Measurement of hemorrhage-related severe maternal morbidity with billing versus electronic medical record data.

OBJECTIVE: Measurement of obstetric hemorrhage-related morbidity is important for quality assurance purposes but presents logistical challenges in large populations. Billing codes are typically used to track severe maternal morbidity but may be of suboptimal validity. The objective of this study was to evaluate the validity of billing code diagnoses for hemorrhage-related morbidity compared to data obtained from the electronic medical record. STUDY DESIGN: Deliveries occurring between July 2014 and July 2017 from three hospitals within a single system were analyzed. Three outcomes related to obstetric hemorrhage that are part of the Centers for Disease Control and Prevention definition of severe maternal morbidity (SMM) were evaluated: (i) transfusion, (ii) disseminated intravascular coagulation (DIC), and (iii) acute renal failure (ARF). ICD-9-CM and ICD-10-CM for these conditions were ascertained and compared to blood bank records and laboratory values. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) with 95% confidence intervals (CI) were calculated. Ancillary analyses were performed comparing codes and outcomes between hospitals and comparing ICD-9-CM to ICD-10-CM codes. Comparisons of categorical variables were performed with the chi-squared test. T-tests were used to compare continuous outcomes. RESULTS: 35,518 deliveries were analyzed. 786 women underwent transfusion, 168 had serum creatinine ≥1.2 mg/dL, and 99, 40, and 16 had fibrinogen ≤200, ≤150, and ≤100 mg/dL, respectively. Transfusion codes were 65% sensitive (95% CI 62-69%) with a 91% PPV (89-94%) for blood bank records of transfusion. DIC codes were 22% sensitive (95% CI 15-32%) for a fibrinogen cutoff of ≤200 mg/dL with 15% PPV (95% CI 10-22%). Sensitivity for ARF was 33% (95% CI 26-41%) for a creatinine of 1.2 mg/dL with a PPV of 63% (95% CI 52-73%). Sensitivity of ICD-9-CM for transfusion was significantly higher than ICD-10-CM (81%, 95% CI 76-86% versus 56%, 95% CI 51-60%, p < .01). Evaluating sensitivity of codes by individual hospitals, sensitivity of diagnosis codes for transfusion varied significantly (Hospital A 47%, 95% CI 36-58% versus Hospital B 63%, 95% CI 58-67% versus Hospital C 80%, 95% CI 74-86%, p < .01). CONCLUSION: Use of administrative billing codes for postpartum hemorrhage complications may be appropriate for measuring trends related to disease burden and resource utilization, particularly in the case of transfusion, but may be suboptimal for measuring clinical outcomes within and between hospitals.

Dynamic queuosine changes in tRNA couple nutrient levels to codon choice in Trypanosoma brucei.

Every type of nucleic acid in cells undergoes programmed chemical post-transcriptional modification. Generally, modification enzymes use substrates derived from intracellular metabolism, one exception is queuine (q)/queuosine (Q), which eukaryotes obtain from their environment; made by bacteria and ultimately taken into eukaryotic cells via currently unknown transport systems. Here, we use a combination of molecular, cell biology and biophysical approaches to show that in Trypanosoma brucei tRNA Q levels change dynamically in response to concentration variations of a sub-set of amino acids in the growth media. Most significant were variations in tyrosine, which at low levels lead to increased Q content for all the natural tRNAs substrates of tRNA-guanine transglycosylase (TGT). Such increase results from longer nuclear dwell time aided by retrograde transport following cytoplasmic splicing. In turn high tyrosine levels lead to rapid decrease in Q content. Importantly, the dynamic changes in Q content of tRNAs have negligible effects on global translation or growth rate but, at least, in the case of tRNATyr it affected codon choice. These observations have implications for the occurrence of other tunable modifications important for 'normal' growth, while connecting the intracellular localization of modification enzymes, metabolites and tRNAs to codon selection and implicitly translational output.

The nuclear and cytoplasmic activities of RNA polymerase III, and an evolving transcriptome for surveillance.

