Outcomes following physical restraint reduction programs in two acute care hospitals.

BACKGROUND: Physical restraint rates can be reduced safely in long term care settings, but the strategies used to prevent wandering, falls, and patient aggression have not been tested for their effectiveness in preventing therapy disruption. A restraint reduction program (RRP) consisting of four core components (administrative, educational, consultative, and feedback) was implemented in 1998-1999 in 14 units at two acute care hospitals in geographically distant cities. METHODS: The RRP was targeted at units with prevalence rates of > or = 4% for non-intensive care units (non-ICUs) and > or = 25% for ICUs, as well as two additional units. The RRP was implemented by an interdisciplinary team consisting of geriatricians and nurse specialists. RESULTS: Of the 16,605 admissions to the RRP units, 2,772 cases received RRP consultations. Only six units (four of seven general units and two of six ICUs) demonstrated a relative reduction of > or = 20% in the physical restraint use rate. No increase in secondary outcomes of patient falls and therapy disruptions (patient-initiated discontinuation or dislodgment of therapeutic devices) occurred, injury rates were low, and no deaths occurred as a direct result of either a fall or therapy disruption event. DISCUSSION: Given the minimal success in the ICU settings, further studies are needed to determine effective nonrestraint strategies for critical care patients. ICU clinicians need to be persuaded of the favorable risk-to-benefit ratio of alternatives to physical restraint before they will change their practice patterns. SUMMARY: Efforts to identify more effective interventions that match patient needs and to identify non-clinician factors that affect physical restraint use are needed.

Stereoselective inhibition of glutamate carboxypeptidase by chiral phosphonothioic acids.

A series of phosphonothioic acid derivatives of (S)-2-hydroxyglutarate with various alkyl or aryl ligands to the central phosphorus atom was examined for stereoselective inhibition of the glutamate carboxypeptidase, carboxypeptidase G. The inhibitory potencies of these stereoisomers were compared to corresponding synthetic phosphonic acid analogues in order to reveal the significance of the sulfur ligand of the phosphonothioic acid motif upon the inhibition of this metallopeptidase. The acquisition of the individual phosphonothioic acid diastereomers was achieved through the resolution of the respective phosphonate ester precursors. In all cases, the (+)p-diastereomers of these phosphonothioic acid derivatives of (S)-2-hydroxyglutarate were found to be more potent inhibitors of glutamate carboxypeptidase than the corresponding (-)p antipodes with the most dramatic difference observed for the butyl isomers (13.6-fold). Based upon Ki values obtained, the most potent inhibitor of the series by nearly an order of magnitude was the (+)p-n-butylphosphonothioic acid derivative, revealing specific structural and stereochemical requirements by this glutamate carboxypeptidase. With the exception of the (+)p-n-butyl analogue, the isosteric replacement of oxygen with sulfur of the phosphonic acid moiety did not enhance inhibitory potency.

Methodologic issues in conducting research on hospitalized older people.

OBJECTIVE: To describe challenges in conducting research with hospitalized geriatric patients. DESIGN: Quasi-experimental longitudinal study with inperson interviews at baseline and discharge and a three-month postdischarge telephone interview. Study protocol required baseline interviews within 48 hours of admission for patients or 72 hours for proxies. SETTING: 813-bed urban teaching hospital. PARTICIPANTS: 240 patients, mean age 83.8 years, at moderate to high risk for functional decline during hospitalization, admitted from the emergency room to a general medical unit. MEASUREMENTS: Delays starting or interruptions continuing interviews; patient and environmental conditions potentially affecting data quality; and information on proxy use. RESULTS: Timely access to patients or proxies was a major difficulty, resulting in the screening of only 53.1% of 867 potentially eligible patients. Multiple patient contacts and visits were required to complete interviews. Only 61.3% of baseline and 28.1% of follow-up interviews were completed on the initial day of contact. Despite having on-site interviewers 7 days a week, 29% of discharge interviews were conducted by telephone. Interviews were >90% complete in 487 of 503 of encounters (97%). Baseline delays and interruptions were usually due to the presence of medical staff, off-unit tests, patient illness, nurse unavailability for interview, and need for a proxy. Most in-hospital interviews were conducted with others present. Proxies were required for approximately one-third of patients at all three interviews. CONCLUSION: Conducting clinical research with older adults in the current inpatient setting, where patients are more severely ill yet have shorter lengths of stay now than in the past, proves a challenging yet achievable goal. Effective procedures for negotiating the acute care environment are critical to successful studies.

