Applications of forensic identity testing in the clinical laboratory

DNA analysis is becoming routine in the clinical laboratory for the diagnosis of human diseases using various tissue sources. Most clinical specimens are followed by tracking forms that include patient demographic data, accession number, and date and time of collection. As part of a thorough quality assurance program, proper documentation of test requisitions and tracking forms is mandatory. Despite these efforts, specimen mislabeling or other mix-ups can, and do, occur. We demonstrate the utility of the PM + DQA1 typing kit and STR analysis using the Visible Genetics automated DNA sequencing system in the proper identification of such clinical specimens as urine, blood, and paraffin-embedded tissues. In each case, sufficient DNA was extracted from these specimen types using a nonorganic extraction protocol for typing purposes. We conclude that DNA typing methods are feasible for distinguishing clinical laboratory specimens of questionable identity and compliment existing quality assurance techniques.

The effect of augmentation with moclobemide on symptoms of schizophrenia

The effectiveness of adding moclobemide to antipsychotic treatment in schizophrenic patients with prominent negative symptoms was examined. Eleven chronic schizophrenic patients had their regular antipsychotic treatment augmented by the addition of moclobemide 450 mg/day for 8 weeks. A significant improvement was seen on the Positive and Negative Syndrome Scale (PANSS) negative factor and for the Scale for the Assessment of Negative Symptoms (SANS) scores, PANSS total score, PANSS general factor score and Hamilton Depression Scale scores. Positive symptoms were not altered. Moclobemide augmentation may ameliorate negative, depressive and general symptoms in schizophrenia.

Augmentation with fluvoxamine but not maprotiline improves negative symptoms in treated schizophrenia: evidence for a specific serotonergic effect from a double-blind study

There is considerable evidence that adding selective serotonin reuptake inhibitor (SSRI) antidepressants to antipsychotic treatment improves negative symptoms of schizophrenia. This augmentation effect may be due to "nonspecific" antidepressant action or be specifically related to action on the serotonergic system. This study examined the serotonergic specificity of SSRI augmentation by comparing an SSRI antidepressant with a comparably effective antidepressant acting via the noradrenergic system. Consenting patients having chronic schizophrenia with prominent negative symptoms were studied. Either fluvoxamine or maprotiline was added to their regular antipsychotic treatment in a double-blind manner for 6 weeks. Patients were assessed using the Brief Psychiatric Rating Scale, the Scale for the Assessment of Negative Symptoms, the Scale for the Assessment of Positive Symptoms, the Montgomery-Asberg Depression Rating Scale (MADRS), and the Neurological Rating Scale for Extrapyramidal Side Effects. Twenty-five patients completed the study. Negative symptoms improved significantly in the fluvoxamine group, but not in the maprotiline group. MADRS scores, which were low, did not change significantly in either group. Positive symptoms were not affected by either treatment. It is concluded that the mechanism by which fluvoxamine augmentation improves negative symptoms involves the serotonergic system and is distinct from its antidepressant action.

Kidney 11 beta-HSD2 is inhibited by glycyrrhetinic acid-like factors in human urine

We have previously shown that human urine contains substances that, like glycyrrhetinic acid, inhibit 11 beta-HSD1. We have named these substances "glycyrrhetinic acid-like factors" or GALFs. We now have found that human urine contains measurable quantities of both 11 beta(HSD1)- and 11 beta(HSD2)-GALF inhibitory substances. Both are markedly elevated in pregnancy. Their chemical and high-performance liquid chromatography (HPLC) characteristics suggest that several of the GALFs are steroidal. Large quantities of neutral 11 beta(HSD1)- and 11 beta(HSD2)-GALFs can be extracted directly from urine into ethyl acetate, yielding fraction EA1. Hydrolysis of the GALFs remaining in the aqueous phase by beta-glucuronidase markedly increases the total amounts of GALFs, with the majority now being ethyl acetate extractable (fraction EA2). These EA2 post-hydrolysis GALFs can be separated by HPLC resulting in at least six components with inhibitory activity against each isoenzyme. Only two GALF peaks are active against both 11 beta-HSD1 and 11 beta-HSD2. The others are peaks with specific 11 beta(HSD1)- and 11 beta(HSD2)-GALF inhibitory activity. The GALFs in the same posthydrolysis EA2 extract are also inhibitory toward the 11 beta-HSD1 that is present in vascular smooth muscle where they may play a role in the mechanisms controlling blood pressure. We have also found that 11 beta-HSD2 is selectively inhibited by 5 alpha- (but not by 5 beta-) reduced steroids. GC-MS analysis of the 11 beta(HSD2)-GALFs in EA2 is now being performed to determine whether this group includes 3 alpha,5 alpha-ring A-tetrahydro-reduced derivatives of steroids.

