Next phase of medical management systems: automating administrative transactions to integrate payors and providers.

Today, medical management is burdened by the cost and hassle of manual administrative tasks. Manual intensive processing (that is, phone and fax) of referral requests and institutional authorization transactions results in significant unnecessary costs for the providers and payors, delays in approval, and problems with errors. To address these administrative burdens, the next phase of online (Internet- and wireless-enabled) medical management applications will focus on the administrative and transaction side, including self-service referral and authorization processing between the payor and provider. The advent of the Health Insurance Portability and Accountability Act (HIPAA) greatly improves the ability to gain widespread adoption of these online applications thanks to mandated standardization of many routine transactions. This article explores this next phase of online administrative and transaction medical management applications from the payors' perspective and explores their connectivity with providers. Payors are striving to meet several objectives as they implement these online administrative and transaction medical management systems: reducing the administrative burden and cost, changing traditional medical policies, increasing provider adoption of connective technologies, addressing HIPAA compliance, and achieving higher levels of system integration.

Direct measurement of ferrous ion transport across membranes using a sensitive fluorometric assay.

The fluorophore, Phen Green SK (PGSK), was assessed for its suitability to be used in an assay for ferrous ion transport into membrane vesicles. The long wavelengths of excitation and emission (506 and 520 nm, respectively) enable PGSK fluorescence to be detected in membranes, such as the chloroplast inner envelope, that contain high levels of carotenoids which absorb light at lower wavelengths. At low concentrations of Fe2+, less than 3 microM, the interaction between PGSK and Fe2+ appears to result in both static and dynamic quenching of the PGSK fluorescence. The characteristics of this quenching were used to develop a calibration curve to determine the concentration of free Fe2+ at these low concentrations. Pronounced quenching of PGSK fluorescence entrapped within chloroplast inner envelope membrane vesicles was observed when Fe2+ was added. The extent of quenching of PGSK fluorescence trapped inside asolectin vesicles on Fe2+ addition was much less. The kinetics of the quenching of PGSK fluorescence by Fe2+ in vesicles was quite different from that for PGSK and Fe2+ in solution. Using the calibration curve developed for interaction of PGSK and low Fe2+ concentrations the initial rates of iron transport could be determined for the chloroplast inner envelope membranes.

Direct measurement of calcium transport across chloroplast inner-envelope vesicles

The initial rate of Ca2+ movement across the inner-envelope membrane of pea (Pisum sativum L.) chloroplasts was directly measured by stopped-flow spectrofluorometry using membrane vesicles loaded with the Ca2+-sensitive fluorophore fura-2. Calibration of fura-2 fluorescence was achieved by combining a ratiometric method with Ca2+-selective minielectrodes to determine pCa values. The initial rate of Ca2+ influx in predominantly right-side-out inner-envelope membrane vesicles was greater than that in largely inside-out vesicles. Ca2+ movement was stimulated by an inwardly directed electrochemical proton gradient across the membrane vesicles, an effect that was diminished by the addition of valinomycin in the presence of K+. In addition, Ca2+ was shown to move across the membrane vesicles in the presence of a K+ diffusion potential gradient. The potential-stimulated rate of Ca2+ transport was slightly inhibited by diltiazem and greatly inhibited by ruthenium red. Other pharmacological agents such as LaCl3, verapamil, and nifedipine had little or no effect. These results indicate that Ca2+ transport across the chloroplast inner envelope can occur by a potential-stimulated uniport mechanism.

Measurement of carbonic anhydrase activity using a sensitive fluorometric assay.