Inhibition of glutamate carboxypeptidase II by phosphonamidothionate derivatives of glutamic acid.

A limited series of N-thiophosphonyl-glutamates were found to be inhibitors of the prostate-specific membrane antigen (PSMA) form of glutamate carboxypeptidase II. Comparative inhibitory profiles of an analogous O-thiophosphonyl-2-hydroxyglutarate revealed that the amido-linkage of the N-thiophosphonyl-glutamate provides a significant enhancement of inhibitory potency presumably due to significant hydrogen-bonding interactions with acceptor groups in the active-site of PSMA resulting in tighter binding. An analogous N-phosphonyl-glutamate exhibited significantly greater inhibitory potency than the parent N-thiophosphonyl-glutamate indicating that the sulfur ligand of the N-thiophosphonyl-glutamates is responsible for less favorable active-site interactions than oxygen, potentially due to steric crowding from the longer P-S bond or as a result of active-site metal substitution of Co(II) for Zn(II) arising from assay conditions.

Catalytic antibodies that hydrolyze (-)-cocaine obtained by a high-throughput procedure.

Antibodies to a 2beta-carboxamido-2beta-phosphonate transition-state analog of (-)-cocaine benzoate ester hydrolysis were elicited in mice. A large number of hybridoma cell lines were propagated, and the catalytic activity of culture fluid was determined with a high-throughput photometric assay using cocaine benzoyl thioester as substrate. Binding avidity of the hybridoma supernatants to the phosphonate hapten was also determined. The initial rate constants for cocaine benzoyl thioester hydrolysis and binding avidity for a large number of hybridoma supernatants elicited to the phosphonate hapten did not always correlate. The lack of correlation of substrate hydrolysis with the binding affinity of 70 catalytic antibodies was also observed for (-)-cocaine hydrolysis using derivatization and HPLC analysis of methyl ecgonine as meta-nitrococaine. The k(cat) values for cocaine benzoyl thioester hydrolysis by monoclonal antibodies 3, 5, and 12 were 38, 4.2, and 0. 6 min(-1), respectively. For monoclonal antibody 5, the selectivity ratios (K(i) value divided by the K(m) value for the hydrolysis of cocaine benzoyl thioester) with ecgonine benzoyl ester, ecgonine methyl ester, norcocaine, and ecgonine were 101, 25, 9.4, and 4, respectively. Three active esterolytic monoclonal antibodies identified with the high-throughput assay procedure were examined in detail for their ability to hydrolyze (-)-cocaine. The k(cat) values for the hydrolysis of (-)-cocaine with monoclonal antibodies 3, 5, and 12 were 6.6, 0.4, and 0.1 min(-1), respectively. Hydrolysis of (-)-cocaine by monoclonal antibody 3 approached the k(cat) value for that of human butyrylcholinesterase. Cocaine esterolytic catalytic antibodies that approach or exceed the catalytic efficiency of human butyrylcholinesterase may represent a new pharmacological intervention approach to the treatment of cocaine abuse, and the high-throughput process described here represents an advance in the effort to develop clinically useful antibodies.

Sexual contact with clients: assessment of social workers' attitudes and educational preparation.

