Protein-only nanocapsules induce cross-presentation in dendritic cells, demonstrating potential as an antigen delivery system.

Templating has been demonstrated to be an efficient method of nanocapsule preparation. However, there have been no reports of using protein-only nanocapsules as an antigen delivery system. Such a system would enable the delivery of antigen without additional polymers. This study focused on defining the structural and cellular characteristics of nanocapsules consisting of antigen (ovalbumin) alone, synthesized by the templating method using highly monodispersed solid core mesoporous shell (SC/MS) and mesoporous (MS) silica nanoparticles of 410 nm and 41 nm in diameter, respectively. The synthesized ovalbumin nanocapsules were homogeneous in structure, and cellular uptake was observed in DC2.4 murine immature dendritic cells with minimal cytotoxicity. The nanocapsules were localized intracellularly and induced antigen presentation by the cross-presentation pathway. The templating system, using SC/MS and MS silica nanoparticles, was demonstrated to be an effective nanocapsule synthesis method for a new antigen delivery system.

Seafood allergy: A comprehensive review of fish and shellfish allergens.

Seafood refers to several distinct groups of edible aquatic animals including fish, crustacean, and mollusc. The two invertebrate groups of crustacean and mollusc are, for culinary reasons, often combined as shellfish but belong to two very different phyla. The evolutionary and taxonomic diversity of the various consumed seafood species poses a challenge in the identification and characterisation of the major and minor allergens critical for reliable diagnostics and therapeutic treatments. Many allergenic proteins are very different between these groups; however, some pan-allergens, including parvalbumin, tropomyosin and arginine kinase, seem to induce immunological and clinical cross-reactivity. This extensive review details the advances in the bio-molecular characterisation of 20 allergenic proteins within the three distinct seafood groups; fish, crustacean and molluscs. Furthermore, the structural and biochemical properties of the major allergens are described to highlight the immunological and subsequent clinical cross-reactivities. A comprehensive list of purified and recombinant allergens is provided, and the applications of component-resolved diagnostics and current therapeutic developments are discussed.

Evolution of thyroid hormone distributor proteins.

Thyroid hormones (THs) are evolutionarily old hormones, having effects on metabolism in bacteria, invertebrates and vertebrates. THs bind specific distributor proteins (THDPs) to ensure their efficient distribution through the blood and cerebrospinal fluid in vertebrates. Albumin is a THDP in the blood of all studied species of vertebrates, so may be the original vertebrate THDP. However, albumin has weak affinity for THs. Transthyretin (TTR) has been identified in the blood across different lineages in adults vs juveniles. TTR has intermediate affinity for THs. Thyroxine-binding globulin has only been identified in mammals and has high affinity for THs. Of these THDPs, TTR is the only one known to be synthesised in the brain and is involved in moving THs from the blood into the cerebrospinal fluid. We analysed the rates of evolution of these three THDPs: TTR has been most highly conserved and albumin has had the highest rate of divergence.

Why the distribution of medical errors matters.

During the last decade, interventions to reduce the number of medical errors have been largely ineffective. Although it is widely assumed that medical errors follow a Gaussian distribution, they may actually follow a Power Rule distribution. This article presents the evidence in favor of a Power Rule distribution for medical errors and then examines the consequences of such a distribution for medical errors. As the distribution of medical errors has real-world implications, further research is needed to determine whether medical errors follow a Gaussian or Power Rule distribution.

The schizophrenia of physician extender utilization.

The Patient Protection and Affordable Care Act of 2010 provides incentives for healthcare to be delivered by Affordable Care Organizations (ACOs). The public face of many, if not most, ACOs is likely to be the Patient Centered Medical Home (PCMHs), a business structure that evolved from Retail Medical Clinics, which made greater use of physician extenders (PAs). Accordingly, this paper examines the evolution and structure of PCMHs as well as how the PCMH is regulated. As neither legal or market regulatory mechanisms are ideal for policing business structures that employ PAs, this paper concludes that the tort reform most appropriate for PCMHs is the introduction of either no-fault or enterprise liability coverage.

