Chloralanyl and propargylglycyl dipeptides. Suicide substrate containing antibacterials

A set of dipeptides containing the amino acid residues beta-chloroalanine and propargylglycine, which are mechanism-based inactivators of purified microbial enzymes (alanine racemase and cystathionine gamma-synthase, respectively), have been synthesized, and their antibacterial properties in vitro have been evaluated. Dipeptides containing a single beta-chloro-L-alanyl residue (e.g., 3, 5, 9, and 10) or a single L-propargylglycyl residue (e.g., 12 and 15) are potent antibacterials. The in vitro antibiotic activity of beta-chloro-L-alanine and of L-propargylglycine is increased as much as 4000-fold by incorporation of these residues into a dipeptide. Compounds that contain only a single enzyme-inactivating amino acid together with a second L-alanyl residue (3, 5, 12, and 15) have a restricted range of activity: of the species tested, only Streptococcus agalactiae, Staphylococcus aureus, and Staphylococcus epidermidis are sensitive. However, peptides that contain two suicide-substrate residues [e.g., beta-Cl-LAla-beta-Cl-LAla (8) or LppGly-LppGly (18)] are broad-spectrum antibacterials; as many as 12 different species of the 16 surveyed are sensitive. Dipeptides that contain an amino-terminal L-methionyl (9) or an L-norvalyl (10) residue and a carboxy-terminal beta-chloro-L-alanyl unit are also effective against a large number of organisms; the spectra of activity are like those seen for 8 and 18. A "mixed" dipeptide [beta-Cl-LAla-LppGly, (21)] gives apparent synergism of antibiotic action of beta-chloro-L-alanine and of L-propargylglycine when these two residues are incorporated into a single structure. Peptides of the D,D configuration (4, 6, 13, 16, and 20) and ones of L,D stereochemistry (e.g., 7) are not antibacterials. Peptides containing one (11 and 14) and two (17) D,L-propargylglycyl residues are unresolved sets of diastereomers; the mixtures of compounds are between two- and fourfold less active than the correspondingly resolved L,L dipeptides (12, 15, and 18). These findings are consistent with a mechanism of action for these antibiotics involving stereoselective processing of the peptidyl unit in vivo.

Recognition of patients' worries by nurses and by other patients

Previous studies indicate that patients' worries may not be communicated very effectively to hospital staff. The current study examines whether other patients know more about surgical patients' worries than the nursing staff on the ward. For each patient, the patient, a nurse and a colleague-patient completed a checklist to describe the patients' worries. The results showed that the other patients were more accurate than the nurses both in terms of overall accuracy and, more tentatively, using signal detection theory estimates of sensitivity. As in a previous study, the nurses overestimated the number of worries; the overestimation did not appear to be related to the content of the items nor was it due to patients' underreporting of problems. Relationships between patients, both on the surgical ward and in self-help groups, are discussed.

Absorption and antidysrhythmic activity of oral disopyramide phosphate after acute myocardial infarction

1 In a prophylactic, double-blind, randomized placebo-controlled trial of oral disopyramide phosphate, initiated within 12 h of suspected acute myocardial infarction (MI), antidysrhythmic effect was evaluated. The loading dose was 150, 200, or 300 mg followed 6 h later by 100, 150, or 200 mg every 6 h for patients assessed to weigh <55, 55-85, or >85 kg, respectively. After each loading dose and a maintenance dose on one of days 4-7, 2 and 6 h venous blood samples were obtained for determination of plasma disopyramide and mono-N-dealkylated disopyramide (MND) concentrations (expressed herein as levels), by a technique incorporating fluorescence photometry and thin layer chromatography. Of 121 patients entering the trial, 101 had confirmed acute MI and of these, 12 on active drug were recalled during convalescence and restudied after a loading dose.

2 In acute MI patients on disopyramide phosphate, an important degree of antidysrhythmic effect was observed (on active drug and placebo, 19% v 37%, respectively (P = 0.047), received lignocaine for `warning arrhythmias'), even though in the first 6 h post-loading dose, disopyramide and MND levels were low and variable.

