Stress associated with tasks for family caregivers of patients with cancer in Hong Kong

Family caregivers share the strain of cancer and are at risk of physical and psychological symptoms in relation to caregiver stress. This study investigated the relationships between perceived difficulty in managing caregiver tasks and the experience of stress symptoms among 26 family caregivers of terminally ill patients with cancer in Hong Kong. The findings revealed that more stress symptoms were experienced by caregivers who had reported increased difficulty in managing caregiver tasks (rs = 0.64; p < 0.001). Wilcoxon signed-ranks test indicated that psychological stress symptoms, rather than physical symptoms, overwhelmed most of the caregivers (z = -2.15; p < 0.05). There were significantly more negative responses to stress by caregivers who had a shorter duration of experience in providing care. In addition, caregivers who had less education were at higher risk of developing stress (p < 0.01). These findings indicate the need for the provision of support to facilitate the emotional and physical adaptation of caregivers at risk for health problems.

Spontaneous abortion: a randomized, controlled trial comparing surgical evacuation with conservative management using misoprostol

OBJECTIVE

To compare the efficacy of surgical evacuation of the uterus with medical evacuation using misoprostol in cases of spontaneous abortion.

DESIGN

A prospective, randomized, controlled trial.

SETTING

A university teaching hospital.

PATIENT(S)

Six hundred thirty-five women who aborted spontaneously and who consented to pretreatment randomization.

INTERVENTION(S)

Routine surgical evacuation or medical evacuation of the uterus using misoprostol.

MAIN OUTCOME MEASURE(S)

Immediate, short-term (2-3 weeks), and medium-term (6 months) medical complications.

RESULT(S)

There was a significantly lower incidence of immediate and short-term complications in the group treated with misoprostol compared with the surgically treated group. There were also fewer major complications in the 6 months after treatment in the medically treated group. Approximately 50% of the medically treated group subsequently required surgical evacuation, and these subjects required significantly more analgesia.

CONCLUSION(S)

Treatment with misoprostol can reduce the demand for surgical evacuation in cases of spontaneous abortion, and its use is associated with fewer medical complications.

Dichotomization of continuous measurements using generalized additive modelling--application in predicting intrapartum caesarean delivery

In prediction model development, continuous variables are often dichotomized at empirically chosen thresholds to simplify calculations and facilitate decision making. However, these choices are often made in the absence of estimated covariate effects and may be inaccurate, thus weakening the models. To improve this approach, generalized additive modelling that allows non-parametric estimation of the true covariate effects is used for threshold selection. In this study, this approach is illustrated by development of prediction models for intrapartum Caesarean deliveries. The prediction performance of the models thus developed is significantly better than that developed using empirically chosen thresholds for dichotomization.

The effect of percutaneous oestradiol on atheroma formation in ovariectomized cholesterol-fed rabbits

OBJECTIVE

The aim of this study was to examine the effect of percutaneous oestradiol on the lipid profile and on atheroma formation using an animal model.

METHODS

The study was of 12 weeks duration. Fifty sexually mature female New Zealand White rabbits were divided into five groups of equal size. Two groups acted as controls and received normal rabbit chow. Rabbits in one of these groups were ovariectomized. The remaining three groups were ovariectomized but received 1% cholesterol enriched rabbit chow. One of these cholesterol-fed groups received 0.3 mg/kg percutaneous oestradiol daily whilst another received 0.1 mg/kg oral oestradiol daily. Measurements of concentrations of total cholesterol (TC), high density lipoprotein cholesterol (HDL-C) and triglycerides (TG) were made at the beginning and end of the study. Aortic atheroma formation was measured using computerized image analysis of uptake of Sudan III staining.

RESULTS

After 12 weeks there were significant increases in the mean concentrations of TC in the three cholesterol-fed groups compared with controls (P < 0.001). Changes in HDL-C and TG concentrations were less consistent. The mean area of aortic atheroma formation was significantly less in both the percutaneous oestradiol group (4.9%) and the oral oestradiol group (8.6%) compared with the non-oestrogen-treated cholesterol-fed group (19.5%) (P < 0.001, < 0.01 respectively).

CONCLUSION

These results suggest that percutaneous oestradiol has a direct protective effect on atheroma formation independent of serum concentrations of total cholesterol.

Methylation of p16INK4A in primary gynecologic malignancy

The p16INK4A gene mapped on band p21 of chromosome 9 can be inactivated via multiple mechanisms including homozygous deletion, point mutation and promoter hypermethylation in various human tumors. A polymerase chain reaction (PCR) based analysis was performed to examine methylation of the p16INK4A gene promoter in 196 primary gynecologic malignancies including 98 cervical, 49 endometrial and 49 ovarian carcinomas. Methylation of p16INK4A was detected in 31% of cervical, 20% of endometrial, and 4% of ovarian carcinomas, respectively. The incidence of p16INK4A methylation in patients with cervical and endometrial carcinomas at advanced stages (stages III-IV) was statistically higher than those at early stages (stages I-II). There were also significant differences in the incidence of p16INK4A methylation in both cancers between the patients who had died of their disease or were alive with evidence of disease, and those without evidence of disease. The results indicate that methylation of the p16INK4A gene is present in a proportion of primary gynecologic malignancies and this alteration may be associated with poor outcome in cervical and endometrial carcinomas.

Translation of questionnaires and issues of equivalence

The validity of studies using translated instruments may be questioned when there is a lack of attention to and/or minimal explanation of the procedures used for determining the equivalence between the primary and secondary language tool. Ensuring equivalence of a translated Chinese version of the Menstrual Distress Questionnaire is an important prerequisite for identifying culturally specific expressions of concepts under investigation and for cross-cultural comparisons. This paper examines the principles and procedures for determining equivalence of translated tools and their application to the development of an equivalent Chinese version of the Menstrual Distress Questionnaire. Translation and back-translation were used to develop a Chinese version of the Menstrual Distress Questionnaire. Bilingual university students completed both versions of the Menstrual Distress Questionnaire. Most of the Menstrual Distress Questionnaire items had an acceptable Kappa of >0.4. Intraclass correlation coefficients indicated moderate to high levels of equivalence for total scores and all scales. Improvement in the translation of some items is needed to further enhance the equivalence of the Chinese version of the Menstrual Distress Questionnaire.

