Discussion sections in reports of controlled trials published in general medical journals: islands in search of continents?

CONTEXT

Several journals have adopted the Consolidated Standards of Reporting Trials (CONSORT) recommendations to make assessment of the quality of randomized controlled trials (RCTs) easier. One of these recommendations is that the trial's results be discussed in light of the totality of the available evidence.

OBJECTIVE

To assess the extent to which reports of RCTs published in 5 general medical journals have discussed new results in light of all available evidence.

DESIGN

Assessment of the discussion sections in all 26 reports of RCTs published during May 1997 in Annals of Internal Medicine, BMJ, JAMA, The Lancet, and The New England Journal of Medicine.

MAIN OUTCOME MEASURE

The inclusion or mention of a systematic review in the discussion section of each article.

RESULTS

In only 2 articles were the RCT's results discussed in the context of an updated systematic review of earlier trials. In a further 4 articles, references were made to relevant systematic reviews, but no attempts were made to integrate the results of the new trials in updated versions of these reviews. One article was probably the first published trial to address the question studied. The remaining 19 articles included no evidence that any systematic attempt had been made to set the reported trial's results in the context of previous trials.

CONCLUSION

There is little evidence that journals have adequately implemented the CONSORT recommendation that results of an RCT be discussed in light of the totality of the available evidence.

Capsaicin sensitivity is associated with the expression of the vanilloid (capsaicin) receptor (VR1) mRNA in adult rat sensory ganglia

A vanilloid receptor (VR1) has recently been cloned and shown to be a target for capsaicin, the excitotoxic component of capsicum peppers (Caterina, M.J., Schumacher, M.A., Tominaga, M., Rosen, T.A., Levine, J.D. and Julius, D., Nature, 389 (1997) 816-824). The effects of capsaicin appear to be selective for a subset of sensory neurones which includes polymodal nociceptors. The present study describes the distribution of VR1 mRNA, together with measurements of capsaicin sensitivity, in sensory nerve ganglia of different embryological origins and a single sympathetic ganglion, the superior cervical ganglion (SCG). In situ hybridisation revealed the expression of VR1 mRNA in small-to-medium-sized neurones of the dorsal root, trigeminal and vagal ganglia. No hybridisation signal was observed in the SCG neurones. This pattern of expression correlated with capsaicin sensitivity measured by whole-cell voltage clamp where, in similar sized cells, over 80% of neurones from dorsal root and vagal ganglia were capsaicin sensitive, but all SCG neurones were insensitive to capsaicin.

The S. cerevisiae CLU1 and D. discoideum cluA genes are functional homologues that influence mitochondrial morphology and distribution

The cluA gene, encoding a novel 150 kDa protein, was recently characterized in Dictyostelium discoideum; disruption of cluA impaired cytokinesis and caused mitochondria to cluster at the cell center. The genome of Saccharomyces cerevisiae contains an open reading frame (CLU1) that encodes a protein that is 27% identical, 50% similar, to this Dictyostelium protein. Deletion of CLU1 from S. cerevisiae did not affect cell viability, growth properties, sporulation efficiency, or frequency of occurrence of cells lacking functional mitochondria. However, in clu1Delta cells the mitochondrial reticulum, which is normally highly branched, was condensed to one side of the cell. Transformation of cluA- Dictyostelium mutants with the yeast CLU1 gene yielded amoebae that divided normally and had dispersed mitochondria. The mitochondria in cluA- Dictyostelium cells complemented with CLU1 were not as widely scattered as in cluA+ Dictyostelium cells, but formed loose clusters throughout the cytoplasm. These results indicate that the products of the CLU1 and cluA genes, in spite of their limited homology, are functional homologues.

Individual patient data meta-analysis in cancer

As in many areas of health care, treatments for cancer may differ only moderately in their effects on major end points, such as death. But, such differences are worth knowing about, particularly in common diseases in which they could represent a substantial benefit to public health. Large-scale randomized evidence allows moderate differences to be investigated reliably, and one way to achieve this is by meta-analyses of updated and centrally collected individual patient data from all relevant trials. This paper illustrates why this form of research can often be important in cancer. It also offers the first list of such projects, as a source of information on current and past research in this area.

