The experience and training of British general surgeons in trauma surgery for the abdomen, thorax and major vessels

BACKGROUND

The report Better Carefor the Severely Injured [London: The Royal College of Surgeons of England and the British Orthopaedic Association; 2000] states that an experienced general surgeon trained in the techniques required to perform life-saving emergency surgery is vital in the management of major trauma. The experience and training of general surgeons in the UK in the management of trauma to the abdomen, thorax and major vessels has never been assessed.

METHOD

Postal questionnaire sent to UK general surgical consultants and Higher Surgical Trainees (HSTs).

RESULTS

A total of 854 (48%) questionnaires were completed. Of respondents, 85% believe that major trauma should be directed to hospitals that provide a dedicated trauma service. Of non-vascular specialists, 43% felt their training was adequate to manage vascular trauma and only one-third of general surgical consultants felt adequately prepared to manage acute cardiothoracic injuries. The median number of trauma laparotomies undertaken annually was 2 for blunt injury and 1 for penetrating injury. Of HSTs, 21% had not performed a splenectomy for trauma and 44% had no experience of packing for liver injuries.

CONCLUSIONS

There is limited experience and training in the surgical management of torso trauma in the UK. Implementation of the recommendations from Better Care for the Severely Injured will be hampered unless steps are taken to maximise experience and improve training.

Darbepoetin alfa is more potent in vivo and can be administered less frequently than rHuEPO

doi:10.1038/sj.bjc.6600506www.bjcancer.com

© (2002) Cancer Research UK

Knowledge, risk perceptions and condom usage in male sex workers from three Australian cities

The study identifies factors associated with knowledge and perception of risk of HIV/AIDS, as well as attitudes to and usage of condoms by a sample of male sex workers (MSW). One hundred and eighty-five male sex workers completed a self-reported questionnaire, including knowledge about HIV transmission, attitudes to condom use and perceptions and personal susceptibility to HIV and sexually transmitted infection (STI) risk, and a two-week diary recording use of condom during commercial sex encounters. The findings reveal that condom use was found in 77.7% of the encounters with clients and the majority of the respondents perceived themselves to be at no risk for HIV because of sex work. Independent sex workers from Melbourne and workers who owned their place of residence used condoms in a significant lower proportion. Generally speaking, knowledge about the risks associated with AIDS was high, with respondents showing lower knowledge about the risks associated with unprotected receptive or active oral sex. Participants held a positive attitude to condom use; most considered the provisions of condoms to be their responsibility rather than clients; and they were more worried about contracting an STI than HIV. Those who scored higher on the knowledge scale had more positive attitudes to condom use and those who had a more positive attitude to condom use recorded a perceived lower risk of contracting STI but not HIV. The study discusses the relevance of these findings for public health risk reduction and sexual health education campaigns.

Male sex workers in three Australian cities: socio-demographic and sex work characteristics

This article describes the socio-demographic and sex work characteristics of sex workers in Sydney, Melbourne, and Brisbane. A total of 185 male sex workers completed the questionnaire component of the study. The results of this study serve to debunk many of the myths surrounding the popular view of the male sex worker (MSW). The respondents in this study were on average 27 years old, and the majority had completed secondary education, with 30% having gained some form of tertiary qualification. Interestingly, those MSWs who had not completed secondary education were mostly street workers and were generally aged under 25 years. The majority of sex workers lived in rented accommodation, with only 6% reporting to be homeless. Half of all respondents identified as being "gay," 31% as "bisexual" and 5.5% as "straight." More than half of the respondents were in a permanent relationship. Only 7.3% of this group reported using heroin daily, although the majority consumed alcohol, tobacco, marijuana, and ecstasy. The majority of sex workers had been in the profession for less than six months, although some had been working in the industry for more than ten years. Most of the sex workers reported having taken an HIV test and a preference to offer safer sex. The article highlights ways in which the work context of MSW can be better understood and supported by education and public policy programs.

Development of a novel method for assessing balance: the quantitative posturography system

Balance is the ability to maintain equilibrium while sitting or standing. There are a number of different methods which are used to assess balance: technical methods such as sway magnetometry, ataxia meter and force platforms, and clinical methods such as the functional reach test, Berg balance test and fall risk index. The most frequently used technical method is the force platform. There are two types of force platform, a static and a dynamic force platform, of which the dynamic force platform has been found to be more sensitive to detect impaired balance. The quantitative posturography system (QPS) described in this paper is a type of dynamic force platform; however, it has a simpler design than the currently available dynamic force platforms and can match the subject's sway exactly for tilting in the anterio-posterior and medio-lateral directions with its novel design. This paper describes the novel design of the QPS and its calibration.