Managing caregiver tasks among family caregivers of cancer patients in Hong Kong

Twenty-nine family caregivers of terminally ill cancer patients in Hong Kong were asked about their perceived difficulty in managing caregiver tasks. Results showed that the level of difficulty in handling the three main aspects of tasks, that is the direct care, intrapersonal tasks, and interpersonal ties, were similar (chi2 = 0.71, P > 0.05). The individual tasks identified as extremely difficult included compensation for personal time (31%), updating knowledge of reimbursement mechanism (20.7%), and emotionally accepting the likelihood of a progressive downward course of illness (17.2%). Mann-Whitney tests indicated that caregivers who had a shorter duration of caregiving experience perceived significantly greater difficulty in direct care (P < 0.05), intrapersonal tasks (P < 0.05), and overall tasks (P < 0.05). These findings indicate the need for the provision of counselling and educational support for these caregivers.

Rapid clearance of fetal DNA from maternal plasma

Fetal DNA has been detected in maternal plasma during pregnancy. We investigated the clearance of circulating fetal DNA after delivery, using quantitative PCR analysis of the sex-determining region Y gene as a marker for male fetuses. We analyzed plasma samples from 12 women 1-42 d after delivery of male babies and found that circulating fetal DNA was undetectable by day 1 after delivery. To obtain a higher time-resolution picture of fetal DNA clearance, we performed serial sampling of eight women, which indicated that most women (seven) had undetectable levels of circulating fetal DNA by 2 h postpartum. The mean half-life for circulating fetal DNA was 16.3 min (range 4-30 min). Plasma nucleases were found to account for only part of the clearance of plasma fetal DNA. The rapid turnover of circulating DNA suggests that plasma DNA analysis may be less susceptible to false-positive results, which result from carryover from previous pregnancies, than is the detection of fetal cells in maternal blood; also, rapid turnover may be useful for the monitoring of feto-maternal events with rapid dynamics. These results also may have implications for the study of other types of nonhost DNA in plasma, such as circulating tumor-derived and graft-derived DNA in oncology and transplant patients, respectively.

State self-esteem following stroke

BACKGROUND AND PURPOSE

Physical rehabilitation after stroke is often highlighted in the absence of consideration of psychosocial factors. This study sought to determine the relationship between state self-esteem and functional independence in patients recovering from stroke.

METHODS

In a longitudinal study, data were collected from 152 stroke patients within 48 hours of admission to a rehabilitation hospital and at 2 weeks and 3 months after admission. The Modified Barthel Index was used to assess functional ability. Patients' current feelings of self-worth were assessed with use of the State Self-Esteem Scale. Additional variables included perceived social support, trait self-esteem, age, previous stroke, side of stroke, comorbidity, marital status, and gender.

RESULTS

State self-esteem was significantly correlated to functional independence. The results of linear stepwise regression analysis indicated that functional ability and state self-esteem at 2 weeks, as well as the presence of heart disease, were significant predictors (55%) of functional ability at 3 months. For those with a functional ability score of >/=81 on admission to the rehabilitation unit, state self-esteem and functional ability at 2 weeks as well as previous stroke explained 53% of the variance in functional ability at 3 months. When functional ability was </=80, baseline and 2-week functional ability, state self-esteem at 2 weeks, and age predicted 53% of the variance in functional ability at 3 months.

CONCLUSIONS

Functional ability at 2 weeks was a stronger predictor than baseline functional ability in this study. The level of state self-esteem was also a consistent factor in the prediction of functional outcome of patients after stroke.

Prospective randomized study of the effect of "add-back" hormone replacement on vascular function during treatment with gonadotropin-releasing hormone agonists

BACKGROUND

Gonadotropin-releasing hormone agonists (GnRHas) are a group of drugs that with long-term use induce a pseudomenopausal state in which estrogen production is suppressed. They are commonly used in the treatment of sex steroid-dependent conditions. "Add-back" hormone replacement therapy is used to prevent menopause-like symptoms and bone loss during GnRHa treatment, but it is also recognized that hypoestrogenism adversely affects vascular function. The aim of this study was to examine the effect of GnRHa and add-back therapy on vascular reactivity. This model serves as a paradigm for the effect of hormone replacement therapy in postmenopausal women.

METHODS AND RESULTS

Measurements of endothelium-dependent and endothelium-independent vascular reactivity were compared in 2 groups of women treated with a GnRHa for 6 months. One group received estrogen/progestogen add-back therapy during the second 3 months of GnRHa treatment. Vascular reactivity was examined by use of ultrasound measurements of changes in brachial artery diameter. Endothelium-dependent changes were assessed during reactive hyperemia, whereas endothelium-independent changes were measured after the administration of glyceryl trinitrate sublingual spray. Treatment with the GnRHa alone had an inhibitory effect on endothelium-dependent relaxation. However, endothelium-dependent relaxation significantly improved in the group receiving add-back therapy (14.6%) compared with the group treated with GnRHa alone (8.6%) (P<0.01). There were no significant endothelium-independent changes in either group.

CONCLUSIONS

These results suggest that the administration of add-back therapy has a protective effect on vascular function in GnRHa-induced hypoestrogenism. As a model for the menopause, these results also suggest that the long-term administration of hormone replacement therapy would result in endothelium-dependent arterial relaxation, an observation previously attributed only to the acute administration of estrogen.

Metabolic and inflammatory responses after laparoscopic and abdominal hysterectomy

OBJECTIVE

Our purpose was to quantify and compare the metabolic and inflammatory changes after laparoscopic and abdominal hysterectomy.

STUDY DESIGN

Forty-four patients with no major medical disease requiring abdominal hysterectomy for benign disorders were randomly assigned to have laparoscopic hysterectomy (n = 20) and abdominal hysterectomy (n = 24). Venous blood and 24-hour urine samples were collected the day before and for each of the first 3 postoperative days.

