Challenges that opioid-dependent women present to the obstetric anaesthetist

A retrospective casenote review was performed to identify anaesthetic challenges relevant to the opioid-dependent obstetric population. Medical records showed that of the 7,449 deliveries during a 24 month period, 85 women (1.1%) were taking regular opioids such as methadone and/or heroin. Of these 67 (79%) received anaesthetic services, ten of whom (11.7%) were referred antenatally. Forty opioid-dependent women (47%) received epidural analgesia in labour compared with the overall hospital rate of 38%. Twenty-three women (27%) delivered by caesarean section: five received general anaesthesia, five combined spinal anaesthesia, five spinal anaesthesia and eight epidural anaesthesia. Twenty opioid-dependent women (23.5%) had documented problems related to labour analgesia and 17 (74%) had problems with analgesia after caesarean section. A variety of postoperative analgesia methods were administered in addition to maintenance methadone. Fourteen patients (16.5%) had difficult intravenous access and seven "arrest" calls were documented. One anaesthetist was exposed to hepatitis C. This review demonstrates the demands placed on obstetric anaesthetic services by opioid-dependent women. Early antenatal referral for anaesthetic review is recommended.

Novel DNA sequence variants in the hHR21 DNA repair gene in radiosensitive cancer patients

PURPOSE

Radiation therapy is an important treatment modality for oncology patients. DNA sequence variants have so far been identified in only a few genes in radiosensitive cancer patients. Patients known to be clinically radiosensitive were tested for mutation of a gene involved in DNA double-strand break repair and sister chromatid cohesion--hHR21.

METHODS AND MATERIALS

Clinically radiation-sensitive patients were accrued to the study after giving informed consent. Blood samples were obtained and lymphoblastoid cell lines established. Reverse transcriptase-polymerase chain reaction (RT-PCR) was performed to amplify the hHR21 gene, and the DNA product was sequenced to identify any genetic abnormalities. Northern blot analysis, cell survival, and growth assays were performed on control cells and cells with hHR21 variants, and a restriction digest assay was developed to screen for carriers of a detected gene variant.

RESULTS

The DNA sequence of the hHR21 gene was determined in 19 radiation-sensitive cancer patients. In 6 of the 19 patients, a thymidine (T) to cytosine (C) transition was detected at position 1440 of the hHR21 open reading frame (T1440C). This variant did not alter the amino acid sequence and was likely to be a polymorphism. One patient with a particularly severe radiation reaction had a second sequence variant immediately adjacent to the first. This was a guanine (G) to adenine (A) transition (G1441A), resulting in a change of the amino acid sequence (glycine --> arginine) in a portion of the protein conserved in evolution. This suggests that this DNA alteration may be biologically significant. Restriction digest with the HpaII enzyme confirmed the presence of both sequence variants on the same allele.

CONCLUSIONS

We describe the first two DNA sequence variants ever found in the hHR21 gene, in patients with clinical radiation hypersensitivity. Although no direct evidence for the involvement of hHR21 alterations in the radiosensitivity of the cancer patients examined has been demonstrated, the possibility exists that homozygous mutations or other mutations of this gene could contribute to radiosensitivity. A simple test is described that could be applied to screening for these variants in relevant populations.

Is reduced dermatoglyphic a-b ridge count a reliable marker of developmental impairment in schizophrenia?

BACKGROUND

Finger and hand prints are formed during the late first and second trimester of foetal development, after which they remain unchanged. Their expression may be influenced by both genetic and environmental factors. Some studies have suggested that a reduced total finger ridge count (TFRC) and, in particular, a reduce total a-b ridge count (TABRC), may be associated with schizophrenia.

AIM

To study these two variables in a large, ethnically homogenous sample and to compare our findings with those of other recent studies.

METHOD

Finger and hand prints of 150 people with DSM-III-R schizophrenia were compared with those of 92 healthy controls.

RESULTS

Patients had a reduced mean TABRC (P = 0.03) compared with controls. There was a significant (P=0.02) linear trend for lower TABRC and increasing incidence of schizophrenia (ORlineartrend = 1.3; 95%CI1.1-1.7), implying a continuous increase in the risk for schizophrenia with reduction in TABRC. No significant difference between groups was observed for TFRC.