Investing in medical students: which ones are worth a surgeon's time?

BACKGROUND: Little information exists on which third-year medical students will become worthy protégés. METHODS: Performance and encounter metrics for 4 classes of medical students were correlated with the students who matched into a surgery residency. RESULTS: Overall, 68 of 422 (16%) graduating seniors matched into a surgery residency. Male students were twice as likely as female students to match in surgery were, and most (81%) matching students took their general surgery rotation at the university hospital. Students who took certain elective rotations (eg, urology and orthopedics) tended to enter those surgical professions. Grades, test scores, clinical performance, oral presentation skills, and encounter data were not predictive of which students would enter the surgical profession. CONCLUSION: For surgeons who are willing to mentor medical students, our data suggest that currently, the selection of medical students worthy of surgeon-mentor's time will remain an art.

The impact of provider-specific report cards on coronary artery bypass graft volume.

PURPOSE: Reporting states (RS) publish hospital-specific report cards for coronary artery bypass graft (CABG) (MS-DRG 235 and 236) surgery. When RS are compared with non-reporting states (NRS), do report cards influence the volume of CABG surgery performed? METHODS: Using publicly available Medicare data (hospitalcompare.hhs.gov) for CABG-only procedures, the volume of CABG procedures performed in RS (CA, MA, NJ, NYS, and PA) was compared with the volume of these procedures performed in NRS. RESULTS: In the continental US during the financial year 2008 a total of 41,589 Medicare patients underwent a CABG (33,318 CABGs in NRS versus 8,272 CABGs in RS). A similar percentage of states in each group regulated their markets with certificate-of need statutes (30% NRS versus 40% RS). Per million capita (pmc), the number of CABG providers in the two groups was similar with respect to hospitals (4.1±1.6 hospitals pmc in NRS versus 2.9±1.2 hospitals pmc in RS); cardiac surgeons (2.4±1.5 surgeons pmc in NRS versus 5.1±2.9 surgeons pmc in RS); and interventional cardiologists (ICs) (18.3±5.5 ICs pmc in NRS versus 21.2±5.0 ICs pmc in RS). However, pmc, NRS performed significantly more CABG procedures (152.0±62.6 CABGs pmc in NRS versus 113.8±31.6 CABG pmc in RS; p=0.05). CONCLUSIONS: States that publish hospital-specific report cards perform significantly fewer CABGs per capita than states without report cards. As the government's national hospital-specific report card becomes more popular, the per capita performance of CABGs in NRS could fall to the level found in RS due to the reputational incentives created by the use of hospital-specific report cards.

Will India set the price for teleradiology?

BACKGROUND: With a lower cost for labour, Indian teleradiologists have an absolute price advantage in the global market. However, because trade is determined by comparative advantage rather than absolute price advantage, India's ability to export teleradiology services may be limited. The issue is, can the 'India price' for teleradiology set the price for these services in the USA? METHODS: Review of the economic literature concerning the global teleradiology market. RESULTS: Currently, minimal information exists concerning the economic of global teleradiology market. However, a Ricardian analysis of this market suggests that India's ability to export teleradiology may be limited by rising opportunity costs (i.e. social unrest). Similarly, Heckscher-Ohlin analysis suggests that a lack of English-speaking physicians will limit India's ability to export teleradiology services to the USA. CONCLUSION: It appears unlikely that India will gain sufficient market share in the USA to determine the price of teleradiology services.

Heart hospitals, medicare, and cross-subsidization.

