Administrative relationships between medical schools and community preceptors.

PURPOSE: To determine the current administrative relationships between medical schools and community preceptors, with special emphasis on arrangements for academic appointment, review, and promotion. METHOD: In 1999, administrative contacts at all 126 U.S. allopathic medical schools were mailed a ten-item questionnaire to elicit information concerning the current practices of the schools regarding community preceptors, who were defined as volunteer or part-time physician faculty, primarily practicing at non-university-owned facilities, who contribute to medical students' and/or residents' education in various specified ways. RESULTS: Responses were received from 71 (56%) of the schools; they were in general a representative sample of U.S. medical schools. The numbers of preceptors per school ranged from 40 to 3,500. Sixty-seven percent of reporting schools identified clinical departments as the main administrative interface with preceptors. Only three schools used a central office; none exclusively used a regionalized system. Forty-four schools (63.8%) reported using formal written criteria for all preceptor appointments. Sixty-six schools (93%) used consistent academic titling systems, with 83.3% using titles including the word "clinical." Thirty-three schools (47.8%) reported that their departments conducted regular preceptor reviews; an additional 28 reported reviews by some departments. Preceptors were eligible for promotion at 94.4% of the responding schools. At 46.8%, specific promotion criteria exist; four schools were developing such criteria. Preceptors' interest in academic promotion was perceived to be moderate or low. CONCLUSION: A substantial proportion of U.S. medical schools have taken action to recognize preceptors as a unique faculty group. The comments received indicate that this is an active area of development in faculty affairs policy.

The effects of transdermal nicotine therapy for smoking cessation on depressive symptoms in patients with major depression.

This study examines the effects of transdermal nicotine patches for smoking cessation on depressive and withdrawal symptoms among 38 non-medicated subjects with Major Depressive Disorder. The study was conducted over a 29-day period, which included a 7 day baseline phase, a 14 day treatment phase, and an 8 day placebo phase. During the treatment phase subjects received either active nicotine patches (N = 18) or placebo patches (N = 20) that were administered in a randomized, double-blind fashion. The target quit date (TQD) was day 8. Significantly, more subjects in the placebo group than in the nicotine group resumed smoking following the TQD (50% vs. 22%). There was little evidence for effects of active nicotine patches on measures of mood (HRSD, BDI, POMS) or withdrawal symptoms among subjects that remained abstinent throughout the study (N = 24). Those who resumed smoking had more severe withdrawal symptoms than those who remained abstinent. One patient in the placebo group (n = 20) became more depressed after 2 weeks of abstinence. None of the patients in the nicotine group (n = 18) became more depressed.

Characterization of a selective protein kinase C substrate derived from the MARCKS phosphorylation site domain for use in brain tissue homogenates.

Protein kinase C (PKC) isozymes play crucial roles in neuronal signal transduction and can regulate transmitter release, ion channels, neural development, and plasticity. In vitro assays of PKC are frequently used to associate PKC activity with cellular function, and the availability of selective PKC substrates can facilitate such studies. We have characterized a commercially available 12 amino acid peptide derived from the myristoylated alanine-rich C kinase substrate (MARCKS-PSD, Calbiochem) for use in crude rat brain homogenates. Assays were performed at 25 degrees C for 10 min (linear up to 12 min) using optimal concentrations of calcium and lipid cofactors. Kinetic analysis of MARCKS-PSD phosphorylation by PKC purified from rat brain gave a K(m) of 2.3 microM, which was similar to the K(m) of 2.8 microM obtained using rat brain cortical homogenates. The selective PKC inhibitor bisindolylmaleimide reduced phosphorylation of MARCKS-PSD in a concentration-dependent manner, with greater than 95% inhibition at 1.0 microM. MARCKS-PSD was more potent than another widely used selective PKC substrate (neurogranin((28-43)) and was a good substrate for human recombinant PKC alpha, delta, and epsilon but not zeta. The ontogeny of PKC activity was examined in the cortex and cerebellum. PKC activity was low at birth and reached adult levels by 21 days of age in both regions. Calcium-independent PKC activity in brain homogenates could be measured with MARCKS-PSD and accounted for approximately 25 and 10% of total activity in 1-day-old and adult rat cortex, respectively. These results suggest that the MARCKS-PSD peptide can be used as a selective PKC substrate in rat brain homogenates.