RESULTS

No differences were present in demographic characteristics, operating time, and uterine weight between the two groups. No major complications were encountered. The laparoscopic hysterectomy group had a significantly lower postoperative morphine consumption (median 5.5 vs 14 mg, P < .05), lower febrile morbidity rate (15% vs 45.8%, P < .05), and shorter hospital stay (median 4 vs 6 days, P < .001) and demonstrated a less intense stress response in terms of serum interleukin-6 (median 50.6 vs 73.9 pg/mL x hour x 10, P = .01), C-reactive protein (median 28.1 vs 44.7 mg/L x hour x 10(2), P = .005), cortisol (median 23.4 vs 27.2 mg/mL x hour x 10(3), P = .04), white blood cell count (median 59.5 vs 69.8 10(9)/L x hour x 10, P = .009), 24-hour urinary excretion of cortisol (median 34.8 vs 44.2 nmol/L x hour x 10(3), P = .02), and norepinephrine (median 80.8 vs 132.4 nmol/L x hour x 10(2), P = .001). No significant difference was detected in plasma glucose (median 41.5 vs 45.6 mmol/L x hour x 10, P = 6) and 24-hour urinary excretion of epinephrine (median 32.2 vs 34.1 nmol/L x hour x 10(2), P = .3).

CONCLUSION

Laparoscopic hysterectomy is associated with a lower morbidity and a less intense stress response than abdominal hysterectomy for benign diseases.

Nursing activities following the introduction of health care assistants

AIM

The purpose of this study was to determine changes in the work nature of nurses after the introduction of Health Care Assistants (HCAs).

BACKGROUND

HCAs with a role similar to those adopted in the UK of assisting the nurse were piloted in a teaching hospital in Hong Kong.

METHOD

A quasi-experimental design was used to compare the observed activities of HCAs and nurses in four wards of a teaching hospital, before and after the introduction of HCAs. As the amount of staff activity is influenced by the amount of work, patient dependency data were gained from record reviews and nurse interviews.

FINDINGS

HCAs in orthopaedic and medical wards provided more basic care than those in surgical and gynaecological wards. Nurses in wards with HCAs performed significantly fewer activities than nurses in control wards.

CONCLUSIONS

HCAs presence accounted for a reduction in both direct and indirect care provided by nurses. Overall, HCAs provided more basic than technical and indirect care.

Site-selective differences in cytochrome P450 isoform activities. Comparison of expression in rat and rhesus monkey lung and induction in rats

The distribution of pulmonary cytochrome P450 (P450 or CYP) isoforms has been investigated primarily in immunohistochemical studies, which are neither quantitative nor reflective of the functions of these enzymes. Studies of enzyme activities have been performed using whole-lung homogenates or isolated cells, but there is little information on the regioselective expression of P450 monooxygenases. The aims of this study were to compare the activities of P450 monooxygenases in different lung subcompartments in two commonly studied animal models, i.e. rats and monkeys, and to explore the possibility that inducing agents would result in activity up-regulation that is highly site-selective, using rats as a model. Microdissection techniques were used to separate the airways from blood vessels and lung parenchyma. In rats, CYP1A1 (ethoxyresorufin) and CYP2B (pentoxyresorufin) dealkylase activities were highest in the parenchyma, whereas CYP2E1 (p-nitrophenol) hydroxylase activity was highest in the airways. P450 reductase activities were similar in airways and parenchyma and were lower in trachea. In monkeys, no significant site-selective differences in CYP1A1 and CYP2B1 activities were found. In contrast, CYP2E1 activity was higher in the distal bronchioles and parenchyma than in the proximal airways. P450 reductase activities were similar in microsomes prepared from all subcompartments of monkey lung. Induction of rat CYP1A1 activity by beta-naphthoflavone (administered ip) was much greater in the airways and lung parenchyma ( approximately 30-fold) than in the liver ( approximately 10-fold) or trachea ( approximately 2.5-fold). Oral administration of phenobarbital or acetone increased CYP2B and CYP2E1 activities in rat liver but had no significant effect on P450 activities in subcompartments of rat lung. These findings support the conclusion that there are regiospecific and species-specific differences in the activities of P450 isoforms and that the inducibility of rat pulmonary P450s is dependent on the isoform and lung region.

Quantitative analysis of fetal DNA in maternal plasma and serum: implications for noninvasive prenatal diagnosis

We have developed a real-time quantitative PCR assay to measure the concentration of fetal DNA in maternal plasma and serum. Our results show that fetal DNA is present in high concentrations in maternal plasma, reaching a mean of 25.4 genome equivalents/ml (range 3.3-69. 4) in early pregnancy and 292.2 genome equivalents/ml (range 76. 9-769) in late pregnancy. These concentrations correspond to 3.4% (range 0.39%-11.9%) and 6.2% (range 2.33%-11.4%) of the total plasma DNA in early and late pregnancy, respectively. Sequential follow-up study of women who conceived by in vitro fertilization shows that fetal DNA can be detected in maternal serum as early as the 7th wk of gestation and that it then increases in concentration as pregnancy progresses. These data suggest that fetal DNA can be readily detected in maternal plasma and serum and may be a valuable source of material for noninvasive prenatal diagnosis.

Relationship between premenstrual tension syndrome and anxiety in Chinese adolescents

This study examined the relationship between anxiety and premenstrual tension syndrome. One hundred and fifty-three schoolgirls completed Spielberger's Trait Anxiety Inventory and Abraham's Menstrual Symptom Questionnaire. The high level of trait anxiety found in this sample was related to an increase in premenstrual tension symptoms.

Can health care assistants replace student nurses?

With the implementation of Project 2000 in the UK the traditional student nurse workforce has largely been replaced by health care assistants (HCAs). This study was carried out in Hong Kong at a time when university-based nurse education is gradually being introduced. Evaluation of a HCA pilot programme in an acute care hospital in Hong Kong provided the opportunity to examine the work of HCAs and hospital-based student nurses during the gradual introduction of university-based nurse education. The data used in this paper were drawn from a larger study evaluating the use of HCAs. The observational data collected at two phases after the introduction of HCAs were analysed using Kruskal-Wallis one way analysis of variance. No significant differences were found in the total amount of all types of activity performed by SNs and HCAs. However in the direct care type of work HCAs performed significantly more basic care and less technical activity than any level of student at phase 1 (P < 0.001) and phase 2 (P < 0.001). These differences in the work undertaken suggest that qualified staff do not perceive SNs and HCAs as equally unqualified. Thus the replacement of SNs with HCAs alone is likely to lead to a notable change in the role of qualified staff in terms of their direct and indirect care activities and in the amount of time spent delegating and supervising unqualified staff.

