Assessing compliance to antihypertensive medications using computer-based pharmacy records

Systematic approaches for compliance problem detection and intervention are needed if the benefits of prescribed drug therapy in chronic disease management are to be optimized. As with all measures of compliance, computer algorithms based on refill patterns have advantages and disadvantages. They are unobtrusive and easily determined, but they measure the timeliness of prescription refills, not actual drug-taking. Computer-generated algorithms for assessing compliance based on refill patterns should be used by practitioners with caution, because they are not only markers for potential drug taking compliance problems, but also for discrepancies between the medical chart, pharmacy records and verbal advice given to the patient. Because patients may obtain refills before depleting their supply, compliance rates using this methodology are best determined across several refills. In particular, we urge caution in applying them over time periods of less than 60 days. Longer minimum time periods further decrease the likelihood of "false positives" but limit the number of patients for whom a compliance measure can be computed. For the health professional (eg, the pharmacist) responsible for monitoring drug-taking compliance of patients, the message seems clear: when reviewing computer-generated noncompliance "flags," the first task is to fully explore the possibility of discrepancies in drug records before initiating compliance-related interventions.

Correlates and effect of non-response in a postpartum survey of obstetrical care quality

This study investigated the differences between unprompted respondents, prompted respondents, and non-respondents to a postpartum postal survey, and determined the likely impact of non-response on the accuracy of calculations of patient assessments of obstetrical care quality. Birth certificate and hospital discharge data were obtained for 1664 live births at three hospitals in Washington State between 8/91-10/91 and linked with 1268 completed postpartum maternal postal surveys. Non-white race, public insurance payer, unmarried status, and smoking in pregnancy were independent risk factors for non-participation. Among participants, non-white race, unmarried status, and having an infant who was low birthweight, preterm, or discharged late were independent risk factors for prompted response. The inclusion of prompted respondents did not substantially alter the calculated proportion of women rating obstetrical care quality as low, and these figures were similar to proportions estimated for the entire intended cohort using a modification of Drane's method. A one-time mailing of an obstetrical care quality survey can provide information similar to that obtained with more extensive follow-up even though substantial differences may exist between unprompted and prompted respondents, and with adjustment for factors related to non-participation and timing of response, it may be possible to obtain accurate estimation of outcome prevalences for the entire intended cohort.

Comparison of the Musculoskeletal Function Assessment questionnaire with the Short Form-36, the Western Ontario and McMaster Universities Osteoarthritis Index, and the Sickness Impact Profile health-status measures

We compared the reliability, validity, and responsiveness of the Musculoskeletal Function Assessment (MFA) questionnaire with those of three commonly used health-status measures: the Short Form-36 (SF-36), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Sickness Impact Profile (SIP). The MFA, like the other health-status measures, demonstrated good reliability (intraclass correlation coefficients of more than 0.70), good sensitivity and specificity (more than 70 per cent), good criterion validity that correlated with physicians' ratings (p < 0.01), and good construct validity that correlated with the characteristics of the patients (p < 0.01). It also demonstrated better content validity than the other questionnaires, with no ceiling or floor effects for the total score. In addition, it was more responsive than the SF-36; for eight of the eleven comparisons, it was more efficient (relative efficiency of more than 2.00) in measuring changes in function between the baseline values and the values determined at the latest follow-up evaluation. These findings suggest that the MFA can be used to assess the health status of patients who have a musculoskeletal disorder.

Health care utilization for the "newly insured": results from the Washington Basic Health Plan

The risk of providing coverage for low-income people formerly without insurance is unknown. We conducted an evaluation to describe the use of services from 1989-1992 for members of the Basic Health Plan (BHP), a subsidized health insurance program for low-income individuals in the state of Washington. There was evidence of pent-up demand for care for those who had been without insurance for more than a year. Overall, members in the BHP program were not high users of care, although one of the three plans we examined had significantly higher utilization than the other two. BHP total expenditures were comparable to those for state employees and lower than those for Medicaid recipients.

What do women want to know after childbirth?

BACKGROUND

Postpartum women have demonstrated a variety of health care concerns. This study, conducted in Washington state in 1991, investigated predictors of primiparas' and multiparas' desire to receive more information about 18 self-care and baby care topics at 7 weeks postpartum in relation to prenatal class attendance, short postpartum hospital stay, and other variables.

