41 Using Patient Centred Care to Redesign Integrated Discharge Services in Derby

Background

Discharge to Assess as outlined by the Department of Health was adopted in Derby in 2016. Previously the discharge pathways to community settings from the acute trust were complex. Challenges included: Operating from a traditional residential care home.No integration of community health staff and social care teams leading to delays in treatment and decision making as well as multiple referrals and hand-overs and no joint communication which was confusing for patients.Stakeholder anticipation of 6 weeks length of stay.Limited responsiveness to capacity demand within planned and unplanned community physiotherapy.Changing the culture and mind-set of staff.Different health and social care processes and procedures, IT systems, working patterns, contracts and pay scales.

Methods

A new service model, joint processes and standard operating procedures was developed with the patient at the centre of the design. Trusted assessment and information sharing reduce multiple assessments and hand overs, ensuring a smoother and improved patient experience.

Outcomes

Triage of patients from the Integrated Discharge Hub to the appropriate pathway, early discharge planning, board rounds and MDT's and timely assessments combined with an enablement ethos have increased the flow of patients through the service, decreased care package hours and increased capacity through reducing both length of stay and delayed transfers of care. The health and social care teams are now delivering fully integrated care and undertaking joint training. This has led to a reduction in treatment times from 20 days to 12 days, reductions in DTOC to average of 8 days per month and improved access to community based routine therapy from 85% of referrals being seen by 6 weeks 2017-18 to 99% in 2018-19.

Conclusions

The integrated service delivers more for less resulting in significant savings in the healthcare and social care system while maintaining quality standards and outcomes.

An empirical assessment of the short-term impacts of a reading of Deborah Zoe Laufer's drama Informed Consent on attitudes and intentions to participate in genetic research

OBJECTIVE

This study assessed the short-term impact of the play "Informed Consent" by Deborah Zoe Laufer (a fictionalized look at the controversy over specimens collected from the Havasupai Tribe for diabetes research in 1989) on perceptions of trust, willingness to donate biospecimens, and attitudes toward harm and privacy among the medical and undergraduate students, faculty, and the public in the Intermountain West.

METHODS

Surveys were administered before and after a staged reading of the play by professional actors. Survey items included the short form Trust in Medical Researchers, and single-item questions about group identity, ethics of genetic testing in children, and willingness to donate biospecimens. In addition, respondents were given the option to answer open-ended questions through e-mail.

RESULTS

Out of the 481 who attended the play, 421 completed both the pre and post surveys, and 166 participants completed open-ended questions online approximately 1 week after the play. Across all participants, there were significant declines for trust in medical researchers and for the survey item "is it ethical for investigators to test children for adult onset diseases" (p < .001 for both) following the play. There was a significant increase in agreement to improve group identity protections (p < .001) and there were no differences on willingness to donate biospecimens to research (p = .777). Qualitative data provided extensive contextual data supporting these perspectives.

DISCUSSION

This is one of the first studies to document short-term impacts of a theatrical performance on both attitudes and behavioral intentions toward research ethics and clinical research participation. Future research should continue to explore the impact of theatrical performances among public and investigators on the ethical issues and complexities in clinical research.

Low Temperature Electronic Absorption Spectra of Oxidized and Reduced Spinach Ferredoxins. Evidence for Nonequivalent Iron(III) Sites

The electronic absorption spectra of oxidized and reduced spinach ferredoxins have been measured between 1200 and 600 nm at low temperature in D(2)O/ethylene glycol glasses. Relatively weak absorption bands are observed at 720, 820, and 920 nm in oxidized ferredoxin, and at 652, 820, and 920 nm in reduced ferredoxin. The spectral results show that the two Fe(III) centers in oxidized ferredoxin are not equivalent, and that the 820- and 920-nm bands are associated with the nonreducible site. Assignment of the reducible site as tetrahedral Fe(III) is indicated. The 720-nm (13.9 kcm(-1)) band in oxidized ferredoxin is attributed to an intensity-enhanced (6)A(1) --> (4)T(1)d-d transition, whereas the 652-nm (15.3 kcm(-1)) feature of reduced ferredoxin could be due either to (5)E --> (3)T(1) in tetrahedral Fe(II)S(4) or an Fe(II) --> Fe(III) intervalence excitation.

