Differential matrix metalloproteinase expression in cases of multiple sclerosis and stroke

Multiple sclerosis (MS) and stroke pathology are characterized blood-brain barrier breakdown, leucocyte emigration, and tissue destruction. Each process is thought to involve the matrix metalloproteinases (MMP), but little is known of their expression. We undertook to investigate whether MMP expression is dependent on the nature of the CNS lesion and whether expression would coincide with the histopathology. MS or cerebral-infarct tissue was examined for the presence of gelatinase-A, gelatinase-B, matrilysin and stromelysin-1. Gelatinases A and B and matrilysin expression was found to be up-regulated in microglia/macrophages within acute MS lesions. In active-chronic MS lesions, matrilysin and gelatinase-A expression was pronounced in the active borders. In chronic MS lesions, the expression of matrilysin was confined to macrophages within perivascular cuffs. The pattern of MMP expression in infarct lesions differed considerably. Gelatinase-B was strongly expressed by neutrophils in tissue from patients up to 1 week after an infarct, whereas gelatinase-A and matrilysin staining was much less marked. From 1 week to 5 years, neutrophils were absent and the large number of macrophages present were expressing matrilysin and gelatinase A. Only a low level of gelatinase-A and matrilysin expression was observed in normal brain controls. Thus, MMPs are expressed in inflammatory lesions in the CNS, but their individual expression is dependent on the nature and chronicity of the lesion. However, the general pattern of expression, in perivascular cuffs and in active lesions, supports a role for these enzymes as mediators of blood-brain barrier breakdown and tissue destruction, both in MS and in cerebral ischaemia.

Patients' views of nurse prescribing

In 1994 the law was changed to allow nurses to prescribe from a limited formulary. The Department of Health commissioned research to evaluate nurse prescribing in eight pilot sites in England. This article presents part of this research. In particular, it examines how patients perceived the role of nurses and health visitors as prescribers. The study involved interviewing patients seen by community nurses before and after the introduction of nurse prescribing. The advantages patients identified coincided with the anticipated benefits, while the disadvantages that had been anticipated before the study were not confirmed. Patients were positive about nurses as prescribers and in some instances preferred nurses to doctors.

Axonal damage in acute multiple sclerosis lesions

One of the histological hallmarks of early multiple sclerosis lesions is primary demyelination, with myelin destruction and relative sparing of axons. On the other hand, it is widely accepted that axonal loss occurs in, and is responsible for, the permanent disability characterizing the later chronic progressive stage of the disease. In this study, we have used an antibody against amyloid precursor protein, known to be a sensitive marker of axonal damage in a number of other contexts, in immunocytochemical experiments on paraffin embedded multiple sclerosis lesions of varying ages in order to see at which stage of the disease axonal damage, in addition to demyelination, occurs and may thus contribute to the development of disability in patients. The results show the expression of amyloid precursor protein in damaged axons within acute multiple sclerosis lesions, and in the active borders of less acute lesions. This observation may have implications for the design and timing of therapeutic intervention, one of the most important aims of which must be the reduction of permanent disability.

Nurses' and GPs' views of the nurse prescribers' formulary

This article presents the findings from the evaluation of nurse prescribing, undertaken in eight demonstration sites since October 1994. The authors examine in particular the nurses' prescribing behaviour and the type of items nurses and GPs would like to see added to the formulary. The opportunities for prescribing and the limitations of the formulary for health visitors and practice nurses are highlighted.

Analysis of hospitalization rates by electoral ward: relationship to accessibility and deprivation data

The objective of this paper is to investigate the relevance of access to hospital services in explaining utilization rates at a District Health Authority level in the UK. In order to test the hypothesis that access is important, it is necessary to develop a means of scoring access factors and then combining these scores with other more recognized influences on hospitalization rates e.g. deprivation measures. Acknowledging that hospitalization rates are not merely products of a population's socio-economic characteristics, the effect of accessibility to hospital services for the resident population is investigated through the derivation of an access score using both private and public transport from electoral ward of residence. Deprivation and accessibility to services were both found to be significant factors in determining hospitalization rates at electoral ward level. The chosen supply variable--number of GPs--was not found to be significant in any of the models developed using linear regression techniques. To conclude, it appears that access plays an important role in determining hospitalization rates within a given population. If high hospitalization rates are accepted as an indicator of effectively met demand then policy makers may have to consider increasing the accessibility of hospital services.

