A survey of the current clinical practice of psychiatrists and accident and emergency specialists in the United Kingdom concerning vitamin supplementation for chronic alcohol misusers

Although it is well known that B-vitamin deficiencies directly affecting the brain are common in alcohol misuse, no concise guidelines on the use of vitamin supplements in alcohol misusers currently exist in the UK. The purpose of this study was to assess current practice and opinion among UK physicians. Questionnaires were completed by a total of 427 physicians comprising Accident and Emergency (A&E) specialists and psychiatrists, with a response rate of 25%. The main findings were that vitamin deficiency was perceived as being uncommon amongst alcohol misusers (<25%) and there was no consensus as to which B vitamins are beneficial in treatment or the best method of administration of B-vitamin supplementation. The majority of psychiatrists favoured oral administration for prophylaxis against the Wernicke-Korsakoff syndrome in chronic alcohol misusers and parenteral therapy in patients with signs of Wernicke-Korsakoff syndrome. Whilst only just over half the A&E specialists expressed a preference, most favoured parenteral therapy in both cases. Most respondents did not currently have a unit policy/protocol on the management of vitamin supplementation in chronic alcohol misusers. Overall, the findings suggest that there is wide variation in current practice and highlight the need for guidelines in this area.     

Models of commissioning health services in the British National Health Service: a literature review.

The commissioning of health services is an under-researched area and yet it is critical to the way services meet health needs and to the quality of care. Recent emphasis in the United Kingdom and elsewhere has been on a 'primary care led National Health Service', particularly on locality commissioning through primary care groups. However, there are other models of commissioning using 'programmes of care' (focused on diseases or patient groups rather than geography) which may offer greater benefits. There is little research comparing the benefits and costs of these models, and most are not even clearly enough described to be replicated. There will always be a political dimension to models of commissioning, dependent, for example, on the balance of power in the decision-making process. None the less, a broader knowledge of possible models and a willingness to evaluate rigorously are needed if commissioning of health services is to result in better patient care.     

Antibiotic resistance in nosocomial isolates in Scotland

In this first multi-centre study in Scotland, 1028 consecutive Gram-negative and staphylococci strains were obtained from four major teaching hospitals. E. coli was the most common organism among both intensive care units (ICUs) (39%) and non-ICU strains (46.6%). The prevalence of antibiotic resistance among E. coli was always higher in isolates from ICUs than non-ICUs: ceftazidime (14.1%, 7.2%), ceftriaxone (12.7%, 6.1%), cefotaxime (15.5%, 8.7%), cefuroxime (28.8%, 20.8%), amoxicillin plus clavulanic acid (52.2%, 38.8%) and gentamicin (7.0%, 2.8%). The highest incidences of resistance were identified among Enterobacter/Citrobacter spp. from ICUs; 43.8%, 41.7%, 45.8%, 54.2%, 87.5% and 10.4% of these organisms were resistant to ceftazidime, ceftriaxone, cefotaxime, cefuroxime, amoxicillin plus clavulanic acid and gentamicin, respectively.     

Vitamin A utilization status in chronic alcoholic patients

The utilization status of vitamin A (retinol) (treated with oral retinol - 2500 I.U. daily (=250 micrograms) x 5 days - "OROVITE -7", Bencard, England) in 25 patients (M = 23, F = 2; mean age +/- S.D. = 43.88 +/- 12.67; range = 28-70 years), 3 out of 25 patients (12%) were found to be deficient in the vitamin and during treatment further improvement of the blood levels of the vitamin was observed in all except one elderly male patient (age 61 years) and the mean levels on admission (661.04 micrograms/l) was also slightly improved after treatment (662.84 micrograms/l). Night blindness, alcoholic liver disease and hypogonadism are commonly seen in chronic alcoholic patients. Falling plasma levels of the vitamin indicate exhaustion of its hepatic storage. It is therefore suggested that chronic alcoholics should be given vitamin A supplementation along with other polyvitamins during conventional detoxification therapy for ethanol withdrawal syndrome in order to prevent dangerous manifestations of hypovitaminosis A, such as night blindness, cancer, hypogonadism and alcoholic liver disease.     

