The Effect of an Individualized Practice-Based CME Program on Physician Performance and Patient Outcomes

The Professional Competence Assurance Program (PROCAP) is an individualized educational program that examines physicians'' performance in ambulatory practice. It uses medical record review to identify deficiencies in the care process that guides development of the educational intervention. Medical care is reassessed one year later. This program was used with 51 private practitioners to assess the care of 1,229 hypertensive patients. The educational program included a computer printout comparing one physician''s performance with that of peers, readings targeted to management problems, and a conference call or group seminar with an expert stressing issues relevant to each physician''s performance. Postintervention assessment showed that physicians prescribed beta-blockers (P<.01) and vasodilators (P<.01) more often. Improvement (P<.05) occurred in the control of diastolic blood pressure (≤90 mm of mercury) and in several other criteria. These results show that well-designed, individualized continuing medical education addressing specific deficiencies can change physicians'' performance and patients'' intermediate outcome.     

Differentiation in mouse melanoma cells: initial reversibility and an on-off stochastic model

Various proposals that a stochastic event, "commitment," is the first and rate-limiting step in mammalian cell differentiation were tested in one cell type, B16C3 mouse melanoma cells. Differentiation (pigment production) was observed in time-lapse films and in cloned single cells. As predicted by all the theories, onset of differentiation was at widely variable times in different cells after stimulation; and selection experiments showed that little of the variability was genetic. Contrary to some theories, differentiation appeared unrelated to cell division. Two properties of the melanoma cells did not fit any of the theories: times of differentiation were highly correlated in sister cells; and differentiation could be reversed in a proportion of cells, which was highest at the lowest levels of pigmentation. Dedifferentiation was associated with cell proliferation, so that most pigmented clones were small and most unpigmented clones large. These findings are accommodated by a model in which functions associated with differentiation can switch on and off, but an inhibition of the off transition builds up in the on state.     

Kinetic studies of adenosine kinase from L1210 cells: a model enzyme with a two-site ping-pong mechanism

Purified adenosine kinase from L1210 cells displayed substrate inhibition by high concentrations of adenosine (Ado), ATP, and MgCl2. When incubated with ATP and MgCl2, the enzyme was phosphorylated, and the phosphorylated kinase transferred phosphate to adenosine in the absence of ATP and MgCl2. Substrate binding, isotope exchange, and kinetic studies suggested that the enzyme catalyzes the reaction by means of a two-site ping-pong mechanism with the phosphorylated enzyme as an obligatory intermediate. Among many possible pathways within this mechanism probably a random-bi ordered-bi route is the preferred sequence in which the two substrates, adenosine and MgATP, bind in a random order to form the ternary complex MgATP . E . Ado followed by the sequential dissociation of MgADP and AMP. Dissociation constants of various enzyme-substrate and enzyme-product complexes and the first-order rate constant of the rate-limiting step were estimated.     

New In-vitro Test for IgE-mediated Hypersensitivity in Man

A new simple and sensitive in-vitro method for the diagnosis of type 1 (IgE-mediated) hypersensitivity in man is described. Sliced human skin is passively sensitized by reaginic serum from allergic patients and the presence of antigen-specific IgE on the sensitized slices is detected by assay of antigen-evoked histamine release. Serum from 12 out of 14 patients with clinical respiratory allergy and positive skin tests gave significant antigen-specific histamine release. This method, which is essentially an in-vitro model of the Prausnitz-Küstner reaction, should prove of value in the diagnosis of human reaginic hypersensitivity in man.     

Stimulation of Mycelial Growth of Endothia parasitica by Heavy Metals

Of 16 metal cations tested on agar medium, only copper and iron stimulated mycelial growth of Endothia parasitica in relatively high concentrations. Similarly enhanced growth was produced in high (32%) glucose concentrations and also when the fungus was grown on cellophane placed over the agar surface. E. parasitica secreted large amounts of oxalate that precipitated primarily as calcium oxalate at the periphery of the fungal colony, causing an opaque halo in the medium. Mycelial growth was retarded greatly when calcium oxalate accumulated, but retardation was reversed by copper and iron salts that prevented accumulation of the calcium oxalate crystals. E. parasitica grew well on media containing copper oxalate and copper-calcium oxalate but grew poorly with calcium oxalate as the carbon source and was inhibited by sodium oxalate in the medium. The specificity by which only copper and iron salts stimulated mycelial growth suggested that the metal and oxalate ions interact to form specific oxalate complexes that reverse the inhibition of simple oxalate salts. This probably accounts for enhanced growth in the presence of otherwise toxic levels of metals and oxalate. The stimulation did not occur in liquid cultures.     

Isolation, Mapping, and Characterization of Trehalaseless Mutants of Neurospora crassa

Mutant strains of Neurospora crassa that lack trehalase and are unable to grow on trehalose were isolated, and the gene (tre) was positioned on the right arm of linkage group I. Maltase and beta-galactosidase activities are almost identical in tre(-) strains, whereas that of invertase was reduced by more than half and those of acid phosphatase and amylase were somewhat increased. Heterocaryons between standard and trehalaseless strains yield less than one-tenth the activity of the former. In addition, strains with duplications heterozygous for trehalase produce less than 1% of the activity of the standard strain. An inhibitor of trehalase has been found in tre(-) strains; its sensitivity to heat and proteolysis, and its nondialyzability suggest that this substance is a protein. The mig gene, which determines the rate of migration of trehalase on acrylamide gels, has been shown to be less than 1 map unit away from the tre gene.     

Fate of corticotrophins in an isolated adrenal-cell bioassay and decrease of peptide breakdown by cell purification

1. The fate of corticotrophins in a trypsin-dispersed rat adrenal-cell assay system was investigated with a view to establishing whether differences in the rate of inactivation might contribute to potency differences observed between analogues. 2. Corticotrophin-(1-24)-tetracosapeptide and to a lesser extent synthetic 1-39 corticotrophins were found to be inactivated during incubation with cell suspension. 3. Peptide fragments were isolated by using [[(3)H(2)]Tyr(23)]corticotrophin-(1-24)- tetracosapeptide as a marker. The fragments indicate a peptidase with a predominantly tryptic specificity. 4. The peptidase is present in the extracellular fluid and is released from cells when they are damaged. 5. Cells were fractionated on an albumin gradient. Cells from the zona fasciculata and the zona intermedia or reticularis were present in fractions which produced fluorogenic steroids in response to corticotrophin. 6. Purification of the cells by centrifugation through albumin decreased degradation by peptidases, so that if the assay is carried out with a dilute suspension of purified cells peptide breakdown should not affect the observed potencies of adrenocorticotrophin analogues. 7. No binding of [[(3)H(2)]Tyr(23)]corticotrophin-(1-24)- tetracosapeptide to cells could be detected at low concentrations of the peptide. This indicated that less than 120 receptors/cell are occupied during stimulation by a dose that would elicit approx. 80% of the maximal response.