Audit of an inpatient neurology consultation service in a tertiary referral centre: value of the consulting neurologist

The Mater Misericordiae Hospital is a 575-bed tertiary referral centre with busy medical and surgical subspecialty services (including the national cardiac, cardiothoracic, spinal cord injury and pulmonary hypertension units). An audit of in-patient referrals to a neurology service was carried out over the twelve-month period of January to December 2002 inclusively. Five hundred and seventy seven inpatients were evaluated and managed in conjunction with the referring services. Consultation by the neurological service led to a significant contribution in the management of clinical cases in one of three ways: establishing a de novo diagnosis in patients admitted with active neurological symptoms where no working diagnosis exists (40.7% of referrals), significant alteration in diagnosis where the referring service have already established a specific working diagnosis (11.1% of referrals), or offering advice in the ongoing management of active neurological symptoms when the diagnosis is historically established and secure (48.2% of referrals). In order of frequency the most common reason for referral was stroke (131 cases (22.7%)), seizures unrelated to alcohol (59 cases (10.2%)), alcohol-related neurological problems (55 cases (9.5%)), movement disorders (41 cases (7.1%)), neuromuscular (40 cases (6.9%)), coma (35 cases (6%)), disorders of cognition (31 cases (5.3%)), acute headache (28 case (4.8%)) and functional neurological syndromes (26 cases (4.5%)). This audit highlights the value of a consulting neurology service in a multidisciplinary tertiary referral setting.     

Repeat consultations after antibiotic prescribing for respiratory infection: a study in one general practice.

BACKGROUND. Several new antibacterial drugs have been introduced in the last 10 years with the aim of improved treatment of respiratory tract infection. AIM. The study set out to use repeat consultations as a measure of the outcome of antibiotic treatment for respiratory tract infection, and to develop a simple model for discussion of the cost effectiveness of alternative antibiotic treatments. METHOD. All consultations to one practice during a single winter were reviewed by one general practitioner. RESULTS. A total of 1140 patients had acute symptoms suggestive of respiratory infection. Of these, 899 patients (79%) were prescribed antibiotics at the first consultation and 160 of the 899 patients (18%) returned for one or more repeat consultations; only nine repeat consultations were due to adverse effects of the antibiotics prescribed. Only two patients were admitted to hospital for respiratory symptoms following initial antibiotic therapy and both patients had additional reasons for their admission. Using the highest estimates, the cost of a repeat consultation was found to be 28.54 pounds. These data were used to calculate how much more might be spent on more effective antibiotics at the first consultation. It would be difficult to justify increasing the cost of antibiotic treatment by more than 5 pounds per patient, even if the new treatment were 100% effective and all repeat consultations were due to treatment failure (5 pounds is equal to 28.54 pounds x 0.18, which is the maximum cost of a repeat consultation multiplied by the proportion of patients prescribed antibiotics who make repeat consultations). CONCLUSION. From these results and a review of the literature it can be concluded that new antibacterial drugs will have to be carefully targeted if they are to prove cost effective in practice. Other methods for reducing repeat consultation merit investigation.     

Hydrogen peroxide Modulates Ca2+-Activation of Single permeabilized Fibres from Fast- and Slow-twitch Skeletal Muscles of Rats

We examined the effects of redox modulation on single membrane-permeabilized fibre segments from the fast-twitch extensor digitorum longus (EDL) and slow-twitch soleus muscles of adult rats to determine whether the contractile apparatus was the redox target responsible for the increased contractility of muscles exposed to low concentrations of H₂O₂. The effects of H₂O₂ on maximum Ca²⁺-activated force were dose-dependent with 30 min exposure to 5 mM H₂O₂ causing a progressive decrease by 22 ± 3 and 13 ± 2% in soleus and EDL permeabilized muscle fibres, respectively. Lower concentrations of exogenous H₂O₂ (100 M and 1 mM) had no effect on maximum Ca²⁺-activated force. Subsequent exposure to the reductant dithiothreitol (DTT, 10 mM, 10 min) fully reversed the H₂O₂-induced depression of force in EDL, but not in soleus muscle fibres. Incubation with DTT alone for 10 min did not alter Ca²⁺-activated force in either soleus or EDL muscle fibres. The sensitivity of the contractile filaments to Ca²⁺ (pCa₅₀) was not altered by exposure to any concentration of exogenous H₂O₂. However, all concentrations of H₂O₂ diminished the Hill coefficient in permeabilized fibres from the EDL muscle, indicating that the cooperativity of Ca²⁺ binding to troponin is altered. H₂O₂ (5 mM) did not affect rigor force, which indicates that the number of crossbridges participating in contraction was not reduced. In conclusion, H₂O₂ may reduce the maximum Ca²⁺ activated force production in skinned muscle fibres by decreasing the force per crossbridge.     

Molecular heterogeneity and fine specificity of BALB/c antibodies elicited by isologous myeloma protein.