The purpose of this study was to assess social work students' attitudes about sexual contact with clients and their perceptions about their training and education in this area. The sample included 349 social work students in their final semester of an MSW program. There were relatively high levels of approval for sexual contact between social workers and clients in certain circumstances. Approval was not limited to circumstances in which professional relationships were terminated, were brief, or had involved only concrete services. Students with less social work experience and who thought class content on sexual ethics was inadequate were more likely to approve of sexual contact between social worker and client. Students did not feel that they had received adequate education or training on sexual ethics, and many felt unprepared to handle sexual feelings from or toward a client. Implications for education, training, and practice, and suggestions for future research are discussed.

A general high-performance liquid chromatography-based assay for the hydrolysis of N-acyl glutamates.

A rapid and simple HPLC assay has been developed to separate and quantify N-acyl glutamates and the corresponding carboxylic acids of the acyl moiety. This method was specifically developed to assay hydrolytic activity for glutamate carboxypeptidases. Although established assays for specific substrates of such enzymes exist, they may not be amenable for examining the hydrolytic activity of new substrate probes. This assay was developed to accommodate such probes.

Competitive inhibition of a glutamate carboxypeptidase by phosphonamidothionate derivatives of glutamic acid.

Several N-thiophosphonyl-glutamates were found to be potent competitive inhibitors of a zinc-dependent glutamyl hydrolase, carboxypeptidase G (CPG). Weak inhibition exhibited by an analogous N-phosphonyl-glutamate suggests that the enhanced potency of the phosphonamidothioates is due to the presence of their sulfur ligand and its favorable interactions with active site features, presumably zinc(II).

Kinetic evidence for different mechanisms of acetylcholinesterase inhibition by (1R)- and (1S)-stereoisomers of isomalathion.

Inhibition of acetylcholinesterase (AChE) by isomalathion has been assumed to proceed by expulsion of diethyl thiosuccinyl to produce O, S-dimethyl phosphorylated AChE. If this assumption is correct, AChE inhibited by (1R)- or (1S)-isomalathions should reactivate at the same rate as AChE inhibited by configurationally equivalent (S)- or (R)-isoparathion methyl, respectively, which are expected to inhibit AChE by loss of 4-nitrophenoxyl to yield O,S-dimethyl phosphorylated AChEs. Previous work has shown that rat brain AChE inhibited by (1R)-isomalathions reactivates at the same rate as the enzyme inhibited by (S)-isoparathion methyl. However, although rat brain AChE inhibited by (R)-isoparathion methyl reactivates at a measurable rate, the enzyme inhibited by (1S)-isomalathions is intractable to reactivation. This surprising finding suggests the hypothesis that (1R)- and (1S)-stereoisomers of isomalathion inhibit AChE by different mechanisms, yielding enzymatic species distinguishable by their postinhibitory kinetics. The present study was carried out to test this hypothesis by comparing kinetic constants of reactivation (k+3) and aging (k+4) of hen brain AChE and bovine erythrocyte AChE inhibited by the four stereoisomers of isomalathion and the two stereoisomers of isoparathion methyl. Both AChEs inhibited by either (1R,3R)- or (1R,3S)-isomalathion had comparable corresponding k+3 values (spontaneous and oxime-mediated) to those of AChEs inhibited with (S)-isoparathion methyl. However, spontaneous and oxime-mediated k+3 values comparable to those of (R)-isoparathion methyl could not be obtained for AChEs inhibited by (1S,3R)- and (1S,3S)-isomalathion. Comparison of k+4 values for hen brain AChE inhibited by each stereoisomer of isomalathion and isoparathion methyl corroborated that only the (1S)-isomalathions failed to produce the expected O,S-dimethyl phosphoryl-conjugated enzymes. The results for (1R)-isomalathions suggest that the mechanism of inhibition of AChE by these isomers is the expected one involving diethyl thiosuccinyl as the primary leaving group. In contrast, the results for (1S)-isomalathions are consistent with an alternative mechanism of inhibition by these isomers implicating loss of thiomethyl as the primary leaving group.

Attitudes toward physician-assisted suicide among persons with multiple sclerosis.

