Impact of the fetal fibronectin assay on admissions for preterm labor

OBJECTIVE

The aim of the study was to determine whether use of the fetal fibronectin assay would decrease the number of admissions to labor and delivery for diagnosis and treatment of preterm labor.

STUDY DESIGN

A prospective cohort design was used to compare preterm labor admissions during a 12-month period of fetal fibronectin assay use (study) against a baseline period before fetal fibronectin assay was implemented as standard protocol. Patients coming to the physician's office or hospital with signs and symptoms of preterm labor had a sample obtained for fetal fibronectin assay per labeling criteria. Comparisons were made with the Mann-Whitney U test, independent Student t test, chi2 test, and Fisher exact test. P <.05 was considered significant.

RESULTS

There was no difference noted in the number of deliveries between the baseline and study years. During the study year 251 of 330 patients evaluated for preterm labor met study criteria and had the fetal fibronectin assay completed. Eight patients did not have fetal fibronectin assay results available because of specimen handling errors, leaving 243 subjects available for study. Compared with the baseline year, the study year had significantly fewer admissions for preterm labor, preterm labor admissions per patient, and prescriptions written for tocolytic agents. In addition, the length of stay per admitted patient was significantly reduced. The study population had no differences in neonatal outcomes from the baseline population in terms of deliveries at <35.0 weeks' gestation, number of admissions to the neonatal intensive care unit, neonatal intensive care unit length of stay, or days of ventilatory support per patient admitted to the neonatal intensive care unit.

CONCLUSIONS

Use of the fetal fibronectin assay resulted in significantly reduced preterm labor admissions, length of stay, and prescriptions for tocolytic agents. No negative impact on neonatal outcomes was observed. Reductions in admissions for preterm labor and in charges per admission resulted in approximately $486,000 saved during the study period. A trend toward increased corticosteroid administration (for neonates ultimately admitted to the neonatal intensive care unit) was noted.

High throughput liquid chromatography/mass spectrometry bioanalysis using 96-well disk solid phase extraction plate for the sample preparation

The 96 well solid phase extraction (SPE) operated by robot in the LC/MS/MS bioanalysis offered rapid sample preparation for drugs and metabolites in biological matrices, based on simultaneous extraction of 96 samples. The use of a disk as sorbent in the 96 well plate further improved the performance of SPE and allowed for small elution volumes, making it possible to 'dilute and shoot" after SPE elution. In this study, a 96 well plate (Empore) was developed, characterized and optimized for several pharmaceutical compounds. In addition, a robot (MultiProbe) was modified to automate the 96 well plate operation. Examples were given to illustrate the major differences of using 96 well disk plate SPE in the method development as compared to the traditional SPE. This technology has been successfully used to support many clinical studies. Typically, a batch of 96 samples were prepared in 1-1.5 hours unattended (except for the replacement of a collection plate). Considerable savings in disposable supplies were also noted.

Cord blood mononuclear cell transformation assay for screening for the presence of Epstein-Barr virus

EBV-induced lymphoproliferative disease (EBV-LPD) is a serious and potentially fatal complication following stem cell transplantation. Strategies have been developed for the cultivation of donor-derived, EBV-specific cytotoxic T lymphocytes (CTL) for stem cell transplant (SCT) patients affected with these disorders, using donor-derived, EBV-transformed B lymphoblastoid cell lines (BLCL) as stimulators. Although cultivation of EBV-transformed BLCL is possible without using an exogenous source of EBV, transformation of autologous B cells with endogenous virus may be slow and inconsistent. Therefore, if exogenous strains of EBV are used to generate BLCL, it may be beneficial to patients to ensure that these cell lines are not producing virus that potentially could be conveyed at the time of CTL infusion. A reliable method of screening for EBV using a cord blood transformation assay has been developed and is described.

