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The titration of the active centers of cellobiohydrolase from Trichoderma reesei.

A novel approach has been developed for the titration of enzyme active centers and for the determination of the molecular activity of enzymes. It is based on the simultaneous use of a nonspecific chromogenic substrate and a specific ligand (a substrate or an inhibitor), the latter being tightly bound with the enzyme's active center. The approach is demonstrated using the titration (that is, the determination of the molar concentration of the enzyme active centers) of purified cellobiohydrolase I (CBH I) (EC 3.2.1.91) of the fungus Trichoderma reesei. p-Nitrophenyl-beta-D-lactoside was used as a reference substrate (Km = 0.5 mM), and cellobiose and CM-cellulose as specific ligands. The molecular weight of CBH I as it was determined by the titration with cellobiose was 42,000 +/- 3,000. The inhibition constant by cellobiose was (6 +/- 1) X 10(-6) M. The value of the catalytic constant for the hydrolysis of p-nitrophenyl-beta-D-lactoside calculated from the titration data was equal to 0.063 s-1. CM-cellulose turned out to be more efficient titration agent for cellobiohydrolase than cellobiose, and might be used for the titration of the enzyme in concentrations of the latter of 0.008-0.02 mg/ml. The titration data showed that the inhibition constant of CM-cellulose toward CBH I was equal to (1.0 +/- 0.2) X 10(-7) M.

Binding Sites↗

Coupled chemical processes at clay/electrolyte interface: a batch titration study of Na-montmorillonites.

The present work addresses the protolytic charge of montmorillonite, which occurs on the broken-bond sites at the particle edges. The purpose is to overcome the general difficulty arising in potentiometric titration due to coupled side reactions, which severely impede the titrant budget (partial dissolution of the clay and of secondary phases, hydrolysis and readsorption of dissolved species, cation exchange). Batch potentiometric titrations were carried out on the montmorillonite fractions extracted from two bentonites (MX80 and SWy2) to quantify their protolytic charge. The effects of equilibration time (24 h and 7 days), pH from 4 to 10, and ionic strength (0.1 and 0.01 mol L(-1)) were extensively studied for the MX80 sample. Quantification of dissolution was achieved by analysis of the equilibrium solutions for dissolved species and by La(3+) exchange of the readsorbed species. The results clearly show that secondary phases such as iron- or silica-rich minerals contribute to the dissolved species, according to the nature of the raw bentonite. Furthermore, readsorption affects significant amounts of dissolved species. The overconsumption of proton/hydroxide due to dissolution, readsorption, and hydrolysis of dissolved species was evaluated using a self-consistent thermodynamic calculation. The ability of such calculation to correct the raw titration curves in order to extract the titrable surface charge of montmorillonite was evaluated by comparison with the continuous titration procedure. Especially in the alkaline domain, correcting the raw batch titration curves for the measured side reactions failed to reproduce the continuous titration curves. These observations demonstrate the limitations of the batch titration method and the superiority of fast, continuous methods for quantifying the dissociable surface charge of clays.

Adsorption↗

Pharmacokinetic, pharmacodynamic, and safety evaluation of an accelerated dose titration regimen of sotalol in healthy middle-aged subjects.

BACKGROUND: Current labeling recommends that therapy with sotalol be initiated in a monitored setting at 80 mg every 12 hours for 2 to 3 days, followed by 120 to 160 mg every 12 hours for at least 2 days before safety and efficacy can be ascertained and patients discharged. An accelerated titration regimen that shortens hospital stay without compromising patient safety would improve the usefulness of the drug. Although such regimens have been used by clinicians, they have not been formally evaluated. METHODS: Healthy, middle-aged sedentary men and women received sotalol in a double-blind, two-way crossover study with a 2-week washout phase to evaluate an accelerated titration regimen--placebo every 6 hours for four doses, followed by 80 mg sotalol every 6 hours for four doses, then 160 mg sotalol every 12 hours for nine doses--and compare it with the standard titration--placebo alternating with 80 mg sotalol every 6 hours for eight doses, followed by 160 mg sotalol every 12 hours for nine doses. QT intervals, RR intervals, and sotalol concentrations in plasma were measured at specific times throughout the study and during washout in a similar fashion for both regimens. RESULTS: Thirty-four subjects completed both regimens. The target prolongation of QTc (90% of the value achieved at steady state) was achieved 22 1/2 hours sooner with the accelerated titration regimen (P = .0003). There were no cardiovascular adverse events during either loading phase. At no time during the accelerated titration regimen did the sotalol concentrations in plasma or the QTc or RR interval prolongation exceed the values eventually achieved at steady state. The relationship between sotalol concentration and QTc was linear and independent of the regimen. CONCLUSION: The accelerated titration regimen for sotalol can shorten the time to attain the dosage usually required to effectively control arrhythmias, without excessive QT prolongation and the associated increased risk of torsades de pointes. The hospital stay of patients in whom antiarrhythmic therapy with sotalol is initiated can be shortened by 1 day if this accelerated titration regimen is used.

