New labour and the third way in the British National Health Service

The British Labour Party claims that its policies are based on a "third way," new and distinct from both the old left and the new right. This article critically examines this claim with respect to health policy. After examining the Conservative legacy in the National Health Service and the evolution of Labour's health policy, the author introduces the concept of the "third way" and discusses the extent to which Labour's health policy can be seen in these terms, using the themes of spending, competition, accountability, and public health. There are many differences between the health policies of New and Old Labour, and some differences between those of New Labour and the Conservatives. Indeed, to a large extent Labour's health policy is built on the legacy of the Conservatives and is characterized by evolution. It is difficult to find any "big idea" or coherent philosophy behind the third way. Rather than being a new and distinctive approach rejecting both the old left and the new right, it seems to be a pragmatic pick and mix, attempting to combine the best from the market approach of the Conservatives and the hierarchical approach of Old Labour.

A feasibility study of continuous hyperfractionated accelerated radiotherapy (CHART) and brachytherapy in patients with early oral or oropharyngeal carcinomas

Overall time is important in the curative treatment of head and neck cancer (Dische, S., Saunders, M.I., Barrett, A., Harvey, A., Gibson, D., Parmar, M., 1997, Radiother. Oncol., 44:123-136). Results are presented on outcome and morbidity in ten patients with head and neck cancer treated with external beam irradiation (CHART protocol) and interstitial implantation, completing treatment in 12 days. Local control and overall survival at 5 years was 67%. Acute and late morbidity was acceptable giving scope for dose escalation.

Experience with dose escalation using CHARTWEL (continuous hyperfractionated accelerated radiotherapy weekend less) in non-small-cell lung cancer

Results from the multicentre randomized trial of CHART (continuous, hyperfractionated, accelerated radiotherapy) in non-small-cell lung cancer (NSCLC) showed a significant increase in survival (P=0.004) compared with conventional radiotherapy and a therapeutic benefit relative to late radiation-induced morbidity. However, 60% of patients died because of failure to control locoregional disease. These findings have stimulated interest in assessing the feasibility of dose escalation using a modified CHART schedule. Acute and late morbidity with a CHARTWEL (CHART WeekEnd Less) schedule of 54 Gy in 16 days was compared with that observed with 60 Gy in 18 days in patients with locally advanced NSCLC. The incidence and severity of dysphagia and of analgesia were scored using a semiquantitative clinical scale. Late radiation-induced morbidity, namely pulmonary, spinal cord and oesophageal strictures, were monitored using clinical and/or radiological criteria. Acute dysphagia and the analgesia required to control the symptoms were more severe and lasted longer in patients treated with CHARTWEL 60 Gy (P< or = 0.02). However, at 12 weeks, oesophagitis was similar to that seen with 54 Gy and did not lead to consequential damage. Early radiation pneumonitis was not increased but, after 6 months, there was a higher incidence of mild pulmonary toxicity compared with CHARTWEL 54 Gy. No cases of radiation myelitis, oesophageal strictures or of grade 2 or 3 lung morbidity have been encountered. CHARTWEL 60 Gy resulted in an enhancement of oesophagitis and grade 1 lung toxicity compared with CHARTWEL 54 Gy. These were of no clinical significance, but may be important if CHARTWEL is used with concomitant chemotherapy. These results provide a basis for further dose escalation or the introduction of concurrent chemotherapy.

Analysis of autoantibody epitopes on steroid 21-hydroxylase using a panel of monoclonal antibodies

