The effects of swaddling on oxygen saturation and respiratory rate of healthy infants in Mongolia

BACKGROUND

Infant swaddling is common practice in some developing countries where infant respiratory morbidity is also prevalent. Little is known about the effect of swaddling on respiratory variables in healthy infants. Such information could have important implications for respiratory diseases.

AIMS

To compare respiratory rates (RR) and arterial oxygen saturations (SaO2) of healthy swaddled infants and non-swaddled infants during different conditions of sleep and arousal.

SETTING

Community based, nested case control study in Ulaanbaatar, Mongolia.

SUBJECTS AND METHODS

Habitually swaddled and non-swaddled infants aged 9-10 weeks taking part in a randomised controlled trial of swaddling. Respiratory rate and SaO2 were measured during quiet wakefulness, feeding, quiet and active sleep. Habitually swaddled infants were studied in swaddled and non-swaddled conditions. Habitually non-swaddled infants were studied only in the non-swaddled state.

RESULTS

SaO2 was higher during awake states compared with sleep states in all groups of infants. Habitually swaddled infants had lower mean SaO2 in the swaddled compared with non-swaddled condition (96.5% vs. 96.9%, p < 0.01) but these were not significantly different from the mean SaO2 of non-swaddled infants (96.9%, minimum p = 0.22). Habitually swaddled infants in the swaddled and non-swaddled states had similar respiratory rates, but these were, in both cases, significantly lower than in habitually non-swaddled infants.

CONCLUSION

Swaddling has little or no clinical effect on SaO2 or respiratory rates in healthy 9-10-week-old infants in Mongolia.

Welfare rights services for people disabled with arthritis integrated in primary care and hospital settings: set-up costs and monetary benefits

OBJECTIVE

To quantify the set-up costs and monetary benefits of a welfare rights service integrated within an NHS service provider, that selects eligible patients using the Health Assessment Questionnaire (HAQ) and offers welfare rights advice to assist in application for Disability Living Allowance and Attendance Allowance.

METHOD

(1) DESIGN: a cost evaluation of a social intervention, screening with the HAQ and welfare rights advice in primary care and hospital settings. (2) SETTING: Eight general practices and four hospital rheumatology out-patient departments were selected from four localities in the southwest of England. (3) PARTICIPANTS: Two hundred and sixty-eight eligible patients with arthritis accepted an interview with a welfare rights officer (WRO) from a sample of 1989 service users identified from GPs' records and hospital out-patient lists. Two hundred and forty two service users expressed an interest in take up of the social intervention. (4) Service users with a HAQ score >/=1.5 were contacted by telephone and offered an appointment with an experienced WRO to help them complete a welfare benefit application form. A 'micro-costing' study was undertaken with assessment of monetary benefits received.

RESULTS

The indicative set-up costs of similar welfare rights services are pound 8125 in a GP setting and pound 9307 per annum in a hospital setting at 2002 prices. Total annual unclaimed Disability Living Allowance/Attendance Allowance granted to successful claimants was pound 184,382 in the GP setting (n = 84 from 137) and pound 169,309 in the hospital setting (n = 79 from 131).

CONCLUSIONS

Welfare rights advice received during a visit to a GP practice or a hospital out-patient department can substantially reduce the level of unclaimed benefit in arthritic populations including the elderly; with mobility and care difficulties. A welfare rights service integrated within a GP practice or hospital that screens people with arthritis using HAQ scores and encourages those with scores >/=1.5 to see a WRO for help with welfare benefit confers monetary benefits for service users that substantially outweigh set-up costs.

Using the Health Assessment Questionnaire and welfare benefits advice to help people disabled through arthritis to access financial support

OBJECTIVES

To test, in a variety of health settings, the ability of the Health Assessment Questionnaire (HAQ) disability index to predict the eligibility of patients with moderate or severe arthritis for disability living allowance or attendance allowance.

METHODS

The study included patients from 20 general practices and four hospital out-patient departments across four areas in the southwest of England. Adults with an established diagnosis of rheumatoid arthritis, or osteoarthritis of the hip or knee, and who were not in receipt of Disability Living Allowance (DLA) or Attendance Allowance (AA) were sent an HAQ. Those who scored 1.5 or more were offered an appointment with a welfare advice worker at which they completed an application for DLA or AA. After 3 months they were contacted by the advice worker and asked about the outcome of their applications.

RESULTS

Over half of those who completed an HAQ scored 1.5 or over (moderate to severe disability as measured by the HAQ) and were offered advice from experienced welfare benefits advisors. Of these, 87% applied for DLA or AA. Sixty-nine per cent of the applicants were successful. Those scoring 1.75 and over were more likely to be awarded benefit (73% success CLs 67, 79) than people scoring between 1.5 and 1.625 where 55% (CLs 41,69) of applicants were successful.