Adrenergic beta-Antagonists↗

Low-dose protamine based on heparin-protamine titration method reduces platelet dysfunction after cardiopulmonary bypass.

OBJECTIVE: The heparin-protamine titration method that uses the Hepcon hemostasis management system (Medtronic HemoTec Inc, Englewood, Colo) reduced blood loss in cardiac surgery in previous reports, but the mechanism is not fully understood. This study tests the hypothesis that reduced protamine administration preserves platelet function in human cardiac surgery. METHODS: Platelet count, alpha-granule secretion, and aggregation to thrombin before and after cardiopulmonary bypass in human beings were evaluated. In the control group (n = 14), a fixed dose of protamine (3 mg/kg) was administered. In the titration group (n = 20), protamine doses were based on the heparin concentration measured by the Hepcon system. RESULTS: Heparin concentrations before protamine administration were higher in the titration group (P =.0012), but protamine doses of patients in the titration group were markedly lower than those of the control group (P <.0001). During protamine infusion at a rate of 0.3 mg. kg(-1). min(-1), the percentage of granule membrane protein-140-positive platelets significantly increased in the control group compared with the titration group (18.8% +/- 8.6% vs 13.0% +/- 5.3%, P =.0188). After protamine administration, aggregation of washed platelets to thrombin recovered almost to the preoperative level in the titration group; however, it remained lower in the control group (20% +/- 20% vs 55% +/- 18%, P =.0009). CONCLUSION: Low-dose administration of protamine, based on a heparin-protamine titration method, restores not only the blood coagulation but also the platelet responses to thrombin and attenuates platelet alpha-granule secretion during heparin neutralization. Overdose of protamine activates platelets and may predispose patients to excessive bleeding after cardiac surgery.

Blood Loss, Surgical↗

Proteolytic footprinting titrations for estimating ligand-binding constants and detecting pathways of conformational switching of calmodulin.

To dissect the chemical basis for interactions controlling regulatory properties of macromolecular assemblies, it is essential to explore experimentally the linkage between ligand binding, conformational change, and subunit assembly. There are many advantages to using techniques that will probe the occupancy of individual binding sites or monitor conformational responses of individual residues, as described here. Proteolytic footprinting titrations may be used to infer binding free energies for ligands interacting with multiple sites or domains and to detect otherwise unrecognized "silent" interdomain interactions. Microgram quantities of pure protein are required, which is low relative to the hundreds of milligrams needed for comparable discontinuous equilibirum titrations monitored by NMR. By running comparative studies with several proteases, it is easy to determine whether resulting titration curves are consistent, independent of the protease used and therefore representative of the structural response of the protein to ligand binding or other differences in solution conditions (pH, salt, temperature). The results from multiple techniques (e.g., NMR, fluorescence, and footprinting) applied to aliquots from the same discontinuous titration may be compared easily to test for consistency. Classic methods for determining thermodynamic and kinetic properties of calcium binding to calmodulin include filter binding and equilibrium or flow dialysis (employing the isotope 45Ca), spectroscopic studies of stopped-flow fluorescence, calorimetry, and direct ion titrations. A cautionary note is that many different sets of microscopic data would be consistent with a single set of macroscopic constants determined by classic methods. This was well illustrated in Fig. 9. Thus, while it is important to compare results with those obtained by classic binding methods, they are, by definition, incapable of resolving the microscopic constants of interest. Thus, there is only one "direction" for comparison. Quantitative proteolytic footprinting titrations applied to studying calmodulin provided the first direct quantitative estimate of negative interactions between domains. Although studies of site-knockout mutants had suggested interactions between domains, this approach gave the first evidence for the pathway of anticooperative interactions between domains by showing that helix B responds structurally to calcium binding to sites III and IV in the C-domain. Despite two decades of study of calmodulin and the application of limited proteolysis studies to the apo and fully saturated forms, this finding emerged only when titration studies were undertaken as described. This highlights the general observation that while the behavior of the intermediate states in a cooperative switch are the key elements of the transition mechanism, they are the most difficult to observe. The unexpected finding that the isolated domains are nearly equivalent in their calcium-binding properties (Fig. 23 B) leaves us with many of the questions we had at the start: How does the sum of two nearly equivalent domains result in a molecule that switches sequentially rather than simultaneously? But it underscores why it is not yet possible to understand similar proteins by sequence gazing alone.