METHODS

Data from 1161 women who completed a survey were analyzed. Percentages of women desiring more information on each topic were calculated stratified by parity; mean numbers of chosen health topics were calculated in relation to prenatal education, length of postpartum hospitalization, maternal age, education, social support, and type of delivery; and association between desire for more information on specific topics and length of postpartum hospitalization, maternal age, maternal education, and social support were calculated.

RESULTS

Over three-fourths of women wanted more information on at least one topic, and the highest percentage wanted more information on exercise, diet, and nutrition; getting along with their other children; and recognizing infant illness. Primiparas and multiparas who desired more information were under 25 years of age and had low levels of social support; in addition, multiparas with unmet information needs had low education and short postpartum stays. Prenatal education was unrelated to postpartum desire for more information.

CONCLUSION

Most postpartum women want self-care and baby care information, a need that is not completely met by prenatal or postpartum education. Postpartum follow-up programs with a strong educational component and special targeting of high-risk women may enable health caregivers to better address this need.

Dissatisfaction and disenrollment in a subsidized managed care program

We studied members of the subsidized Basic Health Plan (BHP)from four managed health care organizations (MHCO). We compared low-income enrollees' and disenrollees' satisfaction with benefits, membership, and care from their MHCOs. Enrollees disenrolled primarily because they became insured through an employer, their income increased, or they moved out of the area. These disenrollees were less satisfied overall and with the amount of premiums and the total amount of medical costs covered. Disenrollees were also less satisfied with the ease and convenience of obtaining care, availability of phone advice, and quality of care. Disenrollees were more likely to be employed or to have a family member in fair or poor health. Satisfaction was high with MHCOs, although it varied considerably by site, particularly with ability to select doctors. Respondents reported affordability the most desired feature and lack of prescription coverage the least desired feature. Overall, disenrollment was not associated highly with dissatisfaction.

Effects of perceptual training based upon synthesized voice signals

28 undergraduate students participated in a perceptual voice experiment to assess the effects of training utilizing synthesized voice signals. An instructional strategy based upon synthesized examples of a three-part classification system: "breathy," "rough," and "hoarse," was employed. Training samples were synthesized with varying amounts of jitter (cycle-to-cycle deviation in pitch period) and harmonic-to-noise ratios to represent these qualities. Before training, listeners categorized 60 pathological voices into "breathy," "rough," and "hoarse," largely on the basis of fundamental frequency. After training, categorizations were influenced by harmonic-to-noise ratios as well as fundamental frequency, suggesting that listeners were more aware of spectral differences in pathological voices associated with commonly occurring laryngeal conditions. 40% of the pathological voice samples remained unclassified following training.

Conducting a randomized controlled trial of CQI and academic detailing to implement clinical guidelines

BACKGROUND

A multisite, randomized controlled trial was conducted from August 1994 through January 1996 to compare the impact of two strategies-academic detailing (AD) and continuous quality improvement (CQI) teams-on the implementation of national guidelines for the primary care of hypertension and depression.

STUDY

Twelve small groups of providers at four clinics-two at Group Health Cooperative of Puget Sound (Seattle) and two at academic medical centers-were randomized in blocks along with their primary care patients to receive AD alone, AD plus CQI, or usual care. A detailing session conducted by a physician and two follow-up sessions conducted by a pharmacist lasted an average of 8-9 minutes. Each CQI team, which met, on average, 14 times in nine months, devised at least one intervention (for example, weight loss counseling for hypertensives by nurse practitioners).

RESULTS

The detailing endeavors differed greatly across organizations. Although all teams generally worked well together, organizational factors such as staff layoffs and reorganizations competed for the teams' attention. Team leaders differed in their ability to inspire members to "run with" ideas and to motivate personnel outside the team to implement interventions.

SUMMARY AND CONCLUSIONS

Surveys and semi-structured interviews suggest that both the AD and CQI interventions involved complex social interactions that resulted in varied implementation across the different organizations. Final analyses will need to focus on identifying factors associated with the relative success or failure of both clinical change techniques.