3 Disopyramide levels 2 h post-loading dose were lower in acute MI than in non-MI patients (P = 0.004), and similarly in the limited within patient study corresponding levels after acute MI were lower than during convalescence (P = 0.013). At 6 h post-loading dose, the levels had increased in acute MI patients but decreased in non-MI patients, this change being significantly different (P = 0.048). A similar significant difference existed in the limited within patient data available during acute MI and convalescence (P = 0.002).

4 Acute MI patients on active drug developing `warning arrhythmias' had lower post-loading dose, 2 and 6 h levels than in those without `warning arrhythmias' (P = 0.012 and P = 0.0002, respectively).

5 One patient who developed renal insufficiency developed excessive disopyramide levels.

6 On any given dose, there was no significant correlation between disopyramide level and body weight.

7 In acute MI patients given oral disopyramide phosphate (a) there was marked interindividual variation in the ensuing drug and metabolite levels, (b) absorption of disopyramide into the circulation was delayed, (c) prophylactic antidysrhythmic activity was present at levels of about 1.5 mg/l which is about half the minimal level recommended hitherto, (d) disopyramide accumulated in renal insufficiency, (e) elaborate dosage adjustments based on body weight are not useful.

A placebo-controlled study to determine the efficacy of oral disopyramide phosphate for the prophylaxis of ventricular dysrhythmias after acute myocardial infarction

1 To evaluate oral disopyramide phosphate in the prophylaxis of dysrhythmias occurring in acute myocardial infarction (MI) patients (presenting within 12 h of symptoms, age 21-70 years), a placebo-controlled, randomized double-blind, in hospital trial was conducted. After prognostic stratification (anterior and non-anterior MI at each of 4 regional hospitals) patients were randomly assigned to receive oral disopyramide phosphate (loading dose 150, 200, or 300 mg followed 6 h later by 100, 150, or 200 mg every 6 h for patients assessed to weigh less than 55, 55-85, or greater than 85 kg, respectively or matching placebo. The primary exclusion criteria were overt heart failure, systolic BP less than 100 mmHg, significant heart block or history of urinary retention. Active drug or placebo was continued for 7 days or until (a) detection of "warning arrhythmias' requiring i.v. lignocaine intervention (greater than 5 for 7 days or until (a) detection of "warning arrhythmias' requiring i.v. lignocaine intervention (greater than 5 premature ventricular contractions (PVCs)/min, R on T PVCs, multifocal PVCs, bigeminal PVCs, ventricular tachycardia or ventricular fibrillation) or (b) onset of exclusion criteria. In addition, plasma drug concentrations were determined and 24 h electrocardiographic tapes were obtained on day 1, and on one of days 4-7 but these results are not presented here. 2 Out of 121 patients entering the trial, 101 had confirmatory ECG and enzyme changes. Of these, 9 of 47 patients receiving disopyramide phosphate required lignocaine compared to 20 of 54 receiving placebo (19% v 37%; P = 0.047). Corresponding numbers for patients discontinuing trial medication for other non-fatal complications of MI were 5 and 3, and for those dying, were 3 (2 infarct extensions and 1 massive infarction), and 0, respectively. Respective numbers discontinuing trial medication for possible drug side effects (viz. urinary retention requiring catheterization) were 6 and 1 (P = 0.031). 3 In circumstances where i.v. therapy is deemed impractical, use of oral disopyramide phosphate given prophylactically in patients with acute MI may reduce the incidence of "warning arrhythmias' by a clinically significant extent.

