The implementation of bedside bladder ultrasound technology: effects on patient and cost postoperative outcomes in tertiary care.

RESEARCH PROBLEM: The purpose of this study was to determine the effect of ultrasound assessment of bladder volume on patient and cost outcomes for patients needing postoperative catheterization. RESEARCH METHODS: Prospective descriptive and quasi-experimental designs were used with patients having general surgery (N = 50) and patients having orthopaedic surgery (N = 103), respectively. Four outcomes were measured: number of catheterizations over the hospitalization period, infection rates, cost, and patient and provider satisfaction. RESULTS: Accuracy of the technology ranged from .76 to .97 (p = .01). Catheterizations were avoided in 38% (in the "Due to Void" category) and in 81% (in the "Void with Residual" category) of patients in the general surgery group. Patients in the orthopaedic surgery group having ultrasound experienced 1.68 and the standard catheterization group, 1.96 catheterizations, throughout hospitalization. This difference was not statistically significant. UTI rates from admission to 30 days after discharge were 4% and 13% of patients in the ultrasound and standard orthopaedic groups, respectively, and 17% of patients in the general surgical population. Based on acquisition catheter cost, approximately 3 years of ultrasound machine use would be needed to recover the acquisition cost for each machine. The satisfaction rate with the technology was 93% of patients and 97% of nurses. In postoperative patients, bedside bladder ultrasound is accurate, is effective in decreasing numbers of catheterizations, reduces cost over time, and provides high patient and provider satisfaction.

Improving pain management after total joint replacement surgery.

PURPOSE: To test the effects of implementing evidence-based postoperative pain management content and strategies on patient, provider (nurse and physician), and fiscal outcomes. SAMPLE: 118 patients, 57 before and 61 after implementation, having total knee replacement (TKR) (54%) and total hip replacement (THR) (45%), and 28 orthopaedic nurses. METHODS: A research utilization approach with a pretest/posttest design was used. Independent variables (interventions) included evidence-based pain management content, education of care providers and patients, and system changes at the point of care. Dependent variables (outcomes) were patient perception of the postoperative pain experience, provider practice patterns, and length of stay (LOS). FINDINGS: The hypotheses of decreased provider use of meperidine and increased use of hydromorphone, i.v. route, pain plans of care, and nurse knowledge were supported. LOS was significantly reduced. The patient hypotheses decreased pain intensity and side effects and increased satisfaction and function were not supported. CONCLUSION: Methodical implementation of evidence-based pain management information changed practice and fiscal outcomes. Improvement in the patient perception of pain management was more difficult to achieve.

Role of MgATP in the activation and reassociation of cAMP-dependent protein kinase I: consequences of replacing the essential arginine in cAMP binding site A.

The type I form of cAMP-dependent protein kinase binds MgATP with a high affinity, and binding of MgATP decreases the affinity of the holoenzyme for cAMP [Hofmann et al. (1975) J. Biol. Chem. 250, 7795]. Holoenzyme was formed here with a mutant form of the bovine recombinant type I regulatory subunit where the essential arginine in site A, Arg-209, was replaced with Lys. Although this mutation does not significantly change the high-affinity binding of MgATP to the holoenzyme, it does abolish high-affinity binding of cAMP to site A. In the absence of MgATP, binding of cAMP to site B is sufficient to promote dissociation of the holoenzyme complex and activation of the catalytic subunit [Bubis et al. (1988) J. Biol. Chem. 263, 9668]. In the presence of MgATP however, holoenzyme formed with this mutant regulatory subunit is very resistant to cAMP. The Kd(cAMP) was greater than 1 microM, and the Ka(cAMP) increased 60-fold from 130 nM to 6.5 microM in the presence of MgATP. Thus, MgATP serves as a lock that selectively stabilizes the holoenzyme and inhibits activation. Both site A and site B are shielded from cAMP in the presence of MgATP. These results suggest that Arg-209 may play a role in stabilizing the MgATP.holoenzyme complex in addition to its role in binding the exocyclic oxygens of cAMP when cAMP is bound to the regulatory subunit. The catalytic subunit also reassociates rapidly with this mutant regulatory subunit, and in contrast to the wild-type regulatory subunit, holoenzyme formation does not require MgATP.

A point mutation abolishes binding of cAMP to site A in the regulatory subunit of cAMP-dependent protein kinase.