This study was conducted to estimate the level of interest in assisted suicide among persons with multiple sclerosis (MS), the hypothetical conditions under which they would consider assisted suicide, and the factors associated with such interest. The sample of 511 members drawn from the Oregon and Michigan chapters of the National Multiple Sclerosis Society (NMSS) completed a mail questionnaire indicating whether they had ever considered assisted suicide, under what conditions they would consider it, and the correlates of considering assisted suicide. Close to one third of persons with MS in this study had thought about assisted suicide as an option for themselves. One quarter to one half would consider assisted suicide in five hypothetical circumstances, including experiencing unbearable pain, being unable to do things that made them happy, causing financial burden to caregivers or family members, or experiencing extreme emotional distress. Religiosity, social support, depressive symptomatology, MS symptoms, NMSS chapter, years since diagnosis, and gender were associated with some or all of the responses to the hypothetical conditions. The clinical and policy implications of these findings are discussed.

The relationship between ethnoracial group and functional level in older persons.

The objective of this study was to determine: (1) the differences between blacks, Latinos, and whites in relation to functional level, (2) whether these differences could be entirely explained by differences in socioeconomic status (SES) for both blacks and Latinos, and (3) which SES indicators might account for differences in function. Data from the 1570 respondents in the Growing Older in New York City Study, a representative sample of black, Latino, and non-Latino white persons, age 65 years and over, were used. Latinos were significantly more functionally impaired than the other two ethnoracial groups, but this was accounted for by income, education, and the residential environment. Blacks were the least functionally impaired when income, education and the residential environment were controlled. Possible explanations for these results and implications for service delivery are discussed.

Cocaine benzoyl thioester: synthesis, kinetics of base hydrolysis, and application to the assay of cocaine esterases.

The synthesis and characterization of diastereomers of cocaine benzoyl thioester is described. Allococaine benzoyl thioester and allopseudococaine benzoyl thioester were synthesized by the conjugate addition of p-methoxytolyl thiol to ecgonine methyl ester followed by debenzylation and benzoylation. The absolute structure of the hydrochloride salt of the major ecgonine p-methoxytolyl sulfide formed was determined by single-crystal diffraction analysis and used to establish the addition geometry. When placed in aqueous solution, the cocaine benzoyl thioester diastereomers hydrolyzed to give thioecgonine methyl ester. The rate of cocaine benzoyl thioester hydrolysis was carefully investigated spectrophotometrically by using the Ellman reagent. At neutral pH, the hydrolysis of the diastereomers was found to proceed at detectable rates. Upon increasing pH, the rate of hydrolysis of cocaine benzoyl thioester diastereomers was increased and the reaction was catalyzed by basic buffer species. In addition to defining the kinetics of hydrolysis in aqueous solution, cocaine benzoyl thioester was utilized as a highly efficient method to monitor the activity of cholinesterases and pig liver esterase. Use of cocaine benzoyl thioester represents a rapid and sensitive way to screen for cocaine esterase activity.

The relationship among income, other socioeconomic indicators, and functional level in older persons.

Socioeconomic status (SES) is well established as a cause of morbidity and mortality, but relatively few studies have investigated the relationship between SES and functional level. Functional level is closely related to the use of long-term care services and is a more salient indicator of quality of life than specific diseases. We used data from 1,570 respondents in the Growing Older in New York City Study, a probability sample of people age 65 and older, to examine this relationship. The association between income and function was seen throughout the full gradient of income and remained significant when controlling for age, gender, race/ethnicity, household size, education, occupation, age of immigration, and locus of control. Education and residential environment, but not occupation, were independently associated with functional level. These findings support both the association between SES and functional limitation and the hypothesis that the SES and health association continues into old age.

Evaluation of phosphorus-containing inhibitors of gamma-glutamyl hydrolase.