Dose ranging study of the oxytocin antagonist atosiban in the treatment of preterm labor. Atosiban Study Group

OBJECTIVE

To evaluate the minimal effective dose regimen of the oxytocin antagonist atosiban in the treatment of acute preterm labor and the effect of a bolus on uterine activity within the first 2 hours compared with no bolus and the same infusion rate.

METHODS

A randomized, double-blind (except the ritodrine group), parallel group, multicenter study compared four different intravenous atosiban regimens (6.5 mg bolus plus 300 micrograms/minute, placebo bolus plus 300 micrograms/minute, 2mg bolus plus 100 micrograms/minute, and 0.6 mg plus 30 micrograms/minute) and intravenous ritodrine with respect to the cessation of uterine contractions for 1 hour or more during infusion, four or fewer contractions per hour in the last hour of therapy, and discontinuation because of adverse experiences. Three hundred two patients were enrolled.

RESULTS

The lowest dose of atosiban (0.6 mg plus 30 micrograms/minute) was significantly less effective than ritodrine with respect to cessation of contractions and four or fewer contractions per hour in the last hour of therapy. Other atosiban regimens were comparable to ritodrine, except for the drug discontinuation rate for adverse experiences. Bolus therapy with high-dose atosiban resulted in a significantly greater proportion of patients who stopped contracting within the first 2 hours of treatment (17 of 63) compared with those not receiving a bolus (six of 58, P = .017). Because of adverse experiences, the study drug was discontinued in one of 244 atosiban patients and 15 of 58 ritodrine patients.

CONCLUSION

Atosiban's effect on uterine activity in preterm labor was enhanced by bolus infusion and was similar to the effect of ritodrine, but with fewer side effects.

Effects of fetal number and multifetal reduction on length of in vitro fertilization pregnancies

OBJECTIVE

To determine the effects of multifetal reduction and other variables on the duration of gestation of in vitro fertilization (IVF) pregnancies.

METHODS

All 274 IVF pregnancies from the inception of the Women and Infants' Hospital IVF Program on May 26, 1988, until December 31, 1993, were evaluated.

RESULTS

Spontaneous reduction occurred in ten pregnancies, and multifetal reduction was elected in 28 multiple gestations. Among 260 pregnancies that remained viable beyond 20 weeks, 162 singletons (37.9 +/- 0.29 weeks; mean +/- standard error) had a longer mean gestation than did 64 twins (34.6 +/- 0.61 weeks), 25 pregnancies reduced to twins (33.4 +/- 1.0 weeks), or nine triplets (29.7 +/- 1.9 weeks). Triplets delivered 4.9 weeks earlier than nonreduced twins (P < .05) and 3.7 weeks before twins resulting from multifetal pregnancy reduction (P < .05). Regression analysis showed that at the 8-week ultrasound, each viable fetus could be expected to reduce the duration of the gestation by about 3.6 weeks, and each fetus reduced medically or as a result of natural causes could be expected to prolong the gestation by approximately 3.0 weeks. Only 14% of triplet pregnancies underwent spontaneous multifetal reduction.

CONCLUSION

Multifetal reduction of pregnancies with three or more fetuses was beneficial and increased the duration of gestation.

Treatment of preterm labor with the oxytocin antagonist atosiban

The purpose of this study was to describe the course of preterm labor in patients receiving a standard intravenous infusion of the oxytocin antagonist atosiban. An open-labeled, non-randomized study was conducted at 4 sites. Successful tocolysis was defined as delay of delivery larger than 48 hours from starting atosiban and no need for an alternate tocolytic. Atosiban was administered by continuous intravenous infusion at a rate of 300 micrograms per minute until uterine contractions were absent for 6 hours, or up to a maximum infusion time of 12 hours. Sixty-two patients of between 20 and 36 weeks' gestation were enrolled over 6 months. One had rupture of membranes and was excluded. Successful tocolysis was noted in 43 of 61 (70.5%). Four delivered spontaneously within 48 hours and 14 (23.0%) required an alternate tocolytic agent. The chance of successful tocolysis was related to the degree of cervical dilation at the start of therapy. Cessation of uterine contractions was noted in 38 patients (62.3%). A decrease in uterine contraction frequency of 50% or more was noted in 50 of 61 patients (82.0%). Four patients reported side effects (nausea, vomiting, headache, dysguesia, chest pain), but in no case did side effects require discontinuation of the medication. Intravenous administration of atosiban is associated with a delay in delivery comparable to that seen with other tocolytics. If this effect is confirmed in planned placebo-controlled trials, its favorable side effect profile may give it a place in the armamentarium.

No difference in the effect of biperiden and amantadine on parkinsonian- and tardive dyskinesia-type involuntary movements: a double-blind crossover, placebo-controlled study in medicated chronic schizophrenic patients

BACKGROUND

There are few objective guidelines for the clinician in the choice of antiparkinsonian drugs, even though these drugs are a heterogeneous group. We compared the effect of biperiden (M1 selective anticholinergic) and amantadine (dopaminergic) on neuroleptic-induced parkinsonian extrapyramidal symptoms (EPS) and tardive dyskinesia (TD)-type involuntary movements.

