Optimal pain management requires compliance with objective assessments, interventions, monitoring and documentation. Optimal documentation has been challenging for many organizations. At Children's National Medical Center the electronic medical record (EMR) was introduced to include provider documentation of pain assessment before and after intervention. We hypothesized that assessment of pain would improve by combining EMR documentation with quality improvement methods. A multidisciplinary team designed a monthly automated pain assessment report using EMR-derived data. The report includes pain assessment data upon admission, each shift and after each intervention. Data are aggregated, analyzed and reported to bedside providers, managers and leadership in a standardized, comparative manner for each unit. All pediatric inpatients were studied and intervention strategies developed. Categorical data were analyzed using Chi square and continuous variables using t-test and analysis of variance. The project has resulted in reliable and accurate data to characterize the effectiveness of pain assessment. Admission pain assessment data has been collected on 1,059 patients, shift assessment data on 2,745 events and reassessment data on 629 events. Pain assessment feedback in the form of unit-based scorecards has been widely embraced by providers, managers and leadership. Preliminary data since June 2008 suggest overall improvements in pain assessment each shift (5.5%) and after intervention (21.1%). The use of the EMR as a tool to accurately and reliably document pain assessment has been valuable. Sharing of this data across the organization has been effective in delineating areas of strength and opportunities for improvement. Preliminary results suggest important trends in improved pain assessment. We anticipate our results will assist in improving compliance with the assessment of pain in children; decreasing the response time to pain intervention; and enhancing the overall quality of pediatric pain management.

Human lymphocytes were cultivated for 75 hours in the presence of various concentrations of bromodeoxyuridine (BrdU). The cells were stained with the fluorochrome Hoechst 33258 plus Giemsa. Cells in the first, second and third division could be distinguished, as well as sister chromatid exchanges (SCE) and centromeric exchanges (CME). BrdU-concentrations higher than 100 μM decreased the relative number of cells in the third division and increased the number of cells in the first division in vitro, indicating that higher BrdU-concentrations considerably inhibit cell propagation. The frequency of SCE and CME increased significantly for each stepwise rise in the BrdU concentration between 20–500 μM, suggesting that the vast majority of SCE and CME are induced by BrdU. The average frequency of SCE per cell in 100 μM of BrdU ranged between 18–28 for 8 control subjects with a group mean of 22.2±3.4. BrdU-induced SCE were found to be equally distributed between chromosomes in relation to their lengths while the frequency of CME was independent of chromosome length. High concentrations of BrdU (200–500 μM) significantly increased the number of chromosome aberrations in the cells of all of four subjects investigated. The aberrations were mainly chromosome breaks.

Gossypol, a human antifertility agent isolated from the cotton plant, was found to induce a dose-dependent increase in the frequency of DNA-strand breaks in human leukocytes exposed to 2–40 μg/ml of the drug for 1 h in serum-free medium in vitro. DNA-strand breaks were studied by alkaline elution or alkaline unwinding of DNA followed by hydroxylapatite-chromatography. No decrease of gossypol-induced DNA-strand breaks was observed after post-treatment incubation times up to 24 h, whereas X-ray-induced DNA breaks disappeared within 2 h under the same incubation conditions. Cells exposed to gossypol in the presence of 10% fetal calf serum showed no or little increase of DNA breaks, suggesting that serum proteins inhibit the DNA-damaging activity of the drug. Both optical isomers of gossypol induced DNA-strand breaks. However, the effect of (−)-gossypol was only about half of that of (+)-gossypol and the racemic form. The induction and persistence of DNA-strand breaks by gossypol, as well as the reduction of this effect in the presence of serum should be considered in the evaluation of the potential in vivo genotoxicity of the drug.

Human leucocytes were incubated in the presence of vinyl acetate or acetaldehyde (10–20 mM) for 4 h at 37°C in vitro. DNA damage was analysed by alkaline elution. None of the compounds induced a detectable increase in the frequency of DNA strand breaks. Cells exposed to 5 Gy of X-ray immediately after treatment and before alkaline elution showed a clear, dose-dependent retardation of the elution rate in comparison with X-irradiated control cells. These results demonstrate that both vinyl acetate and acetaldehyde induce DNA cross-links in human cells.

The induction of SCE was studied in PHA-stimulated human lymphocytes exposed to nitrogen mustard (HN2) or methyl methanesulfonate (MMS) for various time periods in the G1 phase. HN2 was found to induce about 10 times more SCE when cells were exposed in late G1 (24 h after PHA) as compared to early G1 (immediately after PHA). In contrast, only a small difference was observed between cells exposed to MMS in late or early G1. The results suggest that different types of SCE-inducing alkylating damage agents are removed at widely different rates in human G1-lymphocytes.