CONCLUSION

These results provide further evidence that dermatoglyphic abnormalities exist in at least some patients with schizophrenia and that the a-b ridge count may be a marker of disruption, probably environmental, that occurs when the developing brain may also be particularly vulnerable to such insult. These findings support the concept that some cases of schizophrenia may be due to adverse intrauterine events.

Small cell carcinoma of the vagina

A case of localized small cell neuroendocrine carcinoma of the vagina is reported. The patient was treated with concurrent chemoradiation with significant toxicity but obtained a complete response. Thirteen months after therapy the patient developed distant metastasis and died shortly thereafter. Review of the literature found that patients treated with local therapy alone had a shorter survival and died of systemic disease. As with small cell neuroendocrine carcinomas arising from other sites, systemic relapse remains an important issue that warrants combination therapies, although in pelvic sites this may be associated with an increase in side-effects.

Developing guidelines for smoking cessation interventions for pregnant adolescents

More than 400,000 deaths a year in the United States are attributed to active and passive tobacco smoke exposure. Healthy People 2000 objectives target a reduction in the tobacco use of high-risk populations such as youth and pregnant women. This article describes guidelines for health professionals to address smoking cessation when working with pregnant adolescents and teen mothers who smoke.

An assessment of nicotine dependence among pregnant adolescents

Studies have reported that between 28 and 62% of pregnant teenagers smoke (Cornelius, Taylor, Geva, & Day, 1995; Trollestrup, Frost, & Starzyk, 1992). Because smoking is prevalent among pregnant teenagers, the purpose of this research is to assess nicotine dependence in this high-risk group. This study analyzed baseline data from a sample of pregnant teen smokers who had volunteered to participate in a smoking cessation study (N = 94). Nicotine dependence was measured by adapting the Fagerstrom Tolerance Questionnaire (FTQ; Prokhorov, Pallonen, Fava, Ding, & Niaura, 1996), and by a 6-item withdrawal symptom scale. The overall FTQ score found among pregnant adolescents was 3.10 (SD = 2.3) compared to the mean overall FTQ score among vocational-technical students of 4.27 (SD = 2.2) (Prokhorov et al., 1996). Duration of smoking in years was significantly correlated with the overall FTQ score (r = 0.43, p < .01). Quantity of smoking, as measured by average number of cigarettes smoked, significantly correlated with overall FTQ scores (r = 0.67, p < .01). Lighter smokers were more likely to have previously attempted to quit, however, among the quit attempters, those who smoked 10+ cigarettes per day reported greater severity of withdrawal symptoms than those who smoked less per day. Prenatal education and smoking cessation programs for pregnant teenagers, and pregnant women in general, need to consider that nicotine dependence is an important issue. Early pregnancy may be an opportune time to intervene among pregnant smokers; incentives may be necessary to attract those women who are the heaviest smokers, and possibly the most dependent on nicotine.

Vision 2006 brings data quality management into view

One of the goals of the vision 2006 initiative has been to identify new career opportunities for HIM professionals. Recently, a group of AHIMA volunteers has provided a framework and tools for developing data quality management expertise. Here's an overview of their work and a look at resources for those who want to learn more.

The anthropometric assessment of dysmorphic features in schizophrenia as an index of its developmental origins

BACKGROUND

Evidence suggests that schizophrenia may be a disorder with origins in early intrauterine mal-development. We have constructed a comprehensive anthropometric scale for the evaluation of dysmorphic features as an index of the nature and timing of developmental disturbance.

METHOD

A detailed set of craniofacial and bodily measures was compiled and applied to 174 patients with schizophrenia and 80 matched control subjects.

RESULTS

Patients had significantly higher scores on this scale and displayed multiple anomalies of the craniofacial region with an overall narrowing and elongation of the mid-face and lower face. Twelve craniofacial anomalies independently distinguished patients from controls and these variables correctly classified 95% of patients and 80% of control subjects.