Amino Acid Sequence↗

Fixed versus titrated interferon-alpha 2B in chronic hepatitis C. A randomized controlled multicenter trial. The Swiss Association for the Study of the Liver.

BACKGROUND/AIM: Interferon has become the mainstay of treatment of chronic hepatitis C; however, duration of treatment and dose remain unresolved questions. The present study aimed to compare standard dose interferon with a titrated dose regimen carried out for 1 year. METHODS: This was a randomized, controlled multicenter trial. Patients with chronic hepatitis C were randomly allocated to a control group (n = 30), to a fixed dose group (n = 31) where interferon-alpha 2b 3 MU thrice weekly was given for 1 year or a titrated group (n = 34) where interferon was titrated starting at 5 MU thrice weekly to the lowest dose keeping the patient in remission as assessed by a normal ALT value. Liver biopsies were obtained before and at the end of treatment; in addition, galactose elimination capacity was measured as a measure of cytosolic function. RESULTS: In the control, fixed and titrated groups a complete response was achieved in 2/29, 10/28 and 15/31, respectively (p < 0.001 in favor of treatment, p = n.s. for the two treatments). The corresponding figure for sustained response was 1/29, 5/28 and 6/ 31 (p = n.s). In the titrated group, a complete (sustained) response was achieved with 5 MU in 2 (2), with 4 MU in 1 (0), with 3 MU in 4 (0), with 2 MU in 3 (0) and with 1 MU in 5 (4). Liver biopsy score and galactose elimination capacity improved significantly in responders but not in treatment failures. CONCLUSIONS: Both fixed and titrated dosing of interferon given for 1 year induced virus clearance in only a minority of treated patients. However, in a small number of patients, a complete and sustained response can be achieved with low doses of interferon. Dose titration could be an interesting approach to decreasing the cost and side effects in the treatment of chronic hepatitis C.

Adult↗

Concentration determination of methyl magnesium chloride and other Grignard reagents by potentiometric titration with in-line characterization of reaction species by FTIR spectroscopy.

A potentiometric titration method for methyl magnesium chloride and other Grignard reagents based on the reaction with 2-butanol in THF has been developed and validated. The method employs a commercially available platinum electrode, using an electrolyte compatible with non-aqueous solvents. Well-defined titration curves were obtained, along with excellent method precision. The endpoint was precisely determined based on the first derivative of the titration curve. Different solvents such as THF, diethyl ether and methylene chloride provided similar results with regard to sharpness of the endpoint and method precision. The method was applied to a wide array of Grignard reagents including methyl magnesium bromide, ethyl magnesium chloride, propyl magnesium chloride, vinyl magnesium chloride, phenyl magnesium chloride, and benzyl magnesium chloride with similar precision and accuracy. Application of in-line FTIR was demonstrated for in situ monitoring of the titration reaction, allowing characterization of the reaction species. An authentic spectrum of the MeMgCl-THF complex was obtained using spectral subtraction and the vibrational absorbance bands were identified. FTIR also provided an alternative for detecting the titration endpoint, and the titration results so obtained, provided a cross-validation of the accuracy of the potentiometric titration.

Butanols↗

Sertraline treatment of obsessive-compulsive disorder: efficacy and tolerability of a rapid titration regimen.