Relationships between leisure time physical activity and perceived stress.

This study investigated the relationship between physical activity during leisure time and perceived stress among working adults (N = 32,229). Data were gathered on physical activity, perceived stress, current health status, age, gender, life changes, ongoing problems, number of techniques used for stress reduction, and number of personality traits related to Type A behavior. To control for confounding variables Mantel-Haenszel summary risk estimates were used. Employees who expended more than 3.0 Kcal/kg(-1) . day(-1) in physical activity during leisure time were 0.78 and 0.62 times less likely to have moderate and high perceived stress, respectively. Working adults participating in moderate amounts of these activities have about half the rate of perceived stress as nonparticipants.

Antimicrobial activity of CS-940, a new trifluorinated quinolone.

The antimicrobial activity of CS-940, a new trifluorinated quinolone drug, was tested against 761 clinical isolates. CS-940 activity against members of the family Enterobacteriaceae was most similar to that of ciprofloxacin and ofloxacin, with a large range of MICs inhibiting 90% of isolates tested (MIC90S) of 0.015 to 16 micrograms/ml (median MIC90, 0.06 micrograms/ml). CS-940 had greater activity than ciprofloxacin or ofloxacin when they were tested against Acinetobacter spp. (MIC90S, 0.03 micrograms/ml) and Stenotrophomonas (Xanthomonas) maltophilia (MIC90S, 2 micrograms/ml). CS-940 demonstrated a high degree of potency against Haemophilus influenzae, Moraxella catarrhalis, and Neisseria spp. (MIC90S, < or = 0.06 micrograms/ml). CS-940 was two- to eightfold more active than ciprofloxacin or ofloxacin against oxacillin-susceptible Staphylococcus aureus, Staphylococcus epidermidis, Staphylococcus haemolyticus, and coagulase-negative Staphylococcus spp. CS-940 was also very active against Streptococcus spp. and enterococci, for which MIC90S were < or = 2 micrograms/ml; for Enterococcus faecium, however, the MIC90 was 4 micrograms/ml. CS-940 was generally less active than a comparison investigational fluoroquinolone, clinafloxacin. This compound appears promising by in vitro test analysis and warrants further in vivo trials.

Evaluation of S1 chromogenic cephalosporin beta-lactamase disk assay tested against gram-positive anaerobes, coagulase-negative staphylococci, Prevotella spp. and Enterococcus spp.

The efficacy of three rapid colorimetric disk assays to detect beta-lactamase production in 60 clinical isolates was evaluated. Two chromogenic cephalosporin substrates (S1 and nitrocefin) and an acidimetric test were in complete agreement when tested against Enterococcus spp. (20 strains, not Enterococcus faecalis), Prevotella spp. (10 strains) and Gram-positive anaerobic cocci (10 strains). However, the acidimetric test produced documented false-negative results in detecting the beta-lactamases from coagulase-negative staphylococci (two of 20 strains tested). The time required to produce a positive result for the discordant Staphylococcus epidermidis isolate favored S1 compared with nitrocefin. These studies indicate that the acidimetric test was less sensitive than the chromogenic cephalosporin substrates and that nitrocefin and S1 could be used to screen for beta-lactamase production in these tested species.

Automation of polymerase chain reaction tests. Reduction of human errors leading to contamination.

We compared the performance over 21 months of manually performed polymerase chain reaction (PCR)-based DNA analysis experiments with 25 months of automated PCR performed by a Zymark robotic system. Automation of the PCR technique resulted in a sixfold reduction in the number of experiments reporting carryover contamination and decreased the overall rate of contamination among total reactions 68-fold. Whereas contamination occurrences among manual experiments were evenly dispersed over the study interval and correlated with the lack of experience of laboratory personnel, the contamination that occurred with the robotic system was confined to the first 10 months of operation. In manual experiments, many of the 81 no-target false positives were sufficiently strong to result in the invalidation of 151 samples and positive controls. The seven no-target control false positives in the automated system were weak bands that were easily subtracted as background. Because none of the negative samples had DNA bands, no sample on the automated system has ever been invalidated as a result of contamination. Automation of PCR tests appears to offer great promise in reducing contamination to acceptable levels (e.g., < or = 0.1%).