Spontaneous abortion: short-term complications following either conservative or surgical management

Spontaneous abortion is a common gynaecological condition. It is a commonly held belief that medical morbidity associated with this condition is low and that routine treatment should be surgical evacuation of the uterus. This study was performed to study the short-term complications of spontaneous abortion and its management. Transvaginal sonography (TVS) was used to determine whether retained products of conception (POCs) were visible inside the uterus in women presenting with spontaneous abortion. If tissue was present, surgical evacuation of retained products of conception (ERPC) was performed. If the uterus was empty, the patients were managed expectantly. Four hundred and seventy women were treated with ERPC and 297 were managed expectantly. The complication rate was 3.0% in those managed expectantly compared with 5.8% for those treated by ERPC. Subjects with no POCs on TVS can therefore be managed expectantly without increasing the risk of morbidity associated with this condition.

Lipid peroxidation in cord blood at birth: a marker of fetal hypoxia during labour

OBJECTIVE

This prospective study examined purine metabolism in relation to free oxygen radical activity, as reflected by lipid peroxide levels in umbilical cord blood at birth.

SETTING

Departments of Obstetrics and Gynaecology and of Chemical Pathology, the Chinese University of Hong Kong, Hong Kong, and Purine Research Laboratory, UMDS of Guy's and St. Thomas' Hospitals, London, UK.

METHODS

Umbilical cord arterial and venous blood samples were collected from 132 singleton term deliveries for determination of hypoxanthine, xanthine, inosine, uric acid, organic hydroperoxides (OHP) and malondialdehyde. Oxygen saturation, PO2, pCO2, pH, and base excess (BE) were also measured.

RESULTS

There was a significant correlation between umbilical arterial and venous levels of hypoxanthine, xanthine, inosine, uric acid and all acid-base parameters (p < 0.001). Significant arteriovenous differences were observed for all parameters with the exception of inosine, uric acid and OHP. Umbilical arterial xanthine and potassium correlated significantly with OHP, but hypoxanthine, inosine and uric acid did not. In 13 babies classified as severely asphyxiated at birth (umbilical arterial pH <7.15, BE <-8), xanthine and OHP levels were significantly elevated when compared with non-asphyxiated babies. No significant differences were observed for hypoxanthine, inosine or uric acid.

CONCLUSION

The findings indicate that OHP, either in cord arterial or venous blood, is the best marker of free oxygen radical activity in the fetus, and that this correlates with other evidence of cellular hypoxia-reperfusion injury. We propose OHP is a better measure of perinatal outcome than either acid-base balance or hypoxanthine.

Computerised estimation of the baseline fetal heart rate in labour: the low frequency line

OBJECTIVE

To develop and evaluate a computerised algorithm for the estimation of the fetal heart rate baseline (low frequency line) during labour.

DESIGN

Retrospective observational study.

METHODS

Fetal heart rate signals were obtained from women in labour using the Nottingham fetal ECG monitor. The computerised algorithm for the baseline estimation was developed for intrapartum applications and is based on averaging modal fetal heart rate values. Evaluation was carried out on sixty cardiotocographic recordings by 12 experts and by the computer. These estimates were compared with those obtained from the computerised system using paired differences and intraclass correlation.

RESULTS

The study showed that it is possible to produce a low frequency line from data obtained from intrapartum records. The system could not estimate the low frequency line in four records, whereas experts were also unable to estimate between one and seven tracings. The 95% CI for the paired differences between computer and experts was -12 to 15 bpm, whereas between the experts this was -10 to 10. With the exception of one expert, there was a high concordance between experts and between computer and experts (intraclass correlation > 0.9).

CONCLUSIONS

The performance of this computerised algorithm cannot be distinguished from that of experienced clinicians. There were no significant differences between baseline values obtained by the computerised algorithm and those by the clinicians.

Antepartum and intrapartum prediction of cesarean need: risk scoring in singleton pregnancies

OBJECTIVE

To demonstrate the use of generalized additive logistic regression in the development of a risk-scoring system to predict cesarean delivery.

METHODS

Women who delivered in the Prince of Wales Hospital, Hong Kong, from 1994 to 1995 were the subjects of our study. Cases included were term singleton pregnancies with cephalic presentation, excluding those requiring cesarean delivery before labor. The cases were divided randomly into two sets. The prediction models were developed from set A and tested on set B, and vice versa. Maternal demographic and obstetric variables were used as potential predictors. Two models were formed, one before and one after the onset of labor. The generalized additive logistic regression was used to achieve optimal dichotomization of continuous measurements, and the predictive models were then developed. The validating results were pooled, represented, and compared as areas under receiver operating characteristic (ROC) curves.

RESULTS

The first prediction model used maternal age, height, and weight at delivery as well as nulliparity, history of cesarean delivery, and the need for induction of labor. The second model had in addition the need for labor augmentation. The areas under the ROC curve for the models were 0.81 and 0.82, respectively, a statistically significant difference (z = 5.75, P < .001).

CONCLUSION

The use of generalized additive logistic regression optimizes dichotomization of continuous measurements and facilitates the development of precise and reproducible prediction models. Generalized additive logistic regression appears to be a useful tool, and its use is commended.

Evaluation of a health care assistant pilot programme

Health Care Assistants (HCAs) were piloted in four wards of a large teaching hospital in Hong Kong. Evaluation of this pilot programme was based on patients' and nurses' satisfaction with HCAs, the HCAs' job satisfaction, and the retention rate of HCAs. Data were collected at 3 and 6-months following the introduction of HCAs to ascertain the level of satisfaction and the rate of HCA retention. Overall, the HCAs' work was seen as satisfactory and contributing to the work being carried out on each ward. Both nurses and patients were highly satisfied with HCA's, the mean total levels of satisfaction by nurses being 97 out of a possible range of 26-104 and for patients 53 out of a possible range of 14-56. While there was a high level of nurses' approval of introducing HCAs into the health care team there were significant differences (P < 0.05) with Nursing Officer, followed by Ward Managers being more in agreement than Registered Nurses. There were eight HCA activities seen by more than 70% of nurses to have been carried out frequently. The mean total job satisfaction of HCAs was 67 out of a possible 17-95. Although the 50% retention rate of HCAs was poor, there was overall satisfaction with the work of the HCAs.