The objective of this study was to compare in a single blind manner, over a period of 12 weeks, the efficacy and tolerability of two different titration regimens of sertraline in the treatment of OCD: 150 mg/day reached at day five from the beginning of therapy (rapid titration regimen) versus 150 mg/day reached at day 15 from the beginning (slow titration regimen). Patients with a DSM-IV diagnosis of OCD and a Y-BOCS greater or equal to 16 were randomly assigned to receive one of the two dosing regimens; an upper target dose of 150 mg/day was selected on the basis of a review of mean dosages used in flexible-dose sertraline studies. The primary efficacy measure was the Y-BOCS, which was completed at baseline and every 2 weeks. Thirty-two patients referred to the Anxiety and Mood Disorders Unit of the University of Turin were included in the study. Seventeen were assigned to the rapidly escalating dose regimen and 15 to the other titration regimen. Twenty-seven (84.4%) patients completed the 12 weeks of the study: 14 (82.4%) patients in the rapid and 13 (86.7%) in the slow titration regimen. The ANOVA analysis showed a significant difference between treatment groups at week 4 and 6 in favor of the rapid titration regimen group; this difference faded afterwards. Both titration regimens were effective in reducing OC symptoms and were well tolerated: no differences in drop-out or in adverse event rates emerged between the two groups. Limitations of the present study are the single-blind design and the lack of power to detect differences in tolerability.

Analysis of Variance↗

Application of inhibitor titrations for the detection of oxidative phosphorylation defects in saponin-skinned muscle fibers of patients with mitochondrial diseases.

Inhibitor titrations were applied to characterize functional changes in mitochondrial energy metabolism in the skeletal muscle of patients with mitochondrial diseases. For this we titrated the maximal mitochondrial respiration rate of saponin-skinned muscle fibers isolated from the skeletal muscle biopsy with the specific inhibitors of mitochondrial oxidative phosphorylation complexes I, IV and V-rotenone, azide and oligomycin. For three patients with deletions of mitochondrial DNA and one patient with a complex I deficiency the titrations revealed at rather normal respiration activities of saponin-skinned fibers significant differences to healthy controls: (i) The inhibitor titration curves of the affected enzyme were much steeper and (ii) for almost complete inhibition of respiration a smaller amount of the inhibitor is necessary. The detailed analysis of the titration curves within the framework of metabolic control theory indicated elevated flux control coefficients of the respective complex of respiratory chain. On the other hand, for one patient with a mitochondrial DNA depletion syndrome, decreased respiration activities of skinned fibers but no redistribution of flux control was observed. We conclude, therefore, that application of inhibitor titrations and the quantitative description of the titration curve can be a valuable approach to elucidate functional defects of mitochondrial oxidative phosphorylation.

Adult↗

Tracer monitored titrations: measurement of total alkalinity.

We introduce a new titration methodology, tracer monitored titration (TMT), in which analyses are free of volumetric and gravimetric measurements and insensitive to pump precision and reproducibility. Spectrophotometric monitoring of titrant dilution, rather than volume increment, lays the burden of analytical performance solely on the spectrophotometer. In the method described here, the titrant is a standardized mixture of acid-base indicator and strong acid. Dilution of a pulse of titrant in a titration vessel is tracked using the total indicator concentration measured spectrophotometrically. The concentrations of reacted and unreacted indicator species, derived from Beer's law, are used to calculate the relative proportions of titrant and sample in addition to the equilibrium position (pH) of the titration mixture. Because the method does not require volumetric or gravimetric additions of titrant, simple low-precision pumps can be used. Here, we demonstrate application of TMT for analysis of total alkalinity (A(T)). High-precision, high-accuracy seawater A(T) measurements are crucial for understanding, for example, the marine CaCO3 budget and saturation state, anthropogenic CO2 penetration into the oceans, calcareous phytoplankton blooms, and coral reef dynamics. We present data from 286 titrations on three types of total alkalinity standards: Na2CO3 in 0.7 mol kg x soln(-1) NaCl, NaOH in 0.7 mol kg x soln(-1) NaCl, and a seawater Certified Reference Material (CRM). Based on Na2CO3 standards, the accuracy and precision are +/-0.2 and +/-0.1% (4 and 2 micromol kg x soln(-1) for A(T) approximately 2100-2500 micromol kg x soln(-1), n = 242), using low-precision solenoid pumps to introduce sample and titrant. Similar accuracy and precision were found for analyses run 42 days after the initial experiments. Excellent performance is achieved by optimizing the spectrophotometric detection system and relying upon basic chemical thermodynamics for calculating the equivalence point. Although applied to acid-base titrations in this paper, the approach should be generally applicable to other types of titrations.

Journal Article↗

1H NMR study of effects of synergistic anion and metal ion binding on pH titration of the histidinyl side-chain residues of the half-molecules of ovotransferrin.

