers and one sister aged 41 to 47 years. Their father had died from antral cancer at the age of 34 years. These cancers had two characteristic clinical features: rapid course and distant malignant dissemination. In all three patients, polymerase chain reaction-sequencing of the E-cadherin (CDH1) gene of white blood cells identified a heterozygous nonsense mutation of exon 3, producing a stop codon at position 95 (Q95X), resulting in a truncated protein. The alteration of this protein, which plays a crucial role in epithelial cell adhesion, probably explains the clinical expression in this type of familial diffuse gastric cancer.

[Application of the gel test using and anti-IgA antiglobulin for the immunologic diagnosis of autoimmune hemolytic anemia with a negative direct Coombs test]. / Application du gel test utilisant une antiglobuline anti-IgA au diagnostic immunologique d'anémie hémolytique auto-immune à test de Coombs direct négatif.

Autoimmune hemolytic anemias (AIHA) are characterized by hyperhemolysis associated with the presence of the immunoglobulins IgG, IgM or IgA on the red cell membrane. These immunoglobulins react as auto-antibodies against the red cell auto-antigens of the patient. The diagnosis is supported by clinical and biological signs of hemolysis, and by the identification of the auto-antibodies using the direct antiglobulin test (DAT). Here we report 14 cases of patients who showed the clinical and biological profile of AIHA, but who gave a negative DAT. We therefore tried to determine the presence of IgA on the red cell membrane with a method more sensitive than the DAT: the gel test using anti-IgA. With such a gel test, we demonstrated that there were IgA auto-antibodies on the red cell membrane in the 14 cases, therefore confirming the diagnosis of AIHA. We discuss the interest of performing a gel test with anti-IgA in each case where AIHA is suspected, but in which a negative DAT has been observed.

[Laryngeal mucociliary clearance: influence of beta-2 agonists, beta antagonists, and alpha-agonists. An experimental study in rabbits]. / Transporte mucociliar laríngeo: influencia de los beta-2 estimulantes, betabloqueantes y alfaestimulantes. Un estudio experimental en conejos.

Laryngeal mucociliary clearance was studied in 35 rabbit larynxes in the immediate post mortem period using charcoal powder. Mucociliary currents flowed from the subglottic walls to the posterior commissure. The normal laryngeal mucociliary clearance rate was 3.7 +/- 1.1 mm/min. Salbutamol accelerated mucociliary clearance (p < 0.01). Propranolol significantly reduced the mucociliary clearance rate (p < 0.001). Mucociliary clearance was not observed in any methoxamine-treated larynxes.

Strong increase in the percentage of the CD8bright+ CD28- T-cells and delayed engraftment associated with cyclosporine-induced autologous GVHD.

Four children with acute lymphoblastic leukaemia had autologous bone marrow (BM) or peripheral stem cell (PSC) transplantation with low dose of cyclosporine (CsA, img/kg/d i.v. during the first 28 d) to induce an autologous GVHD (auto-GVHD). Two children did not have clinical auto-GVHD and they relapsed 3 and 4 months after treatment. The 2 other children had clinical signs of auto-GVHD (grade I and grade II); they both are in complete remission but after a first normal haematological recovery they had a prolonged period of aplasia until month 9 for 1 patient and still persistent at month 7 in the other case. We studied lymphocyte subsets reconstitution after transplantation in these patients. All patients had an important decrease in the CD4/CD8 ratio related both to a strong decrease in the CD4+ cells and a strong increase in the CD8+ cells. Most of the CD8+ cells were of the CD8bright+ CD28- phenotype. These CD8bright+ CD28- T-cells represented from 33% to 68% of the total lymphocytes. We discuss the role of these cells after autologous transplantation with CsA, and wonder if these cells could mediate cytotoxicity. In conclusion, among 4 children who received autologous BM or PBC transplantation with low dose of CsA, we observed a complete remission after an auto-GVHD and a prolonged period of aplasia in 2 patients and a relapse of leukaemia in 2 other patients. All these 4 patients had an increase in the CD8bright+ CD28- T lymphocytes.