Determination of SR 49059 in human plasma and urine by LC-APCI/MS/MS

SR 49059 ((2S 1-[(2R 3S)-5-chloro-3-(2-chlorophenyl)-1-(3, 4-dimethoxybenzene-sulfonyl)-3-hydroxy-2,3-dihydro-1 H-indole-2-carbonyl]-pyrrolidine-2-carboxamide) is an orally active non-peptide vasopressin V1a antagonist. A sensitive, selective, and robust LC-MS/MS method was developed to determine the plasma and urine concentrations of SR 49059 in support of clinical studies. Plasma samples were prepared based on a rapid extraction procedure using Chem Elut cartridges. The extracted samples were analyzed on a C18 HPLC column interfaced with a Finnigan TSQ 700 mass spectrometer. Positive atmospheric chemical ionization (APCI) was employed as the ionization source. The analyte and its internal standard (2H6-SR 49059) were detected by use of multiple reaction monitoring (MRM) mode. The plasma matrix had a calibration range 0.2-20 ng ml-1, with within and between run accuracy and precision both less than 10%. The chromatographic run time was approximately 3 min. Urine samples were prepared based on a simple dilution with water, followed by analysis under the same conditions as plasma. The calibration range for urine matrix was 20-5000 ng ml-1, with within and between run accuracy and precision less than 11%. The method has been successfully applied to the clinical sample analysis. The plasma assay was also evaluated on a Finnigan TSQ 7000 mass spectrometer. The performance based on precision and accuracy was virtually identical to that on the TSQ 700, with the exception of linearity in calibration curve (the TSQ 700 was linear, the TSQ 7000 was quadratic).

Community action for health promotion: a review of methods and outcomes 1990-1995

OBJECTIVE

Our objective was to explore the effectiveness of community action as a strategy for health promotion, through a critical review of five years of community action evaluation literature.

METHODS

Community action was defined as a health promotion, program that involved the community in implementation and control of the process of the program. Criteria for scientific evaluation of programs were proposed for sampling and control procedures, reliability and validity of instruments, analysis techniques, and specification of details of the intervention. A critical review of the literature, located by an on-line and related reference search, was undertaken for community action aimed at reducing cancer and cardiovascular disease, between January 1990 and May 1995.

RESULTS

None of seven community action studies (17 articles) that examined cancer risk factors fulfilled all the criteria for rigorous scientific evaluation. The most methodologically adequate cancer study, the COMMIT intervention, had only a moderate degree of success in reducing community smoking rates. Similarly, none of the six studies (25 articles) on cardiovascular disease fulfilled all the criteria. The results for the most methodologically adequate study, the Minnesota Heart Health Program, were disappointing, with strong secular trends preventing adequate assessment of the intervention effect.

CONCLUSIONS

The finding that none of the reviewed studies met all evaluation criteria was due to several factors, including political considerations, feasibility, and the continued evolution of the science of evaluation in health promotion. Some important questions are posed for researchers by the failure of methodologically superior projects, such as COMMIT, to show major gains in reducing health risk behaviors.

Distribution of growth-associated class I alpha-tubulin and class II beta-tubulin mRNAs in adult rat brain

A comprehensive survey of class I alpha-tubulin (alpha 1) and class II beta-tubulin (beta II) mRNAs was performed using in situ hybridization in order to determine the extent of continued expression of these immature tubulin isotype mRNAs in the adult rat brain. Qualitatively similar distributions of the two isotype mRNAs were observed, with marked variations in hybridization intensity of both probes apparent across different brain regions. Neurons in a wide variety of structures throughout the brain exhibited intense hybridization signals. While the presence of large numbers of neurons with a moderate hybridization intensity could account for the relatively high level of total binding in some regions such as the cerebellar and dentate granule layers, in most cases higher regional mRNA levels reflected greater hybridization intensity per neuron. Little variability in hybridization intensity was typically seen between individual cells within specific nuclei throughout the brain. The presence of occasional intensely labeled neurons scattered throughout the basal ganglia provided the most striking exception to this pattern. While no qualitative differences between the distributions of alpha 1-tubulin and beta II-tubulin mRNAs were observed, consistent differences in the relative intensity of hybridization for alpha 1-tubulin versus beta II-tubulin mRNA were apparent in a few brain regions. Expression by glia did not appear to contribute significantly to detectable levels of either alpha 1-tubulin or beta II-tubulin mRNA. These findings suggest that continued expression of growth-associated tubulin isotype mRNAs may have functional significance in specific neuronal populations of the adult brain. Partial overlap between the distributions of alpha 1- and beta II-tubulin mRNAs and that of GAP-43 mRNA is discussed, as are potential roles for growth-associated tubulin gene expression in supporting cytoskeletal turnover, reactive axonal growth, and dendritic remodeling in the adult brain.

