Evaluation of nurse triage in a British accident and emergency department.

OBJECTIVE--To compare formal nurse triage with an informal prioritisation process for waiting times and patient satisfaction. SETTING--Accident and emergency department of a district general hospital in the midlands in 1990. DESIGN--Patients attending between 8:00 am and 9:00 pm over six weeks were grouped for analysis according to whether triage was operating at time of presentation and by their degree of urgency as assessed retrospectively by an accident and emergency consultant. PATIENTS--5954 patients presenting over six weeks. MAIN OUTCOME MEASURES--Time waited between first attendance in the department and obtaining medical attention, and patient satisfaction measured by questionnaire. RESULTS--Complete data on waiting time were collected on 5037 patients (85%). Only 1213 of the 2515 (48%) patients presenting during the triage period were seen by a triage nurse. Patients in the triage group waited longer than those in the no triage group in all four retrospective priority categories, though differences were significant for only the two most urgent categories (difference in median waiting time 10.5 (95% confidence interval 3.5 to 14) min for category 1 and 8.5 (3 to 12) min for category 2). Responses to the patient satisfaction questionnaire were similar in the two groups except for the question relating to anxiety relating to pain. CONCLUSIONS--This study fails to show the benefits claimed for formal nurse triage. Nurse triage may impose additional delay for patient treatment, particularly among patients needing the most urgent attention.     

Biosynthesis of chloramphenicol

The current knowledge concerning the biosynthesis of chloramphenicol is discussed. Cultures of Streptomyces sp. 3022a fed ¹⁴C-shikimie acid incorporated the label to the same extent into phenylalanine, tyrosine, and chloramphenicol. Of possible precursors of the phenylpropanoid nucleus of this antibiotic only p-aminophenylalanine and DL-threo-p-amino phenylserine specifically labeled chloramphenicol. On the basis of these results a pathway for the biosynthesis of chloramphenicol is presented. The lack of specific incorporation of ¹⁵N-nitrogen from a competitive feeding experiment in which both ^l5N-nitrate and ¹⁴N-DL-serine were fed to growing cultures suggests that both the amido- and the nitro-nitrogen atom present in this antibiotic are derived from a common pool. Studies on the enzyme, DAHP synthetase, show that in streptomyces sp. 3022a it is not subject to feed back inhibition by either phenylalanine, tyrosine, or chloramphenicol.     

Biosynthesis of chloramphenicol in Streptomyces species 3022a: the nature of the arylamine synthetase system

The arylamine synthetase which catalyses the conversion of chorismic acid to p-aminophenylalanine in Streptomyces species 3022a was separated from aminotransferase by DEAE-cellulose chromatography. Recovered activity was further fragmented into three separate components by passage through a Sephadex G-100 column. Only one component produced p-aminophenylalanine but in combination the three stimulated each other activity. Although the products of the other two components were unstable, an infrared spectrum of one of them was obtained and confirmed the presence of an aromatic amine, but other functional groups could not be ascertained. This product was not recognized as a substrate by the arylamine synthetase complex and it was suggested that it may be a degradation product of an intermediate of p-aminophenylalanine biosynthesis or an unknown intermediate of later biosynthetic steps of the chloramphenicol pathway. It is further suggested that acrylamine compounds produced by this organism are the result of interaction of a core protein with other macromolecules and small molecular weight effect or molecules.