Commissioning conferences: a consultative approach to purchasing.

In 1991 the South East London Health Authority developed a process called 'commissioning conferences' to help them purchase services. The first commissioning conference was used to produce a specification of service for people with diabetes mellitus. For this, 120 local people and 15 independent experts were consulted in a structured way.

Guidelines for medical audit: seven principles.

The government, general managers, and professional bodies all agree that medical audit should be implemented throughout the United Kingdom. Nevertheless, it is not yet decided either nationally or locally how audit should be defined and what its implications will be. In an analysis to find ways of measuring the design and effectiveness of hospital audit, therefore, seven main measures emerged that might serve as practical criteria. These were the definition of medical and managerial responsibilities; medical organisation; scope of audit; essential characteristics; resources needed; record keeping; and evaluation. Though generally consistent with the proposals of the government and the Department of Health, these seven principles offer some alternative approaches.

Electroconvulsive therapy and the brain: evidence for increased dopamine-mediated responses.

The growth-hormone (GH) response to subcutaneous administration of the dopamine agonist, apomorphine (0.005 mg/kg), was assessed in 15 depressed patients at the beginning and at the end of a course of electroconvulsive therapy (ECT). After ECT there was a significant increase in the GH response to apomorphine, supporting the hypothesis that ECT produces an enhancement of dopamine-mediated responses in the brain. Additional studies in depressed patients receiving other antidepressant treatment suggested that the increase in apomorphine response following ECT was not attributable either to concurrent antidepressant medication or to clinical recovery from depressive illness.

Enhanced 5-hydroxytryptamine-mediated behavioural responses in rats following repeated electroconvulsive shock: relevance to the mechanism of the antidepressive effect of electroconvulsive therapy.

Treatment of rats with one electroconvulsive shock (ECS) per day for 10 days enhanced the hyperactivity syndrome produced by administration of tranylcypromine (10 mg kg-1) and L-tryptophan (50 mg kg-1) given 24 h after the final shock. Similar enhancement was seen whether the shock was alternating sinusoidal or direct current (fractionated), whether it was given through unilaterally or bilaterally placed electrodes and whether or not a neuromuscular blocking agent (fazadinium) was used. Five shocks spread over 10 days or 8 shocks spread over 17 days were similarly effective, whilst 8 shocks in 1 day were ineffective. Therefore when ECS are given to rats in ways similar to those in which electroconvulsive therapy is given to patients with depression, enhancement of behavioural responses to increased 5-HT function is produced.

beta-Adrenoceptor antagonists inhibit the behavioural responses of rats to increased brain 5-hydroxytryptamine.

1 The effect of various beta-adrenoceptor blocking agents on the 5-hydroxytryptamine (5-HT)-induced hyperactivity response produced in rats by administration of tranylcypromine (10 mg/kg i.p.) followed by L-tryptophan (50 mg/kg i.p.) has been investigated. 2 (+/-)-Alprenolol, (+/-)-timolol, (+/-)-sotalol, (+/-)-pindolol (all at 40 mg/kg) all inhibited the hyperactivity response to some degree when given 45 min before the tranylcypromine, as did (+/-)-oxprenolol when given after the L-tryptophan. 3 beta-Adrenoceptor antagonists that are not found in the brain appreciable amount after peripheral injection, (+/-)-atenolol, (+/-)-practolol, (+/-)-labetalol and (+/-)-acebutalol, did not inhibit the 5-HT-mediated behaviour. 4 Neither the beta1-selective drug (+/-)-metoprolol, nor the beta2-selective drug (+/-)-butoxamine inhibited the behavioral response. 5 The drugs that blocked the 5-HT-mediated behaviour did not alter brain 5-HT concentrations, synthesis rate or the accumulation of 5-HT following tranylcypromine/L-tryptophan. However, they did inhibit the hyperactivity produced by the suggested 5-HT agonist, 5-methoxy N,N-dimethyltryptamine, indicating that the beta-adrenoceptor blocking drugs were inhibiting the post-synaptic 5-HT-mediated response. 6 Circling produced by methamphetamine (3 mg/kg) in unilateral nigro-striatal lesioned rats was not altered by alprenolol, sotalol, pindolol or metaprolol, indicating that these drugs do not alter dopamine-mediated behaviour. 7 It is concluded that non-selective (beta1 and beta2) adrenoceptor antagonists which have a high brain/blood ratio following their peripheral injection, block 5-HT-mediated behavioural responses in the rat.