Inflammatory cytokines in patients with persistence of the acute respiratory distress syndrome

To determine the relationship between airspace cytokines and cellular inflammatory responses in patients with the acute respiratory distress syndrome (ARDS), we performed bronchoalveolar lavage (BAL) in 82 prospectively identified, mechanically ventilated patients on Days 3, 7, 14, and/or 21 after the onset of ARDS. We studied the relationships between bronchoalveolar lavage fluid (BALF) cell populations and the concentrations of two potent neutrophil (PMN) chemoattractants, interleukin-8 (IL-8) and epithelial cell-derived neutrophil activator-78 (ENA-78); two potent monocyte chemoattractants, monocyte chemotactic peptide-1 (MCP-1) and macrophage inflammatory peptide-1 alpha (MIP-1 alpha); and the early response cytokine interleukin-1 beta (IL-1 beta) and its naturally occurring antagonist, IL-1 receptor antagonist protein (IRAP). We found that all of these cytokines were significantly increased regardless of the duration of ARDS. IL-8 and ENA-78 were the cytokines most strongly and consistently correlated with PMN concentrations in the lung fluids of patients with ARDS, and the correlations were independent of the other cytokines or coexisting lung infection. None of the cytokines tested correlated with macrophage concentrations. MCP-1 was directly correlated with lung injury score on Days 7, 14, and 21. Although neither IL-8 nor ENA-78 was associated with outcome, levels of IL-1 beta measured on Day 7 were associated with an increased risk of death (odds ratio [OR] = 2.8; 95% confidence interval [CI] = 1.1 to 7.4). These data demonstrate potential molecular mechanisms of the persistent inflammatory process in the lungs of patients with ARDS.

Will uninsured people volunteer for voluntary health insurance? Experience from Washington State

OBJECTIVES

In national and local discussions of health care reform, there is disagreement about whether a national health insurance plan should be mandatory or voluntary. This study describes characteristics of low- income people who were more likely or less likely to be covered by a voluntary plan.

METHODS

Survey data were available from an evaluation of Washington State's Basic Health Plan, which offered subsidized health insurance to low-income residents. For those subjects who were eligible and uninsured at baseline, those who joined were compared with those who did not join on a variety of demographic and health-related characteristics.

RESULTS

There were substantial differences between those who did and did not join the Basic Health Plan. Those who did not enroll were generally less well-off, with less education, lower income, and worse health. Many had never had health insurance.

CONCLUSIONS

If health care reform results in a voluntary plan, additional measures may be needed to ensure that less advantaged citizens have adequate access to health care.

Musculoskeletal Function Assessment instrument: criterion and construct validity

The Musculoskeletal Function Assessment (MFA) instrument, a health status instrument with 100 self-reported health items, was designed for use with the broad range of patients with musculoskeletal disorders of the extremities commonly seen in clinical practice. In this paper, we report on its criterion and construct validity. Criterion validity was tested against physicians' ratings of patient functioning (e.g., upper functioning, lower functioning, daily activities, recreational functioning, emotional adjustment, and overall functioning) and standard clinical measures (e.g., grip strength, walking speed, fine motor skills, knee and elbow strength, and range of motion). Significant correlations (p < or = 0.05) between its scores, physicians' ratings, and clinical measures support the MFA's criterion validity. Construct validity was demonstrated against existing measures of health status (e.g., measures of lower and upper mobility, activity level and satisfaction, health status, social support, pain, emotional status, and quality of life), in accordance with clinical hypotheses about the effect of musculoskeletal disorders on functioning (e.g., type and number of problems, severity of illness or injury, and comorbidities) and by an analysis of demographic characteristics (e.g., sex, education, income, health insurance, and employment) against the MFA scores. Discriminant construct validity was supported in an analysis of MFA scores by patient disease groups (p < or = 0.01).