Separation of ovotransferrin into C-terminal (OTf/2C) and N-terminal (OTf/2N) half-molecules has made possible the resolution of all expected histidinyl C(2)H resonances by proton nuclear magnetic resonance at 250 MHz. The chemical shift of many of the resonances decreases with increasing pH, allowing construction of titration curves, whereas a few resonances fail to titrate. On formation of the GaIIIOTf/2(C2O4) ternary complexes, two of the low-field C(2)H resonances in each half-molecule fail to titrate. This behavior implicates the imidazole groups giving rise to these resonances as ligands to the bound metal ion. A third C(2)H resonance in each half-molecule undergoes a marked reduction in pK'a on formation of the ternary complex. The imidazole group displaying this resonance is implicated in a proton-relay scheme involved in binding the synergistic anion, oxalate, and a water of hydration on the bound metal ion. The titration curves for the various imidazole resonances have been fit to a four-parameter equation involving estimation of the pK'a, the limiting chemical shift values, and a Hill constant n. Hill constants of less than 1 can be rationalized by correcting the titration curve for the charge Z on the protein as a function of pH and the work function w. The titration curve for the imidazole group in OTf/2C involved in the proton-relay scheme shows a value for n greater than 1, which suggests positive cooperativity in the titration of this residue. The basis for this behavior cannot be rationalized at this time.(ABSTRACT TRUNCATED AT 250 WORDS)

Anions↗

Titration of mixed micelles containing a pH-sensitive surfactant and conventional (pH-Insensitive) surfactants: a regular solution theory modeling approach.

We present a thermodynamic theory to model the hydrogen-ion titration of mixed micelles containing a pH-sensitive surfactant and any number of conventional (pH-insensitive) surfactants. In particular, a simple expression is derived for the pKm, a parameter analogous to the pKa of simple acids, which describes the deprotonation equilibrium of the micellized pH-sensitive surfactant. The pseudophase approximation and regular solution theory (RST) are used to relate the pKm to (1) the pKa of the surfactant monomers, (2) the critical micelle concentrations (cmc's) of the protonated and deprotonated forms of the pH-sensitive surfactant, (3) the composition of the mixed micelle, and (4) parameters characterizing pairwise interactions between the surfactant molecules in the mixed micelle. Micellar titrations can be used to determine the magnitude of these interaction parameters. Conversely, knowledge of the cmc's and the interaction parameters allows the prediction of the pKm, which can then be used to calculate the micelle composition and surface charge as a function of solution pH. In addition, we have found that, in the context of RST, multicomponent surfactant mixtures are equivalent to a binary surfactant mixture of the pH-sensitive surfactant and a single effective surfactant whose interactions with the pH-sensitive surfactant are an average of those in the multicomponent surfactant mixture. We also discuss the experimental uncertainty in the pKm measurements. To account for the increased uncertainty in the pKm data at extreme micelle compositions, a weighted regression is proposed for the analysis of experimental titration data characterized by widely varying uncertainties. The theory presented here is validated using micellar titration data from the literature for several pH-sensitive surfactants in solutions containing 0.1 M salt. In most cases, the parameters extracted from an analysis of the titration data agree with the cmc and interaction parameters obtained by other means. One notable exception is the surfactant tetradecyldimethylamine oxide (C14DAO), which appears to have concentration-dependent interactions due to extensive growth of cylindrical micelles. Micellar titrations were also conducted on binary surfactant mixtures containing the pH-sensitive surfactant dodecyldimethylamine oxide (C12DAO) and either the cationic surfactant dodecyltrimethylammonium bromide (C12TAB) or the nonionic surfactant dodecyl octa(ethylene oxide) (C12E8). The theory provides a reasonable description of the experimental titration data at all surfactant mixing ratios, although a larger discrepancy is found in the C12DAO/C12E8 system, in which C12E8 interacts preferentially with the protonated, cationic form of C12DAO. Interestingly, C12TAB was also observed to interact preferentially with the protonated, cationic form of C12DAO, although the preference is much weaker than that in the C12DAO/C12E8 system.

Journal Article↗

Postoperative titration of intravenous morphine.