Coordinated upregulation of alpha 1- and beta II-tubulin mRNAs during collateral axonal sprouting of central peptidergic neurons

An in situ hybridization study was performed to determine the relationship between levels of mRNAs for the axonal growth-associated alpha 1-tubulin and beta II-tubulin isotypes and the process of collateral axonal sprouting by identified central nervous system (CNS) neurons. A unilateral hypothalamic knife-cut was used to hemisect the hypothalamoneurohypophysial tract, which results in a robust collateral sprouting response by the uninjured neurons of the contralateral supraoptic nucleus (SON) (Watt and Paden: Exp Neurol 111:9-24, 1991). At 10 and 30-35 days after the lesion, cryosections of the SON were obtained and hybridized with 35S-labeled cDNA probes specific to alpha 1- and beta II-tubulin mRNAs. Quantitative evaluation of the resulting autoradiographs revealed that alpha 1-tubulin mRNA levels were significantly increased by 10 days in SON neurons that were undergoing collateral sprouting compared to controls and that this increase was sustained at 30-35 days post-lesion. Less marked increases in hybridization intensity of the beta II-tubulin probe were also apparent in sprouting neurons at both 10 and 30-35 days after the lesion, but were statistically significant only at 10 days. The measured increases in intensity of hybridization of alpha 1- and beta II-tubulin probes are likely to be conservative estimates of the underlying increase in alpha 1- and beta II-tubulin mRNA levels because sprouting SON neurons undergo significant hypertrophy. High levels of both alpha 1- and beta II-tubulin mRNAs were also seen in surviving axotomized SON neurons ipsilateral to the hypothalamic lesion. We conclude that the pattern of regulation of alpha 1- and beta II-tubulin mRNAs in CNS neurons which are capable of supporting new axonal growth includes three elements: maintenance of significant basal alpha 1- and beta II-tubulin mRNA pools in mature neurons, rapid increases in the pool size of the mRNAs following stimulation of collateral sprouting, and sustained elevation of mRNA levels during the period of axonal sprouting.

Rapid assay for gamma-aminobutyric acid in mouse brain synaptosomes using gas chromatography-mass spectrometry

A sensitive and efficient assay for gamma-aminobutyric acid (GABA) was applied to fresh mouse whole brain synaptosomes where the extracted GABA was analyzed as its di(tert.-butyl(dimethylsilyl)) derivative by gas chromatography-mass spectrometry (GC-MS) using GABA-d6 as an internal standard. Endogenous levels of 20.01 +/- 0.75 nmol GABA/mg protein were found. The method is characterized by a detection limit of about 10 fmol injected GABA derivative and coefficients of intra-day and inter-day variation of 0.95% and 7.7%, respectively. The rate of synaptosomal GABA synthesis was used to determine the activity of glutamate decarboxylase (GAD) as 314.9 +/- 9.0 nmol GABA/mg protein/h. Both GABA levels and GAD activity were significantly elevated by therapeutic doses of the antiepileptic drug valproic acid.