The mouse Clock mutation behaves as an antimorph and maps within the W19H deletion, distal of Kit

Clock is a semidominant mutation identified from an N-ethyl-N-nitrosourea mutagenesis screen in mice. Mice carrying the Clock mutation exhibit abnormalities of circadian behavior, including lengthening of endogenous period and loss of rhythmicity. To identify the gene affected by this mutation, we have generated a high-resolution genetic map (> 1800 meioses) of the Clock locus. We report that Clock is 0.7 cM distal of Kit on mouse chromosome 5. Mapping shows that Clock lies within the W19H deletion. Complementation analysis of different Clock and W19H compound genotypes indicates that the Clock mutation behaves as an antimorph. This antimorphic behavior of Clock strongly argues that Clock defines a gene centrally involved in the mammalian circadian system.

Frequent loss of heterozygosity of chromosome 3 short arm detected by PCR-based microsatellite polymorphisms in cervical squamous cell carcinoma

Karyotypic studies have shown that genetic aberrations of the short arm of chromosome 3 (3p) may be involved in the pathogenesis of cervical carcinoma. In this study we analyzed nine polymorphic microsatellite repeats on 3p using a PCR-based assay for loss of heterozygosity (LOH) in 64 invasive squamous cell carcinomas of the cervix. These markers encompass chromosome region 3p13-25. LOH at one or more loci was detected in 46 (79%) out of the 58 informative cases. The incidence of LOH at locus D3S643 (3p13) was the highest among nine markers examined. The difference between the frequency of LOH at D3S643 in early stage (I-II) disease (43%) and those with advanced stage (stage III-IV) (79%) was statistically significant (P < 0.05). The results indicate that tumor suppressor gene(s) that play a role in cervical cancer may be located on the short arm of chromosome 3, likely near or at 3p13. The LOH at 3p13 appears to be a late event in tumor progression and may serve as an indicator for a less favorable clinical outcome.

Functional identification of the mouse circadian Clock gene by transgenic BAC rescue

As a complementary approach to positional cloning, we used in vivo complementation with bacterial artificial chromosome (BAC) clones expressed in transgenic mice to identify the circadian Clock gene. A 140 kb BAC transgene completely rescued both the long period and the loss-of-rhythm phenotypes in Clock mutant mice. Analysis with overlapping BAC transgenes demonstrates that a large transcription unit spanning approximately 100,000 base pairs is the Clock gene and encodes a novel basic-helix-loop-helix-PAS domain protein. Overexpression of the Clock transgene can shorten period length beyond the wild-type range, which provides additional evidence that Clock is an integral component of the circadian pacemaking system. Taken together, these results provide a proof of principle that "cloning by rescue" is an efficient and definitive method in mice.

p16INK4 and p15INK4B alterations in primary gynecologic malignancy

Chromosome 9 abnormalities have been found in primary tumors and cell lines from human gynecologic malignancy. Alterations of p16INK4 and p15INK4B genes mapped on the band p21 of chromosome 9 have been detected in various human tumors, but the role of these genes as tumor suppressors in vivo appear to be dependent on tumor type. Polymerase chain reaction (PCR)-based analysis was performed to search for lesions of these genes in 202 primary gynecologic malignancies. Homozygous deletions of p16INK4 were detected in 7 of 128 (5%) cervical, 1 of 41 (2%) endometrial, 2 of 27 (7%) ovarian, and 3 of 6 (50%) vulvar carcinomas, while homozygous deletions of p15INK4B were detected in 19 of 128 (15%) cervical, 1 of 41 (2%) endometrial, 9 of 27 (33%) ovarian, and 3 of 6 (50%) vulvar carcinomas, respectively. No mutations were found in exon 2 of p16INK4 from 161 cases of gynecologic malignancy without deletion of p16INK4. All 3 cases of vulvar carcinoma showing homozygous deletions of p16INK4 and p15INK4B were at advanced clinical stage (stage III-IV), while all 7 cases of cervical carcinoma and 2 cases of ovarian carcinoma showing homozygous deletion of p16INK4 were at early stage (stage I-II). The results indicate that homozygous deletions of p16INK4 and/or p15INK4B genes may play a role in a subset of primary gynecologic malignancy.

The effect of different sampling intervals on the measurement of intrapartum fetal heart rate variability

OBJECTIVE

To test the hypothesis that increasing the sampling interval affects the intrapartum fetal heart rate (FHR) variability measurement.

METHODS

Fetal electrocardiograms were obtained from women in labor. Using the peak of the fetal R wave, the R-R interval and FHR were calculated on a beat-to-beat basis. Retrospectively, the original data were repartitioned using different intervals (2-900 seconds) to generate a window of measurement (epoch). The mean value for each epoch and the last FHR in that epoch (epochal value) were compared with published animal and human data. Errors were quantified by comparing the epochal and mean values for each epoch. Fetal heart rate variability between epochs and within each epoch was compared.

RESULTS

Fetal heart rate and R-R interval were measured in 146 cases. The FHR had a normal distribution (mean 140.1 beats per minute, +/- standard deviation [SD] 15.6, skew -0.07), but its inverse, the R-R interval, was not normally distributed (mean 432 milliseconds, +/- SD 52.4, skew 1.78). Using a single value for an epoch duration of 2 seconds resulted in an error that was similar to the within-epoch variability (+/- SD of 2.2 beats per minute difference between mean and epochal value compared to +/- SD of 2 beats per minute within epoch) but which increased with epoch duration.

CONCLUSION

An epoch duration of 2 seconds and a single sampled value within this period may be appropriate for measurement of both medium and long-term variability in any computerized intrapartum FHR interpretation system. Fetal heart rate (not R-R interval, because of its normal distribution) should be used to design such a computerized system.

A medical approach to management of spontaneous abortion using misoprostol. Extending misoprostol treatment to a maximum of 48 hours can further improve evacuation of retained products of conception in spontaneous abortion

BACKGROUND

To compare a 48 hour non surgical policy in the management of spontaneous abortion with a policy of routine, universal uterine curettage.