Development of a musculoskeletal extremity health status instrument: the Musculoskeletal Function Assessment instrument

Despite an increasing reliance on the use of health status measures to assess and evaluate medical care, no single instrument is currently available for use with the broad range of patients with musculoskeletal disorders of the extremities that is commonly seen in clinical practice. In this paper, we report on the development of the Musculoskeletal Function Assessment instrument, a 100-item self reported health status instrument that is designed to meet this need. The instrument was developed in two phases. During the first phase, items were selected on the basis of interviews with 135 patients and 12 clinicians and from reviews of existing health status instruments. The items then were grouped into categories. During the second phase, the instrument was tested for reliability and content validity using a sample of 327 patients with one of five musculoskeletal disorders of the upper and lower extremities (fractures, soft-tissue injuries, repetitive motion disorders, osteoarthritis, and rheumatoid arthritis). The patients were selected from both community and academic sites. Content validity also was demonstrated, based on a review of item selection procedures, expert opinion, and the distribution of scores on the instrument.

Comparison of the profiles of agonists as stimulants of the beta 3-adrenoceptor in vitro with their gastroprotective effects in the conscious rat

1. This paper compares the activity of a range of agonists as stimulants of the beta 3-adrenoceptor in rat isolated oesophagus with their ability to afford protection against indomethacin-induced gastric damage in the conscious rat. 2. The beta 3-adrenoceptor agonists, CL 316243 and BRL 37344, the non-selective beta-adrenoceptor agonist, isoprenaline and the selective beta 2-adrenoceptor agonist, salmeterol, all evoked concentration-dependent relaxation of precontracted muscularis mucosa from rat oesophagus. The rank order of agonist potency was BRL 37344 > CL 316243 > isoprenaline >> salmeterol. The selective beta 1-adrenoceptor agonist, denopamine, did not relax the preparation. 3. The relaxant responses to all agonists were resistant to blockade by atenolol (10 microM), and ICI 118551 (1 microM) thus suggesting that they were not mediated by either beta 1- or beta 2-adrenoceptor stimulation. In contrast, cyanopindolol and propranolol did inhibit responses to BRL 37344, CL 316243 and isoprenaline, giving pA2 values or pKB estimates which were consistent with an interaction at beta 3-adrenoceptors (i.e. approximately 8.0 and 6.5 respectively). However, responses to salmeterol were resistant to blockade by all the antagonists tested, which suggests that the high (> 1 microM) concentrations of salmeterol used exerted non-specific relaxant effects. 4. The agonist effects of CL 316243 and BRL 37344 on beta 1- and beta 2-adrenoceptors were assessed on guinea-pig right atrium and precontracted trachea respectively. Both agonists had minimal activity as stimulants of heart rate, but did relax trachea, being 380 (CL 316243) and 21 (BRL 37344) fold less potent than isoprenaline. 5. CL 316243 and BRL 37344 were potent inhibitors of indomethacin-induced gastric antral ulceration in the conscious rat (ED50 values = 0.24 and 0.09 mumol kg-1, p.o.) Salmeterol was approximately 100 times less potent than BRL 37344 as a gastroprotective agent and denopamine was without effect. 6. The gastroprotective effects of CL 316243 and BRL 37344 were resistant to blockade by ICI 118551 (10 mg kg-1, p.o.) and propranolol (10 mg kg-1, p.o.). In contrast, both antagonists caused dose-related inhibition of the protective action of salmeterol (10 mg kg-1, p.o.). Cyanopindolol was not assessed as an antagonist in vivo because preliminary experiments revealed that it exacerbated indomethacin-induced gastric damage in its own right. 7. In conclusion, the beta 3-adrenoceptor agonists CL 316243 and BRL 37344 were potent inhibitors of indomethacin-induced gastric antral ulceration in the rat. These data suggest that an agonist which is potent and selective for the human beta 3-adrenoceptor may confer mucosal protection in man.

Enzyme-catalyzed synthesis of poly[(R)-(-)-3-hydroxybutyrate]: formation of macroscopic granules in vitro