Partnering. A cooperative approach to dietary procurement

The Toledo Hospital has initiated many innovative quality programs. One initiated with the dietary department involved turning its wholesaler into a partner to provide better-quality products, lower costs and better service. Specific requirements were established in each of these areas including guaranteed mark-ups, price caps and performance reports. The hospital and the wholesaler also do joint negotiating with product manufacturers. Through these and other strategies, the hospital has reduced purchase prices for food items by over 4%, drastically reduced administrative costs of procurement and lead time, increased inventory turns to over 80 and given the dietary department a single resource for "one stop shopping."

Negative affect, absorption, and immunity

Relationships between the psychological characteristics absorption and neuroticism, and in vitro and in vivo measures of cell-mediated immunity were examined. Thirty-nine female subjects responded to questionnaires, donated blood for analysis of T-cell numbers, and were tested for delayed hypersensitivity skin responses. Consistent with the experimental hypothesis, subjects classified as repressors of negative affect (low absorption/low neuroticism), or extreme expressors of negative affect (high absorption/high neuroticism), showed lower immune responses than other groups of subjects. For the in vitro T-cell measures and the in vivo skin induration measures, there were also pervasive main effects of neuroticism, with subjects higher in neuroticism showing higher immunity than subjects lower in neuroticism.

Customer satisfaction planning and industrial engineering move hospital towards in-house stockless program

By integrating customer satisfaction planning and industrial engineering techniques when examining internal costs and efficiencies, materiel managers are able to better realize what concepts will best meet their customers' needs. Defining your customer(s), applying industrial engineering techniques, completing work sampling studies, itemizing recommendations and benefits to each alternative, performing feasibility and cost-analysis matrixes and utilizing resources through productivity monitoring will get you on the right path toward selecting concepts to use. This article reviews the above procedures as they applied to one hospital's decision-making process to determine whether to incorporate a stockless inventory program. Through an analysis of customer demand, the hospital realized that stockless was the way to go, but not by outsourcing the function--the hospital incorporated an in-house stockless inventory program.

Cost offset from a psychiatric consultation-liaison intervention with elderly hip fracture patients

OBJECTIVE

The authors hypothesized that psychiatric liaison screening of elderly patients with hip fractures would shorten the average length of hospital stay and increase the proportion of patients who returned home after discharge.

METHOD

The study was performed at Mount Sinai Medical Center in New York and Northwestern Memorial Hospital in Chicago. The subjects were 452 patients 65 years or older who were consecutively admitted for surgical repair of fractured hips. During a baseline year the patients received traditional referral for psychiatric consultation. During the experimental year all the patients at Mount Sinai and the patients on one Northwestern Unit were screened for psychiatric consultation.

RESULTS

The patients who received psychiatric liaison screening had a higher consultation rate than those who received traditional consultation. The rates of DSM-III disorders in the experimental year were 56% at Mount Sinai and 60% at Northwestern. The mean length of stay was reduced from 20.7 to 18.5 days at Mount Sinai and from 15.5 to 13.8 days at Northwestern, resulting in reductions in hospital costs ($647/day) of $166,926 and $97,361, respectively. Fees generated from Medicare service delivery could have paid for the $20,000 psychiatric intervention cost at each site. There was no difference, however, between the two years in the discharge placement of patients.

CONCLUSIONS

Admission psychiatric liaison screening of elderly patients with hip fractures results in early detection of psychiatric morbidity, better psychiatric care, earlier discharge, and substantial cost savings to the hospital.

Possible impairment of the sympathetic nervous system response to postprandial hypotension in elderly hypertensive patients