The dehydration reaction of bicarbonate was measured using the fluorescent pH indicator, 8-hydroxypyrene-1,3,6-trisulfonate (pyranine), in combination with stopped-flow spectrofluorometry. The initial rate of bicarbonate dehydration was measured after mixing a pH 6.0 solution with a pH 8.0 solution containing bicarbonate. Addition of carbonic anhydrase to the pH 6.0 solution enabled the measurement of the initial rate of activity at physiological temperatures with resolution times of 2 ms. This assay was used to resolve differences in activity and sensitivity to sulfonamides by comparing mammalian carbonic anhydrase isoforms. The fluorescent technique used in this study is very sensitive, allowing the determination of initial rates with a protein concentration as little as 65 ng/ml. Pyranine can also be loaded into membrane vesicles to follow carbonic anhydrase activity within vesicles. The change in pH within vesicles is dependent on the concentration of externally added bicarbonate and the presence of carbonic anhydrase on either side of the membrane. Therefore, this assay can be used to measure carbon dioxide flux across membranes and to assess the contribution of carbonic anhydrase to this flux.

Direct measurement of nitrite transport across erythrocyte membrane vesicles using the fluorescent probe, 6-methoxy-N-(3-sulfopropyl) quinolinium.

Nitrite was shown to quench the fluorescence of 6-methoxy-N-(3-sulfopropyl) quinolinium (SPQ) almost twofold more than chloride. SPQ loaded inside vesicles prepared from asolectin and isolated erythrocyte ghosts allowed for the direct measurement of nitrite movement across these membranes. Movement of nitrite across asolectin occurred by diffusion as HNO2 in a pH-dependent manner. By contrast, erythrocyte ghosts had very low diffusion rates for nitrous acid. Erythrocyte ghosts preloaded with 50 mM nitrite to quench SPQ fluorescence were utilized to study heteroexchange with externally added anions. SPQ fluorescence increases (becomes unquenched) with added bicarbonate and nitrate, indicating that nitrite is moving out of the preloaded vesicles. The pH optimum for this exchange was approximately 7.6 and exchange was inhibited by N-ethylmaleimide (NEM) and dihydro-4,4'-diisothiocyanostilbene-2,2'-disulfonic acid (DIDS). These data indicate that nitrite moves across erythrocyte plasma membranes as NO2- by a heteroexchange mechanism with other monovalent anions.

Nitrite Transport in Chloroplast Inner Envelope Vesicles (I. Direct Measurement of Proton-Linked Transport).

Chloroplast inner envelope membrane vesicles that are loaded with the pH-sensitive fluorophore, pyranine, show rapid internal acidification when nitrite is added. Acidification is dependent upon [delta]pH, with the inside of vesicles being alkaline with respect to the outside. The rate of vesicle acidification was directly proportional to the concentration of nitrite that was added and the imposed pH difference across the membrane. In contrast, added nitrate had no effect on vesicle acidification. Nitrite also caused acidification of asolectin vesicles. The extent of vesicle acidification is dependent on the internal volume of vesicles. Inner envelope and asolectin vesicles that were prepared by extrusion were approximately the same size, allowing them to be compared when the final extent of acidification, measured after the pH gradient had collapsed, was similar. The rate of nitrite-dependent acidification was similar in these two preparations at any single nitrite concentration. These results indicate that nitrite movement occurs by rapid diffusion across membranes as nitrous acid, and this movement is dependent on a proton gradient across the lipid bilayer. Under conditions approximating those in vivo, the rate of diffusion of nitrous acid far exceeds that of nitrite reduction within chloroplasts.

Production of membrane vesicles by extrusion: size distribution, enzyme activity, and orientation of plasma membrane and chloroplast inner-envelope membrane vesicles.

A comparison of plasma membrane vesicles prepared by a freeze/thaw method was made with vesicles prepared by extrusion through a 100-nm polycarbonate filter. Based on ATPase measurements in the presence or absence of detergent, plasma membrane vesicles were approximately 30% right-side-out in freeze/thaw vesicles, whereas vesicles produced by extrusion were approximately 80% right-side-out. Chloroplast inner-envelope membrane vesicles were loaded with a membrane-impermeant, pH-sensitive fluorophore, pyranine, by either freeze/thaw or extrusion techniques. ATP-linked proton transport activity was considerably lower in vesicles prepared by extrusion compared to vesicles prepared by freeze/thaw. However, total ATPase activity measured as ADP release from ATP was equivalent in both preparations of vesicles. These results suggest that the inner-envelope vesicles produced by extrusion were predominantly oriented right-side-out. Inner-envelope vesicles were loaded internally with phosphate to study proton-linked transport of 3-phosphoglycerate. Vesicle acidification by 3-phosphoglycerate addition was similar in both freeze/thaw and extruded vesicle preparations, indicating that metabolite transport by the phosphate translocator is both functional and bidirectional. These results indicate that extrusion can be used as a method to produce proteoliposomes which are competent for transport studies.