CONCLUSIONS

This new scale, while procedurally more exacting than the Waldrop scale, more clearly defines the topography of anomalies previously suspected in individuals with schizophrenia. These findings constitute direct evidence for disturbed craniofacial development in schizophrenia and indicate origins in the foetal period during which the characteristic human facial pattern evolves in close association with brain differentiation.

Adjuvant VHF therapy in locally recurrent and primary unresectable rectal cancer

In a prospective randomized study, 434 mHz microwave therapy combined with external beam radiotherapy (VHF + RT) was compared with standard external beam radiotherapy (RT) in controlling locally recurrent or unresectable primary adenocarcinoma of the rectum. Independent assessors documented quality of life scores, performance status, toxicities, local response to treatment, and systemic disease progression before treatment and after treatment and every 8 weeks thereafter. Of 75 patients randomized, 73 were eligible for inclusion in the study. Forty-three of these patients had local pelvic tumour recurrence only and 21 also had distant metastases. In addition, nine patients had primary inoperable carcinomas, two of whom also had metastases. Thirty-seven patients were randomized to RT and 36 to VHF + RT. The median dose of radiation in the VHF+RT arm was 4275 cGy with a median fraction size of 150 cGy and median duration of therapy of 48.5 days versus 4500 cGy in the RT-only arm with a median fraction size of 180 cGy and median duration of therapy of 38 days. These doses are unlikely to be significantly different in biological effect. No significant difference between the two groups was observed in extent and duration of local control, measures of toxicity or quality of life scores. Additionally, survival and cumulative incidence of pelvic site of first progression did not differ significantly between the groups. We conclude that VHF microwave therapy in conjunction with radiotherapy produces no therapeutic advantage over conventional radiation therapy alone in the treatment of locally recurrent rectal carcinoma.

Psychopathology in adolescent mothers and its effects on mother-infant interactions: a pilot study

OBJECTIVE

This study assessed adolescent maternal psychopathology and its relation to the quality of mother-infant interactions.

METHOD

Twenty-one mother-infant pairs recruited from an adolescent medicine clinic were assessed for socio-demographic background, psychosocial adversity, conduct disorder, alcohol or substance dependence, and depression. Dyads were videotaped during free play and their interactions rated using the Crittenden Child-Adult Relational Experimental (CARE) Index.

RESULTS

A large proportion of mothers exhibited psychopathology. Severity of maternal depression correlated positively with maternal controllingness and infant difficulty. Severity of maternal antisocial history correlated positively with maternal unresponsiveness and infant passivity.

CONCLUSION

Though preliminary, this work suggests that adolescent maternal depression and antisocial history have different effects on the quality of mother-infant interactions. Researchers and clinicians interested in adolescent parenting should consider psychopathology as a contributing variable to the quality of mother-infant interactions.

Prevalence and correlates of mixed-handedness in schizophrenia

Increased rates of nonright-handedness have been reported in schizophrenia, but a clear distinction has not been made between left- and mixed-handedness. Handedness preferences in 96 patients fulfilling DSM-III criteria for schizophrenia and 43 normal comparison subjects were assessed with the Edinburgh Handedness Inventory. A 100% criterion was used to establish left- and right-handedness. Results were analyzed with mantel-Haenszel odds ratios adjusted for age and sex. The schizophrenic group showed a significant increase in the proportion of mixed-handers compared with the normal group. There was no increase in pure left-handedness in the schizophrenic relative to the normal group. Mixed-handedness in the schizophrenic patients was significantly associated with chronicity of illness. Mixed-handed patients were less likely to have a family history of psychotic illness than patients with strong right- or left-handedness. The results indicate a neurodevelopmental rather than a genetic origin for anomalous lateralization in schizophrenia.

Cloning of the capsid protein gene from a blotch isolate of peanut stripe virus

The 3' terminal 1,367 nucleotides (nts) of a blotch isolate of the potyvirus, peanut stripe virus (PStV), were cloned and sequenced. This region included the 861 nts (287 amino acids) of the PStV capsid protein (CP). The amino acid sequence of the predicted proteinase cleavage site was identified. This region shared limited homology with other potyvirus proteinase cleavage sites. The viral CP gene sequence was followed by 254 nucleotides of 3' nontranslated sequence and a poly-A tail. Based on computer modeling, the 3' nontranslated region could form two lengthy stem-loop structures and two pseudoknot structures. Subclones containing the coding sequences of the CP (amino acids 1-287, 17-287, 17-113 and 106-287) were constructed and expressed in Escherichia coli. These polypeptides were detected using polyclonal antibodies in Western blots.