A combined chemical and enzymatic procedure has been developed to synthesize macroscopic poly[(R)-(-)-3-hydroxybutyrate] (PHB) granules in vitro. The granules form in a matter of minutes when purified polyhydroxyalkanoate (PHA) synthase from Alcaligenes eutrophus is exposed to synthetically prepared (R)-3-hydroxybutyryl coenzyme A, thereby establishing the minimal requirements for PHB granule formation. The artificial granules are spherical with diameters of up to 3 microns and significantly larger than their native counterparts (0.5 micron). The isolated PHB was characterized by 1H and 13C NMR, gel-permeation chromatography, and chemical analysis. The in vitro polymerization system yields PHB with a molecular mass > 10 x 10(6) Da, exceeding by an order of magnitude the mass of PHAs typically extracted from microorganisms. We also demonstrate that the molecular mass of the polymer can be controlled by the initial PHA synthase concentration. Preliminary kinetic analysis of de novo granule formation confirms earlier findings of a lag time for the enzyme but suggests the involvement of an additional granule assembly step. Minimal requirements for substrate recognition were investigated. Since substrate analogs lacking the adenosine 3',5'-bisphosphate moiety of (R)-3-hydroxybutyryl coenzyme A were not accepted by the PHA synthase, we provide evidence that this structural element of the substrate is essential for catalysis.

Voluntary public health insurance for low-income families: the decision to enroll

A dominant issue in the health reform debate is whether insurance coverage should be voluntary or mandatory. Clearly, the factors that determine who will seek voluntary coverage are relevant to this policy issue. This article uses experience from Washington State's Basic Health Plan to examine the enrollment choices of low-income families in a state-subsidized voluntary insurance plan offered through managed care organizations. We hypothesize that the decision to enroll, which encompasses the decisions to purchase insurance coverage and to select a particular plan, is influenced by four factors: the family's financial vulnerability, their risk perception, the price of coverage, and the transition costs of enrolling. Our enrollment model is supported by the data and has important implications for the design of voluntary programs. Families who choose to enroll are more likely to have a female head of household, young children, and a family member who has a part-time job and some college education. Higher premiums and availability of other insurance coverage decrease the probability of enrolling.

A very short hydrogen bond provides only moderate stabilization of an enzyme-inhibitor complex of citrate synthase

Two extremely potent inhibitors of citrate synthase, carboxyl and primary amide analogues of acetyl coenzyme A, have been synthesized. The ternary complexes of these inhibitors with oxaloacetate and citrate synthase have been crystallized and their structures analyzed at 1.70- and 1.65-A resolution, respectively. The inhibitors have dissociation constants in the nanomolar range, with the carboxyl analogue binding more tightly (Ki = 1.6 nM at pH 6.0) than the amide analogue (28 nM), despite the unfavorable requirement for proton uptake by the former. The carboxyl group forms a shorter hydrogen bond with the catalytic Asp 375 (distance < 2.4 A) than does the amide group (distance approximately 2.5 A). Particularly with the carboxylate inhibitor, the very short hydrogen bond distances measured suggest a low barrier or short strong hydrogen bond. However, the binding constants differ by only a factor of 20 at pH 6.0, corresponding to an increase in binding energy for the carboxyl analogue on the enzyme of about 2 kcal/mol more than the amide analogue, much less than has been proposed for short strong hydrogen bonds based on gas phase measurements [> 20 kcal/mol (Gerlt & Gassman, 1993a,b)]. The inhibitor complexes support proposals that Asp 375 and His 274 work in concert to form an enolized form of acetyl-coenzyme A as the first step in the reaction.

Comparison of prescription and medical records in reflecting patient antihypertensive drug therapy

OBJECTIVE

To determine the completeness of prescription records, and the extent to which they agreed with medical record drug entries for antihypertensive medications.

SETTING

Three clinics affiliated with two staff model health maintenance organizations (HMOs).

PARTICIPANTS

Randomly selected HMO enrollees (n = 982) with diagnosed hypertension.

METHODS

Computer-based prescription records for antihypertensive medications were reviewed at each location using an algorithm to convert the directions-for-use codes into an amount to be consumed per day (prescribed daily dosage). The medical record was analyzed similarly for the presence of drug notations and directions for use.

RESULTS

There was a high level of agreement between the medical record and prescription file with respect to identifying the drug prescribed by drug name. Between 5 and 14 percent of medical record drug entries did not have corresponding prescription records, probably reflecting patient decisions not to have prescriptions filled at HMO-affiliated pharmacies or at all. Further, 5-8 percent of dispensed prescription records did not have corresponding medical record drug entry notations, probably reflecting incomplete recording of drug information on the medical record. The percentage of agreement of medical records on dosage ranged from 68 to 70 percent across two sites. Approximately 14 percent of drug records at one location and 21 percent of records at the other had nonmatching dosage information, probably reflecting dosage changes noted on the medical record but not reflected on pharmacy records.