METHOD

Thirty-two schizophrenic (DSM-III-R) inpatients on long-term stable antipsychotic and trihexyphenidyl treatment entered the study. Antipsychotics were kept constant, but trihexyphenidyl was replaced by placebo under single-blind conditions for 1 week, and the the patients were randomly assigned to either amantadine 100 mg b.i.d. or biperiden 2 mg b.i.d. treatment under double-blind conditions for 2 weeks. After a second 1-week placebo period, the test drugs were crossed over under double-blind conditions. Assessments of tardive dyskinesia (Abnormal Involuntary Movement Scale [AIMS]) and of parkinsonian extrapyramidal side effects (Simpson-Angus Neurologic Rating Scale) were made pretreatment and posttreatment.

RESULTS

Twenty-six patients completed all study procedures. Amantadine and biperiden were equally effective in relieving neuroleptic-induced EPS and did not exacerbate TD-type movements. AIMS scores during treatment were significantly lower than during placebo period. The findings were similar in patients with diagnosable TD.

CONCLUSION

Amantadine and biperiden have similar effects on neuroleptic-induced EPS and TD and may ameliorate mild TD.

Effects of biperiden and amantadine on memory in medicated chronic schizophrenic patients. A Double-blind cross-over study

BACKGROUND

The effects on memory of an anticholinergic (biperiden) and a dopaminergic (amantadine) anti-Parkinsonian agent were compared.

METHOD

Twenty-six chronically medicated schizophrenic (DSM-III-R) in-patients received amantadine (200 mg/day) or biperiden (4 mg/day) for two weeks in a double-blind cross-over design.

RESULTS

Biperiden treatment was associated with significantly lower scores on Benton Visual Retention Test (P < 0.003) and the visual subscale of Wechsler Memory Scale (WMS) (P < or = 0.02), with a trend to poorer scores on WMS total (P = 0.086) and the digit span (P = 0.07) and logical memory (P = 0.06) subscales.

CONCLUSIONS

In usual clinical doses, biperiden interferes with memory, particularly visual, more than amantadine.

Pretreatment with sedative-hypnotics, but not with nondepolarizing muscle relaxants, attenuates alfentanil-induced muscle rigidity

STUDY OBJECTIVE

To evaluate and compare the efficacy of various pretreatment agents to attenuate or prevent opioid-induced muscle rigidity using a well-established, previously described clinical protocol.

DESIGN

Prospective, controlled, single-blind, partially randomized study.

SETTING

Large medical center.

PATIENTS

ASA physical status I-III patients undergoing elective surgical procedures of at least 3 hours' duration.

INTERVENTIONS

The effect of pretreatment with nondepolarizing muscle relaxants (atracurium 40 micrograms/kg or metocurine 50 micrograms/kg), benzodiazepine agonists (diazepam 5 mg or midazolam 2.5 mg), or thiopental sodium 1 mg/kg on the increased muscle tone produced by alfentanil 175 micrograms/kg was compared with a control group (given no pretreatment).

MEASUREMENTS AND MAIN RESULTS

Rigidity was assessed quantitatively by measuring the electromyographic activity of five muscle groups (biceps, intercostals, abdominals, quadriceps, and gastrocnemius). Rigidity also was rated qualitatively by attempts to initiate and maintain mask ventilation, attempts to flex an extremity, and the occurrence of myoclonic movements. Pretreatment with the two nondepolarizing muscle relaxants had no effect on the severe muscle rigidity produced by high-dose alfentanil. Whereas thiopental was only mildly effective, the benzodiazepines midazolam and diazepam significantly attenuated alfentanil rigidity (p < 0.05).

CONCLUSION

This study suggests that benzodiazepine pretreatment is frequently, but not always, effective in preventing opioid-induced muscle rigidity.

Drug abuse in schizophrenia: comparison of patients who began drug abuse before their first admission with those who began abusing drugs after their first admission

The relationship between the onset of drug abuse and onset of illness (first hospitalisation) and its correlates were examined in 42 hospitalised schizophrenics identified as drug abusers. 60% of the patients began drug use before their first hospitalisation. No differences on sociodemographic or clinical parameters between patients who began drug use before their first hospitalisation and those who began after it were detected when drug abuse was treated as a unitary phenomenon. Use of specific drugs was associated with significant differences in age, age at first hospitalisation, premorbid functioning and type of schizophrenia between patients who began drug pre-morbidly and those who began to use drugs post-morbidly. The differences were not uniform for the different drugs used. The findings are discussed in relation to vulnerability and self medication models of comorbidity of drug abuse and schizophrenia.