A 1969 report that described biochemical and activity properties of the three eukaryotic RNA polymerases revealed Pol III as highly distinguishable, even before its transcripts were identified. Now known to be the most complex, Pol III contains several stably-associated subunits referred to as built-in transcription factors (BITFs) that enable highly efficient RNA synthesis by a unique termination-associated recycling process. In vertebrates, subunit RPC7(α/ß) can be of two forms, encoded by POLR3G or POLR3GL, with differential activity. Here we review promoter-dependent transcription by Pol III as an evolutionary perspective of eukaryotic tRNA expression. Pol III also provides nonconventional functions reportedly by promoter-independent transcription, one of which is RNA synthesis from DNA 3'-ends during repair. Another is synthesis of 5'ppp-RNA signaling molecules from cytoplasmic viral DNA in a pathway of interferon activation that is dysfunctional in immunocompromised patients with mutations in Pol III subunits. These unconventional functions are also reviewed, including evidence that link them to the BITF subunits. We also review data on a fraction of the human Pol III transcriptome that evolved to include vault RNAs and snaRs with activities related to differentiation, and in innate immune and tumor surveillance. The Pol III of higher eukaryotes does considerably more than housekeeping.

The leucine-NH4+ uptake regulator Any1 limits growth as part of a general amino acid control response to loss of La protein by fission yeast.

The sla1+ gene of Schizosachharoymces pombe encodes La protein which promotes proper processing of precursor-tRNAs. Deletion of sla1 (sla1Δ) leads to disrupted tRNA processing and sensitivity to target of rapamycin (TOR) inhibition. Consistent with this, media containing NH4+ inhibits leucine uptake and growth of sla1Δ cells. Here, transcriptome analysis reveals that genes upregulated in sla1Δ cells exhibit highly significant overalp with general amino acid control (GAAC) genes in relevant transcriptomes from other studies. Growth in NH4+ media leads to additional induced genes that are part of a core environmental stress response (CESR). The sla1Δ GAAC response adds to evidence linking tRNA homeostasis and broad signaling in S. pombe. We provide evidence that deletion of the Rrp6 subunit of the nuclear exosome selectively dampens a subset of GAAC genes in sla1Δ cells suggesting that nuclear surveillance-mediated signaling occurs in S. pombe. To study the NH4+-effects, we isolated sla1Δ spontaneous revertants (SSR) of the slow growth phenotype and found that GAAC gene expression and rapamycin hypersensitivity were also reversed. Genome sequencing identified a F32V substitution in Any1, a known negative regulator of NH4+-sensitive leucine uptake linked to TOR. We show that 3H-leucine uptake by SSR-any1-F32V cells in NH4+-media is more robust than by sla1Δ cells. Moreover, F32V may alter any1+ function in sla1Δ vs. sla1+ cells in a distinctive way. Thus deletion of La, a tRNA processing factor leads to a GAAC response involving reprogramming of amino acid metabolism, and isolation of the any1-F32V rescuing mutant provides an additional specific link.

A Framework for Improving Characterization of Obstetric Hemorrhage Using Informatics Data.

OBJECTIVE: To characterize postpartum hemorrhage trends and outcomes using bioinformatics and electronic health record data. METHODS: This retrospective analysis included all women who delivered in a four-hospital system from July 2014 to July 2017 during implementation of a postpartum hemorrhage bundle. Data on billing codes, uterotonics, transfusion, intrauterine tamponade device placement, and hysterectomy were analyzed. A framework of four postpartum hemorrhage levels based on hemorrhage interventions was created using this informatics data. Levels were analyzed in relation to hematocrit drop from the highest predelivery to the lowest postpartum level. Changes in treatment patterns were assessed with risk-adjusted regression models with adjusted odds ratios (aOR) and 95% CI as the measures of effect. Postpartum hemorrhage-associated severe maternal morbidities were analyzed with adjusted models. RESULTS: The cohort included 43,657 deliveries. Four mutually exclusive postpartum hemorrhage levels were created based on informatics and billing criteria. Level 1: receipt of uterotonic other than oxytocin (3.7% of patients); level 2: billing diagnosis code for postpartum hemorrhage (3.0% of patients); level 3: placement of the intrauterine tamponade device, transfusion of 1-3 units red blood cells (RBCs), or both (1.8% of patients); and Level 4: hysterectomy, 4 or more units RBCs, or both (0.6% of patients). Higher postpartum hemorrhage levels were associated with higher hematocrit drops. In postpartum hemorrhage levels 1 through 4, 1.6%, 5.6%, 30.2%, and 30.7% of women had hematocrit drops greater than 40%, compared with 0.4% of women without postpartum hemorrhage. Over the course of the study, hematocrit drops within a given level did not change. Postpartum hemorrhage interventions such as uterotonics increased significantly (aOR 1.16, 95% CI 1.11-1.21, with aOR denoting change in outcome across 1 year). Although severe maternal morbidity did not change significantly, risk of hysterectomy decreased significantly (aOR 0.52, 95% CI 0.40-0.68). CONCLUSION: Postpartum hemorrhage can be characterized in a granular fashion with informatics data. Informatics data are becoming increasingly available and can provide detailed assessment of postpartum hemorrhage incidence, management, and outcomes to facilitate surveillance and quality improvement.