CONCLUSION

The HAQ was shown to be a good predictor of eligibility for AA or DLA. It can be used, in a variety of health settings, to indicate patients who, with help from an experienced advisor, are likely to gain increased financial help.

Clinical and psychological outcome from a randomized controlled trial of patient-initiated direct-access hospital follow-up for rheumatoid arthritis extended to 4 years

BACKGROUND

Patients with rheumatoid arthritis (RA) are traditionally seen regularly as out-patients, irrespective of whether it is appropriate or timely to see them. A randomized controlled trial has shown that over 2 yr, seeing patients only when they or their general practitioner (GP) request a review saves time and resources and is more convenient. This study aimed to assess clinical and psychological outcomes when the trial was extended to 4 yr.

METHOD

A total of 209 patients were randomized into either 'routine review' (control) or 'no routine follow-up' but access to rapid review on request (direct access). Clinical and psychological status and patient satisfaction and confidence were reviewed after 24 and 48 months.

RESULTS

Mean age at entry was 56 yr and mean disease duration 11 yr, and 134 patients remained in the study after 48 months. There were no differences between the groups, nor between those who completed the study and those who did not. There were no major differences in clinical or psychological status between the groups at 24 or 48 months. However, self-efficacy for function was stronger at 48 months for direct access patients (mean 64.0 vs 52.0, P=0.005), as was self-efficacy for other symptoms (mean 67.8 vs 59.3, P=0.009). Satisfaction at 48 months was increased in direct access compared with control (mean 8.7 vs 7.6, P=0.01) as was confidence in the system (8.9 vs 7.6, P<0.01).

CONCLUSION

It is effective for patients with rheumatoid arthritis to have no regular follow-up, provided they have access to rapid review when they or their GP request it. Patients using a self-referral system of care had higher self-efficacy and greater satisfaction and confidence than those using the traditional system.

A comparison between the distinct inward currents activated in rat cultured dorsal root ganglion neurones by intracellular flash photolysis of two forms of caged cyclic guanosine monophosphate

Whole cell inward currents activated by intracellular photorelease of cyclic guanosine monophosphate (cGMP) were investigated in cultured dorsal root ganglion (DRG) neurones. The actions of two distinct types of caged cGMP (NPE-caged cGMP and a highly water-soluble caged cGMP) were compared. Rapidly activating inward currents were evoked by cGMP in a subpopulation (12.5%) of neurones and these currents may be due to activity of cyclic nucleotide-gated channels. In contrast in 52% of DRG neurones intracellular photorelease of cGMP activated a delayed Ca(2+)-dependent inward current through the generation of cyclic ADPribose and mobilisation of Ca(2+) from ryanodine sensitive intracellular stores. Similar delayed inward currents were activated by both caged compounds but only NPE-caged cGMP evoked rapidly activating currents. Cyclic GMP appears to increase excitability in some DRG neurones by diverse mechanisms.

An evaluation of the First Parent Health Visitor Scheme

AIMS

To assess outcomes in families who received the First Parent Health Visitor Scheme (FPHVS), in comparison with families who received conventional ("generic") health visiting.

METHODS

Retrospective data on 2113 families were collected during 1986-92 as part of National Health Service (NHS) service provision. Prospective data were collected during 1993-98 on 459 mothers and their children, with outcomes assessed at one year (93% follow up) and two years (80% follow up).

RESULTS

There were no differences between the groups of mothers in self esteem, locus of control, or depression rates. The women who received the FPHVS were more likely to have changed partners, but they also had a wider support network than comparison women, and consulted their general practitioner (GP) less often. Breast feeding rates were higher in the FPHVS mothers, who also gave their infants more fruit juice drinks than the comparison group. No differences were apparent in developmental outcome using the Bayley Scales at 1 and 2 years of age. Both height and weight Z scores at 2 years of age were lower in the FPHVS children than the comparison children. Receipt of the FPHVS was associated with increased use of electric socket covers and lower accident rates in the second year of life. No differences were seen in immunisation rates, uptake of child health surveillance, or use of hospital services. A higher proportion of families who received the FPHVS were registered on the local child protection register compared with comparison families.

CONCLUSION

Clustering effects dominated the analysis, but overall this evaluation could not show a clear advantage for the FPHVS over conventional health visiting.