RU 41 740 (Biostim) and IL-4, or IL-13, have opposite effects on CD14, CD23, HLA-DR and HLA-DQ on monocytes.

RU 41 740 (Biostim) is a glycoprotein extract obtained from Klebsiella pneumoniae. Its immunostimulating properties on monocytes have been established in vivo and in vitro. To confirm its spectrum of action at molecular level we studied its role on the modulation of four molecules involved in antigen presentation (HLA-DR, HLA-DQ), uptake of endotoxin (CD14) and activation (CD23). These four molecules are known to be modulated by interleukins IL-4 and IL-13. We found that HLA-DR, HLA-DQ, CD14 and CD23 were differentially regulated by biostim and IL-4 or IL-13. Surprisingly, Biostim inhibited the IL-4 or IL-13-induced expression of CD23, HLA-DQ and HLA-DR, while it did not have any action on these molecules by itself. We therefore hypothesize that Biostim, through the action on its receptor, could interact with the IL-4 receptor and IL-13 receptor and/or inhibit the IL-4 and IL-13 receptor transducing signal.

Allogenic BMT in children: differential lymphocyte subset reconstitution according to the occurrence of acute GVHD.

To acquire some biological markers associated with the occurrence of acute graft-versus-host disease (aGVHD) after allogeneic bone marrow transplant (BMT) in children, we have studied the lymphocyte subset reconstitution and the percentage of peripheral blood mononuclear cells bearing HLA-DR and HLA-DQ class II molecules. This study included 37 allogeneic BMT: either with (n = 17) or without (n = 20) aGVHD. Within 2 months after transplantation, we observed that patients with aGVHD had a unique mononuclear cell profile characterized by (i) a significant increase in the percentages of CD8bright+CD28- T cells (P = 0.05) and CD3+ T cells (P = 0.001), (ii) an important decrease in the percentage of CD56+ cells (P = 0.0001), and (iii) a decrease in the percentages of HLA-DQ+ and HLA-DR+ monocytes (P = 0.001) and HLA-DQ+ T lymphocytes (P = 0.0001), in comparison with patients without aGVHD. Moreover, statistical studies indicate that there was a positive correlation between CD8bright+CD28- and CD3+ T cells, whereas CD3+ T cells were negatively correlated to CD56+ cells. We did not find any statistical correlation between the percentages of HLA-DQ+ or HLA-DR+ cells and the percentages of these lymphocyte subsets. Therefore, in this study done in children, we suggest that patients with (i) less than 20% of DQ+ monocytes, (ii) less than 25% of CD56+ lymphocytes, and (iii) an enhanced percentage of CD8bright+CD28- T cells are strongly associated with aGVHD. Unfortunately, these biological markers of a GVHD may not precede the clinical manifestations of the disease.

Immotile cilia syndrome: nasal mucociliary function and nasal ciliary abnormalities.

We present 17 patients with a typical symptomatology of immotile cilia syndrome, seven of them with complete situs inversus. Firstly, a study of the nasal mucociliary transport was made by means of the radioisotopic technique with serum albumin-Tc99m. In all cases there was absence of transport. Secondly, we studied the ultrastructure of the nasal cilia. Defects in the dynein arms were frequently found (65%). In two cases (11%) there were no cilia; in two other cases the cilia were normal, and in another two cases alterations of the central pair of microtubules were seen. Ciliary complexes were detected in all cases. We conclude that in patients with chronic or recurrent infections of the airways without known cause we must initiate a study of the nasal mucociliary transport. If this is absent or decreased, study of ciliary ultrastructure should be carried out. If mucociliary transport is normal, immotile cilia syndrome is ruled out and ultrastructural study of the cilia is not required.

A high percentage of HLA-DQ+ and HLA-DR+ mononuclear cells is associated with a low incidence of acute graft-versus-host disease after allogeneic bone marrow transplantation (BMT) in children.