Metal ion catalyzed hydrolysis of ethyl p-nitrophenyl phosphate

15N isotope effects in the nitro group and 18O isotope effects in the phenolic oxygen have been measured for the hydrolysis of ethyl p-nitrophenyl phosphate catalyzed by several metal ions. Co(III)-cyclen at pH 7, 50 degrees C, gave an 15N isotope effect of 0.12% and an 18O one of 2.23%, showing that P-O cleavage is rate limiting and the bond is approximately 50% broken in the transition state. The active catalyst is a dimer and the substrate is presumably coordinated to the open site of one Co(III), and is attacked by hydroxide coordinated to the other Co(III). Co(III)-tacn under the same conditions shows a similar 15N isotope effect (0.13%), but a smaller 18O one (0.8%). Zn(II)-cyclen at pH 8.5, 80 degrees C, gave an 15N isotope effect of 0.05% and an 18O one of 0.95%, suggesting an earlier transition state. The catalyst in this case is monomeric, and thus the substrate is coordinated to one position and attacked by a cis-coordinated hydroxide. Eu(III) at pH 6.5, 50 degrees C, shows a very large 15N isotope effect of 0.34% and a 1.6% 18O isotope effect. The large 15N isotope effect argues for a late transition state or Eu(III) interaction with the nitro group, and was also seen in Eu(III)-catalyzed hydrolysis of p-nitrophenyl phosphate.

Investigation of substrate specificity of creatine kinase using chromium(III) and cobalt(III) complexes of adenosine 5'-diphosphate

The specificity for substrate binding to creatine kinase for metal-nucleotide complexes of the type Cr-(H2O)4-n(NH3)nADP (where n = 0, 3, or 4) and Co-(H2O)4-m(NH3)mADP (for m = 3 or 4) has been investigated over the pH range 5.5-7.8 with the delta-alpha, beta-bidentate diastereoisomers. These inert nucleotide complexes acted as competitive inhibitors vs. MgADP over this range. In addition, the pH dependence of the V, V/K, and Km values for MgADP has been determined. Metal-nucleotide binding to the enzyme is strongest below an approximate pK of 6.45 but again becomes pH independent above pH 7. This pK is not associated with the metal-nucleotide complex. Instead, we conclude that the pK of the acid-base catalyst (thought to be histidine) is about 6.45 in the absence of nucleotide but is raised to 7.2 in its presence. This perturbation of the pK may result from a protein conformational change that allows a hydrogen bond to form between the phosphorylated nitrogen of phosphocreatine and the acid-base catalyst. The pK of the water in Cr(H2O)(NH3)3ADP has been determined to be 6.6, and by comparison of the binding affinity of this complex with that of Cr(NH3)4ADP or Cr(H2O)4ADP, it can be deduced that the hydroxo species binds more strongly than the aquo complex. In general, chromium nucleotides are bound more strongly than cobalt complexes, and binding affinity increases as water replaces ammonia in the first coordination sphere of the metal. Both trends are a result of stronger hydrogen-bond interactions between the metal complex and protein.

Urea kinetics of a carnivore, Felis silvestris catus

The effect of two levels of dietary protein energy, moderate (20%; MP) and high (70%; HP), on urea kinetics in eleven domestic cats was studied. After a 3-week prefeed, a single dose of [(15)N(15)N]urea was administered, and urine and faeces collected over the subsequent 5 d. For each 24 h period, total urea and enrichment of [(15)N(15)N]- and [(15)N(14)N]urea in urine were determined, and a model applied to calculate urea production, entry into the gastrointestinal tract, recycling to urine or faeces and, by difference, retention by the body and potentially available for anabolism. Urea production and excretion increased with dietary protein level Most of the urea produced was excreted, with only a small proportion entering the gut, and with the pattern of urea disposal not significantly different between the HP and MP diets. Thus, the percentages of urea production available to the gut were 15% (MP) and 12% (HP), of which 57% (MP) and 59% (HP) was recycled in the ornithine cycle, 40% (MP and HP) was potentially available for anabolism and the rest lost as faecal N. As a percentage of urea produced the amount potentially available for anabolism was very low at 6.41% (MP diet) and 4.79% (HP diet). In absolute terms urea entering the gut, being recycled in the ornithine cycle and potentially available for anabolism was significantly higher on the HP diet These results show that cats operate urea turnover, but at a lower rate, and with less nutritional sensitivity than has been reported for other species.