Seven-year follow-up of speech/language impaired and control children: psychiatric outcome

This study examined the 7-year psychiatric outcome of 202 speech/language (S/L) impaired and control children selected from a community sample at age 5 years. Children with S/L at age 5 years were more likely to be psychiatric cases at age 12.5 years than were normal controls, even if their S/L improved. Controlling for concurrent psychiatric disorder, S/L impairment at age 5 years was still associated with an increased rate of psychiatric disorder at 12.5 years. Psychiatric disorder at age 12.5 years was more likely to co-occur with language disorder than with speech disorder.

Expenditure on physicians' services in Canada: was Medicare a structural change?

This paper uses cointegration analysis to investigate the question of whether the introduction of national health insurance for physicians' services (Medicare) in the late 1960s caused a structural change in the relation driving national expenditure on physicians' services in Canada. The results support the existence of a single cointegration equation applying to both the Medicare and pre-Medicare periods. Structural change tests do not support the presence of a fundamental structural change associated with the introduction of Medicare.

X-linked anhidrotic (hypohidrotic) ectodermal dysplasia is caused by mutation in a novel transmembrane protein

Ectodermal dysplasias comprise over 150 syndromes of unknown pathogenesis. X-linked anhidrotic ectodermal dysplasia (EDA) is characterized by abnormal hair, teeth and sweat glands. We now describe the positional cloning of the gene mutated in EDA. Two exons, separated by a 200-kilobase intron, encode a predicted 135-residue transmembrane protein. The gene is disrupted in six patients with X;autosome translocations or submicroscopic deletions; nine patients had point mutations. The gene is expressed in keratinocytes, hair follicles, and sweat glands, and in other adult and fetal tissues. The predicted EDA protein may belong to a novel class with a role in epithelial-mesenchymal signalling.

A study of the quality of life and cost-utility of renal transplantation

The objective of this study was to assess the cost-utility of renal transplantation compared with dialysis. To accomplish this, a prospective cohort of pre-transplant patients were followed for up to two years after renal transplantation at three University-based Canadian hospitals. A total of 168 patients were followed for an average of 19.5 months after transplantation. Health-related quality of life was assessed using a hemodialysis questionnaire, a transplant questionnaire, the Sickness Impact Profile, and the Time Trade-Off Technique. Fully allocated costs were determined by prospectively recording resource use in all patients. A societal perspective was taken. By six months after transplantation, the mean health-related quality of life scores of almost all measures had improved compared to pre-transplantation, and they stayed improved throughout the two years of follow up. The mean time trade-off score was 0.57 pre-transplant and 0.70 two years after transplantation. The proportion of individuals employed increased from 30% before transplantation to 45% two years after transplantation. Employment prior to transplantation [relative risk (RR) = 23], graft function (RR 10) and age (RR 1.6 for every decrease in age by one decade), independently predicted employment status after transplantation. The cost of pre-transplant care ($66,782 Can 1994) and the cost of the first year after transplantation ($66,290) were similar. Transplantation was considerably less expensive during the second year after transplantation ($27,875). Over the two years, transplantation was both more effective and less costly than dialysis. This was true for all subgroups of patients examined, including patients older than 60 and diabetics. We conclude that renal transplantation was more effective and less costly than dialysis in all subgroups of patients examined.

The Nottingham Study of Neurotic Disorder: influence of cognitive therapists on outcome

BACKGROUND

In previously published papers from the Nottingham Study of Neurotic Disorder a short treatment package of cognitive-behaviour therapy was no more effective than placebo drug treatment after 10 weeks' assessment in a cohort of 210 patients with neurotic disorders. This paper examines the outcome over two years of the patients treated by cognitive-behaviour therapy separated into two therapist groups, those who were competent in administering treatment and those of uncertain competence.

METHOD

The therapists (mainly community psychiatric nurses) of 70 patients with an original DSM-III diagnosis of either dysthymic, panic or generalised anxiety disorder were separated into two groups on the basis of their perceived competence by their supervisor (DK). Ratings of psychopathology were made at regular intervals over two years by assessors blind to knowledge of treatment or therapist.

RESULTS

The patients treated by competent therapists (n = 30) generally showed greater improvement than those allocated to therapists of uncertain competence (n = 40), mainly with respect to depressive symptoms, and the difference persisted over two years, long after the cognitive-behaviour therapy had been completed.

CONCLUSIONS

Cognitive-behaviour therapy given by competent therapists over a 10 week period is of lasting benefit in neurotic disorder.

A controlled trial of dothiepin and placebo in treating benzodiazepine withdrawal symptoms

BACKGROUND

The possibility that treatment with tricyclic antidepressants, in the form of dothiepin, might attenuate benzodiazepine withdrawal symptoms was investigated in a double-blind trial.

