Accessing the online evidence: a guide to key sources of research information on clinical and cost effectiveness

Advice on how to access the best available online sources of research evidence on clinical and cost effectiveness published in three recent issues of Effectiveness Matters is reviewed.

Pharmacological properties of l-glutamate receptors associated with the crayfish hindgut

Pharmacological agents were used to characterize glutamate receptors associated with crayfish hindgut. l-Glutamate reliably increased tonus in isolated hindguts of Procambarus clarkii and suppressed spontaneous hindgut contractions at concentrations of 10 micromol l(-1) or higher. Quisqualate and ibotenate mimicked the effects of L-glutamate. Experiments with strips and rings of hindgut tissue indicate that glutamate acts on both circular and longitudinal muscles. Hindgut contractions were not affected by (+/-)-alpha-amino-3-hydroxy-5-methyl-isoxazole-4-propionoic acid, N-methyl- d-aspartate, domoate or the metabotropic glutamate receptor agonist, (1S,3R)-1-amino-1-carboxycyclopentane-3-acetic acid. Picrotoxin, at 50 micromol l(-1), did not alter the ibotenate-induced reduction in contraction frequency, suggesting that this effect is not produced by inhibitory glutamate receptors. The glutamate-induced increase in tonus was antagonized by Joro spider toxin, JSTX-3. Thus, glutamate receptors associated with crayfish hindgut muscles are of the quisqualate type but are also sensitive to ibotenate. Elevating extracellular potassium concentration mimicked all of the effects of glutamate, suggesting that excessive depolarization may contribute to the suppression of contractions at high agonist concentrations.

Interventions for the treatment and management of chronic fatigue syndrome/myalgic encephalomyelitis



 The research evidence on the effectiveness of interventions for the treatment and management of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) published in a recent issue of Effective Health Care is reviewed.

Centrally administered corticotropin-releasing hormone and peripheral injections of strychnine hydrochloride potentiate the acoustic startle response in preweanling rats

Attempts to condition fear potentiation of startle (FPS) in rats younger than 23 days of age have not been successful, regardless of the type of aversively conditioned stimulus used (P. S. Hunt, R. Richardson, & B. A. Campbell, 1994; R. Richardson, G. Paxinos, & J. Lee, 2000; R. Richardson & A. Vishney, 2000). In the present study, the authors report that peripheral injections of strychnine hydrochloride, a glycine receptor antagonist, and intracerebroventricular infusions of corticotropin releasing hormone (CRH) both potentiated the acoustic startle response (ASR) in 16-18-day-old rats. Because strychnine and CRH have distinct sites of activation in the primary startle pathway, it can be concluded that this pathway is functional and modifiable in rats younger than 23 days of age. This finding suggests that the failure to observe conditioned FPS in preweanling rats is due to an immaturity of the secondary fear circuit responsible for enhancing the ASR during a fear state.

Centrally administered corticotropin-releasing hormone and peripheral injections of strychnine hydrochloride potentiate the acoustic startle response in preweanling rats

Attempts to condition fear potentiation of startle (FPS) in rats younger than 23 days of age have not been successful, regardless of the type of aversively conditioned stimulus used (P. S. Hunt, R. Richardson, & B. A. Campbell, 1994; R. Richardson, G. Paxinos, & J. Lee, 2000; R. Richardson & A. Vishney, 2000). In the present study, the authors report that peripheral injections of strychnine hydrochloride, a glycine receptor antagonist, and intracerebroventricular infusions of corticotropin releasing hormone (CRH) both potentiated the acoustic startle response (ASR) in 16-18-day-old rats. Because strychnine and CRH have distinct sites of activation in the primary startle pathway, it can be concluded that this pathway is functional and modifiable in rats younger than 23 days of age. This finding suggests that the failure to observe conditioned FPS in preweanling rats is due to an immaturity of the secondary fear circuit responsible for enhancing the ASR during a fear state.

The profile of substance-using pregnant mothers and their newborns at a regional rural hospital in New South Wales

We conducted an audit study of identified substance-using mothers and their neonates at Lismore Base Hospital in the Northern Rivers region of New South Wales between January 1995 and December 1999. Women using marijuana and/or alcohol only were excluded. The average number of total births during the study period was 1,363 per year. Forty-nine mothers were identified as substance users with an incidence of seven per 1,000 total births. Twenty-three (47%) were methadone users, 14 (29%) methadone and intravenous heroin users, 11 (22%) heroin users, and one (2%) used amphetamines. Twenty-seven (55%) had irregular antenatal visits. Forty-one (89%) were hepatitis C positive. Forty-seven neonates were live-born and there were two stillbirths. Thirty-seven (79%) required admission to the special care nursery, 40% of them for withdrawal alone. Twenty-seven (55%) babies had neonatal withdrawal and 23 (49%) required medication for withdrawal. The incidence of substance abuse among the pregnant women in this region is ten times higher than the previously quoted figures in metropolitan areas of Australia.

Performance-related pay in health care

OBJECTIVE

Performance-related pay (PRP) has been widely extended within the British public sector in the last 15-20 years, mostly because of pressure from central government. Its penetration in the National Health Service (NHS) has not so far been very deep but it has been sufficient to permit preliminary judgements on its likely impact.

METHODS

Review of published accounts of the extent of use of PRP in the NHS and its impact, plus two case studies.