Nutrition in the elderly hospital patient Nottingham studies

Forty percent of elderly hospital admissions in the UK are undernourished, half severely so. Most continue to lose weight in hospital. not only because of disease, but also because of failure to identify and treat malnutrition and due to shortcomings in hospital food provision, upon which most patients depend for their nutritional care. Our studies have shown that more than 40% of food set before patients is left, and therefore wasted. This means that elderly patients are taking less than 70% of their energy (30-35 kcal/kg/day), and protein (1 dram/kg/day) requirements. Catering strategies, such as provision of smaller volume, high energy and protein density meals with snacks and, if necessary, proprietary oral supplements, have been shown not only to improve nutritional status of patients, but to result in improved clinical outcome. Our work has shown a relationship between malnutrition and loss of thermoregulation, which is reversed by appropriate feeding. We have also described the beneficial effects of overnight nasogastric tube feeding in undernourished patients with fractured femur. Like others, we have used a percutaneous endoscopic gastrostomy in the management of elderly patients with cerebrovascular and motor neurone disease, and have published audits of outcome in this field.

Sumatriptan treatment for migraine in a health maintenance organization: economic, humanistic, and clinical outcomes

This study was undertaken to assess the impact of 12 months of sumatriptan therapy (6 mg subcutaneously) for migraine on health care use, health-related quality of life, productivity, patient satisfaction with the medication, and clinical efficacy in a health maintenance organization (HMO). One hundred forty-eight patients received open-label sumatriptan for 12 months for the treatment of migraine. Medical records were reviewed to obtain information on the frequency of migraine-related health care use during the 12 months before and during sumatriptan treatment. Patients completed questionnaires on their productivity at work, health-related quality of life, and satisfaction with medication at baseline and after 3, 6, and 12 months of sumatriptan treatment. For each migraine, patients recorded pain severity scores before and after taking sumatriptan and the time between dosing and onset of meaningful relief. Sumatriptan was associated with significant reductions in migraine-related use of general outpatient services, telephone calls, urgent care services, and emergency department visits (P < 0.05); a significant increase in the use of pharmacy services (P < 0.05); and significant and sustained improvements in health-related quality-of-life scores compared with baseline (P < 0.001). Patients lost significantly less time from work and were significantly more satisfied with sumatriptan compared with their usual therapy (P < 0.05). Two hours after dosing, 81% of patients experienced reduction of moderate or severe pain to mild or no pain, and 90% of all patients experienced meaningful relief of pain. The use of sumatriptan for 12 months in an HMO was associated with reductions in health care use and improved health-related quality of life, productivity, and patient satisfaction with medication.

New reference reagent for the quality assurance of anti-D antibody detection

A UK BTS-NIBSC freeze-dried anti-D preparation has been prepared and used to monitor the performance of routine antibody detection tests and of the test operators. With the day-to-day use of this preparation, adverse changes in test performance and in test operator may be detected and appropriate action taken before the effect becomes significant. Two dilutions of this preparation have been defined, one which should be detected unequivocally in every test; the other, more dilute, may not be detected in every test but is used to monitor changes in performance. Experience with the use of this preparation is reported from three test centres undertaking routine antibody detection tests. By monitoring results over a series of working days, significant differences were noted in operator performance within one test centre, as was a reduced sensitivity of a given test system within one test centre compared with the same system in the other test centres. These differences were detected only by monitoring the results obtained with this preparation.

Long-term outcome and cost-effectiveness of parenteral nutrition for acute gastrointestinal failure

Although there are several published audits of long-term home parenteral nutrition for chronic gastrointestinal failure, there is little data concerning the long-term outcome following prolonged in-patient parenteral nutrition for an episode of acute gastrointestinal failure. Between 1983 and 1 July 1993, 162 patients received total parenteral nutrition (TPN) in our unit for acute gastrointestinal failure for a total of 4997 patient days and using 192 central venous catheters. Over the 10 years there were 11 mechanical complications resulting in one death. Although the overall catheter infection rate was 5.7%, in the last 4 years it was 0%, associated with a reduction in the frequency of site dressing and change of giving set from three times to once weekly. All patients had lost more than 10% of their body weight before TPN. In the non-malignant group, fed for more than 21 days (mean 50 days), the 10-year survival was 74% at a cost of 4723 pounds sterling per year of life saved. In the malignant group, the 5-year survival was 27% at a cost of 8351 pounds sterling per year of life saved. These costs compare favourably with other technologies, such as dialysis for acute renal failure. Better patient selection, fewer complications and lower costs are obtained when this treatment is carried out by an expert team.