A quality control procedure for force platforms

A force platform is a technical method of quantitatively assessing balance indirectly. The use of force platforms in physiotherapy departments has become more prominent over the last few years. However, the main drawback in the use of force platforms is the lack of comprehensive calibration procedures, which casts doubt on the results obtained with these systems. Existing calibration tests are limited to testing the spatial accuracy of the force platform. This paper describes a comprehensive quality control test procedure which was developed. It is proposed that the developed quality control test procedure could be used to test all types of force platform and it includes a description of how the tests should be carried out, the frequency with which they should be carried out and the expected performance for each of the tests as recommended for the most part by the Association Francaise de Posturologie.

An anchored YAC-STS framework for the rat genome

We report here the first YAC-STS framework for the rat genome. A total of 417 anchor microsatellite markers were used to screen a 10-fold redundant YAC library. One or more unambiguous YACs were identified for 372 markers. Assuming the genetic length of the rat genome to be 2,000 cM (Bihoreau et al. 1997b), the YAC-STS framework will provide, on average, one informative YAC clone every 5.4 cM. A total of 111 anchor markers used in this study were derived from known gene regions. We also demonstrated one of the important and immediate uses of this YAC-STS framework, which is to establish a correlation between the genetic and cytogenetic maps in the rat through FISH analysis.

An instrument to measure safer sex strategies used by male sex workers

Several studies have related safe sex in the commercial sex encounter to the ability of sex workers to apply specific safer sex strategies. However, no instrument has been previously available to measure these skills. The Safer-Sex Strategy Scale (SSS) was developed for such purposes. The psychometric properties (reliability and validity) were evaluated with a sample of sex workers recruited from Australian cities. A questionnaire was administered to 184 sex workers aged 18-58 years using a convenience sampling method. Results indicated that the SSS can be conceptualized as a four variation construct and can be reliably (all subscales yielded at least a Cronbach's alpha = .60) and validly measured. Additionally, the relationship of the SSS to various sex work experiences was explored. The results show that the length of time working as a sex worker and contact with sex work organizations and sexual health clinics appear to influence the level of agreement of using the safer sex strategies evaluated.

The use of EMLA reduces the pain associated with digital ring block for ingrowing toenail correction

Treatment of ingrowing toenail is commonly performed under local anaesthesia with a digital ring block. Ring block can be associated with significant pain, caused by needle insertion and deposition of the local anaesthetic agent. EMLA, a topical anaesthetic cream, is widely used to alleviate the pain of venepuncture. The aim of this study was to investigate whether the discomfort of digital block could be reduced by prior application of EMLA. Fifty-five patients who were scheduled for ingrowing toenail under local anaesthesia were randomized into two groups. In Group 1 (n = 30), EMLA was applied around the base of the affected hallux for at least 1 h before ring block. In Group 2 (n = 25), a placebo cream was used. In this double-blind study, patients assessed the pain caused by a standardized ring block using 100-mm visual analogue pain score. The mean visual analogue pain score in Group 1 was 28.1 and 50.1 in Group 2 (P < 0.0001). We conclude that EMLA significantly reduces the pain associated with digital ring block.

Pneumomediastinum, pneumothorax and subcutaneous emphysema complicating MIS herniorrhaphy

PURPOSE

Videoscopic herniorrhaphy is being performed more frequently with advantages claimed over the conventional open approach. This clinical report describes a pneumothorax, pneumomediastinum and subcutaneous emphysema occurring at the end of an extraperitoneal videoscopic herniorrhaphy.

CLINICAL FEATURES

A 25 yr old ASA I man presented for elective extraperitoneal videoscopic hernia repair. Following intravenous induction with fentanyl, midazolam and propofol a balanced anesthetic technique using enflurane in N2O and O2 was used. Apart from a prolonged operating time (195 min), the procedure and anesthetic was uneventful. At the conclusion of the operation, prior to reversal of neuromuscular blockade extensive subcutaneous emphysema was noted on removal of the surgical drapes. Chest radiography revealed a pneumomediastinum and pneumothorax. A 25 FG intercostal tube was inserted and connected to an underwater seal drain. Sedation and positive pressure ventilation was maintained overnight to permit resolution and avoid airway compromise. The clinical and radiological features had resolved by the next morning and the patient's trachea was extubated. His subsequent recovery was uneventful.

CONCLUSION

Pneumothorax and pneumomediastinum are well recognised complications of laparoscopic techniques but have not been described following extraperitoneal herniorrhaphy. In this report we postulate possible mechanisms which may have contributed to their development, including inadvertent breach of the peritoneum and leakage of gas around the diaphragmatic herniae or tracking of gas retroperitoneally. The case alerts us to the possibility of this complication occurring in patients undergoing videoscopic herniorrhaphy.