A panel of five mouse monoclonal antibodies (MAbs) to human recombinant steroid 21-hydroxylase (21-OH) were produced, characterized, and used to study the interaction of 21-OH autoantibodies (AAbs) with different epitopes on human 21-OH. AAbs in patients with isolated autoimmune Addison's disease, autoimmune polyglandular syndromes types I and II, and 21-OH antibody-positive patients without overt Addison's disease (25 patients in total) were studied. Four MAbs were IgG1 subclass, one was IgG2a, and all had kappa light chains. The affinities of four of the antibodies were in the range 2.0 x 10(8) M(-1) to 7.0 x 10(8) M(-1), and the affinity of the other was 2.3 x 10(7) M(-1) 21-OH MAbs did not cross-react with 17alpha-hydroxylase (17alpha-OH)) or P450 side chain cleavage enzyme. Studies using a series of 21-OH fragments allowed the identification of short stretches of amino acids (AA) that were involved in forming the MAb binding sites. AA 391-405, defined as epitope region (ER) 1, were found to be important for binding of M21-OH1 and M21-OH2, AA 406-411 (ER2) were important for M21-OH3 and M21-OH4 binding, and AA 335-339 (ER3) for M21-OH5 binding. In addition, MAb Fab or F(ab')2 fragments were used to study 21-OH AAb epitopes in competition experiments. These investigations demonstrated that 21-OH AAbs recognize similar epitopes to the MAbs, with ER2 and ER3 being part of two distinct major epitopes, and ER 1 being part of a minor epitope. Mixtures of M21-OH antibody Fab or F(ab')2 fragments caused almost complete inhibition (80%-95%) of AAb binding in 24 out of 25 sera, and in the case of the remaining serum, the effect was marked but incomplete (67% inhibition). There were no major differences between the binding characteristics of AAbs from patients with different forms of autoimmune adrenal disease. All five 21-OH MAbs reacted with human adrenal tissue in an immunofluorescence test, but only M21-OH1 and M21-OH2 reacted with bovine adrenal tissue in these experiments. None of the MAbs reacted with human ovarian tissue in an immunofluorescence test. Overall, these studies indicate that 21-OH AAbs bind to at least three different epitopes in the C-terminal part of 21-OH, and two of these epitopes appear to be human 21-OH specific.

Autoantibody binding to steroid 21-hydroxylase--effect of five mutations

Steroid 21-hydroxylase (21-OH) is a key haem containing steroidogenic enzyme and a major adrenal specific autoantigen. Cys 428 in 21-OH is thought to have an important role in haem binding and we now describe the effects of mutations at Cys 428 (to Ser, Arg and Phe) on 21-OH autoantibody binding. Expression of wild type and mutated 21-OH was carried out using an in vitro transcription/translation (TnT) system and reactivity of 21-OH autoantibodies with mutated 21-OH analysed by western blotting (in the case of unlabelled proteins) or immunoprecipitation assay (IPA) (in the case of 35S-labelled proteins). All 3 substitutions at Cys 428 had similar effects on 21-OH autoantibody binding and each one caused a reduction in autoantibody binding to about 50% of wild type in the case of IPA and to about 70% of wild type in the case of western blotting analysis. In addition to mutations at Cys 428, we studied 2 naturally occurring mutations at Pro 30 to Leu and Ile 172 to Asn which are associated with diminished 21-OH enzyme activity. The Pro 30 mutation had no effect, but the Ile 172 mutation caused a reduction in 21-OH autoantibody binding in the IPA to about 80% of wild type. Overall, our studies emphasise the close relationship between the 21-OH aminoacid sequences important for 21-OH enzyme activity and 21-OH autoantibody binding.

Craniofacial fibrous dysplasia complicated by acute, reversible visual loss: report of two cases

We report two cases of craniofacial fibrous dysplasia which presented with acute visual loss. The first patient had a sphenoid sinus mucocele compressing the optic chiasm. In the second patient the optic canal was narrowed by dysplastic bone. In both cases optic nerve decompression restored vision to normal.