Nursing Outcomes Classification implementation projects across the care continuum

The health care environment in which nurses deliver care is experiencing constant change characterized by decreased lengths of stay in acute care settings, increased use of technology, increasing emphasis on computerized patient records and care planning options, increasing markets dominated by managed care, and an emphasis on outcomes rather than process. These changes dictate that nursing as a profession ensures that the work of nursing is visible in this health care environment and included in the data used to make health policy decisions. This article describes the rich history of a Midwestern hospital's use of standardized nursing languages for the last 25 years. Currently this facility is in the process of implementing the Nursing Outcomes Classification (NOC). Four projects are described that illustrate the ways nurses can use this language with diagnoses from the North American Nursing Diagnoses Association (NANDA) and interventions from the Nursing Interventions Classification (NIC).

Oral health status of Canadian-born and immigrant adolescents in North York, Ontario

Studies from a number of countries, including Canada, have demonstrated that the oral health status of immigrants is worse than that of their native-born counterparts and that they make less use of dental services. To date, however, little information is available which documents changes in immigrant oral health following immigration. This paper reports the results of a study conducted in the City of North York, Ontario, that examined the oral health status of Canadian-born and immigrant adolescents aged 13 and 14 years. The former had better oral health than the latter on all parameters assessed and made more use of dental services. Within the immigrant population, there was a significant association between oral health and time since immigration. Those who had been in Canada 6 or more years were significantly healthier than those who had arrived within the preceding 2 years. While changing patterns of immigration may account for part of these differences, the data suggest that access to dental public health programs, delivered to students between the ages of 4 and 14 years, have been effective in improving the oral health of those born outside Canada. Since these programs cease at age 13 or 14 years, barriers to accessing the private dental care sector may mean that the residual inequities and inequalities evident in the data widen as these individuals age.

Interleukin-12 gene therapy prevents establishment of SCC VII squamous cell carcinomas, inhibits tumor growth, and elicits long-term antitumor immunity in syngeneic C3H mice

Interleukin-12 (IL-12) is an immunostimulatory agent with very promising antitumor activity. Using a retroviral expression vector, the authors have successfully transduced the genes encoding the two subunits of murine IL-12 to the squamous cell carcinoma cell line, SCC VII. Once IL-12 gene transcription and protein production were successfully verified, IL-12 expression was found to inhibit the establishment of SCC VII tumors in syngeneic C3H/HeJ mice inoculated with 1 x 10(6) SCC VII/IL-12 viable tumor cells. Mice immunized in this manner and rechallenged with parent SCC VII were capable of rejecting tumor up to 40% of the time. Treatment of established SCC VII tumors with irradiated IL-12-producing tumors cells led to significant tumor regression in a high percentage of animals.

Tapping the television cable

Immediate access to patient data is essential to support good clinical decision making and support. However, away from the surgery, the doctor is currently unable to have any access to the clinical database. Solutions exist to support remote access, such as modems or radio data networks, but these are slow, with typical speeds in the 2-10 kbaud region. We propose a novel solution, to use the TV cable already installed in many homes. Using this technology, a suitably equipped computer (RF modern) is capable of connecting at speeds in excess of 500 kbaud and will run applications in exactly the same way as if connected to a surgery network: the cable TV becomes a LAN, but on a metropolitan scale. Brunel University, in collaboration with the Cable Corporation, has been piloting such a network. Issues include not only levels of service, but also security on the network and access, since the data are being effectively received in every home. However, close scrutiny of channel use can create closed networks reserved for specific users. The technology involves use of an RF modem to transmit data on a reverse channel (based at 16 MHz) on each subnet to a router at the head end of the cable network. This frequency translates the packet and retransmits it to all the subnets on a forward channel (based at 178 MHz). Each channel occupies the bandwidth normally allocated to one TV channel. Access is based on a modified CSMA/CD protocol, so treating the cable network as single multiple access network. The modem comes as a standard card installed in a PC and appears much as an ethernet card, but at reduced speed. With an NDIS driver it is quite able to support almost any network software, and has successfully demonstrated Novell and TCP/IP. We describe the HomeWorker network and the results from a pilot study being undertaken to determine the performance of the system and its impact on working practice.