Information technology and today's health care management

With the move to CPR, health information managers will be challenged to reengineer the ways they manage processes within the medical record department. A lot of age-old health information problems (i.e., missing documents, lost test results, and missing records) can be solved and productivity improved with imaging. The digitized records will allow simultaneous access to readily available, legible, and usable information for patient care, research, audits, and correspondence. However, the transition from a manual to computerized record presents many challenges. Health information managers will have to monitor the changeover carefully, anticipating the needs for new information and developing the necessary mechanisms to produce it, as well as implementing new technologies as they emerge. Conditions are right for an advance in health care information systems. Pressures and changes in structure in the health care industry require better management tools. Acceptance of HIS as a management tool is growing rapidly among the health care provider community. The technology to realize the CPR and advanced decision support systems is available. All the pieces are there--they just need to come together. As the health care organization's view of and need for information systems change, medical record professionals must draw on their knowledge and experience and make the transition from managers of record systems to managers of health care information systems.

Health information management: better care through quality data

Authors Cassidy, Dowell and Bloomrosen set high goals for health information management professionals as they transform their profession. Their guidelines provide a chart and compass for those striding into the future.

Implementing continuous quality improvement (CQI) in hospitals: lessons learned from the International Quality Study

Continuous Quality Improvement is in the process of being implemented in hospitals around the world. In an attempt to gain a better understanding of the "best management practices" the International Quality Study is being conducted in four countries--Canada, Germany, Japan and the United States--and across four industries--Health Care, Banking, Automotive and Computers. Information collected through a survey process will be analysed through causal modeling to determine correlations between management practices and achievement of quality objectives. Given both the complexity of the models and the number of key concepts involved, 400 hospitals have been invited to participate. The preliminary results show direct correlations between cultural influences and the concept of quality. The perceived definition of quality by the various countries varies and therefore the application of "quality concepts" differs. Once complete, this database of "best management practices" will serve as a worldwide benchmark for quality progress.

Streptococcus bovis meningitis: report of 2 cases

We describe 2 cases of Streptococcus bovis meningitis and review the 9 cases previously reported. This microorganism is a rare cause of meningitis in which there are no distinctive clinical or laboratory features. The Gram stain of the CSF is usually negative. Ten of the 11 cases had some underlying disease or comorbid condition that predisposed to S bovis infection: gastrointestinal disorder, endocarditis, CSF leak, polymyalgia rheumatica, and mandibular block. Treatment with high-dose penicillin is usually adequate.

Maintenance chemotherapy in limited small cell lung cancer: a randomised controlled clinical trial

In a prospective randomised study 68 patients with limited small cell bronchogenic carcinoma were assigned to induction treatment with combined alternating non-cross-resistant chemotherapy plus split course radiotherapy without (NM) or with (M) subsequent maintenance therapy. Induction chemotherapy consisted of cisplatinum and VP16213q. 3 weeks followed by cyclophosphamide, vincristine and methotrexate (CVM)q. 4 weeks. Three courses of this 7-week chemotherapy programme were given. Radiotherapy to the primary lesion of 25 Gy in 13 fractions was given after each of the first and second courses of chemotherapy. Those in complete remission following the induction phase received prophylactic cranial irradiation. Those assigned to maintenance received a further six cycles of CVM after induction. The overall survival of patients randomised to maintenance therapy was significantly inferior to that of those randomised to no maintenance therapy (median survival NM 19.2 vs M 14.1 months, P = 0.05 log rank). Among patients achieving a complete remission of disease on induction therapy those receiving maintenance also showed a trend towards inferior survival (median survival NM 26.8 vs 18.0 months, P = 0.06 log rank). Deaths in each group of patients were predominantly due to tumour progression. The results do not support the use of maintenance chemotherapy after the use of intensive combined therapy induction programmes in the management of limited small cell bronchogenic carcinoma.