Direct Measurement of ATP-Dependent Proton Concentration Changes and Characterization of a K+-Stimulated ATPase in Pea Chloroplast Inner Envelope Vesicles.

Inner envelope membrane vesicles prepared from pea (Pisum sativum L. var Laxton's Progress No. 9) chloroplasts have K+-stimulated ATPase activity with a pH optimum of 8.4. ATP addition to inner envelope vesicles loaded with pyranine caused a decrease in pyranine fluorescence that was consistent with internal acidification. The transmembrane pH change induced by the addition of 5 mM ATP was about 0.4 unit. Measurement of phosphate released by ATP hydrolysis paralleled the pH change, indicating that intravesicular acidification was linked to ATPase activity. Vanadate, molybdate, N-ethylmaleimide, and dithiothreitol inhibited ATP-dependent vesicle acidification completely, whereas ATPase activity was only partially inhibited. These data indicate that pea chloroplast inner envelope vesicles contain a proton translocating ATPase and that the pyranine-loading method can be utilized to study directly ATP-dependent H+ transport across these membranes.

Effects of Glycolate Pathway Intermediates on Glycine Decarboxylation and Serine Synthesis in Pea (Pisum sativum L.).

Glycine decarboxylation and serine synthesis were studied in pea (Pisum sativum L.) leaf discs, in metabolically active intact chloroplasts, and in mitochondria isolated both partially by differential centrifugation (i.e. ;crude') and by further purification on a Percoll gradient. Glycolate, glyoxylate, and formate reduced glycine decarboxylase activity ((14)CO(2) and NH(3) release) in the crude green-colored mitochondrial fractions, and in the leaf discs without markedly altering serine synthesis from [1-(14)C]glycine. Glycolate acted because it was converted to glyoxylate which behaves as a noncompetitive inhibitor (K(i) = 5.1 +/- 0.5 millimolar) on the mitochondrial glycine decarboxylation reaction in both crude and Percoll-purified mitochondria. In contrast, formate facilitates glycine to serine conversion by a route which does not involve glycine breakdown in the crude mitochondrial fraction and leaf discs. Formate does not alter the conversion of two molecules of glycine to one CO(2), one NH(3), and one serine molecule in the Percoll-purified mitochondria. In chloroplasts which were unable to break glycine down to CO(2) and NH(3), serine was labeled equally from [(14)C]formate and [1-(14)C]glycine. The maximum rate of serine synthesis observed in chloroplasts is similar to that in isolated metabolically active mitochondria. Formate does not appear to be able to substitute for the one-carbon unit produced during mitochondrial glycine breakdown but can facilitate serine synthesis from glycine in a chloroplast reaction which is probably a secondary one in vivo.

Alternative pathway respiration and lipoxygenase activity in aged potato slice mitochondria.

Mitochondrial preparations isolated from aged white potato (Solanum tuberosum L.) slices exhibited classical cyanide-insensitive O(2) uptake which was inhibited by salicylhydroxamic acid and tetraethylthiuram disulfide (disulfiram). These mitochondria also possessed lipoxygenase activity, as determined by O(2) uptake in the presence of 4 millimolar linoleic acid. Purification of the mitochondrial preparation on a continuous Percoll gradient resulted in a large decrease in lipoxygenase activity whereas cyanide-insensitive (disulfiram sensitive) O(2) consumption was still observed. These data indicate that cyanide-insensitive O(2) consumption in mitochondrial preparations isolated from aged white potato slices is of mitochondrial origin and not due to lipoxygenase contamination.