Suggested modifications for disk diffusion susceptibility testing criteria for levofloxacin and sparfloxacin following tests with a predictor panel of ciprofloxacin-resistant clinical isolates.

A predictor panel of 300 clinical bacterial isolates (200 resistant to ciprofloxacin) was used to compare 5-micrograms disk diffusion test results with the MICs of ofloxacin (control), levofloxacin, and sparfloxacin. Regression analysis demonstrated high correlations between the methods for all three fluoroquinolones (r > or = 0.95). In order to minimize disk diffusion testing errors among the fluoroquinolone-resistant strains, the following modifications to previously proposed or published interpretive criteria were suggested: for levofloxacin, susceptible at > or = 17 mm (< or = 2 micrograms/ml) and resistant at < or = 13 mm (> or = 8 micrograms/ml); for sparfloxacin, susceptible at > or = 20 mm (< or = 1 microgram/ml) and resistant at < or = 16 mm (> or = 4 micrograms/ml). The study control drug, ofloxacin, did not appear to possess a significant error rate (5% minor error) when fluoroquinolone-resistant strains were tested, and no modifications were proposed. Under these proposed interpretive criteria, the absolute categorical agreements between standardized susceptibility testing methods for levofloxacin and sparfloxacin results were 91.3 and 94.0%, respectively (< or = 0.3% major errors and nil very major errors).

Development, characterization, and initial evaluations of S1. A new chromogenic cephalosporin for beta-lactamase detection.

A novel, chromogenic cephalosporin reagent (S1) for beta-lactamase testing was produced that shares physicochemical characteristics with nitrocefin (formerly 87/312). S1 and nitrocefin in a disk-testing format for beta-lactamase performed at 100% agreement for detecting enzyme-producing isolates of Bacteroides fragilis group, Haemophilus influenzae, Moraxella catarrhalis, Neisseria gonorrhoeae, Staphylococcus aureus, and selected Enterobacteriaceae. The time required to achieve an initial color change or a strong positive reaction was comparable for both chromogenic reagents for all organisms except the Gram-positive species. S1 reaction times were approximately 50% faster than nitrocefin for beta-lactamase-positive enterococci and S. aureus. These results from the developmental studies and a commercially prepared disk lot indicate that S1 is a promising beta-lactamase disk test reagent with the ability to detect all significant enzyme-producing species strains, some significantly earlier than the nitrocefin disk method.

Prediction of piperacillin-tazobactam susceptibility among Enterobacteriaceae, Pseudomonas aeruginosa, and other bacteria using ticarcillin-clavulanic acid, ceftazidime, and other broad-spectrum antimicrobial in vitro test results.

The ability of various in vitro beta-lactam susceptibility test results to predict the susceptibility of piperacillin-tazobactam (a new beta-lactam-beta-lactamase inhibitor combination) was assessed using more than 46,000 recent clinical isolates. The organisms were tested by reference-quality National Committee for Clinical Laboratory Standards (NCCLS) broth microdilution procedures and interpreted by the currently published NCCLS criteria. The recommended antimicrobial tests that would accurately predict the piperacillin-tazobactam in vitro efficacy had an overall very major, false-susceptible rate of only 0.6% (< or = 1.5% is acceptable). The following drug tests can be used to judge piperacillin-tazobactam activity and spectrum (low patient risk) conservatively: for Enterobacteriaceae use ticarcillin-clavulanic acid results (0.6% very major error); for Pseudomonas aeruginosa use piperacillin (0.1%) results; for enterococci use ampicillin or ampicillin-sulbactam (1.8%) results; for Haemophilus influenzae and Moraxella catarrhalis use cefotaxime or cefuroxime or ceftriaxone (1.5%); and for staphylococci use oxacillin by NCCLS recommendations. When the piperacillin-tazobactam testing reagents become available, the direct testing of this combination should be applied to relevant clinical isolates. The piperacillin-tazobactam break points should be reassessed as indicated by the cited minimum inhibitory concentration population analysis to improve predictive accuracy; H. influenzae susceptibility modified to < or = 2/4 micrograms/ml and Enterococcus species susceptibility tested at < or = 16/4 micrograms.

