628 Management of Chyle Leaks Following Oesophagectomy: A Systematic Review

Aim

Chyle leakage is a rare but potentially life-threatening complication following oesophageal resection. The optimal management strategy is not clear.

Method

Searches were conducted up to 31/12/2020 on MEDLINE, Embase and Web of Science for randomised trials or retrospective studies that evaluated the management of chyle leakage following oesophageal resection. Two authors independently screened studies extracted data and assessed for bias. The protocol was prospectively registered on PROSPERO (CRD: 42021224895) and reported in accordance with PRISMA guidelines.

Results

A total of 530 citations were reviewed. Twenty-five studies, totaling 1016 patients met the inclusion criteria, including 2 low-quality clinical trials and 23 retrospective case series. Heterogeneity of study design and outcomes prevented meta-analysis. The overall incidence of chyle leaks was 3.2% but no consistent risk factors were found across studies. Eighteen studies describe management of chyle leaks conservatively, 17 by surgical ligation of the thoracic duct, and 6 described percutaneous lymphangiography with thoracic duct embolisation (TDE) or disruption (TDD). There is a paucity of high-quality prospective studies directly comparing treatment modalities, but there is some low-certainty evidence that percutaneous approaches have reduced morbidity, but lower efficacy compared to surgery.

Conclusions

The evidence-base for optimal management of chyle leakage post-oesophagectomy is lacking, which may be related to its low incidence. Further high quality, prospective studies that compare interventions at different levels of severity are needed to determine the optimal approach to treatment.

Dystrophic calcinosis cutis successfully treated with extracorporeal shockwave lithotripsy

This case illustrates a presentation with dystrophic calcinosis cutis recalcitrant to several treatment modalities. Treatment with extracorporeal shockwave lithotripsy was initiated with near complete resolution of calcium deposits.

Radiotherapy, immunotherapy, and the tumour microenvironment: Turning an immunosuppressive milieu into a therapeutic opportunity

Immune checkpoint blockade (ICB) has revolutionised the treatment of solid tumours, yet most patients do not derive a clinical benefit. Resistance to ICB is often contingent on the tumour microenvironment (TME) and modulating aspects of this immunosuppressive milieu is a goal of combination treatment approaches. Radiation has been used for over a century in the management of cancer with more than half of all cancer patients receiving radiotherapy. Here, we outline the rationale behind combining radiotherapy with ICB, a potential synergy through mutually beneficial remodelling of the TME. We discuss the pleiotropic effects radiation has on the TME including immunogenic cell death, activation of cytosolic DNA sensors, remodelling the stroma and vasculature, and paradoxical infiltration of both anti-tumour and suppressive immune cell populations. These events depend on the radiation dose and fractionation and optimising these parameters will be key to develop safe and effective combination regimens. Finally, we highlight ongoing efforts that combine radiation, immunotherapy and inhibitors of DNA damage response, which can help achieve a favourable equilibrium between the immunogenic and tolerogenic effects of radiation on the immune microenvironment.

'Flower of the body': menstrual experiences and needs of young adolescent women with cerebral palsy in Bangladesh, and their mothers providing menstrual support

Background

This study offers voice to young adolescent women with cerebral palsy (CP) in Bangladesh as they describe their menstrual experiences and needs, and their mothers providing menstrual support.

Method

Semi-structured focus groups with adolescents with CP, and separately their mother. Data was analysed using a material discursive framework and drawing on feminist disability theory. Participants were recruited from the Bangladesh CP Register (BCPR); a population-based surveillance of children and adolescents with CP in rural Bangladesh.

Results

Participants were 45 women including 12 female adolescents with CP and 33 female caregivers. Participants reported a wide range of experiences and needs; menarche acted as a gateway to menstrual information although for some a discourse of silence prevailed due to exclusion from peer and familial networks. Menstruation was discursively constructed as a sign of ‘female maturation’ marked by an expectation of ‘independence’, required for acceptance into socially valued adult roles, and was positioned alongside increased vulnerability to sexual abuse. Young adolescent women with CP were expected to ‘quietly endure’ the material aspects of menstruation although unmanaged pain and distress were described. Mothers reported an imperative for meeting their adolescent’s menstrual needs however this role was discursively positioned as ‘painful’, ‘irritating’ and ‘shameful’, in part due to an absence of affordable, functional menstrual resources.

Conclusion

The findings of the present study provide motivation for disability services in Bangladesh to account for the menstrual needs of young adolescent women with CP within service delivery through strategies such as providing menstrual education and by embedding value in constructs such as ‘interdependence’. Moreover, interventions focused on alleviating menstrual pain among young adolescent women with CP as well as those targeted to alleviate distress among mothers providing menstrual care are required. Finally, policy responses are required to ensure that ‘inclusive development’ considers the needs of menstruating women with disability.