A principled framework for phenotyping postpartum hemorrhage across multiple levels of severity.

Maternal morbidity and mortality have gained major attention recently, spurred on by rising domestic rates even as maternal mortality decreases in Europe. A major driver of morbidity and mortality among delivering women is postpartum hemorrhage (PPH). PPH is currently phenotyped using the subjective measure of 'Estimated blood loss' (EBL), which has been shown to be unreliable for tracking quality. Here we present a framework for phenotyping PPH into multiple severity levels, using a combination of data-driven techniques and expert-derived clinical indicators. We validate the framework by predicting large drops in hematocrit and quantitative blood loss, finding that the framework performs better in predicting coded PPH than a hematocrit-based predictor or predictors based on other metrics such as blood transfusions, and does better in predicting quantitative blood loss, a gold standard metric for blood loss that we have for a subset of patients, than any predictor we could build using hematocrit drops alone. In all, we present a principled framework that can be used to phenotype PPH in hospitals using readily available EHR data, and that will perform with more granularity and accuracy than existing methods.

The epidemic of abnormal copy number variant cases missed because of reliance upon noninvasive prenatal screening.

OBJECTIVE: To assess the implications of increasing utilization of noninvasive prenatal screening (NIPS), which may reach 50% with the concomitant decrease in diagnostic procedures (DPs) for its impact on detection of chromosomal abnormalities. METHODS: We studied our program's statistics over 5 years for DPs and utilization of array comparative genomic hybridization (aCGH). We then modeled the implications in our program if DP had not fallen and nationally of a 50% DP and aCGH testing rate using well-vetted expectations for the diagnosis of abnormal copy number variants (CNVs). RESULTS: Our DP fell 40% from 2013-2017. Utilization of aCGH for DP nearly tripled. We detected 28 abnormal CNVs. If DP had not fallen, we likely would have detected 60. With 4 million US births per year, 2 million DPs would detect 30 000 abnormal CNVs and 4000 standard aneuploidies. At a 1/500 complication-pregnancy loss rate, the detection/complication ratio is 8.5/1. CONCLUSIONS: Noninvasive prenatal screening has significantly changed the practice of prenatal screening. However, while increasing the detection of Down syndrome, the concomitant decrease in DP and lack of aCGH results in missing many more abnormalities than the increase in Down syndrome and complications of DP combined. From a public health perspective, such represents a missed opportunity for overall health care delivery.

The role of intracellular compartmentalization on tRNA processing and modification.

A signature of most eukaryotic cells is the presence of intricate membrane systems. Intracellular organization presumably evolved to provide order, and add layers for regulation of intracellular processes; compartmentalization also forcibly led to the appearance of sophisticated transport systems. With nucleus-encoded tRNAs, it led to the uncoupling of tRNA synthesis from many of the maturation steps it undergoes. It is now clear that tRNAs are actively transported across intracellular membranes and at any point, in any compartment, they can be post-transcriptionally modified; modification enzymes themselves may localize to any of the genome-containing compartments. In the following pages, we describe a number of well-known examples of how intracellular compartmentalization of tRNA processing and modification activities impact the function and fate of tRNAs. We raise the possibility that rates of intracellular transport may influence the level of modification and as such increase the diversity of differentially modified tRNAs in cells.

Retrograde nuclear transport from the cytoplasm is required for tRNATyr maturation in T. brucei.