Several putative, phosphorus-containing inhibitors of gamma-glutamyl hydrolase were synthesized and evaluated for inhibitory activity. The phosphonamidoic acids were shown to be weak competitive inhibitors while both a phosphoramidate diester and a phosphonamidate ester were shown to be potent time-dependent inactivators, presumably through irreversible phosphorylation of an active site nucleophile.

Human liver carboxylesterase hCE-1: binding specificity for cocaine, heroin, and their metabolites and analogs.

Purified human liver carboxylesterase (hCE-1) catalyzes the hydrolysis of cocaine to form benzoylecgonine, the deacetylation of heroin to form 6-acetylmorphine, and the ethanol-dependent transesterification of cocaine to form cocaethylene. In this study, the binding affinities of cocaine, cocaine metabolites and analogs, heroin, morphine, and 6-acetylmorphine for hCE-1 were evaluated by measuring their kinetic inhibition constants with 4-methylumbelliferyl acetate in a rapid spectrophotometric assay. The naturally occurring (R)-(-)-cocaine isomer displayed the highest affinity of all cocaine and heroin analogs or metabolites. The pseudo- or allopseudococaine isomers of cocaine exhibited lower affinity indicating that binding to the enzyme is stereoselective. The methyl ester, benzoyl, and N-methyl groups of cocaine play important roles in binding because removal of these groups increased K(i) values substantially. Compounds containing a variety of hydrophobic substitutions at the benzoyl group of cocaine bound to the enzyme with high affinity. The high K(i) value obtained for cocaethylene relative to cocaine is consistent with weaker binding to the esterase and a longer elimination half-life reported for the metabolite. The spectrophotometric competitive inhibition assay used here represents an effective method to identify drug or environmental esters metabolized by carboxylesterases like hCE-1.

Characterization of two human flavin-containing monooxygenase (form 3) enzymes expressed in Escherichia coli as maltose binding protein fusions.

To examine the possibility for drug metabolism polymorphism, adult human flavin-containing monooxygenases (form 3) (EC 1.14.13.8) that differ at one amino acid were expressed in Escherichia coli as maltose binding protein fusions. The cDNA that was first reported during the cloning of adult human flavin-containing monooxygenase was designated the wild type lys158 enzyme. A second cDNA has been identified as a common polymorphism in some human populations and was designated the glu158 enzyme. The cDNA that encodes both enzymes was subcloned into a high yield protein fusion expression system, expressed, and the protein was partially purified by affinity chromatography and characterized for enzyme activity with selective functional substrate probes. N- and S-oxygenation activity of both enzymes was determined with 10-(N,N-dimethylaminopentyl)-2-(trifluoromethyl)phenothiazine and methyl p-tolyl sulfide, respectively. It was found that expression of both lys158 and glu158 enzymes of the human flavin-containing monooxygenase form 3 as fusions with the maltose binding protein resulted in an enzyme that was soluble and greatly stabilized and had a reduced requirement for detergent during enzyme purification and during the assay for activity. Expression of the fusion proteins has allowed the preparation of stable and highly active enzyme at greater purity than was readily possible in the past. With the exception of the stability and solubility characteristics, the physical and chemical properties of lys158 and glu158 maltose binding fusion proteins of human flavin-containing monooxygenase form 3 variants resembled that of flavin-containing monooxygenase enzyme activity associated with human liver microsomes and enzyme isolated from a previous Escherichia coli expression system that lacked the protein fusion. Comparison of the catalytic activity of the two fusion proteins showed that while both forms were active, there were differences in their substrate specificities. Expression of the adult human flavin-containing monooxygenase form 3 as a maltose binding protein has allowed considerable advances over the previously reported cDNA-expressed enzyme systems and may provide the basis for examining the role of the flavin-containing monooxygenase in human xenobiotic or drug metabolism.

Homophobia and heterosexism in social workers.