BALB/c mice immunized with the isologous myeloma protein MOPC-315 (M315; α, λ₂) develop antibodies most of which are directed to idiotypic antigens (Id315) located in or near the CNP binding sites of M315, In order to more precisely establish the fine specificity of anti-Id315 antibodies, and to obtain an estimate of the size of the BALB/c anti-Id315 repertoire, we examined anti-Id315 antibodies from individual mice by analytical isoelectric focusing followed by autoradiography. ¹²⁵I-labeled probes were prepared from purified mildly reduced and alkylated M315 protein (RA315) (7 S monomer), Fab'315, Fv315, L315, H315, DNP affinity-labeled RA315, mildly reduced and alkylated MOPC-460 (RA460; 7 S; α, k, Fab'460, H460, and DNP affinity-labeled RA460. We observed that (a) the majority of BALB/c antibodies elicited by immunization with RA315 are specific for idiotypic antigens in the variable region which are rendered inaccessible in the presence of DNP-hapten; (b) distinctly separate antibodies are specific for idiotypic antigens also located in the variable regions but which are not influenced by DNP hapten; (c) about 30 % of BALB/c mice develop antibodies which appear to be specific for a determinant located in the second or third, homology regions of the constant region of the α chain which is not influenced by DNP hapten, and which is also present in the same region of H460; (d) none of the antibodies elicited by M315 recognize free L315; (e) the total antibody response is quite restricted; (f) shared spectrotypes are common between individual mice; and (g) unique or infrequently shared spectrotypes do occur. These studies demonstrate, by a direct technique, the fine specificity and the clonal and molecular heterogeneity of the B cell response induced by immunization with RA315.     

Reproduction and thermoregulation in Peromyscus: Effects of chronic short days

Seven groups of laboratory reared Connecticut P. leucopus were exposed to a 9L:15D photoperiod for either 6, 9, 12, 20, 25, 32, or 36 weeks. An eighth group was maintained on 16L:8D. During the final 6 weeks all mice were cold exposed (13°C). Substantial reproductive regression occurred in females following 6 weeks exposure to 9L:15D relative to 16L:8D animals. In males, a slight decrease in testicular weight occurred following 6 weeks on 9L:15D; this effect was pronounced by 9 weeks, along with a decrease in seminal vesicle weight. Reproductive recrudescence occurred in females by week 32 and in males by week 36. Between 10 and 12 weeks on 9L:15D mice exhibited increases in nesting, incidence of daily torpor, and presence of the winter molt. These increases persisted through 36 weeks on 9L:15D. An increase in the interscapular brown fat pad occurred between 12 and 25 weeks. Reproductive and thermoregulatory characters respond differently to prolonged exposure to a short day photoperiod in this species.     

Photoperiod, temperature and melatonin effects on thermoregulatory behavior in Djungarian hamsters

Nesting and burrowing activity were measured in hamsters acclimated to either long or short day photoperiod in thermoneutrality and at 10 degrees C. Hamsters build larger nests under short day photoperiod or at 10 degrees C as compared to long day photoperiod or thermoneutrality. Both environmental cues contributed about 50% to a total increase in nest size from 1.8 g cotton/day to 7.7 g cotton/day (long day thermoneutral versus short day at 10 degrees C). Burrowing activity was suppressed by both cold or short day exposure. Daily melatonin injections, effective in inducing physiological short day adjustment under a long day photoperiod, also increased nesting scores. Hamsters which did not respond to short day conditions or to melatonin treatment physiologically lacked behavioral adjustments as well. Collectively, these results demonstrate analogies in the environmental control of physiological thermoregulatory adjustment and nesting behavior. Burrowing activity seems to be more related to reproductive needs than to thermoregulatory requirements in this hamster.     

Novel germline p16(INK4) allele (Asp145Cys) in a family with multiple pancreatic carcinomas. Mutations in brief no. 148. Online

As part of a search for causative genes of familial pancreatic carcinoma, the p16 genes were sequenced in members of 21 families with a phenotype of familial pancreatic carcinoma (2 or more first degree relatives affected). One family was found in which members carried a novel p16 allele with a G to T transversion at position 451, creating a missense amino acid change at codon 145 (Asp to Cys) and possibly disrupting the donor splice site of the exon 2/3 boundary. This coding change is not a known polymorphism, and occurs at a codon position in which another missese/splicing change has been shown to be linked to familial melanoma/pancreas cancer.     

Absence of a daily neuronal rhythm in the suprachiasmatic nuclei of acircadian Djungarian hamsters.

The suprachiasmatic nuclei (SCN) in mammals generate and maintain a variety of daily rhythms. In nocturnally active rodents, SCN electrical activity is high during the subjective day (that time of locomotor inactivity) and low during the subjective night. The present experiment examines the relationship between SCN neuronal activity and the expression of overt circadian behavior in the Djungarian hamster (Phodopus sungorus). Wheel-running locomotor activity was measured in 2 groups of hamsters housed in constant dark (DD). Twelve hamsters, selected from ongoing experiments in our laboratory, showed no overt circadian rhythm in locomotor activity. A second group of 9 control animals exhibited rhythmic wheel-running activity in DD. In contrast to control animals, in vitro SCN electrical activity in brain slices prepared from acircadian hamsters showed no circadian variation. These data indicate that in acircadian animals SCN electrical activity properly reflects behavioral patterns.