Cholesterol esterase catalyzed hydrolysis of mixed micellar thiophosphatidylcholines: a possible charge-relay mechanism.

Mechanistic features of cholesterol esterase catalyzed hydrolysis of two thiophospholipids, rac-1-(hexanoylthio)-2-hexanoyl-3-glycerophosphorylcholine (6TPC) and rac-1-(decanoylthio)-2-decano-yl-3-glycerophosphorylcholine (10TPC), have been characterized. The hydrolysis of 10TPC that is contained in mixed micelles with Triton X-100 occurs strictly at the micellar interface, since the reaction rate is independent of the micelle concentration but depends hyperbolically on the mole fraction of the substrate in the micelles. This latter observation allows one to calculate the interfacial kinetic parameters V*max and K*m. The hydrolyses of 10TPC and p-nitrophenyl butyrate are similarly inhibited by the transition state analogue inhibitor phenyl-n-butylborinic acid, and therefore, physiological and nonphysiological substrates are processed at the same active site. The similarity of k*cat values for the acyl-similar substrates 10TPC and p-nitrophenyl decanoate indicates that the phospholipase A1 activity of cholesterol esterase is partially rate limited by turnover of a decanoyl-enzyme intermediate. Solvent isotope effects on V*max and V*max/K*m (which monitors acylation only) are approximately 2-3 and are consistent with transition states that are stabilized by general acid-base proton transfers. Proton inventories of V*max/K*m indicate that simultaneous proton transfers stabilize the acylation transition state, which requires a multifunctional acid-base machinery (perhaps a charge-relay system) in the cholesterol esterase active site. Similar results are obtained for the 6TPC reaction, both in the presence and absence of Triton X-100 micelles.

Dimensional mapping of the active site of cholesterol esterase with alkylboronic acid inhibitors.

The cholesterol esterase-catalyzed hydrolysis of the water-soluble substrate p-nitrophenyl butyrate occurs via an acylenzyme mechanism, and is competitively inhibited by boronic acid transition state analog inhibitors. Accordingly, we undertook to dimensionally map the enzyme's active site via synthesis and characterization of a series of n-alkyl boronic acid inhibitors. The most potent of these is n-hexaneboronic acid, with a Ki = 13 +/- 1 microM, since inhibitor potency declines for both longer and shorter boronic acids. No inhibition is observed for methaneboronic acid and n-octaneboronic acid inhibits poorly, with a Ki of 7 mM. These results indicate that the ability of the enzyme to form tight complexes with boron-containing transition state analog inhibitors is sensitive to alkyl chain length. The trend in inhibitor potency is discussed in terms of substrate specificity of and transition state stabilization by cholesterol esterase, and has important implications for the design of optimal reversible inhibitors of the enzyme.

Haloketone transition state analog inhibitors of cholesterol esterase.

The cholesterol esterase-catalyzed hydrolysis of p-nitro-phenyl butyrate is reversibly inhibited by four phenyl haloalkyl ketones. Inhibitor potency is greatest for halogenated acetophenones and parallels the extent of hydration of the various ketones in buffered D2O. These results are consistent with an inhibition mechanism wherein haloketones reversibly form hemiketal adducts at the active site that structurally mimic tetrahedral intermediates of the cholesterol esterase catalytic cycle.

p-Nitrophenyl and cholesteryl-N-alkyl carbamates as inhibitors of cholesterol esterase.