METHODS

A prospective, observational study on 354 women admitted to hospital with spontaneous abortion. Of these, 225 who had retained products of conception were treated with misoprostol for up to 48 hours after 101 were excluded because they had an empty uterus on transvaginal scan (TVS) and another 28 women because they were unsuitable for conservative management. Follow-up was conducted over a 3 week period to assess morbidity. A reference group of 137 women, all of whom had an evacuation of retained products of conception (ERPC) as a routine after they had a TVS documenting retained products of conception (POCs), was used for comparison.

RESULTS

Evacuation of the uterus occurred within 24 hours in 107 women and in 148 at 48 hours after misoprostol treatment was started. There were three uterine curettages up to 14 days after discharge from hospital for persistent bleeding and two cases of pelvic infection. An ectopic pregnancy was diagnosed at follow-up in one woman. In the reference group, there were nine women who had complications, four requiring another ERPC and five had infection, an overall complication rate of 6.6% in the reference group and 1.7% in the protocol treatment group.

CONCLUSION

A 48 hour regimen using transvaginal ultrasound and misoprostol for the management of spontaneous abortion was successful in avoiding surgery in 249 out of a possible 354 (70.6%) women with spontaneous abortion, with a low rate of subsequent morbidity.

Transvaginal sonographic assessment of cervical dynamics during the third trimester of normal pregnancy

BACKGROUND

To obtain a normogram of measurements of the uterine cervix by transvaginal sonography during the third trimester of normal primiparous pregnancies and to relate these measurements to the events surrounding labor.

METHODS

A prospective observational study, set in Guangzhou, Peoples Republic of China, was undertaken. Fifty-five normal nulliparous Chinese women with singleton pregnancies were studied from 30 weeks gestation until delivery. Serial transvaginal ultrasound examinations were performed at 30, 32, 34 and 36 weeks gestation and weekly thereafter.

RESULTS

There was a significant correlation between gestational age and cervical length and width. Funnelling of the internal os was present in 25% of cases, and its earliest appearance was at 36 weeks. There was no consistent relationship between funnel length and width and gestational age. The duration of the first stage of labor was inversely correlated with the last ultrasound measurement of cervical length, but there was no relationship with either cervical width nor the presence of funnelling. The cervical changes in this population differed from those found in Caucasians.

CONCLUSIONS

There is a direct relationship between both cervical width and length and gestational age and an inverse relationship with cervical length and the duration of labor. Funnelling of the internal os was not a predictor of the early onset of labor. The dimensions and features of the Asian cervix differ from those of the Europeans, and this should be considered when conducting further studies of a similar nature.

Laparoscopic management of adnexal mass during pregnancy

BACKGROUND

To assess the use of laparoscopy in the management of persistent adnexal mass during the second trimester of pregnancy.

SUBJECTS

Six consecutive pregnant women undergoing laparoscopic surgery for persistent adnexal masses in the second trimester.

RESULTS

Laparoscopic removal of an adnexal mass was successfully performed in all patients. The median operating time was 37.5 minutes. There were no intra- and post-operative complications. Tocolytic therapy was not required and no patients developed uterine contractions. All patients delivered normal infants vaginally at term without complications.

CONCLUSION

With attention to the surgical technique, laparoscopic removal of persistent adnexal mass during the second trimester of pregnancy is safe and carries the same benefits over laparotomy as in non-pregnant women.

C-myc mutation detected by polymerase chain reaction--heteroduplex in cervical cancer

To evaluate both the incidence of c-myc gene mutation and the relationship of this finding to the clinico-pathologic characteristics of patients with cervical cancer, a polymerase chain reaction (PCR)-based heteroduplex gel electrophoresis method was used to screen DNA extracted from 102 cervical invasive carcinomas referred to the Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong. C-myc mutation was detected and then characterised by sequencing of PCR products in 4 cases (4%). The incidence of c-myc mutation in patients with advanced stage tumours (stage III-IV, 11% was statistically higher than in those with early stages (stage I-II, 1%, p = 0.05). There was also a significant difference in the incidence of c-myc mutation among the patients who had died of their disease (10%), were alive with evidence of disease (25%), and those without evidence of disease (0%, p = 0.0003). These findings indicate that the c-myc mutation is not common in cervical cancer, but where it exists, it may be associated with cancer progression and poorer outcome. Whether the c-myc mutation is an adjunct prognostic indicator in cervical cancer remains to be established in a larger study.

A randomized, double-blind, placebo-controlled, crossover study on the effect of oral oestradiol on acute menopausal symptoms

Acute menopausal symptoms occur less frequently in Asian than in Caucasian women. Oestrogen replacement therapy has been shown to be effective in controlling acute symptoms in Caucasians, but the effect of oestrogens is not well documented in Asian women. A randomized, double-blind, placebo-controlled, crossover study of the effect of oral oestradiol on the incidence of acute menopausal symptoms was conducted in 83 Hong Kong Chinese women who had experienced a surgical menopause. Although there was a significant increase in the oestradiol concentration with treatment compared with placebo (P < 0.001), there were no significant differences in the reporting of symptoms between the treatment and placebo groups. There is no obvious explanation for this apparent lack of effect of oestrogen on acute menopausal symptoms in Chinese women. Whilst it may be related to the generally low incidence of symptoms or to a higher dietary intake of phytoestrogens in Chinese women, further studies are necessary to explain these findings.

Fetal sex as a risk factor for fetal distress leading to abdominal delivery

A retrospective analysis of perinatal information of 7,924 confinements in the calendar year of 1994 was performed to determine whether fetal sex was a significant risk factor for fetal distress in labour leading to abdominal delivery. The sex of the fetus (male) was a significant, independent, risk factor for Caesarean section (odds ratio = 1.26, 95% CI = 1.05 to 1.50). This increase was wholly attributable to the increased risk of having fetal distress in labour (odds ratio = 1.76, 95% CI = 1.32 to 2.34). Male fetuses are at higher risk of developing fetal distress during labour.

The effects of parity on birthweight using successive pregnancies

OBJECTIVE

Accurate assessment of the difference in birthweight between first and second live-births to the same woman having excluded the effects of physiological factors known to affect birthweight.