Characterization of isomers of monoamminechromium-ATP and their use in mapping enzyme active sites

Twelve isomers formed by the reaction of monoamminechromium(III) with ATP have been synthesized. Isomerism in this system results from chirality around the beta-phosphorus of the ATP, the position of the ammonia ligand, the relative orientation of the ammonia and the AMP, and the presence of ring-puckering conformers. By using chromatography on cross-linked cycloheptaamylose, reverse-phase C-18 HPLC, and cation-exchange FPLC, these isomers have been separated and purified. Their structures have been identified by (1) cleavage by periodate, followed by elimination in the presence of diethylenetriamine and subsequent phosphate insertion to give lambda, delta, or meso facial monoamminechromium tripolyphosphate with molar ellipticities of +240, -240, or 0 deg cm2 dmol-1 at 550 nm, respectively, (2) cleavage by nucleotide pyrophosphatase to give meridional or facial monoamminechromium pyrophosphate, (3) spectral data, and (4) rates of interconversion of isomers. All possible isomers are seen except those with ammonia syn to AMP. Since the substitution of ammonia for water in the inner coordination sphere appears to diminish affinity for enzymes when the ammonia is in contact with the protein but not when it faces the solvent, these isomers are useful for mapping of enzyme active sites. Their use as probes of enzyme structure is illustrated by their behavior with yeast hexokinase.

Audit of outcome of long-term enteral nutrition by percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is the preferred method for administration of long-term enteral tube feeding. However, most published studies describe only short-term follow-up in any detail. We report the long-term outcome and complication rate after PEG insertion in 49 patients (mean [SE] age 64 [2] years) whose mean length of PEG feeding was 175 days (range 30-560). Data were collected prospectively. PEG insertion was technically successful in all cases, with a procedure-related mortality of 2%. Early (< 30 days) mortality and morbidity were 8% and 22%, respectively. Of 45 patients surviving for more than 30 days, 76% were able to return home and 6 patients were eventually able to revert to oral feeding. There were 27 late complications: 2 site infections, 17 mechanical problems, and 8 episodes of gastrointestinal dysfunction. 51% of patients had no problems at all and 22% had 2 or more complications. 47% of complications required a hospital visit for resolution. Long-term enteral feeding by PEG was safe, effective, and had a low complication rate. Our patients were managed by a specialist nutrition team, a policy that may reduce the complication rate and hospital visits for patients being fed at home, and allow early discharge of dysphagic patients, thereby reducing costs.

Structures of the monohydrate and dihydrate of (bidentate pyrophosphato) trans-diammine cis-diaqua chromium (III)

(OC-6-32)-Diamminediaqua [pyrophosphato(3-)]chromium(III) monohydrate, [Cr(NH3)2-(H2O)2(HP2O7)]. H2O, Mr = 315.1, triclinic, P1, a = 7.127 (2), b = 8.390 (2), c = 9.619 (2) A, alpha = 72.14 (2), beta = 98.86 (2), gamma = 76.98 (3) degrees, V = 517.7 (3) A3, Z = 2, Dx = 2.02 g cm-3, lambda(Cu K alpha) = 1.5418 A, mu = 129 cm-1, F(000) = 322, T = 293 K. (OC-6-32)-Diamminediaqua[pyrophosphato(3-)]-chromium(III) dihydrate, 0.5( [Cr(NH3)2(H2O)2-(HP2O7)].2H2O), Mr = 0.5(333.1), monoclinic, C2/m, a = 13.118 (3), b = 12.101 (3), c = 7.436 (2) A, beta = 105.09 (2) degrees, V = 1139.7 (3) A3, Z = 8, Dx = 1.94 g cm-3, lambda(Cu K alpha) = 1.5418 A, mu = 118 cm-1, F(000) = 684, T = 293 K. The structures were solved by the multi-solution technique and refined by the method of least squares to yield a final R index of 0.057 for 986 reflections in the monohydrate and a final R index of 0.043 for 1030 reflections in the dihydrate. The six-membered chromium pyrophosphate chelate ring is in a boat conformation for the monohydrate with an intramolecular hydrogen bond between an ammonia proton and a pyrophosphate O atom. In the dihydrate, the chelate ring is bisected by the mirror plane resulting in an unusual planar chelate ring conformation which does not permit intramolecular hydrogen bonding.

Low anthropometric indices in elderly females with fractured neck of femur

Anthropometric measurements were made in 3 groups of elderly females (1) with fractured neck of femur, (2) those admitted to acute medical and geriatric wards, and (3) healthy women in the community. Mid-arm circumference was different in the three groups with mean values of 22.8 +/- 0.21 cm, 25.9 +/- 0.41 cm and 28.6 +/- 0.27 cm respectively; (p < 0.001 for all comparisons). Triceps skinfold thickness was 24.7 +/- 0.70 mm in the healthy elderly but only 13.0 +/- 0.59 mm in the fracture group (p < 0.001). Fractured femur patients are therefore thinner than both healthy controls and unselected elderly female medical in-patients. These differences are most apparent in anthropometric indices dependent on body fat and this may be significant in terms of the aetiology of fractured femur.