Evidence suggests that social workers may be biased when dealing with gay and lesbian populations. The study discussed in this article attempted to measure the extent of homophobia and heterosexist bias and their correlates in a cohort of 187 social workers using the Index of Attitudes toward Homosexuality, the Attitudes toward Lesbians and Gay Men Scales, and a newly created scale to measure heterosexist bias. We found that 10 percent of respondents were homophobic and that a majority were heterosexist. Levels of homophobia and heterosexism were negatively correlated with amount of social contact with homosexual men and women. Religiosity was associated with higher levels of homophobia and heterosexism, and having been in psychotherapy was associated with more positive attitudes toward gay men and lesbians. Amount of education on topics related to homosexuality was not correlated with levels of homophobia and heterosexism.

Stereoselective inhibition of human butyrylcholinesterase by phosphonothiolate analogs of (+)- and (-)-cocaine.

The hydrolysis of cocaine (benzoylecgonine methyl ester) to ecgonine methyl ester by human butyrylcholinesterase (BuChE; EC 3.1.1.8) has been shown previously to constitute an important means to detoxicate this material to pharmacologically inactive metabolites. The naturally occurring (-)-cocaine is hydrolyzed to ecgonine methyl ester approximately 2000 times slower than the unnatural (+)-cocaine isomer. In good agreement with previous studies, (-)-cocaine bound to human BuChE with relatively good affinity and competitively inhibited the hydrolysis of the spectrophotometric substrate butyrylthiocholine with a Ki value of 8.0 microM. Similarly, (+)-cocaine also showed relatively high affinity for the human BuChE and competitively inhibited butyrylthiocholine hydrolysis with a Ki value of 5.4 microM. The phosphonothiolates corresponding to the transition state analogs for both (-)- and (+)-cocaine hydrolysis were synthesized and tested as inhibitors of human BuChE-catalyzed hydrolysis of butyrylthiocholine. The phosphonothiolate corresponding to the transition state for (-)-cocaine hydrolysis was a competitive inhibitor with a Ki value of 55.8 microM. The phosphonothiolate corresponding to the transition state for (+)-cocaine hydrolysis gave a Ki value of 25.9 microM, but, in addition, it also showed irreversible inhibition with a ki of inactivation of 68.8 min-1 M-1. It is likely that the mechanism-based inhibitor described herein may find use as a mechanistic probe of butyrylcholinesterase action and also possibly aid in the purification of this class of esterases.

N-oxygenation of primary amines and hydroxylamines and retroreduction of hydroxylamines by adult human liver microsomes and adult human flavin-containing monooxygenase 3.

Adult human liver microsomes catalyze the NADPH-dependent N-oxygenation of 10-N-(n-octylamino)-2-(trifluoromethyl)phenothiazine to the corresponding oximes through the intermediacy of the hydroxylamine. In the presence of adult human liver microsomes, the primary amine is stereoselectively converted to the cis-oxime, but addition of the alternative competitive substrate hydroxylamine hydrochloride apparently decreases the amount of aliphatic hydroxylamine retroreduction because an increase in oxime formation was observed. In the presence of hydroxylamine hydrochloride, however, the oxime product recovered was formed with very low stereoselectivity. Studies on the biochemical mechanism of oxime formation suggested that cis-oxime formation in the presence of adult human liver microsomes was largely dependent on the human flavin-containing monooxygenase (form 3). This conclusion is based on the effects of incubation conditions on product formation when compared to results observed in the presence of cDNA-expressed human FMO3. The retroreduction of the intermediate hydroxylamine was dependent on NADPH but was not catalyzed by human flavin-containing monooxygenase (form 3) or any one of seven prominent cytochromes P-450 that have been well-characterized in the human liver microsomes examined. The results suggest that aliphatic primary amines are efficiently sequentially N-oxygenated in the presence of human liver microsomes to hydroxylamines and then to oximes mainly by the human flavin-containing monooxygenase. Retroreduction of the intermediate hydroxylamine is apparently facilitated by a novel but as yet poorly characterized enzyme system that does not employ any of the currently known well-characterized cytochrome P-450 enzymes present in adult human liver microsomes.