Caregivers' perceptions following gastrostomy in severely disabled children with feeding problems

Feeding difficulties are common in neurologically impaired children, often leading to great distress and frustration in the child and family. A gastrostomy may be advocated if oral intake is inadequate causing poor weight gain or when there is significant aspiration during feeding, or if feeding is very distressing. To find out if caregivers were happy with the outcome of gastrostomy (with fundoplication, when indicated), a 35-item questionnaire was developed and sent to 38 of them. Twenty-nine replies were received and appeared to be representative of the whole group. Coughing, choking, and vomiting improved in most cases. Weight gain improved in all in whom it had been a problem. In the majority, it became easier to give the children their medications although control of epilepsy was unchanged overall. Time spent feeding the child was reduced and many caregivers had more time to devote to other children and themselves. Only one parent regretted the operation. In children with severe disability and feeding problems, a gastrostomy (with fundoplication if there is significant reflux) can reduce symptoms of vomiting, coughing, and choking, help growth and improve quality of life in the child, when patients are properly selected.

Combating tuberculosis--lessons learnt from a rural community project in the Klein Drakenstein area of the Western Cape

OBJECTIVE

To describe and evaluate a lay worker project designed to enhance the effective control of tuberculosis in a rural/farm setting.

DESIGN

A descriptive cohort study using both qualitative and quantitative research methodology.

SETTING AND PARTICIPANTS

Farming community in the Klein Drakenstein area of Paarl, Western Cape, with health services provided by the Cape Metropolitan Council. The adherence of patients receiving tuberculosis treatment from 1 January 1993 to 31 December 1995 was analysed. The acceptability of the project was assessed using indepth interviews with key stakeholders.

RESULTS

A cohort of 402 tuberculosis patients was included in the study. This cohort was divided into the patients from farms that had participated in the project (intervention group) and those that had not (non-intervention group). The adherence data for children and adults were analysed separately. The adherence rates for children in both groups were the same (RR = 1.00, 95% Cl 0.88-1.14), whereas the adherence rate for the adult intervention group was significantly better than that of the non-intervention group (RR = 1.19, 95% Cl 1.08-1.31). The qualitative component of the investigation indicated a high level of commitment to the intervention from the members of the implementation team, the farm health workers and their employers. The farm health workers described how their role had assisted their communities and had improved their own perceptions of self-efficacy. The close bond that they had developed with the formal health sector had improved the access of the labourers on the farm to primary health care. Although the project had commenced as a tuberculosis initiative, the farm health workers were dealing with a variety of health issues. Their ongoing training was designed to facilitate this development. The formal health sector found their activities facilitated by the easy access that they had with a representative from each farm. The employers were satisfied that the project had increased the cost-effectiveness of their economic endeavours.

CONCLUSION

This farm worker project appears to be a model of a well-designed and expertly managed community-based project for tuberculosis control in rural/farm areas.

The cluA- mutant of Dictyostelium identifies a novel class of proteins required for dispersion of mitochondria

The cluA gene of Dictyostelium discoideum encodes a novel 150-kDa protein. Disruption of cluA results in clustering of mitochondria near the cell center. This is a striking difference from normal cells, whose mitochondria are dispersed uniformly throughout the cytoplasm. The mutant cell populations also exhibit an increased frequency of multinucleated cells, suggesting an impairment in cytokinesis. Both phenotypes are reversed by transformation of cluA- cells with a plasmid carrying a constitutively expressed cluA gene. The predicted sequence of the cluA gene product is homologous to sequences encoded by open reading frames in the genomes of Saccharomyces cerevisiae and Caenorhabditis elegans, but not to any known protein. The only exception is a short region with some homology to the 42-residue imperfect repeats present in the kinesin light chain, which probably function in protein-protein interaction. These studies identify a new class of proteins that appear to be required for the proper distribution of mitochondria.