p-Nitrophenyl and cholesteryl-N-alkyl carbamates are good inhibitors of porcine pancreatic cholesterol esterase-catalyzed hydrolysis of p-nitrophenyl butyrate. p-Nitrophenyl-N-butyl and N-octyl carbamates (compounds 1 and 2, respectively) are potent active site-directed irreversible inhibitors of this enzyme. The inhibition of cholesterol esterase by compound 1 or 2 shows saturation kinetics with increasing inhibitor concentration. The activity of cholesterol esterase in the presence of compound 1 or 2 can be protected by the competitive inhibitor, phenylboronic acid. First-order decreases in cholesterol esterase activity effected by compound 1 or 2 are also observed in the presence of taurocholate/phosphatidylcholine micelles. Dilution of the inhibited enzyme results in a gradual return of activity, the rate of which is increased in the presence of the nucleophile hydroxylamine. Hence, inhibition of cholesterol esterase-catalyzed hydrolysis of p-nitrophenyl butyrate by compound 1 or 2 in the aqueous or micellar phase occurs via a carbamyl-cholesterol esterase mechanism. The turnover of the butyl carbamylenzyme is increased in the presence of micelles, which indicates that the micelles have a direct effect on the catalytic activity of the enzyme. However, this effect is dependent on the structure of the substrate as the turnover of the octyl carbamylenzyme is unaffected in the presence of micelles. A comparison of the second-order rate constants for the inhibition of cholesterol esterase by compound 1 or 2 indicates that the octyl derivative is the more potent inhibitor. Cholesteryl-N-alkyl carbamates do not carbamylate cholesterol esterase but instead act as reversible inhibitors. This is due to the stability of cholesteryl carbamates relative to p-nitrophenyl carbamates.

Phenyl-n-butylborinic acid is a potent transition state analog inhibitor of lipolytic enzymes.

The cholesterol esterase and lipoprotein lipase catalyzed hydrolyses of the water-soluble substrate p-nitrophenyl butyrate are competitively inhibited by butaneboronic acid and phenylboronic acid. Phenyl-n-butylborinic acid has been synthesized and characterized as an ultrapotent transition state analog inhibitor: Ki = 2.9 +/- 0.6 nM and 1.7 +/- 0.3 microM for the cholesterol esterase and lipoprotein lipase reactions, respectively. These results are interpreted in terms of transition state structure and stabilization.

Acylenzyme mechanism and solvent isotope effects for cholesterol esterase-catalyzed hydrolysis of p-nitrophenyl butyrate.

The mechanism of cholesterol esterase- (carboxylic ester hydrolase, EC 8.1.1.1) catalyzed hydrolysis of the water-soluble ester p-nitrophenyl butyrate has been characterized for commercially available preparations from bovine and porcine pancreas and for a purified preparation from porcine pancreas. Kinetic evidence for an acylenzyme mechanism is provided by experiments wherein the butyryl enzyme is trapped by MeOH, EtOH or n-BuOH. For the last alcohol the transacylation product n-butyl n-butyrate was characterized by GC-mass spectrometry. Solvent isotope effects have been measured for Vmax/Km, which is the rate constant for acylation, and for Vmax, which monitors rate-determining deacylation. Isotope effects of 1.5-3 on these rate constants indicate that both steps of the acylenzyme mechanism for cholesterol esterase catalysis involve transition states that are stabilized by general acid-base proton bridges.

Recent concepts in the management of ischaemic cardiac syndromes.

Ischaemic heart disease is the most important cause of death in our society. Knowledge of the natural history of the various ischaemic syndromes leads to better management, with emphasis on prevention of cardiac necrosis rather than management of its sequelae. This article is from the Department of Cardiology, Royal Melbourne Hospital.

Coronary artery graft surgery.

The last decade has seen significant technical advances in equipment for the procedure of, and the surgeon's operating skill in coronary artery by pass surgery. Such surgery is indicated when, despite medical treatment, angina is disabling; although evidence is increasing that patients whose pain is controlled should be considered for surgery. Late operations are more complex and expensive, and patients are exposed to a higher risk of sudden death in the intervening period. Delay may also allow the disease to progress to an inoperable state. Patients unlikely to benefit from medical treatment should be offered surgery as soon as their disease is identified by angiography. Intensive medical treatment, with its poorer control of symptoms, leads to an increasing dependence on the State of medicine, hospital facilities and sickness benefits. The reputedly expensive coronary artery bypass operation is cheaper both to the State and to the patient tha unoperated invalidism.