Hormone replacement therapy: determinants of women's decisions

Hormone replacement therapy: determinants of women's decisions. The purpose of this qualitative study was to explore the decision-making process used by menopausal women initiating or remaining on hormone replacement therapy (HRT), stopping HRT, or never starting HRT. Eight focus groups, composed of women reflecting these categories, were conducted. Four major themes or spheres of influence emerged as important in the women's decision-making process: the woman's internal influence--the interface between her perceptions and feelings including the symptoms of menopause, the benefits realized by HRT usage, and the experiences of negative side effects; interpersonal relationships, including the patient-physician relationship, family, friends and information networks; external influences, such as ageism and sexism; and consequences resulting from whichever treatment decision was chosen. A new concept was elucidated called "weighted influence" to underscore the dynamic interplay among the spheres. As information about HRT continues to grow and change, an understanding and application of these spheres of influence can assist physicians in engaging in a dialogue with their patients that allows individual evaluation and application of this new information.

Back pain during pregnancy and after childbirth: an unusual cause not to miss

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Dose escalation safety and tolerance study of the competitive NMDA antagonist selfotel (CGS 19755) in neurosurgery patients

Selfotel (CGS 19755), a competitive N-methyl-D-aspartate antagonist, is neuroprotective in experimental models of ischemic cerebral injury. We studied the safety and tolerability of a single intravenous dose (0.5 to 2.0 mg/kg) of selfotel in neurosurgery patients. Thirty-two neurosurgical patients undergoing intracranial surgery were given ascending doses of selfotel 2 to 14 h before surgery. Serum selfotel levels were measured over a period of 24 h. Cerebrospinal fluid (CSF) levels were measured 1.5 to 18 h after dosing. Frequent side effects included psychomimetic symptoms such as hallucinations, abnormal dreaming, agitation, and paranoia among 20 (66%) patients. Ataxia was seen among five (16%) and dizziness among eight (25%). Symptoms occurred 38 min to 40 h from administration and persisted 5 min to 4 days. Symptom severity worsened with increasing area under the curve measurements and doses above 1.0 mg/kg. All symptoms were reversible and easily treated with intravenous haloperidol. Modest elevations of hepatic enzymes were observed among four patients. No patient had severe adverse reactions. Maximum selfotel levels attained were 143 mumol (serum) and 4.76 mumol (CSF). Peak serum levels among six patients were within potentially neuroprotective ranges. CSF levels remained detectable up to 18 h after dosing. No obvious relationship was seen between CSF drug levels and symptoms. Selfotel in doses of 0.5 to 2.0 mg/kg can be administered safely to neurosurgical patients. Maximum serum levels attained were within the range shown to be neuroprotective in experimental studies. Side effects even at the highest levels are tolerable and reversible. Selfotel use in patients at risk for cerebral injury should be further explored.

Blunt splenic injury in adults: clinical and CT criteria for management, with emphasis on active extravasation

PURPOSE

To evaluate and determine the relevance of clinical and computed tomographic (CT) criteria, particularly extravasation, for prediction of clinical outcome in adults with splenic injuries.

MATERIALS AND METHODS

Retrospective blinded review was performed of the records of 270 patients with splenic injury during a 5-year period. Of these, 120 died or underwent surgery without CT and 150 underwent dynamic bolus-enhanced CT. Fifty of the latter underwent immediate surgery and 100 initially were treated without surgery, according to CT and clinical criteria: morphologic grade of injury, amount of hemoperitoneum, active extravasation, and injury severity score (a clinical measure of multiorgan trauma).

RESULTS

Of the clinical criteria, injury severity score had the best correlation with outcome. Of the CT criteria, active extravasation correlated best with the need for splenic surgery. Of 96 patients selected for nonsurgical treatment and who did not have active extravasation, 83 recovered without surgery or other intervention. Nonsurgical therapy failed in 15 of the 100 patients. The splenic salvage rate was 59.3% overall and was 92% among the 100 patients with initial nonsurgical management.

CONCLUSION

Standard clinical criteria allow triage of patients into immediate surgery or initial nonsurgical groups. CT criteria, especially absence of active extravasation, can help predict successful nonsurgical management of splenic injuries.