CONCLUSIONS

In the sites studied, dispensed prescription records reasonably reflect chart drug entries for drug name, but not necessarily dosage.

Who enrolled in a state program for the uninsured: was there adverse selection?

Managed care plans may hesitate to participate in programs for uninsured persons because they fear adverse selection, whereby only the sickest people or highest users would choose to join the program. We studied this issue in Washington State's Basic Health Plan, a demonstration program that provides subsidized health insurance for families earning less than 200% of the poverty level. We interviewed people in three counties who enrolled in the program, and compared them to people in the same counties who were eligible but did not enroll. There were substantial differences between enrollees and eligibles in education, age, income, employment, race, and insurance status. In spite of these demographic and access differences, health status was remarkably similar for enrollees and eligibles, with the few significant differences favoring the enrollees. In addition, previous and subsequent use of health services was similar or lower for enrollees. The results for health status and utilization were similar across the three counties, even though the counties and the providers were quite different. We conclude that there is no evidence of adverse selection. This is welcome news for the health plans, but suggests that the BHP may not have reached those most in need of insurance.

Functional characterization of three adenosine receptor types

1. The purpose of the present study was to classify adenosine receptors into A1 and A2 subtypes in a wide range of isolated tissues and cell types (rat adipocytes and atria, guinea-pig ileum and atria (A1); guinea-pig aorta, dog coronary artery and human platelets and neutrophils (A2)) using the R- and S-diastereoisomers of N-phenylisopropyladenosine (PIA), N-cyclopentyladenosine (CPA), the novel compound, N-[(1S,trans)-2-hydroxycyclopentyl]adenosine (GR79236), N-[(2-methylphenyl)methyl]adenosine (metrifudil), 2-(phenylamino)adenosine (CV1808), and 2[[2-[4-(2-carboxyethyl)phenyl]ethyl]amino]-N- ethylcarboxamidoadenosine (CGS21680); N-ethylcarboxamidoadenosine (NECA) was used as a standard. 2. Results obtained in all tissue preparations previously reported to contain A1-receptors could be described by a single rank order of agonist potency: CPA > or = GR79236, R-PIA > or = NECA >> S-PAI > or = metrifudil > or = CV1808, CGS21680. 3. In contrast, two distinct rank orders of agonist potency were observed in preparations previously reported to contain A2-receptors. In dog coronary artery, human neutrophils and platelets the rank order of potency was: CV1808, CGS21680 > or = NECA > R-PIA > or = metrifudil > or = CPA > GR79236 S-PIA. However, in guinea-pig aorta the rank order was: NECA > metrifudil > R-PIA, CPA > CV1808, GR79236 > or = S-PIA, CGS21680. 4. The results of this study are consistent with the existence of three types of adenosine receptor: A1-and two subtypes of A2-receptor. The receptor present in dog coronary artery, human platelets and neutrophils, probably corresponds to the A2a subtype, whilst that present in the guinea-pig aorta may be of the A2b subtype.

Suppression of non-esterified fatty acids and triacylglycerol in experimental animals by the adenosine analogue GR79236

1. This is the first description of the metabolic activity of a novel adenosine A1-receptor agonist, GR79236. GR79236 inhibited catecholamine-induced lipolysis in human, rat and dog isolated adipocytes. 2. Oral administration of GR79236 (0.1-10 mg/kg) to fed rats induced minimal changes in the plasma concentration of non-esterified fatty acids and in the blood concentrations of glucose and lactate. 3. Intravenous infusion of GR79236 to fasted pithed rats, or oral administration of GR79236 to fasted conscious rats and dogs, produced time- and dose-dependent decreases in the plasma non-esterified fatty acid concentration. In the fasted rats, doses of GR79236 that lowered plasma levels of non-esterified fatty acids also produced hypotriglyceridaemia and anti-ketotic effects. 4. Only in the pithed rats were acute effects on the plasma glucose and lactate concentrations observed. Hypoglycaemia and hyperlactataemia occurred over the dose range studied (1 x 10(-11)-1 x 10(-8) mol min-1 kg-1). 5. This profile of activity suggests that compounds such as GR79236 might be agents which can be used to define the role of excessive lipolysis in experimental (and human) pathophysiology.