A new "cool" lens capsulotomy laser

A new infrared "cool" laser has been developed to facilitate extracapsular cataract extraction. It has been used to produce clinically and histologically safe, effective anterior and posterior capsulotomies in animal studies. This newly developed ophthalmic laser system operates at a wavelength of 1220 nm, and has a maximal retinal absorption of only 0.1%. This is 100 times less than the retinal absorption at the wavelength of the neodymium-YAG laser. Retinal safety is not dependent on the creation of a plasma shield or on mechanical safety devices, as it is for the neodymium-YAG laser. The 1220 nm wavelength also enhances the "cool laser" effect, so that only 1/100 of the power intensity of the modelocked neodymium-YAG laser is required. In addition to lowering the required ocular exposure this may reduce the likelihood of intraocular damage. To our knowledge this represents the first intraocular use of a laser at this wavelength region (1200 to 1290 nm). A second generation laser, using erbium yttrium lithium fluoride (YLF) as its lasing medium, is currently being developed.

Steps toward resolving cultural conflict in a pediatric hospital

A serious and potentially life-threatening disease in a young child was identified and resolved through medical intervention. However, in the course of hospitalization, a conflict arose between the mother and the health care providers that required legal constraints on the mother. A retrospective account of this conflict between Western health care providers and a family from a Caribbean culture lends itself to an examination of the role of cultural considerations in pediatric hospital care. Suggestions for resolving cultural conflict in clinical practice are discussed.

Mechanistic studies on the pyridoxal phosphate enzyme 1-aminocyclopropane-1-carboxylate deaminase from Pseudomonas sp

The enzyme 1-aminocyclopropane-1-carboxylate deaminase (ACPC deaminase) from a pseudomonad is a pyridoxal phosphate (PLP) linked catalyst which fragments the cyclopropane substrate to alpha-ketobutyrate and ammonia [Honma, M., & Shimomura, T. (1978) Agric. Biol. Chem. 42, 1825]. Enzymatic incubations in D2O yield alpha-ketobutyrate with one deuterium at the C-4 methyl group and one deuterium at one of the C-3 prochiral methylene hydrogens. Stereochemical analysis of the location of the C-3 deuteron was accomplished by in situ enzymatic reduction to (2S)-2-hydroxybutyrate with L-lactate dehydrogenase and conversion to the phenacyl ester. The C-3 hydrogens of the (2S)-2-hydroxybutyryl moiety are fully resolved in a 250-MHz NMR spectrum. Absolute assignment of 3S and 3R loci was obtained with phenacyl (2S,3S)-2-hydroxy[3-2H]butyrate generated enzymatically by D-serine dehydratase action on D-threonine. ACPC deaminase shows a stereoselective outcome with a 3R:3S deuterated product ratio of 72:28. 2-Vinyl-ACPC is also a fragmentation substrate with exclusive regiospecific cleavage to yield the straight-chain keto acid product 2-keto-5-hexenoate. The D isomer of vinylglycine is processed to alpha-ketobutyrate and ammonia at 8% the Vmax of ACPC, while L-vinylglycine is not a substrate. It is likely that ACPC and D-vinylglycine yield a common intermediate--the vinylglycine-PLP-p-quinoid adduct--which is then protonated sequentially at C-4 and then C-3 to account for the observed deuterium incorporation. The D isomers of beta-substituted alanines (fluoroalanine, chloroalanine, and O-acetyl-D-serine) partition between catalytic elimination and enzyme inactivation. Each shows a different partition ratio, arguing against the common aminoacrylyl-PLP as the inactivating species.

Mechanistic studies on reactions of bacterial methionine gamma-lyase with olefinic amino acids