Transsphenoidal management of 28 symptomatic Rathke's cleft cysts, with special reference to visual and hormonal recovery

OBJECTIVE

This is a retrospective study of a series of 28 Rathke's cleft cysts operated on transsphenoidally that was undertaken for the following reasons: 1) to study the presentation, with particular reference to hormonal and visual disturbances; 2) to study postoperative improvements in endocrine function and vision; 3) to record postoperative complications; and 4) to assess the efficacy of a minor modification of the standard transsphenoidal surgical technique, whereby the cyst is allowed to drain directly into the sphenoid air sinus without fossa floor repair when there is no intraoperative cerebrospinal fluid leak.

METHODS

A retrospective study was made of case notes, radiological findings, and operative notes in the series.

RESULTS

There were 16 female and 12 male patients, with a mean age of 45 years. Endocrine disturbance was the most common presentation (50%), followed by headaches (32.1%) and visual impairment (14.3%). Neuroophthalmological assessment showed central visual acuity and field deficits in 32.1 and 44.6% of eyes, respectively. Biochemically, 85.7% of patients showed hormonal disturbances. Magnetic resonance imaging was used for 84.7% of cases, and 60.7% of cases showed suprasellar extension. Four magnetic resonance imaging patterns were noted. All cases were operated on transsphenoidally. Postoperative complications included cerebrospinal fluid rhinorrhea (7.1%), diabetes insipidus (3.6%), and meningitis (3.6%). Recovery of visual acuity and field was seen in 66.6 and 68% of eyes, respectively. Postoperative prolactin levels declined to normal or nearly normal values in 62.5% of cases, 20% of cases with low preoperative gonadotrophin levels achieved normal levels, and 15.4% of cases with preoperative pan-hypopituitarism achieved normal serum cortisol levels postoperatively. Within the study period there were no recurrences; although a relatively short time interval is presented for this series, a patient with a similar lesion operated on by the same method 7 years previously remains well, without radiological evidence of recurrence.

CONCLUSION

Although comparatively rare and benign lesions, Rathke's cleft cysts are an important cause of hormonal and visual disturbances. Transsphenoidal surgery is safe and efficacious and leads to excellent improvement of function in the majority of cases. The surgical modification described seems safe and satisfactory and is extremely easy to perform.

Effective treatment of chronic plantar fasciitis with dorsiflexion night splints: a crossover prospective randomized outcome study

Chronic plantar fasciitis frustrates patients and treating physicians. Our hypothesis was that use of a dorsiflexion night splint for 1 month would effectively treat patients with recalcitrant plantar fasciitis. A 6-month randomized crossover study included 37 patients with chronic plantar fasciitis. Patients were treated with dorsiflexion night splints for 1 month. Group A wore splints for the 1st month and group B for the 2nd month. No splints were used in either group for the final 4 months of the study. No other medications, stretching, or strengthening exercises were prescribed. Eighty-eight percent of patients who completed the study improved. Eighty percent of the involved feet improved subjectively. Results of the AOFAS Ankle-Hindfoot Rating System and the Mayo Clinical Scoring System demonstrated significant improvement for both groups during the period of splint wear. Improvements were maintained at study completion. Response to splinting did not correlate with foot type, degree of obesity, or the presence of heel spur on radiographs. We believe dorsiflexion splints provide relief from the symptoms of recalcitrant plantar fasciitis in the majority of patients.

Venturi vacuum systems for hypobaric chamber operations

Physiological studies of the effects of high altitude on man often require the use of a hypobaric chamber to simulate the reduced ambient pressures. Typical "altitude" chambers in use today require complex mechanical vacuum systems to evacuate the chamber air, either directly or via reservoir system. Use of these pumps adds to the cost of both chamber procurement and maintenance, and service of these pumps requires trained support personnel and regular upkeep. In this report we describe use of venturi vacuum pumps to perform the function of mechanical vacuum pumps for human and experimental altitude chamber operations. Advantages of the venturi pumps include their relatively low procurement cost, small size and light weight, ease of installation and plumbing, lack of moving parts, and independence from electrical power sources, fossil fuels and lubricants. Conversion of three hyperbaric chambers to combined hyper/hypobaric use is described.