TNF-alpha receptors simultaneously activate Ca2+ mobilisation and stress kinases in cultured sensory neurones

The cytokine tumour necrosis factor-alpha (TNF) has been implicated in autoimmune diseases and may play an indirect role in activation of pain pathways. In this study we have investigated the possibility that TNF directly activates cultured neonatal rat dorsal root ganglion (DRG) neurones and provides a signalling pathway from cells in the immune system such as macrophages to sensory neurones. Expression of TNF receptor subtypes (TNFR1 and TNFR2) on sensory neurones was identified using immunohistochemistry, fluorescence-activated cell sorting analysis and RT-PCR. Biochemical and immunocytochemical analysis showed that TNF activated p38 mitogen-activated protein kinase (p38MAPK) and c-Jun N-terminal kinase (JNK) but not p42/p44 MAPK. TNF treatment evoked transient Ca2+-dependent inward currents in 70% of DRG neurones. These TNF-evoked currents were significantly attenuated by ryanodine or thapsigargin or by inclusion of BAPTA in the patch pipette solution. Responses were also evoked in subpopulations of cultured DRG neurones by human mutant TNFs that cross-reacted with rat receptors and selectively activated TNFR1 or TNFR2 subtypes. TNF-evoked transient increases in [Ca2+]i were also detected in 34% of fura-2-loaded DRG neurones. The link between TNF receptor activation and Ca2+ release from stores remains to be elucidated. However, responses to TNF were mimicked by sphingolipids, including sphingosine-1-phosphate, which evoked a transient rises in [Ca2+]i in a pertussis toxin-insensitive manner in fura-2-loaded DRG neurones. We conclude that distinct receptors TNFR1 and TNFR2 are expressed on cultured DRG neurones and that they are functionally linked to intracellular Ca2+ mobilisation, a response that may involve sphingolipid signalling.

Comparison of UK paediatric cardiac surgical performance by analysis of routinely collected data 1984-96: was Bristol an outlier?

BACKGROUND

Reports of high mortality after paediatric cardiac surgery at the Bristol Royal Infirmary, UK, led to the establishment of an independent public inquiry. A key question was whether or not the mortality statistics in Bristol were unusual compared with other specialist centres. To answer this question, we did a retrospective analysis of mortality in the UK using two datasets.

METHODS

Data from the UK Cardiac Surgical Register (CSR; January, 1984, to March, 1996) and Hospital Episode Statistics (HES; April, 1991, to December, 1995) were obtained for all 12 major centres in which paediatric cardiac surgery is done in the UK. The main outcome measure was mortality within 30 days of a cardiac surgical procedure. We estimated excess deaths in Bristol using a random-effects model derived from the remaining 11 centres. Additionally, a sensitivity analysis was done and case-mix examined.

FINDINGS

For children younger than 1 year, in open operations, the mortality rate in Bristol was around double that of the other centres during 1991-95: within the CSR, there were 19.0 excess deaths (95% interval 2-32) among 43 deaths; and in HES, there were 24.1 excess deaths (12-34) among 41 deaths recorded. There was no strong evidence for excess mortality in Bristol for closed operations or for open operations in children older than 1 year.

INTERPRETATION

Our results suggest that Bristol was an outlier, and we do not believe that statistical variation, systematic bias in data collection, case-mix, or data quality can explain a divergence in performance of this size.

Diagnosis of tuberculosis based on the two specific antigens ESAT-6 and CFP10

Tests based on tuberculin purified protein derivative (PPD) cannot distinguish between tuberculosis infection, Mycobacterium bovis BCG vaccination, or exposure to environmental mycobacteria. The present study investigated the diagnostic potential of two Mycobacterium tuberculosis-specific antigens (ESAT-6 and CFP10) in experimental animals as well as during natural infection in humans and cattle. Both antigens were frequently recognized in vivo and in vitro based on the induction of delayed-type hypersensitivity responses and the ability to induce gamma interferon production by lymphocytes, respectively. The combination of ESAT-6 and CFP10 was found to be highly sensitive and specific for both in vivo and in vitro diagnosis. In humans, the combination had a high sensitivity (73%) and a much higher specificity (93%) than PPD (7%).

Mobilisation of intracellular Ca2+ by mGluR5 metabotropic glutamate receptor activation in neonatal rat cultured dorsal root ganglia neurones