Measuring surgical outcome

A surgical outcome is any event or measure of a patient's health that may occur or change, for better or worse, as a result of an operation. The introduction of clinical governance has led to debate about how to monitor the quality of surgical services in the NHS. One method that has been proposed is the publication of data on surgical outcomes for named hospitals and surgeons (Dobson, 1998).

Presentation of ALS to the otolaryngologist/head and neck surgeon: getting to the neurologist

Patients with early symptoms of bulbar amyotrophic lateral sclerosis (ALS) are usually referred to the otolaryngologist without a diagnosis. Careful examination of the speech quality and a physical exam, including the vocal cords, should be undertaken. The emotional state of the patient should be considered, and a diagnosis should not be offered before a neurologic consultation has been obtained. Patients with late symptoms of bulbar ALS almost always present with both significant speech and swallowing abnormalities. Evaluation can be difficult because many abnormalities are found on examination. Advanced progression of symptoms is a clear indication for rapid referral to a neurologist if a diagnosis has not already been made. Supportive and symptomatic care should be offered to the patient immediately. The University of Washington Neuromuscular Clinic for Speech and Swallowing Disorders has seen 600 new neurologic patients since 1986, 211 of whom were ALS patients. The introduction of percutaneous gastrostomy has greatly changed the management of ALS patients, and 75 patients have undergone this procedure (32% because of inadequate swallowing, 68% for declining vital capacity). Medical management to improve symptoms may be indicated before surgery. Surgical options for patients with late salivary presentation are uncommon and include removal of the submaxillary glands, tracheostomy, and laryngeal or salivary diversion procedures. Laryngectomy or laryngeal diversion procedures are only very rarely indicated. Although tracheostomy usually interferes with swallowing and worsens aspiration, it may rarely be indicated in patients with late airway presentation for glottic narrowing or artificial respiratory support. Symptomatic management of patients with bulbar ALS is usually best undertaken by a multidisciplinary clinic that can provide a physically and psychologically supportive environment.

Topical amethocaine (Ametop) is superior to EMLA for intravenous cannulation. Eutectic mixture of local anesthetics

PURPOSE

A eutectic mixture of local anesthetics (EMLA) is commonly used to provide topical anesthesia for intravenous (i.v.) cannulation. One of its side effects is vasoconstriction, which may render cannulation more difficult. A gel formulation of amethocaine (Ametop) is now commercially available. The aim of this study was to compare EMLA and Ametop with regard to the degree of topical anesthesia afforded, the incidence of vasoconstriction and the ease of i.v. cannulation.

METHODS

Thirty two ASA I adult volunteers had a #16 gauge i.v. cannula inserted on two separate occasions using EMLA and Ametop applied in a double blind fashion for topical anesthesia. Parameters that were recorded after each cannulation included visual analogue pain scores (VAPS), the presence of vasoconstriction and the ease of cannulation, graded as: 1 = easy, 2 = moderately difficult, 3 = difficult and 4 = failed.

RESULTS

The mean VAPS +/- SD after cannulation with Ametop M was 12+/-9.9 and with EMLA was 25.3+/-16.6 (P = 0.002). Vasoconstriction occurred after EMLA application on 17 occasions and twice after Ametop (P = 0.001). The grade of difficulty of cannulation was 1.44+/-0.88 following EMLA and 1.06+/-0.25 with Ametop (P = 0.023).

CONCLUSIONS

Intravenous cannulation was less painful following application of Ametop than EMLA. In addition, Ametop caused less vasoconstriction and facilitated easier cannulation. Its use as a topical anesthetic agent is recommended, especially when i.v. access may be problematic.

Pharmacokinetics of novel erythropoiesis stimulating protein compared with epoetin alfa in dialysis patients

Novel erythropoiesis stimulating protein (NESP) is a hyperglycosylated analogue of recombinant human erythropoietin (Epoetin) which has an increased terminal half-life in animal models. The aim of this study was to extend these observations to humans. Using a double-blind, randomized, cross-over design, the single-dose pharmacokinetics of Epoetin alfa (100 U/kg) and an equivalent peptide mass of NESP were compared following intravenous bolus in 11 stable peritoneal dialysis patients. This was followed by an open-label study to determine the single-dose pharmacokinetics of an equivalent peptide mass of NESP by subcutaneous injection in six of these patients. The mean terminal half-life for intravenous NESP was threefold longer than for intravenous Epoetin (25.3 versus 8.5 h), a difference of 16.8 h (95% confidence interval, 9.4 to 24.2 h, P = 0.0008). The area under the serum concentration-time curve was significantly greater for NESP (291.0 +/- 7.6 ng x h per ml versus 131.9 +/- 8.3 ng x h per ml; mean +/- SEM; P < 0.0005), and clearance was significantly lower (1.6 +/- 0.3 ml/h per kg versus 4.0 +/- 0.3 ml/h per kg; mean +/- SEM; P < 0.0005). The volume of distribution was similar for NESP and Epoetin (52.4 +/- 2.0 ml/kg versus 48.7 +/-2.1 ml/kg; mean +/-SEM). The mean terminal half-life for subcutaneous NESP was 48.8 h. The peak concentration of subcutaneous NESP was approximately 10% of that following intravenous administration, and bioavailability was approximately 37% by the subcutaneous route. The longer half-life of NESP is likely to confer a clinical advantage over Epoetin by allowing less frequent dosing in patients treated for anemia.