Cross-reaction of immune sera from patients with rickettsial diseases

Rickettsia rickettsii and Rickettsia conorii are the causative agents of two common and serious diseases, Rocky Mountain spotted fever and Mediterranean spotted fever, respectively. In patients naturally infected with either of these organisms, antibodies are produced which cross-react with antigens of the other so extensively that diagnostic tests usually cannot identify the causative agents. The results of this study indicate that serodiagnostic tests with antigen from one of these two organisms could be used to detect antibodies in patients with either of the two rickettsial diseases.

Triamminemonoaquocobalt(III) complexes of pyrophosphate and adenosine diphosphate (ADP)

Cobalt(III)H2O(NH3)3 pyrophosphate has been shown by proton and 31P nuclear magnetic resonance (NMR) to be a facial bidentate complex. Cobalt(III)H2O(NH3)3 adenosine diphosphate has been resolved into lambda and delta isomers by chromatography on cycloheptaamylose. Both the lambda and delta forms are a pair of isomers that are not separated by cycloheptaamylose, reverse phase high-pressure liquid chromatography (HPLC), or cation exchange chromatography. These isomers presumably represent syn- and anti-arrangement of coordinated water and adenosine.

Overnight nasogastric tube feeding

Overnight nasogastric tube feeding allows the patient freedom for normal daytime activities and exercise, essential components of rehabilitation. In order to avoid disturbed nights through frequent micturition we have kept the volume of feed to a minimum. Two types of feed have been used: 1. A supplementary isosmolar feed containing 1000 kCals in 1 litre. 2. A concentrated low volume (404 mosm/kg) feed supplying 1800 kCals including 60 g of nitrogen in 1 litre. Both were delivered via a fine bore tube (internal diameter 1 mm) by continuous infusion from a 1-1.5 litre reservoir using a rotary pump. Feed 1 was given to 64 undernourished elderly female patients (group 1) with fractured neck of femur, the tube being tolerated by 78%; 47 patients in this group were fed for more than 5 days. Feed 2 was given to 10 patients in hospital (group 2) and 8 patients at home (group 3). Few side effects were encountered, the hyperosmolar feed causing no diarrhoea, nausea or hyperglycaemia, emphasising the importance of osmoles per unit time rather than per unit volume. Voluntary oral intake was neither impaired nor increased during the period of tube feeding in group 1, in whom anorexia and thinness were longstanding. In group 2, with recent onset of anorexia and weight loss, tube feeding disinhibited appetite, resulting in a doubling of voluntary oral intake. Improvement in anthropometric and biochemical nutritional parameters was seen in all patients. Clinical improvements e.g. closure of fistulae were also observed. This paper describes the results of our trial of both these options in patients treated in hospital or at home.

Benefits of supplementary tube feeding after fractured neck of femur: a randomised controlled trial

A total of 744 elderly women with fractured neck of femur were classified into three groups according to anthropometric measurements on admission: group 1, well nourished; group 2, thin; group 3, very thin. Group 1 ate well and had a low mortality and a short rehabilitation time. The thinner the patients the lower their voluntary food intake, the higher their mortality and the longer their rehabilitation time. A series of 122 patients from groups 2 and 3 were entered postoperatively into a randomised controlled trial of overnight supplementary nasogastric tube feeding (4.2 MJ (1000 kcal), including 28 g protein) in addition to their normal ward diet. This treatment was associated with improvements not only in anthropometric and plasma protein measurements but also in clinical outcome, especially in the very thin group 3 patients. Rehabilitation time and hospital stay were shortened. Mortality in group 3 was less in the tube fed patients (8%) than in the controls (22%) but this difference did not reach statistical significance. One in five patients could not tolerate the nasogastric tube, but in the remainder the treatment caused no side effects and did not seriously diminish voluntary oral food intake by day.

Undernutrition, hypothermia, and injury in elderly women with fractured femur: an injury response to altered metabolism?