Retrograde transport of tRNAs from the cytoplasm to the nucleus was first described in Saccharomyces cerevisiae and most recently in mammalian systems. Although the function of retrograde transport is not completely clear, it plays a role in the cellular response to changes in nutrient availability. Under low nutrient conditions tRNAs are sent from the cytoplasm to nucleus and presumably remain in storage there until nutrient levels improve. However, in S. cerevisiae tRNA retrograde transport is constitutive and occurs even when nutrient levels are adequate. Constitutive transport is important, at least, for the proper maturation of tRNAPhe, which undergoes cytoplasmic splicing, but requires the action of a nuclear modification enzyme that only acts on a spliced tRNA. A lingering question in retrograde tRNA transport is whether it is relegated to S. cerevisiae and multicellular eukaryotes or alternatively, is a pathway with deeper evolutionary roots. In the early branching eukaryote Trypanosoma brucei, tRNA splicing, like in yeast, occurs in the cytoplasm. In the present report, we have used a combination of cell fractionation and molecular approaches that show the presence of significant amounts of spliced tRNATyr in the nucleus of T. brucei. Notably, the modification enzyme tRNA-guanine transglycosylase (TGT) localizes to the nucleus and, as shown here, is not able to add queuosine (Q) to an intron-containing tRNA. We suggest that retrograde transport is partly the result of the differential intracellular localization of the splicing machinery (cytoplasmic) and a modification enzyme, TGT (nuclear). These findings expand the evolutionary distribution of retrograde transport mechanisms to include early diverging eukaryotes, while highlighting its importance for queuosine biosynthesis.

The essential function of the Trypanosoma brucei Trl1 homolog in procyclic cells is maturation of the intron-containing tRNATyr.

Trypanosoma brucei, the etiologic agent of sleeping sickness, encodes a single intron-containing tRNA, tRNA(Tyr), and splicing is essential for its viability. In Archaea and Eukarya, tRNA splicing requires a series of enzymatic steps that begin with intron cleavage by a tRNA-splicing endonuclease and culminates with joining the resulting tRNA exons by a splicing tRNA ligase. Here we explored the function of TbTrl1, the T. brucei homolog of the yeast Trl1 tRNA ligase. We used a combination of RNA interference and molecular biology approaches to show that down-regulation of TbTrl1 expression leads to accumulation of intron-containing tRNA(Tyr) and a concomitant growth arrest at the G1 phase. These defects were efficiently rescued by expression of an "intronless" version of tRNA(Tyr) in the same RNAi cell line. Taken together, these experiments highlight the crucial importance of the TbTrl1 for tRNA(Tyr) maturation and viability, while revealing tRNA splicing as its only essential function.

Sequential Amniotic Fluid Thyroid Hormone Changes Correlate with Goiter Shrinkage following in utero Thyroxine Therapy.

Several isolated reports of fetal goiter treatment have shown limited generalizability of approaches and provide no real guidance for optimal timing, dosages, and treatment strategies. Graves' disease accounts for >60% of these cases. Maternal treatments of hyperthyroidism include antithyroid medications such as methimazole and more commonly propylthiouracil (PTU). Here, our management of a patient with a fetal thyroid goiter from maternal exposure to PTU diagnosed at 23.6 weeks' gestation and the management of other cases allow us propose a general strategy for treatment. Intrauterine therapy with 200 and then 400 µg of levothyroxine (3 weeks apart) showed an 85% reduction in fetal thyroid goiter volume. We collected amniotic fluid samples at the time of treatments and assayed thyroid hormones and associated antibodies which closely reflected the changes in thyroid goiter mass volume. Our observations suggest a weekly or biweekly therapeutic intervention schedule. Utilizing both goiter size as well as a novel approach in using amniotic fluid hormone levels to monitor therapy efficacy might improve the quality of treatments. Only with a standardized approach and collection of amniotic fluid thyroid panels do we have the opportunity to develop the database required to determine the number and timing of treatments needed.

Cutting, dicing, healing and sealing: the molecular surgery of tRNA.

All organisms encode transfer RNAs (tRNAs) that are synthesized as precursor molecules bearing extra sequences at their 5' and 3' ends; some tRNAs also contain introns, which are removed by splicing. Despite commonality in what the ultimate goal is (i.e., producing a mature tRNA), mechanistically, tRNA splicing differs between Bacteria and Archaea or Eukarya. The number and position of tRNA introns varies between organisms and even between different tRNAs within the same organism, suggesting a degree of plasticity in both the evolution and persistence of modern tRNA splicing systems. Here we will review recent findings that not only highlight nuances in splicing pathways but also provide potential reasons for the maintenance of introns in tRNA. Recently, connections between defects in the components of the tRNA splicing machinery and medically relevant phenotypes in humans have been reported. These differences will be discussed in terms of the importance of splicing for tRNA function and in a broader context on how tRNA splicing defects can often have unpredictable consequences.