Comparison of Neoral and Sandimmun cyclosporin A pharmacokinetic profiles in young renal transplant recipients

A major factor influencing whole blood cyclosporin A levels in young children with renal transplants is the variable absorption of Sandimmun (SIM). Neoral (NEO) is a new microemulsion of cyclosporin A (CYA) that has been reported to have better absorption characteristics. We compared the pharmacokinetics of SIM and NEO in nine renal transplant recipients aged less than 11 years (range 4.8-10.9 years) and observed clinical parameters during 6 months of NEO therapy. Median CYA dosage was 149 mg/m2 per day (range 98-226). We observed an increase in the maximum CYA concentration (Cmax) of 114%, an increase in area under the curve (AUC) of 71% and the time to reach Cmax was reduced from 1.75 h to 1.25 h with NEO, while 12-h trough levels (C12 h) did not change significantly. AUC correlated with C12 h for SIM (r2 = 0.833) and NEO (r2 = 0.699) and also C1.5 h for NEO (r2 = 0.775). During 24 weeks' follow-up, the coefficient of variation of CYA levels was lower for NEO (13%) than for SIM (20%). Although CYA dosages at the start and the end of 6 months on NEO were similar, only one patient was maintained on a constant dose. Four patients had acute reversible rises in plasma creatinine which responded to a 11% reduction in NEO dose; their increase in AUC was greater than those patients not showing a rise in plasma creatinine. Overall, median plasma creatinine was unchanged at the end of the study. NEO was well tolerated by the patients; temporary nausea and headache were experienced by three patients and one of them stopped NEO after 20 days. Other biochemical parameters were not significantly different on NEO.

Fetal grafting for Parkinson's disease: expression of immune markers in two patients with functional fetal nigral implants

In a number of centers throughout the world, fetal nigral transplantation is being performed for the treatment of Parkinson's disease (PD). Clinical results have been inconsistent. One parameter that differs among transplant studies is the degree and manner by which patients are immunosuppressed following transplantation. Indeed, the role of the immune system following fetal grafting in humans is not well understood. Recently, two patients from our open label trial that received fetal nigral implants have come to autopsy. These patients were immunosuppressed with cyclosporin for 6 mo posttransplantation and survived for a total of 18 mo postgrafting. Robust survival of grafted dopamine-containing cells was observed in both cases. Immunostaining for HLA-DR revealed a dense collection of cells within grafts from both cases. HLA-DR staining was rarely observed within the host including nongrafted regions of the striatum. A more detailed analysis of immune markers was performed in Case 2. Numerous pan macrophages, T-cells, and B-cells were observed within graft sites located in the postcommissural putamen. In contrast, staining for these immune cells was not observed within the ungrafted anterior putamen. These findings suggest that even in healthy appearing functional nigral implants, grafts are invaded by host immune cells that could compromise their long-term viability and function. Alternatively, immune cells are known to secrete trophic factors, which may ultimately favor graft survival and function. Further work is needed to understand the role of the immune system in fetal grafting.

For debate. Local government and the National Health Service: the new agenda

There are some interesting paradoxes in the relationship between local government and the National Health Service (NHS). Local government is responsible for a range of major services, many of which relate to health broadly defined. The NHS provides many services which are often popularly thought to be part of local government (and, indeed, in many countries are). Local government prides itself on its 'localness'; the NHS, with its services delivered in a very local fashion for the most part, cannot quite decide whether it is a national service or a local one. Yet these two major agencies of governance and public service provision often seem unable to work very well together. In the interests of good government, both agencies need to work together where their interests coincide or abut one another. Differences of perspective, priority, culture and style need to be recognized but resolved. Opportunities for joint working need to be grasped and the experience built on. The paper looks at a series of issues and opportunities which bring local government and the NHS together. They create an incentive to improve working relationships; at the same time they suggest an agenda of future possibilities.