BACKGROUND AND OBJECTIVE: Intravenous morphine titration is used to obtain postoperative pain relief, but few studies have assessed the appropriate regimen. In a quality programme, we performed a prospective non-randomized study of morphine titration in a postanaesthesia care unit (PACU). METHODS: Four regimens of morphine titration were studied: every 10 (group 1, n = 400) or 5 min (group 2, n = 400) with a maximum of five intravenous boluses; every 5 min, without any limitation in the number of boluses (groups 3 and 4, n = 400 each); in groups 1, 2, and 3, subcutaneous morphine was administered 4 h after titration. In group 4, administration of subcutaneous morphine was allowed only 2 h after titration. A visual analogue pain scale (VAPS) > 30 mm was required to administer morphine and pain relief was defined as a VAPS < or = 30 mm. RESULTS: After morphine titration, VAPS was lower and the number of patients with pain relief was greater in patients from groups 3 and 4. Patients from group 4 had the lowest VAPS (26 +/- 17 mm) and the highest percentage of pain relief (73%) at the end of the PACU period. The number of sedated patients increased in groups 3 (62%) and 4 (61%) compared with group 1 (27%). No significant differences in morphine-related adverse effects were observed. CONCLUSION: Intravenous morphine titration every 5 min with an unlimited number of boluses and early subcutaneous administration provided the best analgesic regimen.

Adult↗

Carvedilol titration in patients with congestive heart failure receiving inotropic therapy.

BACKGROUND: Carvedilol has been shown to improve morbidity and mortality in patients with congestive heart failure (CHF). There are limited data of carvedilol use in patients on inotrope therapy. We present our experience with carvedilol titration in New York Heart Association (NYHA) class IIIb/IV patients stabilized on milrinone therapy, as a nonrandomized study with a parallel control group of patients never on inotropes. These patients achieved volume control and stabilization of their symptoms during the course of milrinone therapy. METHODS AND RESULTS: Seventeen patients in class IIIb/IV CHF (group 1) on intermittent intravenous milrinone therapy and 15 patients in class II/IIIa compensated CHF (group 2) on standard triple heart failure therapy were titrated on carvedilol. Success and adverse events during titration were compared between the 2 groups. Fifteen (88%) patients in group 1 and 14 (93%) patients in group 2 were successfully titrated on carvedilol over 8.1 +/- 1.8 weeks and 6.7 +/- 2.8 weeks, respectively. The target dose of carvedilol (25 or 50 mg twice daily) was achieved in 13 (87%) patients (group 1) and 14 (93%) patients (group 2). Seven (47%) patients in group 1 and 4 (28%) patients in group 2 had adverse events during carvedilol titration. Eight (53%) patients in group 1 were weaned off milrinone over a period of 8.4 weeks after carvedilol titration, whereas the rest of the patients had reduction in the frequency of infusion. Ten (63%) patients in group 1 improved by one or more functional classes. CONCLUSIONS: Patients in NYHA class IIIb/IV who are treated with inotropic therapy can be titrated on carvedilol after reaching a stable state while on milrinone and standard oral drugs. Most of these patients can be successfully weaned off of milrinone or have decreased frequency of infusions and demonstrate improved functional status. Prospective randomized trials are required to evaluate these observations made in a limited number of patients in class IIIb and IV CHF because the combination of milrinone and beta-blockers has never been adequately evaluated.

Adrenergic beta-Antagonists↗

Postoperative titration of intravenous morphine in the elderly patient.

BACKGROUND: Intravenous morphine titration is used to obtain rapid and complete postoperative pain relief. Whether this titration can be safely administered in the elderly patients remains a matter for debate. METHODS: Intravenous morphine titration was administered as a bolus of 2 (body weight < or = 60 kg) or 3 (body weight > 60 kg) mg. The interval between each bolus was 5 min. There was no limitation in the number of boluses given until pain relief or severe adverse effect occurred. The visual analog scale threshold required to administer morphine was 30 mm, and pain relief was defined as a visual analog scale score of 30 mm or less. Patients were divided into two groups: young and elderly (age > or = 70 yr) patients. Data were expressed as mean +/- SD. RESULTS: Eight hundred seventy-five patients (83%) were young and 175 patients (17%) were elderly. At the end of morphine titration, the visual analog scale score and the number of patients with pain relief were not significantly different between groups. The total dose of morphine per kilograms of body weight administered was not significantly different between groups (0.15 +/- 0.10 vs. 0.14 +/- 0.09 mg/kg, not significant). No significant differences were observed in the incidence of morphine-related adverse effects (13 vs. 14%, not significant), the number of sedated patients (60 vs. 60%, not significant), and the number of patients whose titration had to be stopped (2 vs. 2%, not significant). CONCLUSION: Intravenous morphine titration can be safely administered to elderly patients. Because titration is adapted to individual pain, the same protocol can be applied to young and elderly patients.