The SCE frequency was studied in PHA-stimulated human lymphocytes exposed to various SCE-inducing agents in different stages of the cell cycle. Melphalan, HN2, MMS, and UV light were found to induce a higher SCE frequency in late G1 (18-24 hr after PHA stimulation) than in early G1 (1-6 hr after PHA) or G0 (before PHA stimulation). In contrast, CCNU induced more SCEs in early G1 than in late G1, and the adriamycin-induced SCE frequency was about the same after treatment in early and late G1. These results suggest that SCE-inducing lesions are being removed at different rates in human G1 lymphocytes. The removal of SCE-inducing HN2 lesions was found to be about 10 times more rapid in late G1 than in early G1, indicating the activation of a cross-link repair mechanism prior to DNA replication in human lymphocytes. Cells treated with MMS in the second G1 (after cultivation for about 55 hr in the presence of PHA and BrdUrd) showed a higher SCE frequency than cells treated with the same dose of MMS in the first G1. This result indicates that some type of interaction occurs between MMS damage and BrdUrd lesions in the DNA during replication, which leads to an enhanced induction of SCE. Analysis of SCEs induced during the 2 first vs. the third cell cycle in third-generation metaphases showed that most of the SCE-inducing damage caused by treatment with HN2 and melphalan in G1 of the first cell cycle are removed before the S phase of the third cell cycle, whereas damage caused by MMS and adriamycin seem to be more persistent. These observations suggest that the rate by which different types of SCE-inducing damage are removed or modified in resting (G0) of PHA-stimulated human lymphocytes can have a great influence on the SCE frequency. This is of practical importance in studies using SCE analysis to evaluate human exposure to suspected genotoxic agents in the environment.

We have previously reported the isolation of 3 mutants of Chinese hamster ovary cells which exhibit hypersensitivity to bleomycin. 2 mutants were isolated on the basis of bleomycin-sensitivity [designated BLM-1 and BLM-2, Robson et al., Cancer Res., 45 (1985) 5304–5309] and 1 as adriamycin-sensitive [ADR-1, Robson et al., Cancer Res., 47 (1987) 1560–1565]. Because bleomycin generates DNA-strand breaks via a free-radical mechanism, we have studied the survival response of these mutants to a range of drugs which also generate free radicals and consequently DNA-strand breaks. The mutants are all hypersensitive to phleomycin, which differs from bleomycin in being unable to intercalate due to a modified bithiazole moiety. However, BLM-2 cells alone are hypersensitive to pepleomycin, a semi-synthetic bleomycin analogue. In contrast, BLM-1 cells are more sensitive than BLM-2 to streptonigrin (which operates via a hydroquinone intermediate). ADR-1 cells show wild-type resistance to streptonigrin. The results obtained with neocarzinostatin, an antibiotic requiring thiol activation, are unusual in that both BLM-1 and BLM-2 are approximately 3-fold more resistant than parental cells. However, the steady-state intracellular level of the major non-protein thiol, glutathione, is not altered in BLM-1 or BLM-2 cells. ADR-1 cells show essentially wild-type resistance to neocarzinostatin.Analysis of cell hybrids shows that BLM-1 and BLM-2 cells are phenotypically recessive in combination with parental CHO-K1 cells and represent different genetic complementation groups not only from one another, but also from the bleomycin-sensitive mutant xrs-6, isolated on the basis of X-ray sensitivity by Jeggo and Kemp [Mutation Res., 112 (1983) 313–319]. These results indicate that at least 3 gene products are involved in cellular protection against bleomycin toxicity in mammalian cells.

The effects of adriamycin (AM) on DNA repair replication, the frequency of sister-chromatid exchange (SCE), the rate of cell proliferation and the frequency of DNA strand breaks were studied in human cells in vitro. No repair replication was observed in lymphocytes exposed to AM in concentrations up to 10−3 moles/1. DNA repair replication induced by UV and alkylating agents was not affected by a concentration of AM that completely inhibited cell proliferation (10−6 moles/1).

Increased rate of sister chromatid exchange (SCE) in peripheral lymphocytes has been observed in smokers as compared to nonsmokers and in patients receiving certain cytostatic drugs. The increased SCE frequency in smokers was shown to depend on the number of cigarettes smoked per day, as well as on the duration of smoking. DNA cross-links caused by photochemotherapy against psoriasis, 8-methoxypsoralen plus UVA irradiation (PUVA), as well as by the anti-cancer chemotherapeutic agent CCNU, were shown to be more effective at inducing SCE's than other types of DNA damage caused by these treatments. These observations suggest that SCE analysis may be used as an indicator of genotoxic exposure in vivo, provided that the various types of DNA damage caused by genotoxic agents and the dose, as well as the time of exposure in relation to the time of sampling, are considered.

Some of the properties of three continuous cell lines derived from BK virus-induced hamster tumors were examined. The cell lines hadin vitro growth characteristics of transformed cells. Morphologically most of the cells were fibroblastic, but multinucleated giant cells were also common. Ultrastructurally all three cell lines displayed the usual features of cells grownin vitro. Marked variation in the nuclear size and shape as well as prominent nucleoli were characteristic to these cells. No viruses or virus-like particles were found. Virus isolation attempts by fusing the cells with Vero cells were negative, and no virion antigen was detected in these cells by immunofluorescence. T antigen similar to that of other papovaviruses was found in the cells. This antigen stained with sera from a number of hamsters carrying transplanted BK virus-induced tumors, and also with SV 40 T antisera. The antigen disappeared after 30 minutes at 56° C. Cytogenetic analyses showed that the three cell lines were heteroploid with subtetraploid numbers of chromosomes. Chromosome abnormalities were also seen. All three cell lines induced sarcomatous tumors in adult hamsters after subcutaneous inoculation.