Methionine gamma-lyase (EC 4.4.1.11), which catalyzes the formation of methanethiol, alpha-ketobutyrate, and ammonia from L-methionine (eq 1), promotes the oxidative deamination of several four- and five-carbon olefinic amino acids (1-5). With the exception of vinylglycine (1), the Vmax rates of keto acid formation from the unsaturated substrate analogues are substantially lower than that for processing of methionine to alpha-ketobutyrate; vinylglycine is deaminated to ketobutyrate and ammonia with a Vmax twice that for L-methionine turnover. L-Allylglycine, L-2-amino-3-trans-pentenoate, and L-2-amino-3-cis-pentenoate (2, 4, 5) are all converted to 2-keto-pentanoic acid (alpha-ketovalerate). L-2-Amino-3-cis-pentenoate (5) is also a time-dependent, irreversible inactivator of the enzyme. None of the other substrate analogues tested appears to inactivate the enzyme. Spectral analysis of the enzymatic reaction with cis isomer 5 reveals the formation of a high-wavelength chromophore (lambda max = 550 nm ) which implies that a beta, gamma-unsaturated pyridoxal p-quinoid (VI) accumulates. No such absorbing species appears to form during the reaction of trans isomer 4 with methionine gamma-lyase. But a 550-nm chromophore develops when both 4 and 5 are reacted with Al(NO3)3 and pyridoxal methochloride in methanolic KOH. It would appear that the geometry of the protein and the olefinic amino acid as an intermediate enzyme-substrate adduct controls the kinetics of reaction, such that azaallylic isomerization becomes selectively rate determining for reaction with 5. When this isomerization is slow, an accumulating Michael-type acceptor (VI) could lead to the observed irreversible inactivation of the enzyme.

The pharmacodynamics of bucainide (RHC G233): pharmacokinetic parameters and relationship between plasma levels and the effect on the electrocardiogram in the dog

The pharmacodynamic profile of bucainide dimaleate (RHC G-233) in dogs has been studied. The first observed pharmacologic effect was a change in the ECG pattern (T-wave duration and amplitude) that occurred after an average intravenous dose of 2.7 mg/kg. The average plasma concentration of bucainide was approximately 350 ng/ml. Analysis of data from dogs that received a dual infusion of bucainide indicated that bucainide has an extensive volume of distribution, with an average value of approximately 26 l/kg. An average terminal half-life of 89 minutes was observed. Studies with the radiolabeled drug in rats and dogs also demonstrated the drug's large volume of distribution, and its initial rapid disappearance from the blood. Tissue distribution studies in the rat after administration of the radiolabeled drug showed that bucainide is rapidly taken up by the tissues.

Effect of maternal cigarette smoking on Apgar scores

As shown in a total of 43,492 live-born singleton infants, the proportion of low and depressed Apgar scores is related to the extent of maternal cigarette usage during pregnancy. In particular, the three-pack level of smoking (41 to 60 cigarettes per day) is reflected in a near-quadrupling of low and depressed one-minute and five-minute Apgar scores in both blacks and whites and also after exclusion of prematurely born infants.

Relationship between pre-operative anxiety and post-operative state

Janis (1958) has proposed a curvilinear relationship pre-operative anxiety and post-operative emotional state. While other hypotheses share the prediction of a poor outcome for patients with pre-operative high anxiety, Janis' theory is unique in predicting a poor outcome for those with low anxiety. Subsequent research has failed to confirm Janis' hypotheses, perhaps because the designs have been insensitive to the predictions for low anxiety patients. The current study tests the hypothesis more directly and finds some support for a linear relationship between pre-operative anxiety and post-operative negative affect, with no support for Janis' curvilinear hypothesis. On the whole, pre-operative anxiety was a poor predictor of other measures of recovery but, on one measure, patients with low anxiety showed a slower recovery than those with moderate anxiety, i.e. supporting the prediction of a poor outcome for low anxiety patients. The implications of these results for pre-operative preparation of surgical patients and the development of theories of anxiety are discussed.

Anxiety in surgical patients

The natural course of anxiety before and after surgery was examined using the State-Trait Anxiety Inventory in 4 studies involving 136 surgical patients. The results suggested that high levels of anxiety were experienced before admission to hospital, between admission and surgery and following surgery, and were not restricted to the immediate pre-operative period. Only a small percentage of patients reached their maximum level of anxiety on the morning of surgery. These results have implications for those planning interventions to alleviate anxiety associated with surgery and for those studying surgical stress as a model for other naturally occurring stresses.