The ability of metabotropic glutamate receptor activation to mobilise intracellular calcium was investigated in cultured dorsal root ganglion (DRG) neurones from neonatal rats using the calcium sensitive fluorescent dye Fura-2. L-glutamate (10 microM) caused sustained and oscillatory increases in intracellular calcium concentration ([Ca2+]i) in a subpopulation of cultured DRG neurones. The oscillatory responses were not blocked by combined application of the ionotropic glutamate receptor antagonists MK 801 (2 microM) and CNQX (20 microM). Oscillations in [Ca2+]i were also observed following application of the nonselective metabotropic glutamate receptor (mGluR) agonist, trans-(1S,3R)-1-aminocyclopentane-1S, 3R-dicarboxylic acid (1S,3R)-ACPD, 20 microM) and the mGluR5 agonist (RS)-2-chloro-5-hydroxyphenylglycine (CHPG, 500 microM). These responses were blocked by the selective Group I mGluR antagonist (RS)-1-aminoindan-1,5-dicarboxylic acid (AIDA) (100 microM) and Ca2+ release channel inhibitors ryanodine (100 microM) and dantrolene (10 microM). The predominantly Group II agonist (2S,2'R,3'R)-2-(2'3'-dicarboxy-cyclopropyl)glycine (DCG-IV, 100 microM) failed to produce Ca2+ transients alone but suppressed responses to CHPG. Reverse transcriptase PCR techniques, using primers specific to Group I mGluRs, revealed the presence of mGluR5 but not mGluR1 mRNA in these cells. Therefore, glutamate can cause a slowly activating and reversible mobilisation of [Ca2+]i in sensory neurones by activation of ionotropic receptors, and can induce oscillatory calcium transients by selectively activating metabotropic glutamate receptors that are likely to be of the mGluR5 subtype.

Metabotropic glutamate receptor activation and intracellular cyclic ADP-ribose release Ca2+ from the same store in cultured DRG neurones

The whole cell patch clamp technique has been used to record Ca(2+)-activated cation and chloride conductances evoked by release of Ca2+ from intracellular stores of cultured neonatal dorsal root ganglion neurones. The aim of this study was to investigate metabotropic glutamate receptor (mGluR) mechanisms and evaluate a possible role for cyclic ADP-ribose as an intracellular signalling molecule. Glutamate and the metabotropic glutamate receptor agonist (1S, 3R)-ACPD-evoked transient depolarizations, Ca(2+)-activated inward currents and rises in intracellular Ca2+. The (1S, 3R)-ACPD-activated currents were insensitive to InsP3 signalling inhibitors, heparin and pentosan polysulphate. Intracellular application of ryanodine alone activated currents in this study and proved a difficult tool to use as a potential inhibitor of cyclic ADP-ribose-mediated responses. However, intracellular dantrolene did attenuate both (1S, 3R)-ACPD and cyclic ADP-ribose responses. Intracellular photo-release of cGMP and cyclic ADP-ribose mimicked the responses to mGluR receptor activation. Intracellular application of nicotinamide and W7 inhibited the responses to photo-released cGMP but did not prevent responses to mGluR activation. The cyclic ADP-ribose receptor antagonist 8-amino cyclic ADP-ribose attenuated responses to (1S, 3R)-ACPD, cGMP and cyclic ADP-ribose, but some Ca(2+)-activated inward currents were still observed in the presence of this antagonist. In conclusion, mGluR receptor activation, cGMP and cyclic ADP-ribose release Ca2+ from intracellular stores. Some evidence suggests that pharmacologically related pathways are involved.

Topical antibiotics in neurosurgery: a re-evaluation of the Malis technique

We report the effect on the neurosurgical wound infection rate of a modification of the 'Malis' technique of antibiotic prophylaxis. In this a combination of antibiotics is given in the form of both parenteral administration and wound irrigation. A series of 1173 clean neurosurgical operations was compared with a historical control of 303 operations. Both treatment and control groups were operated on by the same surgeon, using similar surgical techniques. The control group received parenteral pre- and postoperative antibiotics (flucloxacillin and ampicillin). The treatment group (where the parenteral antibiotics used was cephradine) also received wound irrigation with a solution of gentamicin and flucloxacilin. The infection rate was 0.42% in the treatment group (five patients), in the control group it was 3.96% (12 patients). The difference was highly significant (p = 0.00006). We believe that the use of wound irrigation with antibiotics should receive further study.

Acute fatigue in chronic fatigue syndrome patients

BACKGROUND

Chronic fatigue syndrome (CFS) patients often complain that they are more susceptible to acute mental fatigue. It is important to determine whether this is observed using objective tests of sustained attention and responding.

METHODS

Sixty-seven patients who fulfilled the criteria for CFS proposed by Sharpe et al. (1991) were compared with 126 matched healthy controls. Acute fatigue was assessed by comparing performance at the start and end of a lengthy test session and by examining changes over the course of individual tasks.

RESULTS

CFS patients showed impaired performance compared to the controls and these differences increased as the volunteers developed acute fatigue. In addition, differences between the two groups were larger at the end of the test session.

CONCLUSIONS

The present results show that CFS patients are more susceptible to acute fatigue than healthy controls. This could reflect motor fatigue or an inability to compensate for fatigue with increased effort. This profile is consistent with previous research on fatigue and suggests that interpretation of certain aspects of CFS may be helped by considering it as the end point of a continuum of fatigue rather than a distinct disease.