A profile of the clients of male sex workers in three Australian cities

OBJECTIVE

This paper describes the profile of clients as reported by 186 male sex workers in three Australian cities.

METHOD

The data were collected using a diary which was completed after each commercial sexual encounter with a male client over a two-week period. The data reported in this study are based on reports from 2,088 sex encounters and a profile of 1,776 clients.

RESULTS

The findings reveal, for example, that the most common source used for recruiting clients was advertisements, followed by escort agencies, although there were differences between the three cities; the majority of the clients were in their 40s but clients of street workers were younger; clients were most often classified as 'middle class', with differences by source of client recruitment; less than half the clients were identified as being gay and a significant number were identified as bisexual or straight; alcohol and drug use took place in a small percentage of the encounters; most workers had some information about their clients, such as occupation and home number; violence was infrequent; and unsafe sex was requested in a minority of the encounters.

CONCLUSION

Overall, the results reveal that clients of male sex workers are a highly heterogeneous group.

IMPLICATIONS

The paper highlights a number of issues which can further promote safety and public accountability in male sex work.

An unusual complication of minitracheostomy

A 72-year-old woman had a minitracheostomy inserted for sputum retention. This was undertaken by a relatively junior resident who opted to use an early model minitracheostomy kit Minitrach II. The following day the patients condition deteriorated and intubation was warranted, at which time it was apparent to senior staff that the minitracheostomy had been malpositioned. Ten days later, formal tracheostomy was performed under general anaesthesia. After incision, an abscess in the thyroid gland was found. Histology subsequently revealed a Hurthle cell tumour of the thyroid. Thyroid abscess is exceedingly rare. It typically occurs in abnormal thyroid tissue and with a focus on infection. The combination of Hurthle cell adenoma and a foreign body (the minitracheostomy) was evidently causative in this instance. This complication of minitracheostomy insertion has not to our knowledge, previously been reported.

A gene map of the rat derived from linkage analysis and related regions in the mouse and human genomes

We report the localization by linkage analysis in the rat genome of 148 new markers derived from 128 distinct known gene sequences, ESTs, and anonymous sequences selected in GenBank database on the basis of the presence of a repeated element. The composite linkage map of the rat contributed by our group integrates mapping information on a total of 370 different known genes, ESTs, and anonymous mouse or human sequences, and provides a valuable tool for comparative genome analysis. 206 and 254 homologous loci were identified in the mouse and human genomes respectively. Our linkage map, which combines both anonymous markers and gene markers, should facilitate the advancement of genetic studies for a wide variety of rat models characterized for complete phenotypes. The comparative genome mapping should define genetic regions in human likely to be homologous to susceptibility loci identified in rat and provide useful information for the identification of new potential candidates for genetic disorders.

The effects of EMLA and a topical formulation of 4% amethocaine (Ametop) on pain associated with retrobulbar injection

Retrobulbar block is commonly performed to provide anaesthesia for cataract extraction. This technique can cause significant discomfort. A prospective, randomised, placebo-controlled trial was carried out to investigate the efficacy of a eutectic mixture of local anaesthetics (EMLA) and a 4% amethocaine topical formulation (Ametop) in reducing the pain of retrobulbar injection. Ametop and EMLA proved to be of similar efficacy, both being superior to a placebo in alleviating the discomfort of retrobulbar block. No significant side-effects were observed with the use of either formulation.

Characterization of the murine A1 adenosine receptor promoter, potent regulation by GATA-4 and Nkx2.5

Adenosine acts via A1 adenosine receptors (A1ARs) in the heart and brain to potently influence mammalian physiology. A1ARs are expressed very early in embryonic development, and A1ARs are among the earliest expressed G protein coupled receptors in the heart and brain. To understand the biologic basis of A1AR expression, a genomic fragment containing the murine A1AR promoter was cloned. Reporter assay studies using DDT1 MF2 cells that express A1ARs revealed that 500 base pairs of the proximal A1AR promoter contained essential elements for A1AR gene expression. Transgenic mice with A1AR proximal promoter coupled with the beta-galactosidase reporter gene had heavy labeling of the brain and atria, consistent with normal patterns of A1AR expression. Within the proximal A1AR promoter, putative binding sites for cardiac transcription factors GATA and Nkx2.5 were identified. Co-expression studies revealed that GATA-4 and Nkx2.5 could individually drive A1AR promoter activity and act synergistically to activate A1AR expression. These observations suggest that embryonic A1AR expression involves activation of the A1AR promoter by GATA-4 and Nkx2.5.