Excitatory Connections Between CA1 Pyramidal Cells Revealed by Spike Triggered Averaging in Slices of Rat Hippocampus are Partially NMDA Receptor Mediated

Spike triggered averaging was used to record local circuit connections between pairs of CA1 pyramidal neurons in isolated slices of rat hippocampus. Of 795 pairs of neurons tested, six were connected. These epsps were only partially blocked by 2-amino-5-phosphonovalerate (AP-5), which decreased the amplitude and half width of the epsp, but did not affect the early rising phase. In contrast, 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX) blocked all phases of the epsp and combinations of AP-5 and CNQX blocked the epsp almost entirely. These results indicate that these epsps were mediated by both N-methyl-d-aspartate (NMDA) and non-NMDA excitatory amino acid receptors. Moreover, they exhibited a voltage relation typical of neuronal responses to NMDA, increasing in amplitude and duration as the postsynaptic cell was depolarized. These epsps were brief (10 - 90% rise time < 5 ms, width at half amplitude < 20 ms), indicating a proximal location. Increasing presynaptic firing rate (1 - 4 spikes/s) reduced average epsp amplitude by almost 50%. When epsps were evoked by pairs of spikes (interval 3 - 25 ms), a large response to the first spike precluded a large response to the second. No evidence for selective enhancement of the NMDA receptor component by paired spike activation was found. It is concluded that a significant NMDA receptor mediated input to CA1 is provided by local circuit CA1 - CA1 connections and that these synapses can be demonstrated under control conditions.     

Observer variation in the interpretation of lower limb venograms.

After agreeing on diagnostic criteria and after a pilot study, two experienced radiologists twice independently reviewed 40 lower limb venograms performed by a standard technique in patients suspected or known to have venous thrombosis. The observers reviewed 20 examinations at a time, their analysis requiring separate identification of 11 major veins. At each site observers stated whether thrombus was "absent," "doubtful," "presumed," or "definite," or declared "no opinion possible." They then rediscussed criteria of diagnosis and, using the same experimental design, examined another 40 venograms. To correct for agreement expected by chance, data were analyzed by using the kappa statistic. In general, levels of agreement were higher than those reported for many other clinical and radiologic investigations, probably because of refinement of criteria after the pilot study. Nonetheless, observers disagreed about the probable presence or absence of thrombus at some site in the limb in about 10% of examinations. Observer variation should be considered when venography is used as a reference standard to evaluate other methods of diagnosing thrombi.     

Acupuncture analgesia: an experimental investigation.

A study was designed to establish whether acupuncture has any analgesic properties beyond those of suggestion. In three one-hour experimental sessions the increases in detection thresholds and tolerances for thermal pain at six body locations on 12 subjects were compared. A control session (without needles) was followed by one session in which electrically stimulated needles were inserted in accord with Chinese practice, and another in which the needles were inserted to avoid all recognised acupuncture "points." Acupuncture was significantly more effective than suggestion in raising overall body pain thresholds but just below significance for tolerances. A significant disproportionate effect on the epigastrium, predicted by the choice of acupuncture points, was found for tolerances but not thresholds.     

The diets of preschool children in Newcastle upon Tyne, 1968-71.

1. Ninety-one families containing 140 children under 4 years of age at enrolment were studied. At 1-monthly intervals, the children were weighed and measured and qualitative information about feeding habits was obtained. Weighed dietary surveys for periods of 5 d were made at approximately 8 months, 3 years, and 5 years of age; there were forty-six failures in 260 surveys attempted. 2. At the four specified ages, mean energy intakes were 3-75, 5-03, 5-82 and 6-75 MJ (896, 1203, 1392 and 1613 kcal)/d respectively. At 8 months, milk products provided on average, 43% of the total energy intake, and commerical baby foods provided 17%. These values decreased to 21 and 2% respectively at 20 months and there was little further change therafter. 3. Average intake of energy and of most nutrients met recommended intakes (Department of Health and Social Security, 1969). Iron intakes were marginal, and vitamin D intakes were low. 4. The energy intake of boys was significantly higher than that of the girls at 3 years of age, but the boys were not significantly heavier. The energy intake of children from "manual-worker" families was higher than that from "non-manual" families. Similarly, the energy intake of children from larger families was higher than that of children from smaller families. 5. Energy intakes were correlated with body-weights and with rates of gain in weight. Irrespective of body-weight, "big eaters" at 20 months tended to be "big eaters" at 3 years also.