On the basis of triceps skinfold thickness and arm muscle circumference measurements, 744 elderly women with fractured neck of femur were divided into three groups--well nourished, thin, and very thin. The mortality in the three groups was 4.4%, 8%, and 18%, respectively. Differences were not explained by age, associated disease, dementia, or marital status. Food intake after injury was related to initial nutritional state. There was a midwinter peak in fracture incidence and also a pronounced seasonal variation in the type of patient admitted; a much higher proportion of thin patients presented in winter after accidents indoors. The hypothesis that thinness or under-nutrition may impair thermoregulation and predispose to hypothermia, lack of coordination, and accident was supported by core temperature measurements on admission: those in most very thin patients were less than 35 degrees C, whereas in most well-nourished patients they were greater than 36 degrees C.

The effect of ranitidine and cimetidine on the twenty-four hour intragastric acidity profile and nocturnal acid secretion in duodenal ulcer patients

Ten duodenal ulcer patients were studied during four 36 h periods, receiving either ranitidine 150 mg twice daily, or ranitidine 200 mg twice daily, or cimetidine 200 mg t.d.s. and 400 mg at night, or placebo. Conditions during the four experimental days were standard. Mean 24 h intragastric hydrogen ion activity on placebo (41.8 +/- 1.5 mmol 1(-1)) was decreased to 21.6 +/- 1.2 mmol 1(-1) on cimetidine, and to 13.1 +/- 1.0 and 12.1 +/- 1.1 mmol 1(-1) by the two dose levels of ranitidine. Nocturnal acid output was decreased by 70% by cimetidine and by 90 and 89% by the two dose levels of ranitidine. In this test system ranitidine was more than four times as potent as cimetidine. Greater decreases in daytime acidity and nocturnal acid secretion were produced by twice-daily ranitidine than by the standard four daily doses of cimetidine

Comparison of twice-daily ranitidine with standard cimetidine treatment of duodenal ulcer

One hundred and three outpatients with endoscopically diagnosed duodenal ulcer were randomly allocated to treatment with either cimetidine 200 mg tds and 400 mg nocte, or ranitidine 150 mg bd for four weeks. The endoscopists were not aware of the treatment and took no part in the clinical management. On completion of treatment ulcers had healed in 43 of 51 (84%) patients given cimetidine and in 40 of 52 (77%) patients given ranitidine. There were no serious unwanted effects in either treatment group. The results show no significant difference between healing rates after four weeks of standard cimetidine therapy or ranitidine 150 mg bd.

Comparison of the effects of ranitidine, cimetidine and placebo on the 24 hour intragastric acidity and nocturnal acid secretion in patients with duodenal ulcer

Twenty-four hour intragastric acidity and nocturnal acid secretion were measured in 10 males with duodenal ulcer in four separate 24 hour studies, during which the subjects ate normal meals, had unrestricted physical activity, and consumed their customary quantities of tobacco. The medication consisted of either placebo, cimetidine 200 mg tds and 400 mg at night, or ranitidine 150 mg bd, or 200 mg bd. Ranitidine 150 mg bd decreased mean 24 hour hydrogen ion activity from 41.8 mmol/l to 13.1 mmol/l (-69%, P less than 0.001) and nocturnal acid output from 6.1 mmol/h to 0.6 mmol/h (-90%, P less than 0.01). This degree of inhibition was significantly greater than that due to cimetidine (P less than 0.001 for 24 hours acidity, less than 0.05 for night time acid output). Plasma concentrations of ranitidine were greater than the IC50 for more than eight hours after the 150 mg dose. Ranitidine 200 mg conferred no additional advantage. Ranitidine 150 mg bd should be tested in therapeutic trials.

Purification and characterization of a ferredoxin from Rhizobium japonicum bacteroids