A radiation hybrid map of the rat genome containing 5,255 markers

A whole-genome radiation hybrid (RH) panel was used to construct a high-resolution map of the rat genome based on microsatellite and gene markers. These include 3,019 new microsatellite markers described here for the first time and 1,714 microsatellite markers with known genetic locations, allowing comparison and integration of maps from different sources. A robust RH framework map containing 1,030 positions ordered with odds of at least 1,000:1 has been defined as a tool for mapping these markers, and for future RH mapping in the rat. More than 500 genes which have been mapped in mouse and/or human were localized with respect to the rat RH framework, allowing the construction of detailed rat-mouse and rat-human comparative maps and illustrating the power of the RH approach for comparative mapping.

Effective treatment of localized Darier's disease with adapalene 0.1% gel

Darier's disease is an autosomal dominant disorder of keratinization that can produce unique clinical manifestations. Oral and topical retinoid products have been the mainstay therapy for this population, but local as well as systemic side effects often limit their effectiveness. A case of localized Darier's disease is presented that responded promptly and with no side effects to the topical application of adapalene 0.1% gel. A review of treatments for Darier's disease is presented.

The transfer of two embryos instead of three to reduce the risk of multiple pregnancy: a retrospective analysis

PURPOSE

Our purpose was to investigate whether a reduction in the number of embryos transferred from three to two would help reduce the incidence of multiple pregnancies and yet leave the pregnancy rate unaffected.

METHODS

Women were treated in a routine clinical in vitro fertilization program and the results analyzed retrospectively.

RESULTS

There was no reduction in the pregnancy rate when two embryos were transferred compared with three. Indeed, there was actually an increase in pregnancy rate after the transfer of two embryos in those cases with one or more embryos remaining after the transfer.

CONCLUSIONS

The transfer of only two embryos compared to three in women younger than 40 years of age does not compromise the chance of pregnancy. Triplets were not seen in the limited series of patients when only two embryos were transferred, but the incidence of twins remained the same. Further consideration should be given to strategies that enable the transfer of single embryos without compromising the pregnancy rate.

A physical map of 30,000 human genes

A map of 30,181 human gene-based markers was assembled and integrated with the current genetic map by radiation hybrid mapping. The new gene map contains nearly twice as many genes as the previous release, includes most genes that encode proteins of known function, and is twofold to threefold more accurate than the previous version. A redesigned, more informative and functional World Wide Web site (www.ncbi.nlm.nih.gov/genemap) provides the mapping information and associated data and annotations. This resource constitutes an important infrastructure and tool for the study of complex genetic traits, the positional cloning of disease genes, the cross-referencing of mammalian genomes, and validated human transcribed sequences for large-scale studies of gene expression.

Quality of life of elderly patients with isolated systolic hypertension: baseline data from the Syst-Eur trial. Syst-Eur Trial Investigators

OBJECTIVE

To describe measures of quality of life of elderly patients with isolated systolic hypertension at entry to a placebo-controlled randomized trial of antihypertensive treatment and to investigate factors associated with these.

DESIGN

Cross-sectional analyses at entry to a randomized controlled trial.

SETTING

Patients attending hypertension clinics or general practitioners' surgeries at 30 centres in 10 European countries.

PATIENTS

Six hundred and thirty-one patients aged 60 years or more, with a sitting systolic blood pressure during the run-in phase of 160-219 mmHg, a sitting diastolic blood pressure below 95 mmHg and a standing systolic blood pressure of 140 mmHg or more.

MAIN OUTCOME MEASURES

Cognitive function tests (Reitan Trail Making A and B), Brief Assessment Index (a measure of depressed mood) and four subscales from the Sickness Impact Profile (Ambulation, Social Interaction, Sleep and Rest and Housework).

RESULTS

Poor quality of life was generally associated with increasing age, previous treatment with antihypertensive drugs, presence of cardiovascular complications and, among women, high diastolic blood pressure, higher consumption of alcohol and high body mass index.

CONCLUSIONS

At entry to the trial there was considerable heterogeneity of patients in terms of measures of quality of life and cognitive performance. It remains to be determined whether these influence subsequent quality of life during randomized treatment.