RESULTS

There have been few rigorous studies reported. PRP has been introduced for a variety of reasons: an incentive to motivate staff; to enhance staff recruitment and retention; to signal a change in organizational culture; to control staff costs; to reduce the power of trades unions; to reinforce staff development policies. Very few NHS provider organizations have implemented PRP. Despite this, senior managers see real merit in it in improving staff performance and delivering a clear message about the importance of organizational performance. Employees are much more skeptical, seeing PRP as having no effect or being detrimental.

CONCLUSIONS

PRP has had, at most, only a very modest beneficial impact in the British NHS. In the absence of better evidence, it would be sensible for government to continue to encourage local initiatives rather than propose a mandatory national scheme. It would also be prudent to subject local schemes to rigorous evaluation.

Prevalence and causes of cough in chronic dialysis patients: a comparison between hemodialysis and peritoneal dialysis patients

Peritoneal dialysis (PD) and hemodialysis (HD) are both common forms of dialysis for patients with end-stage renal disease. A few case reports have suggested that cough is associated with PD. From 1991 to 1998, 17 patients being treated with PD at the Toronto Western Hospital demonstrated persistent cough severe enough for referral to a respirologist. Causes of cough, often more than one cause per patient, included asthma, post-nasal drip, gastroesophageal reflux disease (GERD), chronic obstructive pulmonary disease, congestive heart failure, allergic rhinitis, pleural effusion, and respiratory infection. The aim of this cross-sectional study was to establish the prevalence of cough among PD patients, to determine if PD patients more commonly have a dry persistent cough than do HD patients, and, if the latter case is true, the possible reasons for it. A detailed survey of 92 PD patients and 91 HD patients was conducted in 1998 and 1999 at the University Health Network. Survey questions inquired about patient respiratory symptoms since onset of dialysis. Charts were reviewed to obtain information on use of medications possibly relevant to cough. In the PD and HD groups, 52% and 23% were females (p = 0.001), and the mean ages were 59.1 and 60.1 years, respectively. Angiotensin converting enzyme (ACE) inhibitors had been taken by 65% (PD) and 55% (HD) of patients, and beta-blocking medications by 43% (PD) and 51% (HD). Since initiation of dialysis--mean 2.7 years (PD) and 3.7 years (HD)--22% of PD patients reported persistent cough versus 7% of HD patients (p = 0.003). Although no significant association was seen between cough and self-reported heartburn in HD patients (p = 0.439), a significant association between cough and self-reported heartburn was seen in PD patients: 67% of PD patients with persistent cough reported heartburn versus 29% of those without cough (p = 0.008). The findings suggest that GERD and associated cough are more common in PD patients than in HD patients, perhaps owing to increases in intra-abdominal pressure from the peritoneal dialysate.

A necessary inhumanity?

It is argued that the phrase "Necessary Inhumanity" more accurately describes the alienation required of doctors in some circumstances, than do modern sanitised coinages such as 'clinical detachment.' 'Detachment' and 'objectivity' imply separation, not engagement: creating distance not only from patients, but from the self: the process may well be required, but where it becomes too extreme or prolonged, it can damage everybody, including patients, family members, doctors themselves, and wider society. An awareness of the history of health care in the context of our society might assist self reflection--might help keep initiates in touch with the culture they have been induced to leave and might help them remain humane despite the bruising process of training.

Neuroserpin mutation S52R causes neuroserpin accumulation in neurons and is associated with progressive myoclonus epilepsy

Mutations in the Neuroserpin gene have been reported to cause familial presenile dementia. We describe a new family in which the S52R Neuroserpin mutation is associated with progressive myoclonus epilepsy in 2 siblings. The proband presented myoclonus and epilepsy at age 24, his brother and mother presented a similar disorder when they were 25. A clinical diagnosis of progressive myoclonus epilepsy was made on the proband and his brother. Skin and liver biopsies did not reveal the presence of cytological alterations in the proband. His neurological status worsened over the subsequent 19 yr during which he became demented and had uncontrollable seizures. He died at 43 yr of age from aspiration pneumonia. Neuropathologically, eosinophilic bodies, which were positive for periodic acid-Schiff and immunoreactive with antibodies against human neuroserpin, were present in the perikarya and cell processes of the neurons. They were found in large numbers in the cerebral cortex and substantia nigra and to a lesser extent, in most subcortical gray areas, spinal cord, and dorsal root ganglia. By electron microscopy, the intracytoplasmic bodies were contained within the membranes of the rough endoplasmic reticulum. Occasionally neuroserpin immunopositivity was seen throughout the cytoplasm, even without the presence of well-defined bodies. Our study characterizes for the first time the neuropathologic phenotype associated with hereditary progressive myoclonus epilepsy caused by the S52R Neuroserpin mutation.

The ontogeny of conditioned odor potentiation of startle

During development, conditioned responses usually occur first to olfactory, then to auditory, and finally to visual cues. The authors of the present study report that fear potentiation of startle to an olfactory conditioned stimulus emerges relatively late in development (i.e., at 23 days of age; Experiments 1 and 2). The failure to observe conditioned odor potentiation of startle (OPS) in younger rats was not due to a failure to either acquire or remember the odor-shock association (Experiment 3). Surprisingly, the authors also found that rats trained at 16 but tested at 23 days of age failed to exhibit the OPS effect even though they did exhibit pronounced odor avoidance (Experiment 4). The results are discussed in terms of (a) sensory-specific sequential emergence of learned fear, (b) the neural circuit involved in fear potentiation of startle, and (c) the concept that conditioned responding is appropriate to the animal's age at the time of training rather than its age at testing.