Adult↗

Establishing the safety and efficacy of an opioid titration protocol.

The primary goal of this single-group study was to determine the safety of a standard opioid titration order sheet to manage pain in ambulatory cancer patients. Secondary goals were to examine opioid toxicity and efficacy of this pain protocol. Twenty-seven patients who required fixed-dose opioids and who had uncontrolled pain were enrolled. All patients had their initial opioid dose titrated by the study physician using the opioid titration order sheet. Data were obtained by the study nurse during a weekly telephone interview and used to determine if pain was controlled. After initial titration, a trained study nurse titrated opioid doses based upon the standing order sheet. At each contact, patients were assessed for adverse effects, pain intensity, and analgesics used. Patients who completed the four-week trial (n = 17) did not differ from patients who did not complete the trial. No adverse effects were observed in 39 opioid titrations completed by the study nurse. Opioid toxicities, worst pain, usual pain, and pain-related distress declined from baseline to week four Patients who were adherent to their prescribed medications reported significantly lower pain intensity and distress (ps < or = . 06). The opioid titration order sheet, used by a trained nurse, is safe to use in ambulatory cancer patients who have moderate to severe pain. Common opioid toxicities were reduced. The protocol also demonstrated initial efficacy in improving worst and usual pain and pain-related distress. Further research to establish efficacy of the protocol is recommended.

Ambulatory Care↗

Switching dopamine agonists in advanced Parkinson's disease: is rapid titration preferable to slow?

BACKGROUND: New dopamine agonists are available, but no study has examined safe and effective ways to switch from one agonist to another. OBJECTIVE: To compare rapid- versus slow-titration schedules for starting a new dopamine agonist in patients already on chronic agonist therapy for Parkinson's disease. METHODS: Sixteen patients on stable carbidopa/levodopa and a dopamine agonist (bromocriptine or pergolide) switched to pramipexole using a conversion calculation of 1:1 for pergolide dose and 10:1 for bromocriptine dose. Patients were randomized to two titration schedules-either slow titration, following the package insert and taking up to 8 weeks to reach their equivalent dosage (8 patients), or rapid titration, receiving the full converted dose the day after stopping the former agonist (8 patients) with subsequent weekly dose adjustments. Using a blinded observer, the primary outcome variable was the time required to a Unified Parkinson's Disease Rating Scale (UPDRS) motor score superior to baseline without increased adverse effects. RESULTS: Both groups showed equivalent and statistically significant improvement after switching to the new agonist. The mean time to reach a UPDRS score that was superior to baseline without increased adverse effects was significantly shorter in the rapid-titration group (mean 2.1 weeks versus 5.3 weeks). Furthermore, with slow titration two patients experienced enhanced parkinsonian serious adverse effects requiring hospitalization (two falls with fractures). CONCLUSION: The switchover from one agonist to another can be safely and successfully accomplished with a rapid titration based on an equivalency dose calculation.

Aged↗

Attended home titration of nasal continuous positive airway pressure therapy for obstructive sleep apnea.

Nasal continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA) is usually titrated in a sleep laboratory with full polysomnographic monitoring until apneas, nonapneic desaturation, snoring, and microarousals are eliminated. This titration is sometimes done in the second half of the diagnostic sleep study or commonly on a separate second full night in the sleep laboratory. We performed NCPAP titration in the home in 17 patients with OSA previously documented by full polysomnography. Nasal CPAP was titrated at night in the patient's home by a registered nurse or polysomnography technician monitoring real-time recordings of heart rate, thoracic impedance, oxygen saturation, and pressure at the nasal mask on a four-channel recorder (EdenTec, Eden Prairie, Minn). Recordings of the nasal CPAP titration night were reviewed later by a physician. Apneas, hypopneas, and snoring were successfully eliminated in all patients. Mean nasal CPAP pressure was 10.3 +/- 3.2 cm H2O. At the time of a follow-up interview, 13 of 17 patients continued to be compliant with nasal CPAP therapy. The mean duration of therapy was 13.4 +/- 11.7 months with 7.23 mean hours of use for 6.76 nights per week. This compliance compares favorably with long-term home nasal CPAP compliance previously reported in patients titrated in our sleep laboratory. Home nasal CPAP titration resulted in about a $600 savings per patient.

Home Care Services↗