Separate enzymes catalyze the final two steps of coenzyme A biosynthesis in Brevibacterium ammoniagenes: purification of pantetheine phosphate adenylyltransferase

We have discovered that the final two steps in coenzyme A biosynthesis in Brevibacterium ammoniagenes are catalyzed by distinct enzymes, readily separated by DEAE sepharose anion exchange chromatography. This is in contrast to mammalian tissues in which these two reactions are catalyzed by a single bifunctional enzyme (Worrall, D.M., and Tubbs, P.K. (1983) Biochem. J. 215, 153-157) and Bakers yeast in which these two activities have been identified as part of a multifunctional complex (Bucovaz, E.T., Rhoades, J.L., and Tarnowski, S.J. (1980) Fed. Proc. 39 (6), 142). The pantetheine phosphate adenylyltransferase has been purified to homogeneity and found to exist as a trimeric protein of molecular mass approximately 108 kDa. Of other nucleoside triphosphates tested as substrates, only 2'-deoxy-ATP showed measurable activity, being 27% that of ATP.

A validation of the functional independence measurement and its performance among rehabilitation inpatients

The Functional Independence Measurement (FIM) is a new functional status instrument for use among rehabilitation inpatients, but its validity and reliability have been only partially established. Because of its rapid dissemination, we sought further evidence concerning the FIM's internal consistency, responsiveness over time, and construct validity. We examined Uniform Data System (UDS) data on 11,102 general rehabilitation inpatients from the Pacific Northwest. Mean age was 65 and 51% were male. The most common diagnoses were stroke (52%), orthopedic conditions (10%), and brain injury (10%). Internal consistency of the FIM was calculated using Cronbach's alpha. To assess FIM responsiveness, we examined differences between admission and discharge FIM scores. For construct validation purposes, we hypothesized that the FIM would vary with age, comorbidity, discharge destination, and impairment severity. Comorbidity was quantified with the Charlson Comorbidity Index. The FIM had a high overall internal consistency (discharge FIM alpha = .93). The FIM registered significant functional gains during rehabilitation (33% FIM score improvement, p < .001), as do many other functional status indicators. The greatest and least functional improvements were observed for traumatic brain injury and low back pain (53% and 8% FIM score improvement, respectively). The FIM discriminates patients on the basis of age, comorbidity, and discharge destination. Severity differences could be distinguished among spinal cord injury and stroke patients. We conclude that the FIM has high internal consistency and adequate discriminative capabilities for rehabilitation patients. It is a good indicator of burden of care, and demonstrates some responsiveness, but its capacity to measure change over time needs further examination and comparison with competing scales.

Biochemical characterization of programmed cell death in NGF-deprived sympathetic neurons

Young sympathetic neurons die when deprived of nerve growth factor (NGF). Under such circumstances, cell death is appropriate to the developing nervous system and requires RNA and protein synthesis. We have hypothesized the existence of an endogenous death program within neurons that is suppressed by trophic factors. The extent and timing of required changes in the synthetic events that comprise the death program are unknown. In an effort to characterize the biochemical events that mediate the death program further, we performed several experiments on embryonic rat sympathetic neurons in vitro. The death program was blocked with cycloheximide when total protein synthesis was inhibited > or = 80%. When protein synthesis was inhibited within 22 +/- 4 h of NGF deprivation, death was prevented in half the neurons. Hence, we define the commitment point for protein synthesis to be 22 +/- 4 h. Analogously, the commitment point for RNA synthesis was 26 +/- 4 h and that for NGF rescue, 24 +/- 4 h. We tested the ability of a wide variety of chemicals to interfere with the death program. Most compounds tested were unable to prevent neuronal death. Some treatments, however, did save NGF-deprived neurons and were subsequently characterized. These included ultraviolet light and agents that raise intracellular concentrations of cAMP. Finally, we looked for the neuronal expression in vitro and in vivo of genes that have been associated with programmed death in other cell types, including TRPM-2/SGP-2, polyubiquitin, TGF beta-1, c-fos, and c-myc. None of these genes showed significant activation associated with neuronal death.