In a randomised, single-blind, cross-over study, the effects of a high carbohydrate meal or 'no meal' on BP, pulse rate, blood glucose, plasma insulin and catecholamine levels were assessed in eight fit, untreated, elderly hypertensive subjects. A significantly greater fall in supine (P = 0.006) and erect (P = 0.03) systolic blood pressure (SBP) occurred post-meal compared with the no meal phase. The maximum postprandial fall in supine SBP (-24 mmHg, 95% CI -16 to -32 mmHg) occurred at 60 minutes and was associated with a significant rise in supine pulse rate. No overall difference in diastolic BP was seen between the two phases and orthostatic control of BP was maintained. Blood glucose and plasma insulin levels rose after the meal but plasma noradrenaline levels were unchanged during both phases. Thus in these elderly hypertensive subjects the postprandial fall in SBP was not associated with an overall increase in sympathetic nervous system (SNS) activity (as gauged by plasma noradrenaline levels), unlike the findings previously reported in normotensive elderly and young subjects. These changes in BP and the possible impairment of the SNS response to postprandial hypotension should be considered when assessing the BP control, particularly after therapeutic intervention, in elderly hypertensive patients.

Tamoxifen and partial oestrogen agonism in postmenopausal women

The effect of tamoxifen on the vaginal mucosa and on serum oestrone, oestradiol and gonadotrophin concentrations was investigated in a group of nine postmenopausal women with non-metastatic breast cancer. Compared with fit age-matched controls, the vaginal pH in the tamoxifen-treated group was significantly lower and was comparable to levels in fertile women. Two thirds of tamoxifen-treated women had well oestrogenized vaginal smears compared with none in the control group. Follicle-stimulating hormone was significantly reduced, whilst oestrone and oestradiol levels remained unchanged. We conclude, therefore, that tamoxifen has oestrogen-agonistic properties particularly evident in postmenopausal women, even though it is primarily an antioestrogenic drug.

St Mary's Hospital, Isle of Wight: a suitable background for caring

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Identification of the biliary metabolites of (+/-)-3-dimethylamino-1,1-diphenylbutane HCl (recipavrin) in rats

1. The in vivo biliary metabolites of (+/-)-3-dimethylamino-1,1-diphenylbutane hydrochloride (recipavrin) isolated from Wistar rats have been characterized by g.l.c.-mass spectrometry. 2. Non-conjugated metabolites include recipavrin (1), norrecipavrin (2), diphenylbutanone (3), diphenylbutanone oxime (4), diphenylbutanone phenol (12), diphenylbutanone oxime phenol (14), recipavrin phenol (19), diphenylbutanone O-methylcatechol (16) and diphenylbutanone oxime O-methylcatechol (18). 3. Following beta-glucuronidase hydrolysis and extraction from pH 10 solution, diphenylbutanone (3), diphenylbutanone oxime (4), an unidentified compound (6), primary amine (8), norrecipavrin (2), recipavrin (1), phenols (12, 14, 15), norrecipavrin phenol (13), O-methylcatechols (16, 18), diphenylbutanol O-methylcatechol (17), recipavrin O-methylcatechol (19) and a secondary formamide (5) were identified by g.l.c.-mass spectrometry. 4. Various extraction solvents were employed in sample workup. The formamide (5) was present regardless of solvent used, while the trace presence of secondary acetamide (7) may be associated with the use of ethyl acetate. 5. Metabolites isolated after beta-glucuronidase hydrolysis were characterized by g.l.c.-mass spectrometry of the underivatized form, and as the trimethylsilyl (TMS) derivatives, or following methylation with diazomethane or trimethylanilinium hydroxide (TMAH).

Knowledge and use of postcoital contraception: a survey among health professionals in Tower Hamlets

The knowledge and estimated retrospective use of postcoital contraception was ascertained from health professionals in Tower Hamlets in the summer of 1988 using a postal questionnaire. Eighty five per cent of general practitioners responded and 91% of these had received requests for postcoital contraception within the previous six months. Only one third of general practitioners had information about postcoital contraception available in their surgeries. Family planning doctors and nurses had the most accurate knowledge of the method but many health professionals appeared to lack sufficient knowledge to ensure appropriate prescribing and to publicize this method to their women patients. It is concluded that if the high rate of abortion in the borough is to be reduced, health professionals as well as women need to be further educated as part of a postcoital contraception publicity campaign. Use of the term 'emergency contraception' rather than the non-medical term 'the morning after pill' may be more effective and reduce the present confusion among both groups.