METHOD

Eighty-seven non-depressed psychiatric out-patients with putative normal dose benzodiazepine dependence had their benzodiazepines reduced in stepwise amounts of 20% of the original dose for eight weeks. The patients were randomised to receive dothiepin (with dosage increasing to 150 mg/day) or placebo as an aid to withdrawal before benzodiazepine reduction and these drugs were taken for four further weeks before being stopped.

RESULTS

Fewer patients entered and completed the study than expected and a Type II error was possible in the results. Although there was some evidence of withdrawal symptoms being less marked in those patients allocated to dothiepin this was independent of any antidepressant effect as depression scores were lower in the placebo group in the early phase of withdrawal (P < 0.01). Of those completing the study, greater satisfaction (P = 0.03) was recorded by those who had received dothiepin; no other differences reached statistical significance.

CONCLUSIONS

Dothiepin (and by implication other tricyclic antidepressants) might have some value in reducing benzodiazepine withdrawal symptoms but does not aid drug withdrawal.

Transaction costs, externalities and information technology in health care

This paper discusses some of the economic issues which underpin the rationale for investment in information and communications technologies (ICTs). Information imperfections lead to significant transaction costs (search, negotiating and monitoring) which in turn confer a negative externality on parties involved in exchange. This divergence in private and social costs leads to a degree of resource misallocation (efficiency loss) which, uncorrected, results in a sub-optimal outcome. Traditional solutions to this problem are to rely upon direct government action to reduce the costs of transacting between market agents, or to employ tax/subsidy measures and other legislative action to achieve the desired market outcome. Three key policy questions are raised in the context of the NHS purchaser/provider relationship. Firstly, what is the optimum level of transaction costs; secondly, can ICTs assist in lowering the level of transaction costs to the optimum level; thirdly, who should bear the investment cost in reducing the level of transaction costs? The issue of property rights in different information systems is discussed and raises interesting policy questions about how much investment should be undertaken centrally rather than devolved to a more local level. In some ways this economic framework offers a post hoc justification of why different ICT systems have been introduced at various levels of the NHS. Essentially this reduces to the problem of externalities: providing good information confers a positive externality: not providing relevant, timely and accurate information confers a negative externality, by increasing further the level of transaction costs. The crucial role which ICT systems can play lies in attempting to reduce the level of transaction costs and driving the market towards what Dahlman has described as the transaction-cost-constrained equilibrium.

Mutation of RGA1, which encodes a putative GTPase-activating protein for the polarity-establishment protein Cdc42p, activates the pheromone-response pathway in the yeast Saccharomyces cerevisiae

We have selected yeast mutants that exhibit a constitutively active pheromone-response pathway in the absence of the beta subunit of the trimeric G protein. Genetic analysis of one such mutant revealed that it contained recessive mutations in two distinct genes, both of which contributed to the constitutive phenotype. One mutation identifies the RGA1 locus (Rho GTPase activating protein), which encodes a protein with homology to GAP domains and to LIM domains. Deletion of RGA1 is sufficient to activate the pathway in strains lacking the G beta subunit. Moreover, in wild-type strains, deletion of RGA1 increases signaling in the pheromone pathway, whereas over-expression of RGA1 dampens signaling, demonstrating that Rga1p functions as a negative regulator of the pheromone response pathway. The second mutation present in the original mutant proved to be an allele of a known gene, PBS2, which encodes a putative protein kinase that functions in the high osmolarity stress pathway. The pbs2 mutation enhanced the rga1 mutant phenotype, but by itself did not activate the pheromone pathway. Genetic and two-hybrid analyses indicate that an important target of Rga1p is Cdc42p, a p21 GTPase required for polarity establishment and bud emergence. This finding coupled with recent experiments with mammalian and yeast cells indicating that Cdc42p can interact with and activate Ste20p, a protein kinase that operates in the pheromone pathway, leads us to suggest that Rga1p controls the activity of Cdc42p, which in turn controls the magnitude of signaling in the pheromone pathway via Ste20p.

A model of mixed-market healthcare delivery: the British Columbia Transplant Society

Driven by the twin imperatives of cost and quality, healthcare providers must innovate and adapt new management models which continuously improve performance. Focusing specifically on the British Columbia Transplant Society (BCTS), this article describes a successful mixed-market management model for delivering healthcare services to a relatively well-defined patient population which is suffering from chronic disease and has predictable healthcare needs. The BCTS is an example of a healthcare organization which combines the best aspects of both the Canadian and American healthcare systems.