Cloning, characterization and identification of the gene encoding phosphatidylinositol 4-kinase

The vast majority of AIDS-related deaths are associated with opportunistic infections. For fungal infections, there are few effective antifungals, particularly for systemic use. The discovery that very low doses of the bleomycin family of anticancer chemical congeners compromise the integrity of fungal cell walls led to our approach to identify genes that complement-cell wall defects, and develop methods to facilitate the identification of new antifungals targeted to fungal cell walls. This report describes one of the genes cloned by complementation of the blm1-1 mutation of S. cerevisiae using a YCp50-based yeast genomic library. Characterization and identification of the gene were carried out using drug screening tests, Southern hybridization analyses, DNA sequencing and DNA sequence similarity searches in databases. The gene STT4, is essential for viability and encodes a phosphatidylinositol 4-kinase that plays an important role in the phosphatidylinositol-mediated signal transduction pathway required for cell wall integrity. Like blm1-1 mutant strains, stt4 cells arrest mostly in the G2/M phase of the cell cycle. Further studies using this approach should help us understand the role of PI4-K in maintaining fungal cell-wall integrity, identify additional genes affecting potential target structures in cell walls of opportunistic fungal pathogens in AIDS patients, and assist in drug discovery and antifungal drug design.

Management of blunt splenic trauma: significant differences between adults and children

BACKGROUND

Although highly successful in children, nonoperative management of blunt splenic injury in adults is less defined. The purpose of this study was to determine whether mechanism of injury, grade of splenic injury, associated injuries, and pattern of injury differ between adults and children (younger than 15 years of age).

METHODS

Four hundred eleven patients (293 adults and 118 pediatric patients) with blunt splenic injury were admitted to an affiliated adult/pediatric trauma program from 1989 to 1994. Computed tomography (CT) scans were interpreted in a blinded fashion. Mechanism of injury was significantly different for adults versus children (p < 0.05): motor vehicle crash (66.9% versus 23.7%), motorcycle (8.8% versus 0.8%), sports (2.4% versus 16.9%), falls (8.8% versus 25.4%), pedestrian/automobile (4.4% versus 11.0%), bicycle (1.4% versus 9.3%), and other (7.3% versus 12.7%).

RESULTS

Higher injury severity scores, lower Glasgow Coma Scales, and higher mortality indicated that the adults were more severely injured than the children. Fifty-nine percent of the adults and 7% of the children required immediate laparotomy for splenic injury. Both CT grade and quantity of blood on CT predicted the need for exploration in adults but not in children. An injury severity score above 15 and high-energy mechanisms correlated with the need for operative intervention.

CONCLUSIONS

Rather than children simply being physically different, they are injured differently than adults, hence the high rate of nonoperative management.

Reliability of continuous tracer infusion for measuring glucose turnover rate in rainbow trout

Glucose plays a fundamental role in mammalian energetics but its contribution as a metabolic fuel is not well established for fish; the accurate in vivo measurement of glucose flux is essential to determine the importance of this substrate in the energy budget of teleosts. Therefore, the goal of the present study was to verify the reliability of the continuous tracer infusion method for estimating glucose turnover rate in rainbow trout Oncorhynchus mykiss. Our secondary goals were to determine whether glucose flux can be estimated more accurately from plasma or from whole-blood samples, and to obtain an estimate of renal glucose production. Continuous infusions of [6-3H]glucose were performed in hepatectomized and intact animals. In some hepatectomized individuals, liver glucose production was replaced by a pump infusing unlabelled glucose at a known rate. Renal glucose production was measured in hepatectomized fish where liver glucose production was not replaced, and it averaged 1.1&plusmn;0.1&micro;molkg-1min-1 (mean &plusmn; s.e.m., N=5). Results show that glucose turnover rate is quantified accurately by continuous tracer infusion and that glucose flux can be estimated equally well from plasma (error of -0.7&plusmn;4.9%) and from whole-blood (error of -5.7&plusmn;2.9%) samples (means &plusmn; s.e.m., N=7). This study provides the first experimental validation of continuous tracer infusion in fish, and shows that this method could become a powerful tool to investigate hormonal regulation of glucose metabolism in live teleosts.