Identification of a major susceptibility locus on chromosome 6p and evidence for further disease loci revealed by a two stage genome-wide search in psoriasis

Psoriasis is a common chronic inflammatory disorder of the skin. To further understand the pathogenesis of psoriasis we have chosen to investigate the molecular genetic basis of the disorder. We have used a two-stage approach to search the human genome for the location of genes conferring susceptibility to psoriasis, using a total of 106 affected sibling pairs identified from 68 independent families. As over a third of the extended kindreds included affected relatives besides siblings, in addition to an analysis of allele sharing between affected sibling pairs, a novel linkage strategy was applied that extracts full non-parametric information. Four principal regions of possible linkage were identified on chromosomes 2, 8, 20 (p <0.005) and markers from the MHC region at 6p21 (p <0.0000006) for which significant evidence of linkage disequilibrium was also observed (p <0.00002). Whilst data from limited case control associations exist to implicate the MHC, the results of this genome wide analysis demonstrate that, at least in the population studied, a gene or genes located within the MHC and close to the class 1 HLA loci, represent the major determinant of the genetic basis of psoriasis.

Location of the first genetic locus, PKDr1, controlling autosomal dominant polycystic kidney disease in Han:SPRD cy/+ rat

The Han:SPRD cy/+ strain develops a form of slowly progressive disease that appears similar in many respects to that seen in the autosomal dominant polycystic kidney disease (ADPKD) in humans. We have performed a total genome scan in an experimental backcross population derived from affected Han:SPRD cy/+ rat (PKD) and non-affected Wistar Ottawa Karlsburg rat (WOK) using 117 microsatellite markers. The genetic dissection of PKD allowed us to map on rat chromosome 5, a quantitative trait locus (QTL) controlling PKD, kidney mass and plasma urea concentration. The homology region is likely to reside on human chromosome 8. The gene responsible for PKD in Han:SPRD cy/+ rat is neither PKD1, localised on human chromosome 16, nor PKD2, localised on human chromosome 4. Therefore, we propose that this new locus be denoted PKDr1. The detection of the PKDr1 locus and associated QTL should accelerate research into the genetic causes of ADPKD.

Research directions in male sex work

This paper provides a critical review of the literature relating to male sex work and outlines approaches to theorizing about and researching male sex work. The adequacy of these models to explain the male sex work industry is discussed. The literature reveals that earlier studies conceptualized male sex work as deviance and focused on the individual sex worker and his reasons for engaging in sex work. Although the research agenda has recently moved away from the individual sex worker towards the sex work industry, the focus of the investigation continues to be from a deviance rather than a work perspective. A number of aspects of male sex work have received little attention in the literature. These include the interpersonal dialogues and power relations that constitute the commercial sexual negotiation, the role of political and economic forces, and expressions of male sexuality within the practice of commercial sex. The paper suggests future research directions and argues that researchers need to draw on the strengths of the male sex work community in order to promote safe sex practices in commercial researchers need to draw on the strengths of the male sex work community in order to promote safe sex practices in commercial sexual settings.

A row-action alternative to the EM algorithm for maximizing likelihood in emission tomography

The maximum likelihood (ML) approach to estimating the radioactive distribution in the body cross section has become very popular among researchers in emission computed tomography (ECT) since it has been shown to provide very good images compared to those produced with the conventional filtered backprojection (FBP) algorithm. The expectation maximization (EM) algorithm is an often-used iterative approach for maximizing the Poisson likelihood in ECT because of its attractive theoretical and practical properties. Its major disadvantage is that, due to its slow rate of convergence, a large amount of computation is often required to achieve an acceptable image. Here, the authors present a row-action maximum likelihood algorithm (RAMLA) as an alternative to the EM algorithm for maximizing the Poisson likelihood in ECT. The authors deduce the convergence properties of this algorithm and demonstrate by way of computer simulations that the early iterates of RAMLA increase the Poisson likelihood in ECT at an order of magnitude faster that the standard EM algorithm. Specifically, the authors show that, from the point of view of measuring total radionuclide uptake in simulated brain phantoms, iterations 1, 2, 3, and 4 of RAMLA perform at least as well as iterations 45, 60, 70, and 80, respectively, of EM. Moreover, the authors show that iterations 1, 2, 3, and 4 of RAMLA achieve comparable likelihood values as iterations 45, 60, 70, and 80, respectively, of EM. The authors also present a modified version of a recent fast ordered subsets EM (OS-EM) algorithm and show that RAMLA is a special case of this modified OS-EM. Furthermore, the authors show that their modification converges to a ML solution whereas the standard OS-EM does not.