Each regulatory subunit of cAMP-dependent protein kinase has two tandem cAMP-binding sites, A and B, at the carboxyl terminus. Based on sequence homologies with the cAMP-binding domain of the Escherichia coli catabolite gene activator protein, a model has been constructed for each cAMP-binding domain. Two of the conserved features of each cAMP-binding site are an arginine and a glutamic acid which interact with the negatively charged phosphate and with the 2'-OH on the ribose ring, respectively. In the type I regulatory subunit, this arginine in cAMP binding site A is Arg-209. Recombinant DNA techniques have been used to change this arginine to a lysine. The resulting protein binds cAMP with a high affinity and associates with the catalytic subunit to form holoenzyme. The mutant holoenzyme also is activated by cAMP. However, the mutant R-subunit binds only 1 mol of cAMP/R-monomer. Photoaffinity labeling confirmed that the mutant R-subunit has only one functional cAMP-binding site. In contrast to the native R-subunit which is labeled at Trp-260 and Tyr-371 by 8-N3cAMP, the mutant R-subunit is convalently modified at a single site, Tyr-371, which correlates with a functional cAMP-binding site B. The lack of functional cAMP-binding site A also was confirmed by activating the mutant holoenzyme with analogs of cAMP which have a high specificity for either site A or site B. 8-NH2-methyl cAMP which preferentially binds to site B was similar to cAMP in its ability to activate both mutant and wild type holoenzyme whereas N6-monobutyryl cAMP, a site A-specific analog, was a very poor activator of the mutant holoenzyme. The results support the conclusions that 1) Arg-209 is essential for cAMP binding to site A and 2) cAMP binding to domain A is not essential for dissociation of the mutant holoenzyme.

Stability of wild-type and mutant RTEM-1 beta-lactamases: effect of the disulfide bond.

Uniquely among class A beta-lactamases, the RTEM-1 and RTEM-2 enzymes contain a single disulfide bond between Cys 77 and Cys 123. To study the possible role of this naturally occurring disulfide in stabilizing RTEM-1 beta-lactamase and its mutants at residue 71, this bond was removed by introducing a Cys 77----Ser mutation. Both the wild-type enzyme and the single mutant Cys 77----Ser confer the same high levels of resistance to ampicillin in vivo to Escherichia coli; at 30 degrees C the specific activity of purified Cys 77----Ser mutant is also the same as that of the wild-type enzyme. Also, neither wild-type enzyme nor the Cys 77----Ser mutant is inactivated by brief exposure to p-hydroxymercuribenzoate. However, above 40 degrees C the mutant enzyme is less stable than wild-type enzyme. After introduction of the Cys 77----Ser mutation, none of the double mutants (containing the second mutations at residue 71) confer resistance to ampicillin in vivo at 37 degrees C; proteins with Ala, Val, Leu, Ile, Met, Pro, His, Cys, and Ser at residue 71 confer low levels of resistance to ampicillin in vivo at 30 degrees C. The use of electrophoretic blots stained with antibodies against beta-lactamase to analyze the relative quantities of mutant proteins in whole-cell extracts of E. coli suggests that all 19 of the doubly mutant enzymes are proteolyzed much more readily than their singly mutant analogues (at Thr 71) that contain a disulfide bond.(ABSTRACT TRUNCATED AT 250 WORDS)

Active-site mutants of beta-lactamase: use of an inactive double mutant to study requirements for catalysis.

We have studied the catalytic activity and some other properties of mutants of Escherichia coli plasmid-encoded RTEM beta-lactamase (EC 3.5.2.6) with all combinations of serine and threonine residues at the active-site positions 70 and 71. (All natural beta-lactamases have conserved serine-70 and threonine-71.) From the inactive double mutant Ser-70----Thr, Thr-71----Ser [Dalbadie-McFarland, G., Cohen, L. W., Riggs, A. D., Morin, C., Itakura, K., & Richards, J. H. (1982) Proc. Natl. Acad. Sci. U.S.A. 79, 6409-6413], an active revertant, Thr-71----Ser (i.e., residue 70 in the double mutant had changed from threonine to the serine conserved at position 70 in the wild-type enzyme), was isolated by an approach that allows identification of active revertants in the absence of a background of wild-type enzyme. This mutant (Thr-71----Ser) has about 15% of the catalytic activity of wild-type beta-lactamase. The other possible mutant involving serine and threonine residues at positions 70 and 71 (Ser-70----Thr) shows no catalytic activity. The primary nucleophiles of a serine or a cysteine residue [Sigal, I. S., Harwood, B. G., & Arentzen, R. (1982) Proc. Natl. Acad. Sci. U.S.A. 79, 7157-7160] at position 70 thus seem essential for enzymatic activity. Compared to wild-type enzyme, all three mutants show significantly reduced resistance to proteolysis; for the active revertant (Thr-71----Ser), we have also observed reduced thermal stability and reduced resistance to denaturation by urea.