Socialism and the British National Health Service

This paper examines some of the key characteristics of a socialist health care system using the example of the British National Health Service (NHS). It has been claimed that the NHS has socialist principles, and represents an island of socialism in a capitalist sea. However, using historical analysis, this paper argues that while the NHS claims some socialist ends, they could never be fully achieved because of the lack of socialist means. The socialist mechanisms which were associated with earlier plans for a national health service such as salaried service, health centres, elected health authorities and divorcing private practice from the public service were discarded in negotiation. Moreover, even these would have achieved socialism merely in the sense of distributing health care, without any deeper transformation associated with doctor-patient relationships and prevention. In short, the NHS is more correctly seen as nationalised rather than socialised medicine, achieving the first three levels of a socialist health service identified here. It can be said to have socialist principles in the limited distributional sense and has some socialist means to achieve these. However, it lacks the stronger means to fully achieve its distributional goals, and is very distant from the third level of a radical transformation of health care.

The reticulocalbin gene maps to the WAGR region in human and to the Small eye Harwell deletion in mouse

We describe the localization of the gene encoding reticulocalbin, a Ca2+-binding protein of the endoplasmic reticulum, on human chromosome 11p13 midway between the WT1 and the PAX6 genes and show that it is hemizygously deleted in WAGR individuals. The mouse reticulocalbin gene is also shown to map to the region of conserved synteny on mouse chromosome 2 and to be deleted in the Small eye Harwell (SeyH) mutation. Loss of the reticulocalbin gene could contribute to the early lethality of SeyH and SeyDey homozygotes.

Steroid 21-hydroxylase autoantibodies: measurements with a new immunoprecipitation assay

Autoantibodies (Abs) to steroid 21-hydroxylase (21-OH) are a major component of adrenal cortex Abs and are characteristic of autoimmune Addison's disease. We have developed a new method for measuring Abs to 21-OH based on 125I-labeled recombinant human 21-OH produced in yeast. With this assay, 21-OH Abs were detected in 43 of 60 (72%) sera from patients with isolated Addison's disease, 11 of 12 (92%) autoimmune polyglandular syndrome type I sera, 27 of 27 (100%) autoimmune polyglandular syndrome type II sera, and 24 of 30 (80%) sera from patients who were positive for adrenal cortex antibodies by immunofluorescence but had no overt Addison's disease. 21-OH Abs were found by 125I assay in 4 of 150 (2.7%) sera from patients with insulin-dependent diabetes mellitus, 1 of 77 (1.3%) Graves' sera, 1 of 67 (1.5%) Hashimoto's sera, and 6 of 243 (2.5%) sera from healthy blood donors. 21-OH Abs were not detected in 9 sera from patients with Addison's disease due to tuberculosis, 32 sera from patients with noninsulin-dependent diabetes mellitus, 35 sera from patients with myasthenia gravis, or 17 sera from patients with premature ovarian failure. There was good agreement between the 125I-labeled 21-OH assay and an assay based on 35S-labeled 21-OH produced in an in vitro transcription/translation system (r = 0.86; n = 129; P < 0.001). In the case of sera from patients with Addison's disease, insulin-dependent diabetes mellitus, Graves' disease, and Hashimoto's disease and from healthy blood donors that were low positive in the 125I assay, neutralization studies with unlabeled 21-OH confirmed the presence of specific 21-OH Abs. Overall, the 21-OH Ab assay based on 125I-labeled 21-OH showed good sensitivity, precision, and disease group specificity. This, combined with a simple assay protocol and the convenience of 125I handling and counting, make it attractive for routine use. Further investigations with the new assay should allow wider assessment of the prevalence and pattern of inheritance of adrenal autoimmunity. In addition, studies of the effect of treatment or possible preventative measures on 21-OH Ab levels in individuals without overt adrenal failure may suggest ways of delaying the onset of autoimmune Addison's disease.