Preparation of antisera to recombinant, soluble N-acetylglucosaminyltransferase V and its visualization in situ

N-Acetylglucosaminyltransferase V (GlcNAc-T V) is a glycosyltransferase which transfers N-acetylglucosamine in beta(1,6) linkage to the alpha(1,6)-linked mannose residue of Asn-linked oligosaccharides. This enzyme is characterized by several unusual properties: GlcNAc-T V is the largest lumenal Golgi glycosyltransferase described thus far, and its multiple mRNA transcripts range from 4.5 to about 9.5 kb; GlcNAc-T V mRNA and activity are regulated by the src tyrosine kinase signalling pathway; in brain tissue, large levels of GlcNAc-T V mRNA are present, but only relatively low levels of catalytic activity can be detected; a lectin-resistant cell line, Lec4A, expresses active GlcNAc-T V which is mislocalized intracellularly. In addition, the cell surface oligosaccharide products of this enzyme have been hypothesized to regulate intercellular adhesion. In order to devise specific inhibitors of this enzyme it is necessary to understand its physical structure and how structural changes can influence its activity and localization. We have expressed milligram amounts of a soluble form of recombinant rat GlcNAc-T V, purified it from CHO cell-conditioned media, and used it to prepare specific antisera. This antisera binds selectively to GlcNAc-T V and has been used to visualize B-16 mouse melanoma cell GlcNAc-T V on immunoblots after SDS-PAGE. When the antisera was used in immunofluorescence microscopy experiments on permeabilized B-16 and baby hamster kidney cells, intense, specific staining was observed in intracellular structures which appear to correspond to the Golgi apparatus.

The social meanings behind male sex work: implications for sexual interactions

This qualitative study explores the meanings of the commercial sexual encounter between male sex workers and their clients. The study highlights the various social meanings male sex workers attribute to having sex, their typologies of clients, the psychic contexts of male commercial sex, safer sex interactions, and how these issues inform sexual behaviour. The data shows that the meaning attached to the act of having sex is an important aspect of the way in which participants perceive their partners, conduct themselves during sexual encounters, and engage in safe sex practices. Clients are categorized by sex workers according to their perceptions of 'them', which include 'marrieds', 'easy trade', 'undesirables', 'sugar daddies' and 'heaven trade'. Different types of clients pose alternate levels of risk to the safe sex practices of sex workers. The sex worker's definition of commercial sex as work enables him to separate work and personal sex and define work sex as 'not real sex', in which safe sex practices symbolize both the degree of self that is shared and protective work equipment. It was also found that this sample of sex workers do not negotiate safe sex. Rather they use 'modes of interaction' which direct the encounter either towards safe sex, or they refuse to continue with the transaction. The interactive modes identified are 'natural', 'educative', 'challenge', 'other options' and 'walk-out'. These modes of interaction are effective strategies for ensuring safe sex, and can be used by the broader community to gain partner compliance in safe sex practices.

Anaesthesia for thyroplasty

The purpose of this report is to describe the anaesthetic considerations for layngoplastic procedures. Thyroplasty is a procedure which restores the voice in unilateral vocal cord paralysis. The procedure employs an external approach via a window cut at the appropriate level in the thyroid ala. A wedge of silastic is inserted against the inner perichondrium, thereby displacing the vocal cord medially and permitting voice production. Correct placement of the implant is assessed by asking the patient to phonate; patient cooperation is therefore necessary at certain times during the procedure. We describe our management of a patient undergoing thyroplasty. The use of a benzodiazepine agonist-antagonist combination provided both optimal operating conditions and patient comfort.

Onchocerca volvulus: a comparative study of in vitro neutrophil killing of microfilariae and humoral responses in infected and endemic normals

In vitro neutrophil-mediated microfilarial killing, humoral responses to crude adult worm antigens (OVAg) and to four recombinant Onchocerca antigens (GST-OV7, GST-OV103, GST-OV3.6, and MBP-OV16), as well as Western blot analysis to stage-specific Onchocerca proteins were studied in individuals from Bassa County, Liberia, infected with onchocerciasis and in endemic normals, defined as individuals without microfilaridermia. Both groups exhibited high levels of specific serum-dependent killing of microfilariae but could not be differentiated on the basis of these results. However, infected individuals had a significantly higher frequency of antibody response to OVAg (P = 0.0001) except GST-OV103. Based on the pattern of response to the different antigens, 17 categories of specific recognition were observed. Nine of these categories were common to both the infected individuals and the endemic normals, 2 were unique to the infected individuals, and 6 were unique to the endemic normals. Among the endemic normals, we identified a subcategory of individuals who had nondetectable levels of total IgG to OVAg by ELISA and had significantly lower IgG4 responses to OVAg. These same individuals demonstrated evidence of past infection, based on serum antibodies detectable by Western blot analysis to male and female adult worms and skin microfilariae, and had a positive response to two or less of the recombinant antigens. We believe that this subcategory may represent individuals with a unique status of immunity.