DESIGN

Retrospective longitudinal observational study.

SETTING

Three large obstetric units in the East Midlands of the United Kingdom.

SUBJECTS AND METHODS

Women in whom data were recorded for their first two pregnancies on the UK East Midlands Obstetric database which resulted in the delivery of a liveborn, singleton and congenitally normal baby. Six thousand five hundred and thirty such cases were identified, of which 3457 had complete datasets and delivered both babies at term (259 to 300 days). An analysis was performed of changes between the paired pregnancies of physiological factors known to affect birthweight. Regression analyses were used to enable prediction of the second birthweight with the knowledge of the first birthweight.

RESULTS

The mean crude birthweight difference between first and second pregnancies was an increase of 138 g. Significant differences between the paired pregnancies were found in maternal booking visit weight, blood pressure, maternal age and gestation at delivery. Independent factors affecting difference in birthweight were gestation at delivery, maternal booking weight and baby's sex. Regression towards the mean was demonstrated which meant that a woman delivering a first baby weighing more than 3720 g could expect a lighter baby for her second delivery provided that all other factors remained constant.

CONCLUSIONS

In general terms a woman is more likely to deliver a heavier baby in her second pregnancy than in her first pregnancy. However, maternal physiological factors differ in the two pregnancies and these differences have additional effects on birthweight. The effects of both these observations are tempered by regression towards the mean which has a profound influence in predicting the likely change in birthweight between first and second pregnancies. Clinical decisions should not be based on the assumption that a second baby will inevitably be heavier than the first baby.

HER-2/neu gene amplification in cervical cancer in Chinese women of Hong Kong and China

OBJECTIVE

To determine the amplification of proto-oncogene HER-2/neu in invasive cervical cancer and its relationship with the stage of disease, grade of tumor and prognosis of patients.

METHODS

In this retrospective study 70 women with invasive cervical squamous cell carcinoma were included. DNA was extracted from the paraffin-embedded tumor tissue. The amplification of HER-2/neu was studied using a differential polymerase reaction (PCR) technique. Assessment of significance was performed using Peason's Chi-square test and Fisher's exact test.

RESULTS

Eleven of the 70 cases (16%) showed an amplification of HER-2/neu but there was no relation between amplification and tumor histologic grading (p = 0.408) or clinical staging (p = 0.180). Follow-up information in 67 patients was available. The incidence of amplification in the patients who were alive with disease was not statistically different from that in the patients who were alive with no evidence of disease (p = 0.315). The incidence of amplification in the patients who died of disease was higher than that in the patients who were still alive, but statistical significance did not reached (p = 0.062).

CONCLUSION

The results suggest that HER-2/neu amplification does exist in a subgroup of invasive cervical cancer and may play a role in cervical carcinogenesis. The role as independent prognostic factor has to be evaluated by further prospective studies.

Coincidental renal cell and endometrial carcinoma: a case report

A case of renal cell carcinoma and coexistent endometrial carcinoma is reported. The renal tumor in the lower pole of left kidney was detected by staging preoperative ultrasound scan and was confirmed to be a multilocular cystic renal cell carcinoma. There were two separate foci of moderately differentiated endometrial cancer in the endometrial cavity. Microscopic tumor deposits were also found in the left ovary and the right obturator pelvic lymph nodes. The multicentric involvement of endometrial cavity is uncommon and even rarer is the association with renal cell carcinoma. To the best of our knowledge, this is the first report of an association between renal cell carcinoma and endometrial cancer. This case demonstrates the importance of complete preoperative investigation before any definitive surgery for cancer. Without the abdominal ultrasound scanning, the asymptomatic renal cell carcinoma would probably have been undetected.

Lipid peroxidation in cord blood at birth

OBJECTIVE

The purpose of this study was to determine oxygen free radical activity in the neonate at birth and relate it to umbilical cord blood acid-base status.

STUDY DESIGN

A series of 110 singleton deliveries had determination of two lipoperoxides in umbilical cord blood: malondialdehyde and organic hydroperoxide. Umbilical pH, PO2, PCO2, bicarbonate, and base excess were also measured.

RESULTS

There was a significant association between lipoperoxides and cord blood pH and base excess. A significant difference existed in the levels of umbilical artery lipoperoxides between nonacidemic and acidemic fetus, as defined by an umbilical arterial pH < 7.20.

CONCLUSION

There is a positive association between lipoperoxide production and acid-base balance at delivery.

Postnatal development of cytochrome P4501A1 and 2B1 in rat lung and liver: effect of aged and diluted sidestream cigarette smoke

Earlier studies have shown that both mainstream and sidestream cigarette smoke increase the activities of cytochrome P4501A1 and 2E1 in the lungs of adult animals; however, little information is available on the influence of ambient levels of sidestream cigarette smoke on cytochrome P450 monooxygenase activity in the developing lung. The present studies were conducted to define the developmental profiles of cytochrome P450 monooxygenases 1A1 and 2B1 in rat lung and liver and to assess the effects of aged and diluted sidestream cigarette smoke (ADSS) on the developmental profile of these two enzymes. Accordingly, pulmonary and hepatic microsomal P4501A1 and 2B1 activities were determined by measuring ethoxy- and pentoxyresorufin-O-delakylase (EROD and PROD, respectively) activity in animals exposed to filtered air or ADSS from birth to 7, 14, 21, 50, and 100 days of age. Pulmonary P4501A1 activity in control rats was not detected until 14 days of age. Activities increased threefold between 14 and 21 days of age and remained unchanged to 100 days of age. In animals exposed to ADSS from birth, pulmonary EROD activities were detected as early as 7 days postnatal and were elevated three- to fourfold above control at all other ages examined. Hepatic EROD activities were unaltered by ADSS exposure. Short-term (4-day) ADSS exposure was as effective in upregulating pulmonary microsomal EROD activities as 100-day exposures. Induction of pulmonary EROD activities and the associated increases in mRNA levels were dependent upon the particulate fraction. Stimulation of EROD activities in major and minor daughter subcompartments was three- to fourfold higher in ADSS-exposed animals compared to controls, while there was no induction in the trachea and less than a twofold increase in the parenchyma. Pulmonary PROD activities developed more slowly than EROD and did not reach adult levels until Day 50. ADSS did not alter pulmonary or hepatic PROD activities. These studies show that P4501A1 and 2B1 develop at different rates in rat lung and liver and that exposure to ADSS markedly increases P4501A1 activities in the lung at all ages examined.