Cultural variations in professional and parenting patterns

Existing parental and professional caring patterns are explored in an attempt to lay a foundation for the development of culturally relevant perinatal programs. Beliefs about bonding behavior are discussed as well as exploring whether this new knowledge is consistent with cross-cultural adaptations to the birth process. New rules and customs being introduced by professionals may be fostering a "detachment" phenomenon rather than the desired result of bonding behavior between parent and infant. Finally, a method of examining culturally divergent health beliefs and practices is discussed as a means of evaluating whether such practices are likely to be beneficial or harmful.

Suicide inactivation of bacterial cystathionine gamma-synthase and methionine gamma-lyase during processing of L-propargylglycine

L-Propargylglycine, a naturally occurring gamma, delta-acetylenic alpha-amino acid, induces mechanism-based inactivation of two pyridoxal phosphate dependent enzymes of methionine metabolism: (1) cystathionine gamma-synthease, which catalyzes a gamma-replacement reaction in methionine biosynthesis, and (2) methionine gamma-lyase, which catalyzes a gamma-elimination reaction in methionine breakdown. Biphasic pseudo-first-order inactivation kinetics were observed for both enzymes. Complete inactivation is achieved with a minimum molar ratio ([propargylglycine]/[enzyme monomer]) of 4:1 for cystathionine gamma-synthase and of 8:1 for methionine gamma-lyase, consistent with a small number of turnovers per inactivation event. Partitioning ratios were determined directly from observed primary kinetic isotope effects. [alpha-2H]Propargylglycine displays kH/kD values of about 3 on inactivation half-times. [alpha-3H]-Propargylglycine gives release of tritium to solvent nominally stoichiometric with inactivation but, on correction for the calculated tritium isotope discrimination, partition ratios of four and six turnovers per monomer inactivated are indicated for cystathionine gamma-synthase and methionine gamma-lyase, respectively. The inactivation stoichiometry, using [alpha-14C]-propargylglycine, is four labels per tetramer of cystathionine gamma-synthase but usually only two labels per tetramer of methionine gamma-lyase (half-of-the-sites reactivity). Two-dimensional urea isoelectrofocusing/NaDodSO4 electrophoresis suggests (1) that both native enzymes are alpha 2 beta 2 tetramers where the subunits are distinguishable by charge but not by size and (2) that, while each subunit of a cystathionine gamma-synthase tetramer becomes modified by propargylglycine, only one alpha and one beta subunit may be labeled in an inactive alpha 2 beta 2 tetramer of methionine gamma-lyase. Steady-state spectroscopic analyses during inactivation indicated that modified cystathionine gamma-synthase may reprotonate C2 of the enzyme--inactivator adduct, so that the cofactor is still in the pyridoxaldimine oxidation state. Fully inactivated methionine gamma-lyase has lambda max values at 460 and 495 nm, which may represent conjugated pyridoximine paraquinoid that does not reprotonate at C2 of the bound adduct. Either species could arise from Michael-type addition of an enzymic nucleophile to an electrophilic 3,4-allenic paraquinoid intermediate, generated initially by propargylic rearrangement upon a 4,5-acetylenic pyridoximine structure, as originally proposed for propargylglycine inactivation of gamma-cystathionase [Abeles, R., & Walsh, C. (1973) J. Am. Chem. Soc. 95, 6124]. It is reasonable that cystathionine gamma-synthase is the major in vivo target for this natural acetylenic toxin, the growth-inhibitory effects of which are reversed by methionine.

Insider-out: the health worker as researcher

This article discusses two dimensions related to the insider-outsider dilemma in conducting anthropological research in the health setting. One dimension concerns advantages of the insider's special knowledge in selecting and conducting successful research in a health institution. The other dimension deals with the ambiguity and confusion of roles attributed by staff to the investigator who may be seen as practitioner as well as social scientist. The patient may also see the researcher as performing dual, and possibly conflicting, roles. The advantage gained in the first dimension may be negated, to some extent, by the disadvantages associated with the second.