Onchocerca volvulus: in vitro cytotoxic effects of human neutrophils and serum on third-stage larvae

The cytotoxic effects of neutrophils co-cultured with infective third-stage larvae (L3) and autologous serum from three groups of individuals: infected (INF), non-patent endemic normals (EN) and non-endemic controls (NEC), were compared using a MTT (3-(4,5 dimethylthiazol-2yl)-2,5 diphenyl tetrazolium bromide) reduction assay as a biochemical parameter of larval viability. The MTT assay permitted the detection of L3 which had suffered varying levels of necrosis. The observations from this study indicate that infected individuals and endemic normals are capable of mounting a specific immune response against the infective L3. This is based on our findings of i) significantly greater numbers of L3 showed necrosis in neutrophil cultures of the INF and EN compared to those from the NEC, ii) a superior ability of cultures from these individuals to inhibit the molting of L3 to fourth-stage larvae, iii) IgG antibodies reactive with the surface of L3, detected by immunofluorescence in the serum of the INF and the EN and iv) recognition of specific antigens in extracts of L3 detected by Western blot analysis. The specific immune response directed against L3 is probably a significant immunological defense mechanism used to limit infection in endemic areas.

The relationship of fasting insulin levels to vascular risk factors in a general practice in Northern Ireland

OBJECTIVE

To investigate the relationship between insulin and vascular risk factors in a healthy male population at high risk of ischaemic heart disease.

DESIGN

Computer-generated random number selection of subjects.

SETTING

A suburban general practice population (total practice population 4500) in Northern Ireland.

SUBJECTS

Four hundred male subjects, aged 35-65 years, were randomly selected with 273 responding.

INTERVENTION

At interview, each subject completed a questionnaire, had blood pressure measured and a 12-lead ECG recorded. The next morning, fasting blood samples were taken and a timed overnight urine collection for the albumin excretion rate was returned.

RESULTS

To exclude the confounding effects of other variables on insulin concentrations, a healthy nonobese, nondiabetic, normotensive group with no history of ischaemic heart disease, no family history of diabetes and not taking drugs was identified (n = 120). Within this group there was a significant correlation between insulin and triglyceride (r = 0.30; P < 0.05), high-density lipoprotein (HDL) cholesterol (r = 0.24; P < 0.05) and glucose (r = 0.30; P < 0.05). A group with higher insulin levels (n = 22) were compared to a group with lower insulin levels (n = 22). Serum triglyceride was higher (1.29 +/- 0.1 vs. 1.00 +/- 0.08 mmol L-1; P < 0.05), HDL cholesterol was lower (1.26 +/- 0.06 vs. 1.50 +/- 0.09 mmol L-1; P < 0.05) and plasma glucose higher (5.2 +/- 0.1 vs. 4.9 +/- 0.1 mmol L-1; P < 0.05) in the group with higher insulin levels.

CONCLUSIONS

There is a relationship between insulin and triglyceride, HDL cholesterol and glucose but not blood pressure, cholesterol or low-density-lipoprotein (LDL) cholesterol in a healthy population at high risk of ischaemic heart disease.

Asking effective questions: an important leadership role to support quality improvement

Effective questions stimulate, guide, and empower employees to think critically about the improvement processes that they are involved in as team leaders or team members in their daily activities. Learn how questions must be carefully phrased in order to provide guidance and maintain the integrity of the team's ability to choose options and implement change.

Microalbuminuria does not predict cardiovascular disease in a normal general practice population

Recent studies have suggested that microalbuminuria is relatively common (9.4%) in non-diabetic subjects and that it is an excellent marker for increased cardiovascular risk. In an attempt to assess the prevalence of microalbuminuria in Northern Ireland where there is a high incidence of coronary heart disease, we studied 400 males, age 35-65 years, chosen at random from a Belfast general practice. There was a 73% response rate (n = 273). Sixteen per cent of the population has ischaemic heart disease. Microalbuminuria was defined as an increased urinary albumin excretion rate of 20-200 ug min-1. Thirteen subjects (4.7%) had an albumin excretion rate of 20 ug min-1 or more. After exclusion of subjects with diabetes mellitus or renal diseases, the group with microalbuminuria (n = 8), was compared to those without microalbuminuria (n = 256). There was no significant difference in the incidence of ischaemic heart disease between the two groups, nor did the group with microalbuminuria have a more adverse profile of vascular risk factors, apart from serum triglyceride (1.8 +/- 0.2 v 1.3 +/- 0.0 mmol l-1, p < 0.05) and plasma glucose (5.5 +/- 0.3 v 5.1 +/- 0.3 mmol l-1, p < 0.05) levels. We conclude that in a general practice from an area at high risk of ischaemic heart disease, the prevalence of microalbuminuria was low. Contrary to previous reports, microalbuminuria was not helpful in predicting subjects at risk of ischaemic heart disease.