An eight-iron, eight-sulfur ferredoxin from Rhizobium japonicum bacteroids of soybean root nodules has been purified to apparent homogeneity as judged by disc gel electrophoresis. The purification procedure included chromatography on DEAE-cellulose, Bio-Gel P-60, and hydroxylapatite. Specific activities of several purified preparations of bacteroid ferredoxin ranged from 1700 to 1900 nmol of C2H4 produced . min-1 . mg-1 in the reaction mediating electron transfer between illuminated chloroplasts and bacteroid nitrogenase. A molecular weight of 6740 for the protein was determined by low speed sedimentation equilibrium and a molecular weight of 6500 was estimated from the mobility of bacteroid ferredoxin relative to the mobility of standard proteins during sodium dodecyl sulfate disc gel electrophoresis. All of the common amino acids were present except arginine, methionine, and tryptophan. The absorbance spectrum of the oxidized protein exhibited maxima at 285 nm and 380 nm with a shoulder near 305 nm. The A380/A285 ratio was 0.76 and the extinction coefficient at 380 nm for the oxidized protein was found to be 30,800 M-1. Equilibration of bacteroid ferredoxin with methyl viologen at various potentials revealed a midpoint oxidation-reduction potential of -484 mV. Spectrophotometric examination of iron-sulfur clusters extruded from bacteroid ferredoxin with benzenethiol and the transfer of its iron-sulfur clusters to other ferredoxins established the presence of two [4Fe-4S] clusters in a molecule of bacteroid ferredoxin. The EPR spectrum of oxidized ferredoxin consisted of a small signal at g = 2.02 integrating to 0.19 spin/molecule. The EPR spectrum of ferredoxin reduced with 5-deazaflavin exhibited a signal with features at g values of 1.88, 1.94, 2.01, and 2.07, and integrated to 1.7 spins/molecule. The EPR properties of bacteroid ferredoxin are characteristic of a ferredoxin operating between the 1+ and 2+ oxidation levels. Bacteroid ferredoxin mediated electron transfer to clostridial hydrogenase, but was not reduced by the clostridial phosphoroclastic system in the presence of pyruvate. Bacteroid ferredoxin reduced by illuminated 5-deazariboflavin also supported a high rate of C2H2 reduction by bacteroid nitrogenase which was free of Na2S2O4. It was concluded, on this basis, that bacteroid ferredoxin has the capability of functioning as the electron donor for nitrogenase in R. japonicum.

Effect of comprehensive pharmaceutical services on drug use in long-term care facilities

The effect of comprehensive pharmaceutical services on drug consumption and cost in long-term care facilities was studied over an eight-year period. Medication administration records for 1970-1977 were obtained for all patients in three long-term care facilities served by a centralized pharmaceutical service. Services included unit dose drug delivery, drug use and chart review, and medical staff consultation. Data from a 10% sample of 4,004 patient records were analyzed. A significant (p less than 0.05) decline in the number of prescription drugs (42.8%) and the number of prescription doses (34.6%) consumed occurred over the eight-year period. The number of nonprescription drugs decreased significantly by 34.4%, but consumption of nonprescription drug doses was not changed significantly. When adjusted for inflation, the average monthly medication bill per patient decreased 28.9%, with the average for Medicaid patients being significantly (p less than 0.001) greater than that for private-pay patients. No significant changes occurred in the therapeutic categories of drug use. Centralized pharmaceutical services, pharmacist consultation and drug use review significantly reduced drug use and medication costs in the facilities studied.

Characterization of the iron-sulfur centers in succinate dehydrogenase

Two techniques have been applied to the determination of the number and type (2-Fe, 4-Fe) of iron-sulfur centers in the iron-sulfur flavoprotein succinate dehydrogenase [succinate:(acceptor) oxidoreductase, EC 1.3.99.1]. One procedure uses p-CF3C6H4SH as an extrusion reagent and Fourier transform 19F nuclear magentic resonance as the method of detection and quantitation of extruded cores of these centers in the form of [Fe2S2(SRF)4]2- and [Fe4S4(SRF)4]2- (RF = p-C6H4CF3). The second procedure, interprotein core transfer, involves thiol displacement of iron-sulfur cores followed by specific core transfer to the apoproteins of Bacillus polymyxa ferredoxin and adrenodoxin. Detection and quantitation are accomplished by electron paramagnetic resonance of reduced proteins at low temperatures. Both procedures clearly show that succinate dehydrogenase contains two dimeric (Fe2S2) and one tetrameric (Fe4S4) centers per mole of histidyl flavin, accounting for all eight nonheme iron and eight labile sulfur atoms found by chemical analysis. These results remove uncertainties created by the less than stoichiometric amounts of binuclear centers detected by electron paramagnetic resonance after dithionite reduction and provide secure characterization of the iron-sulfur centers in this enzyme.

Nitrogenase X: Mössbauer and EPR studies on reversibly oxidized MoFe protein from Azotobacter vinelandii OP. Nature of the iron centers