Premenstrual syndrome in employed Chinese women in Hong Kong

Premenstrual syndrome (PMS) has been studied in many countries, but few studies have been reported internationally on the experience of Chinese women. Because culture and employment are important factors in the perception of health status, in this study we sought to determine the existence and features of PMS in Chinese clerical women in Hong Kong. We used a cross-sectional, retrospective approach to collect data with a translation of an established questionnaire (the Menstrual Distress Questionnaire). Fatigue was found to be the most prevalent symptom, and the Pain, Water Retention, Behavioral Change, and Negative Affect scales had more than 64% frequency. The main difference between these findings and those of other studies is that negative affect featured most prominently in Western samples, whereas pain featured most highly in this sample of Chinese women.

Second and early third trimester atrial natriuretic peptide (ANP) levels in pregnancies subsequently complicated by hypertension

OBJECTIVE

To explore the clinical utility of measuring atrial natriuretic peptide (ANP) in the second and early third trimesters of pregnancy in order to predict pregnancy induced hypertension (PIH).

METHODS AND MATERIALS

The study was done in a University Teaching Hospital. A prospective study of 200 women in their first pregnancy was conducted. ANP was measured at 2 gestational windows, 20-26 weeks and 30-34 weeks. This was correlated with pregnancy outcomes, in particular PIH. Student's t-test was used to compare ANP levels between women who developed PIH and those who did not. The receiver operator curve (ROC) was used to determine its clinical utility.

RESULTS

ANP levels were lower at 20-26 weeks in women who subsequently developed PIH but there was no significant difference at 30-34 weeks between women who had normotensive pregnancies and those who later developed PIH. The character of the ROC would indicate that it is not useful for prediction.

CONCLUSION

ANP levels in the second and early third trimesters has limited clinical utility for the prediction of PIH.

Frequent ras gene mutations in squamous cell cervical cancer

Eighty samples of cervical invasive squamous cell carcinoma were examined for ras gene mutations using polymerase chain reaction (PCR) followed by restriction enzyme digestion. We found 28 (35%) cervical cancers contained ras mutations at H-ras codon 12, 49 (61%) at K-ras codon 12, and 5 (6%) at K-ras codon 13. There were no significant differences in incidence of the ras gene mutations among different histologic grades or clinical stages of the cancer (P > 0.05). This result suggests that ras mutation may be an important step involved in a substantial number of cervical carcinoma. The interaction of ras with other genes and/or events may also be involved in pathogenesis of this malignancy.

The prediction of fetal acidosis at birth by computerised analysis of intrapartum cardiotocography

OBJECTIVE

To assess the capability of a computer software interpretation program, using intrapartum fetal heart rate and intrauterine pressure as recorded in a cardiotocogram to predict fetal acidosis at birth.

DESIGN AND SUBJECTS

A retrospective analysis of digitised fetal heart rate and uterine activity values obtained from 73 high risk women in labour.

SETTING

Two university teaching hospitals.

METHODS

A computer software program was constructed to analyse the digitised data and predict acidosis. The results of the analysis were compared with actual umbilical arterial blood pH and base excess at delivery.

RESULTS

The software cardiotocogram interpreter was able to predict a pH of less than 7.15 with an accuracy of 77%, a sensitivity of 88% and specificity of 75% in this set of data. It was able to predict a base excess of less than -8 mmol/l with an accuracy of 81%, a sensitivity of 76% and specificity of 82%.

CONCLUSIONS

A computerised method of analysing fetal heart rate and uterine activity using a simple algorithm has demonstrated a capability to predict fetal acidosis at the time of delivery. Further research in this area is warranted.

A randomised double blind comparison of Syntometrine and Syntocinon in the management of the third stage of labour

OBJECTIVE

To compare the effect of intramuscular Syntometrine and Syntocinon in the management of the third stage of labour.

DESIGN

A randomised double blind prospective study.

SETTING

Department of Obstetrics and Gynaecology, Prince of Wales Hospital, Hong Kong.

SUBJECTS

One thousand consecutive patients with singleton pregnancy and vaginal delivery in February and March 1993.

RESULTS

The use of Syntometrine in the management of the third stage not only reduced the blood loss after delivery but was associated with a 40% reduction in the risk of postpartum haemorrhage (odds ratio 0.60; 95% CI 0.21-0.88), and the need for repeat oxytocic injections (odds ratio of 0.63; 95% CI 0.44-0.89). The two drugs did not differ in their effect on the duration of the third stage. However, the incidence of manual removal of the placenta was higher when Syntometrine was used (odds ratio 3.7; 95% CI 1.03-12.5), although the overall incidence remained low. Side effects from both drugs, such as nausea, vomiting, headache and hypertension, were uncommon.

CONCLUSION

Intramuscular Syntometrine is a better choice than Syntocinon in the management of the third stage of labour.

Role determination in nursing--implications for service provision

The current changes in nursing practice which have placed a greater need than ever before for nurses to have clearly defined roles, has resulted from the demand for cost-effective care and for nurses to justify their contribution to that care. This two stage, descriptive study was undertaken as part of a larger study to determine the implications of definition of the role of nursing for service provision in Hong Kong. The initial data collected using group interviews to generate ideas about the activities of the registered nurse (RN) and enrolled nurse (EN), was followed by a questionnaire to a sample of 410 RNs, representing three different grades of nursing staff. The 5-point Likert type questionnaire asked respondents to indicate levels of agreement with 67 activities. Sixty-five of the 67 activities of the RN were agreed to and were statistically significant (P < 0.001) in the difference from the undecided position. The findings also demonstrated a lack of agreement amongst grades of staff in their perception of nursing role. Fifty-six of the same 67 activities were agreed to for the EN and were statistically significant (P < 0.001) in the difference from the undecided position. This similarity between perceptions of EN and RN activities highlights the need to reconsider the contribution of ENs to patient care within the nursing structure in Hong Kong. These findings have implications not only for the management of nursing but also for further research in determining the interpretation of role in nursing to high quality patient care.