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To: Bluegreen who wrote (9386)	3/27/1999 3:04:00 PM
From: Bluegreen	Respond to of 17367

Genetic basis for biosynthesis, structure, and function of meningococcal lipooligosaccharide. Kahler CM, Stephens DS Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, Atlanta, GA 30303, USA. The exclusive human pathogen Neisseria meningitidis expresses lipooligosaccharide (LOS), an endotoxin that is structurally distinct from the lipopolysaccharides (LPS) of enteric Gram-negative bacilli. Differences that appear to be biologically important occur in the composition and attachment of acyl chains to lipid A, phosphorylation patterns of lipid A, and the incorporation and phosphorylation of sugar residues in the LOS inner core. Further, unlike most enteric LPS, only two to five sugar residues are attached to the meningococcal LOS inner core, and there are no multiple repeating units of O-antigens. In contrast to Escherichia coli, where the LPS biosynthesis genes are organized as large operons, the meningococcal LOS biosynthesis genes are organized into small operons or are located individually in the chromosome. Some of these genetic loci in meningococci and gonococci display polymorphisms caused by localized chromosomal rearrangements. One mechanism of antigenic variation of meningococci LOS is the regulation of glycosyltransferase activity by slipped strand mispairing of homopolymeric tracts within the 5' end of the genes encoding these enzymes, resulting in the addition of different sugar residues to the LOS molecule. Meningococcal LOS is a critical virulence factor in N. meningitidis infections and is involved in many aspects of pathogenesis, including the colonization of the human nasopharynx, survival after bloodstream invasion, and the inflammation associated with the morbidity and mortality of meningococcemia and meningitis. Meningococcal LOS, which is a component of serogroup B meningococcal vaccines currently in clinical trials, has been proposed as a candidate for a new generation of meningococcal vaccines. The rapidly expanding knowledge of the genetic basis for biosynthesis, structure, and regulation of meningococcal LOS provides insights into unique endotoxin structures and the precise role of LOS in the pathogenesis of meningococcal disease.

To: Bluegreen who wrote (9386)	3/27/1999 3:07:00 PM
From: Bluegreen	Respond to of 17367

Adverse outcomes of managed care gatekeeping. Young GP, Lowe RA Emergency Department, Sacred Heart Medical Center, Eugene, OR 97401, USA. OBJECTIVES: To determine whether telephone preauthorization for reimbursement of ED care (medical "gate-keeping") by managed care organizations (MCOs) is associated with adverse outcomes. METHODS: A structured review was performed of case reports solicited during 1994 and 1995 with possible adverse outcomes related to managed care gatekeeping. Gatekeeping was defined as the requirement imposed by an MCO that ED staff contact on-call gatekeepers (i.e., clinical or nonclinical MCO personnel) to request preauthorization for ED treatment (a requirement that such MCOs enforce by refusing payment for the ED care unless preauthorization is obtained). Cases in which gatekeeper denial of preauthorization occurred were sought. Two physicians agreed on patient eligibility and classification criteria, then independently, retrospectively classified case reports identified as MCO ED payment denials into 1 of 4 categories: 1) adverse outcome; 2) patient placed at increased risk of death or disability; 3) "near miss" (emergency physicians prevented adverse outcome by caring for patient despite denial); and 4) none of the above. RESULTS: Of the 143 cases reviewed, 29 reports represented MCO ED payment denial. Of these 29 eligible cases, there were 4 (14%) patients with adverse outcomes, 4 (14%) patients placed at increased risk, and 21 (72%) near misses. All of the 29 cases came from different EDs, representing 9 different states, with the majority from California. Adverse outcomes included respiratory failure from fulminant meningococcemia, hypovolemic syncope from ruptured ectopic pregnancy, hypovolemic arrest from vascular fibroid hemorrhage necessitating emergency hysterectomy, and prolonged postoperative course following ruptured duodenal ulcer. Patients placed at increased risk were diagnosed as having epiglottitis, myocardial infarction, ruptured ectopic pregnancy, and delayed treatment of hip septic arthritis. Near misses included diagnoses of ectopic pregnancy (n = 2), pneumothorax (n = 2), alcohol withdrawal seizures and pancreatitis necessitating intensive care unit admission, appendicitis, bacterial meningitis, cerebrovascular accident, cryptococal meningitis in immuno comprised host, endocarditis, incarerated inguinal hernia, meningocococemia, meninoccocal meningitis, peritonsillar abscess, pneumococcal meningitis, ruptured abdominal aortic aneurysm, shock from gastrointestinal bleeding, small bowel obstruction, schizophrenic crisis resulting in psychiatric hospitalization, suicidal depression resulting in psychiatric hospitalization, and unstable angina. CONCLUSION: Adverse outcomes occur with MCO gatekeeping, Although the present study cannot ascertain whether this is a frequent event or a rare one, the safety of MCO gatekeeping deserves further study.