BACKGROUND: Compared with heart hospitals (HHs), does Medicare provide better reimbursement to traditional hospitals (THs)? METHODS: Diagnosis Related Group (DRG)-specific data from Hospital Compare (www.hospitalcompare.hhs.gov) were used to compare Medicare reimbursement to hospitals in nine HH markets, representing 10% of the national HH market. RESULTS: On average, markets contained 1.2 HHs and 8.1 THs. Average market size for invasive cardiac services was $13+/-8.4 million, with HHs having 36.1% of the market share. Compared with HHs, THs received significantly better reimbursement for coronary artery bypass graft (CABG: $20,281+/-3,047 HH versus $23,958+/-4,562 TH; p=0.004), percutaneous coronary intervention (PCI: $11,230+/-742 HH versus $13,347+/-2,662 TH; p<0.001), heart valve replacement ($33,710+/-4,056 HH versus $39,819+/-6,356 TH; p=0.001), pacemaker implantation ($11,245+/-706 HH versus $13,212+/-2,043 TH; p<0.001), heart failure ($5,622+/-489 HH versus $6,482+/-1,010 TH; p<0.001), chronic obstructive pulmonary disease (COPD: $4,893+/-802 HH versus $5,641+/-841 TH; p=0.013), pneumonia ($5,708+/-763 HH versus $6,456+/-1,136 TH; p=0.012), and diabetes ($4,115+/-355 HH versus $4,963+/-812 TH; p<0.001). CONCLUSIONS: The excessive reimbursement granted to THs for non-cardiac services is likely to reflect a policy decision to assist these hospitals with their cross-subsidization of other services. If Medicare is to cut reimbursement to TH for CABG, PCI, or other services, Medicare should be asked to pay more for the services (e.g. emergency room care) that it currently reimburses only indirectly through the process of cross-subsidization.

Hageseth's principle of extraterritorial jurisdiction and international telemedicine.

At what point does an international telemedicine transaction create a sufficient commercial nexus to allow one country the authority to impose its laws on a foreign telemedicine providers? Some light on this matter was shed by the US case of Hageseth versus Superior Court. The authority for extraterritorial jurisdiction is found in the US Constitution, which requires the states to cooperate in matters of law enforcement. Similar cooperation from foreign nations cannot be expected. Unless a defendant is charged with a capital offence, nations are rarely willing to extradite their citizens. As the unlicensed practice of medicine is not a capital offence, it is unlikely that an unlicensed telemedicine provider would be extradited to the US. Because low-volume unlicensed offshore telemedicine providers are unlikely to be extradited or to be subject to trade sanctions, they may be able to operate beyond the law.

Electronic medical record metadata: uses and liability.

BACKGROUND: Minimal information exists concerning the use and liability of electronic medical record (EMR) metadata. STUDY DESIGN: We performed a retrospective review of Vista Imaging (VI) metadata concerning when and which images residents and medical students on a surgery service actually visualized; and the laws governing e-discovery were reviewed. RESULTS: During a 5-month period, PGY III surgery residents logged in to VI 191+/-18.3 times; PGY II surgery residents logged in 164+/-34.3 times; and PGY I surgery residents logged in 92.0+/-14.8 times. Family practice residents logged in 21.0+/-4.6 times, and medical students logged in 32.0+/-5.7 times (p < 0.01). Surgery residents logged about once a day (1.0+/-0.06 log-ins/day); family practice residents (0.2+/-0.2 log-ins/day) and medical students (0.3+/-0.1 log-ins/day) logged about only once a week. CT scans were the most frequently viewed image: surgery residents viewed CT scans during 81.9+/-14.9% of Vista Imaging sessions to view 69.3+/-36.5 images (range 1 to 863 images); family practice residents viewed CT scans during 58.0+/-43.8% of Vista Imaging sessions to view 19.3+/-22.8 images (range 1 to 112 images); and medical students viewed CT scans during 89.8+/-30.3% of Vista Imaging sessions to view 24.4+/-6.3 images (range 1 to 95 images). Changes in the Federal Rules of Civil Procedure and the need to authenticate electronic medical records will mean more metadata will be discovered during litigation. CONCLUSIONS: Electronic medical records metadata allow for creation of detailed physician profiles and will likely be used increasingly to discredit physicians during medical malpractice litigation.