Under anaerobic conditions the molybdenum-iron protein (MoFe protein) from Azotobacter vinelandii can be reversibly oxidized with thionine. Electron paramagnetic resonance studies reveal that the oxidation proceeds in two distinct phases: the MoFe protein can be oxidized by four electrons without loss of the EPR signal from the S = 3/2 cofactor centers. A second oxidation step, involving two electrons, leads to the disappearance of the cofactor EPR signal. In order to correlate the events during the thionine titration with redox reactions involving individual iron centers we have studied the MoFe proteins from A vinelandii and Clostridium pasteurianum with Mössbauer spectroscopy. Spectra were taken in the temperature range from 1.5 K to 200 K in applied magnetic fields of up to 54 kG. Analysis of the Mössbauer data allows us to draw three major conclusions: (1) the holoprotein contains 30 +/- 2 iron atoms. (2) Most probably, 12 iron atoms belong to two, apparently identical, iron clusters (labeled M) which we have shown previously to be structural components of the iron and molybdenum containing cofactor of nitrogenase. The M-centers can be stabilized in three distinct oxidation states, MOXe- in equilibrium MNe- in equilibrium MR. The diamagnetic (S = 0) state MOX is attained by oxidation of the native state MN with either thionine or oxygen. MR is observed under nitrogen fixing conditions. (3) The data strongly suggest that 16 iron atoms are associated with four iron centers which we propose to call P-clusters. Each P-cluster contains four spin-coupled iron atoms. In the native protein the P-clusters are in the diamagnetic state PN, yielding the Mössbauer signature which we have labeled previously 'components D and Fe2+'. Three irons of the D-type and one iron of the Fe2+-type appear to comprise a P-cluster. A one-electron oxidation yields the paramagnetic state POX. Although the state POX is characterized by half-integral electronic spin a peculiar combination of zero-field splitting parameters and spin relaxation renders this state EPR-silent. Spectroscopically, the P-clusters are novel structures; there is, however, evidence that they are closely related to familiar 4Fe-4S centers.

Cluster characterization in iron-sulfur proteins by magnetic circular dichroism

We report magnetic circular dichroism (MCD) spectra of 4-Fe iron-sulfur clusters in the iron-sulfur proteins Chromatium high-potential iron protein (HIPIP), Bacillus stearothermophilus ferredoxin and Clostridium pasteurianum ferredoxin. The MCD is found to vary significantly with cluster oxidation state but is relatively insensitive to the nature of the protein. The spectra obtained are compared with the corresponding spectra of iron-sulfur proteins containing 2-Fe clusters. It is concluded that MCD is useful for the characterization of iron-sulfur cluster type and oxidation state in iron-sulfur proteins and is superior for this purpose to absorption and natural circular dichroism spectroscopy.

Circular dichroism and magnetic circular dichroism of iron-sulfur proteins

Circular dichroism (CD) and magnetic circular dichroism (MCD) spectra are reported for the 2-Fe ferredoxins from Pseudomonas putida and Spirulina maxima, Chromatium HIPIP, the 4-Fe ferredoxin from Bacillus stearothermophilus, and the 8-Fe ferredoxin from Clostridium pasteurianum. The spectral range spans the near-infrared, visible, and near ultraviolet. In all cases except oxidized 2-Fe ferredoxins, electronic absorption is observed continuously from less than 5000 cm-1 to above 30,000 cm-1. The CD spectra of the two 2-Fe ferredoxins are similar. In contrast, the CD of the 4-Fe and 8-Fe proteins, for a given 4-Fe cluster oxidation level, varies considerable with protein. MCD is less sensitive to protein environment than is CD. In the 2-Fe proteins, MCD at 5 T is appreciably smaller than the CD; in the 4-Fe and 8-Fe proteins, MCD and CD are comparable in magnitude. Both CD and MCD are more highly structured than the corresponding absorption spectra. The CD and MCD spectra reported provide a broader base than heretofore available for the characterization of iron-sulfur proteins containing 2-Fe and 4-Fe clusters and for the evaluation of electronic structural models for these clusters.

Near-infrared magnetic circular dichroism of cytochrome c'

The near-infrared magnetic circular dichroism (MCD) of Rhodospirillum rubrum, Chromatium vinosum, and Rhodopseudomonas palustris cytochromes c' are reported. The spectra of the reduced protein are very similar to those of deoxymyoglobin. The spectra of the oxidized proteins in the pD range 1-13 can be analyzed on the basis of four species A, B, C, and D. The existence of nine species, reported in a recent electron paramagnetic resonance study, is not substantiated. The MCD spectra support the assignment of B as high spin and C and D as low spin. The MCD of species A is close to that of high-spin proteins and does not support the recently proposed assignment of a mixed high- and intermediate-spin ground state for this species. The energies of the near-IR electronic transitions of all four oxidized species point to axial ligation via oxygen, assuming histidine to be the opposite axial ligand. Unfortunately, insufficient model compounds with ligation by carboxyl or hydroxyl moieties exist to enable more precise assignments.