Regions upstream from the core promoter of the rat ribosomal gene are required for the formation of a stable transcription initiation complex by RNA polymerase I in vitro

The sites required for the formation of a stable transcription initiation complex and for the initiation of transcription of rat rDNA in vitro were examined. A series of 5' deletion mutants of the rat transcription initiation region (-167 through +638) were constructed. These mutants were examined for their ability to support the faithful initiation of transcription in vitro. Mutants which contain less than 31 nucleotides upstream of the initiation site (+1) were unable to support detectable initiation of transcription. In this transcription system a series of deletion mutants from -167 to -31 were transcribed with equal efficiency when assayed individually. On the other hand, when the wild-type and mutant templates were compared in order-of-addition assays, they were found to be unequal. The incubation of an extract with a wild-type template, prior to the addition of nucleotides, precluded transcription of any second template added after the preincubation step. However, the preincubation of extract with mutants of the region upstream of the core promoter, from -122 to -31, did not preclude transcription of a wild-type template added after the preincubation step. Formation of the stable preinitiation complex was found to require the region between and -167.

Characterization of rat ribosomal DNA II. identification of the highly repetitive DNA in the 3' non-transcribed spacer

The nucleotide sequence of one of the non-transcribed spacer subclones, p1.7, from the region 3' to rat 45 S pre-rRNA has been determined. Within 1612 base-pairs, the fragment contains two distinct regions of highly repetitive DNA, one of which can serve as a site for initiation in vitro by RNA polymerase III. The first is the alternating purine-pyrimidine sequence (A-C)21. The second of these regions has 95% homology to the identifier sequence and served as the template for RNA polymerase III transcription in vitro. The in vitro polymerase III template is aligned in opposite polarity to the direction of transcription of 45 S rRNA. Located near the identifier sequence is a region that is 59% homologous to the type-II Alu sequences. It would seem, therefore, that members of more than one highly repetitive sequence family have accumulated in the non-transcribed spacers. These data also suggest that within the non-transcribed spacers these families have evolved (sequence variation) at different rates, until one of them, the Alu type-II-like element, may represent a new Alu type-II subfamily.

Characterization of rat ribosomal DNA. The highly repetitive sequences that flank the ribosomal RNA transcription unit are homologous and contain RNA polymerase III transcription initiation sites

The non-transcribed spacers (NTS) of the ribosomal genes of a number of organisms have been studied and were found to contain repetitive sequences. In these studies with plasmid subclones of NTS, designated p3.4, p2.6 and p1.7, which come from both 5' and 3' flanking regions of the rat ribosomal genes, respectively, it has been determined that these sequences are found elsewhere within the genome. Southern hybridization analysis has demonstrated that the 5' and 3' NTS subclones cross-hybridize, and that the cross-hybridizing regions are synonymous with the highly repetitive regions. Sequences homologous to the rat NTS were specifically localized to both 5' and 3' flanking regions as well as to a number of the introns of cloned genes including rat serum albumin, rat alpha-fetoprotein, rat casein and human serum albumin. No hybridization was detected of the 5' NTS subclone to the human Alu sequence clone, Blur 8, or to the rodent equivalent, a clone containing Chinese hamster ovary type I and II Alu sequences. However, as reported for type II Alu sequences, the subcloned rat NTS sequences contain RNA polymerase III initiation sites and also hybridize to a number of small RNAs, but not 4.5 S or 7 S RNA. Sequence analysis of two distinct repetitive regions in p1.7 has revealed a region of alternating purine-pyrimidine nucleotides, potentially of Z DNA, and stretches of repetitive sequences. The possible roles for these repetitive sequences in recombination and in maintaining a hierarchical structure for the ribosomal genes are discussed.