In order to discover some biological markers of acute graft-versus-host disease (aGVHD), we have studied the percentage of peripheral monocytes and T lymphocytes bearing HLA-DR and HLA-DQ class II molecules. This study included 25 allogeneic BMT in children, either with (n = 10) or without (n = 15) aGVHD. Within 2 months after transplantation, a higher percentage of DQ+ and DR+ monocytes and of DQ+ T lymphocytes was observed in patients without aGVHD compared with patients with aGVHD. The most discriminating marker was the strong increase in the percentage of DQ+ monocytes in patients without aGVHD (P = 0.001). In a sequential study, we observed a low percentage of DQ+ and DR+ peripheral blood mononuclear cells (PBMC) as long as the clinical manifestations of aGVHD continued. We speculate if the modulation of DQ and DR molecules on PBMC after BMT is a consequence of the action of some lymphokines, and if it plays a role in the regulation of the acute GVH reaction. We conclude that MHC class II molecules on peripheral mononuclear cells may be reliable biological markers for the diagnosis of aGVHD.

Laryngeal mucociliary transport: normal values and under the influence of anesthetics. An experimental study in rabbits.

The larynx is the point of confluence of all tracheobronchial secretions and of the particles trapped within them. A study is made of laryngeal mucociliary transport using charcoal particles in 8 anesthetized rabbits and in 8 more during the immediate postmortem period. Most secretions were found to reach the posterior commissure, and were then swallowed. In the immediate postmortem rabbits, mucociliary transport velocity was 3.59 +/- 1.23 mm/min., with a transport time of 4.62 +/- 1.5 min. In the 8 rabbits anesthetized with droperidol, diazepam and thiobarbital, transport was found to be significantly slowed (p = 0.001).

[Study of the vestibulospinal reflex. Clinical applications of posturography]. / Estudio del reflejo vestibuloespinal. Aplicaciones clínicas de la posturografía.

The vestibulo-spinal reflex is of great importance in maintaining balance--hence the interest in evaluating it objectively in patients suffering from vertigo. A review is made of the objective exploratory methods currently available, i.e., static posturography, stimulation posturography, dynamic posturography and craneocorpography. The clinical applications of posturographyare discussed, fundamentally as applied to the diagnosis of central vestibular pathology, treatment planning and evolutive monitoriacion of the patient with vertigo.

Prognostic value of histopathological parameters in 51 supraglottic squamous cell carcinomas.

The prognosis for supraglottic squamous cell carcinomas is difficult to establish. A study of 19 histopathological parameters (14 from the primary tumor and 5 from the lymph node metastases) was undertaken in 51 supraglottic epidermoid carcinomas. All patients were subjected to supraglottic horizontal laryngectomy with bilateral functional neck dissection and postoperative radiotherapy. A discriminant analysis was performed to relate the different histopathological variables to 5-year survival. Capsule rupture and the number of metastatic lymph nodes were the only two parameters significantly related to survival (P < .01). Histopathology (in particular, lymph node metastases) proved more effective in predicting patient evolution than TNM staging.

[Kniest syndrome. An audiological study]. / Síndrome de kniest. Estudio audiológico.

In this syndrome there is a disproportionate dwarfism with kyphoscoliosis, stiffness of the joints, minor facial dysmorphia, myopia and both conductive and sensorineural deafness in 50 percent of patients. It is a dominant autosomic heritable malady of unknown incidence, but both sexes seems equally affected. The patient's condition is diagnosed at birth, because of the short limbs and the enlargement of the joints. In the presented case, diagnosed at birth, the deafness was suppose to be transmissive, owing to the coexistence of a cleft palate, and consequently a grommet was inserted in the tympanum. Only afterwards, when the girl was 12 years old, the cochlear component of the hypoacusis fell in consideration.

[Melanoma of the nasal cavity]. / Melanoma de fosa nasal.

Presenting a case of nasal Melanoma, in a patient previously diagnosed and treated from Rhabdomyosarcoma of the same nasal cavity. In our Department has been treated with surgery plus thymostimulin (TP-1 Serono) after surgery. Subject reviewed and clinic features, diagnostic difficulties and nowadays immunotherapy commented.