The nucleotide sequence of 8 S RNA bound to preribosomal RNA of Novikoff hepatoma. The 5'-end of 8 S RNA is 5.8 S RNA

8 S RNA of Novikoff hepatoma was characterized by fingerprinting, sequencing gels, and by hybridization to rat ribosomal DNA clones. The data obtained show that 8 S RNA is 273 or 274 nucleotides long; ribosomal 5.8 S RNA is its 5'-terminal 156 nucleotides. All the post-transcriptional modifications found in 5.8 S rRNA were also found in 8 S RNA; no other modifications were found. The 3'-terminal 118 nucleotides were consistent with the adjoining internal transcribed spacer sequence in rDNA (Subrahmanyam, C. S., Cassidy, B., Busch, H., and Rothblum, L. (1982) Nucleic Acids Res. 10, 3667-3680). Based on its nucleolar localization, the finding that all the 8 S RNA is hydrogen-bonded to preribosomal RNA and its consistency in sequence to the cloned rat ribosomal DNA sequence, it appears that 8 S RNA is a relatively stable intermediate in the formation of 5.8 S rRNA from 45 S pre-rRNA. This stable intermediate RNA may be a useful substrate for studies on rRNA processing and for studies on eukaryotic rRNA-processing enzyme(s).

Transcription initiation site of rat ribosomal DNA

The sequence of 1,100 nucleotides surrounding the transcription initiation site of a cloned rat ribosomal RNA gene (rDNA) has been determined. The location of the 5' terminus of 45S pre-rRNA was determined by S1 nuclease mapping, reverse transcriptase elongation and confirmed by in vitro capping of 45S rRNA and in vitro transcription. Two different plasmid subclones, from two separate genomic clones of rat rDNA, contained the identical sequence surrounding the transcription initiation site: -10GGAGATATAT 1GCTGACACGC TGTCCTTTTG+20. Relatively long, greater than 15 base pairs, regions of sequence homology were found when the sequences of the initiation regions of rat and mouse rDNA (Urano, Y., Kominami, R., Mishima, Y., and Muramatsu, M., Nucleic Acids Res. 8, 6043-6058, 1980) were compared. When both the rat and mouse sequences were compared to that of human rDNA (G. Wilson, personal communication) a sequence of 15 nucleotides immediately following the initiation sites were found to be preserved.

Nucleotide sequence of the region between the 18S rRNA sequence and the 28S rRNA sequence of rat ribosomal DNA

The DNA sequence of the intragenic region of the rat 45S ribosomal RNA precursor was determined. This sequence contains 2282 nucleotides and extends from the conserved EcoR I site near the 3' terminus of 18S rRNA to 69 nucleotides downstream of the 5' terminus of 28S rRNA. The sequences corresponding to 18S and 5.8S rRNA were identified by comparison with previously published data. The 5' terminus of rat 28S rRNA was identified by S1 nuclease protection and reverse transcriptase elongation assays. The internal transcribed spacers were found to be 1066 and 765 nucleotides long and had little homology with those of Xenopus and yeast. Regions of sequence homology between rat and Xenopus were found at the junctions of the internal transcribed spacers with 18S, 5.8S and 28S rRNA. These homologies suggest that these sequences may function as recognition sites for the processing of the ribosomal precursor RNA.

Isolation and characterization of rat ribosomal DNA clones

Four EcoRI fragments, which contain the transcribed portion of the rat rDNA repeat, have been isolated from a rat genome library cloned in lambda Charon 4A vector. Three of the fragments, 9.6, 6.7, and 4.5 kb, from clones lambda ChR-B4, lambda Nr-42, and lambda ChR-C4B9, contained part of the 5'-NTS, the 5'-ETS, 18S rDNA, ITS-1, 5.8S rDNA, 28S rDNA and approximately 3.5 kb of the 3'-NTS. Two EcoRI fragments, from clones lambda ChR-B4 and lambda ChR-B7E12, which coded for the 5'-NTS, the ETS, and most of the 18S rDNA, differed by 1 kb near the EcoRI site upstream of the 5' terminus of 18S rRNA. Restriction maps of the cloned DNA fragments were constructed by cleavage of the fragments with various restriction endonucleases and Southern hybridization with 18S, 5.8S, and 28S rRNA. These maps were confirmed and extended by subcloning several regions of the repeat in pBR322.