Familiality and SNP heritability of age at onset and episodicity in major depressive disorder

BACKGROUND

Strategies to dissect phenotypic and genetic heterogeneity of major depressive disorder (MDD) have mainly relied on subphenotypes, such as age at onset (AAO) and recurrence/episodicity. Yet, evidence on whether these subphenotypes are familial or heritable is scarce. The aims of this study are to investigate the familiality of AAO and episode frequency in MDD and to assess the proportion of their variance explained by common single nucleotide polymorphisms (SNP heritability).

METHOD

For investigating familiality, we used 691 families with 2-5 full siblings with recurrent MDD from the DeNt study. We fitted (square root) AAO and episode count in a linear and a negative binomial mixed model, respectively, with family as random effect and adjusting for sex, age and center. The strength of familiality was assessed with intraclass correlation coefficients (ICC). For estimating SNP heritabilities, we used 3468 unrelated MDD cases from the RADIANT and GSK Munich studies. After similarly adjusting for covariates, derived residuals were used with the GREML method in GCTA (genome-wide complex trait analysis) software.

RESULTS

Significant familial clustering was found for both AAO (ICC = 0.28) and episodicity (ICC = 0.07). We calculated from respective ICC estimates the maximal additive heritability of AAO (0.56) and episodicity (0.15). SNP heritability of AAO was 0.17 (p = 0.04); analysis was underpowered for calculating SNP heritability of episodicity.

CONCLUSIONS

AAO and episodicity aggregate in families to a moderate and small degree, respectively. AAO is under stronger additive genetic control than episodicity. Larger samples are needed to calculate the SNP heritability of episodicity. The described statistical framework could be useful in future analyses.

Hardship, dedication and investment: an exploration of Irish mothers commitment to communicating with their children with cerebral palsy

This qualitative study investigated the experiences of mothers who have a child with communication difficulties resulting from cerebral palsy (CP). There is a dearth of information about parents' experiences of having a child with CP and communication difficulties. Three participants, whose children had moderate or severe CP and communication difficulties, were recruited from a voluntary organization. Participants were interviewed using an in-depth, semi-structured interview guide. Interviews were audio-recorded, then transcribed and subsequently analysed using Grounded Theory methods. Five main themes emerged, combining to form the core category of mothers dedicating their attention to their children. The information gleaned from this study could have important implications for nurses involved in facilitating communication, including speech and language therapists, occupational therapists and registered nurses. By becoming more aware of the experiences of parents with a child with CP and communication disorders, nurses may be better able to plan and implement therapy and also support communication aims. The study concludes with a discussion of further research avenues, suggesting that a study investigating the experiences of parents of children with other types of physical disabilities affecting communication should be conducted to determine the similarities and differences of parents of children with other kinds of disability. A similar study with a larger sample could be conducted to validate the findings of the current study.

“Just using old works”: injecting risk behaviour in prison

A minority of injecting drug users engage in high risk injecting behaviours when in prison. In the United Kingdom between a quarter and a third of injectors who enter prison inject when in prison, and of these about three-quarters share needles and syringes. In the present study, 44 drug injectors who had been released from prison for no longer than 6 months were recruited and interviewed in three geographical areas in England. Interviewees were asked to recount their experiences of drug use during their most recent period of imprisonment. The majority of interviewees were male (38/44), had a mean age of 28 years, with a mean age of 16 years at first drug use, were primarily opiate users (39) and had multiple imprisonments. All respondents reported drug use when imprisoned and drug injecting was reported by 16 interviewees. Most injected at irregular intervals and at a reduced level, compared with injecting when in the community. Nine reported using needles and syringes that others had previously used. When considering other injecting equipment, more sharing occurred than was actually reported. Much re-use of equipment was viewed simply as "using old works". The sharing of "cookers" and "filters", and drug sharing by "backloading" and "frontloading" were common. The concept of "sharing" tended to be understood by respondents as related to the use of tools of injection (needles and syringes rather than other equipment); the use of tools in the act of injection (rather than for mixing drugs); proximity (multiple use of needles and syringes in the presence of others); temporality (shorter time elapse between consecutive use of needles and syringes previously used by another) and source (hired rather than borrowed or bought). We conclude that syringe sharing is an integral part of drug use and drug injecting in prison. Many of those interviewed displayed a restricted understanding of what denotes syringe sharing. Our data reinforce the need for interventions and initiatives to be developed within prisons to deal with the considerable risk posed by continued injecting drug use.

Risky sexual behaviour in context: qualitative results from an investigation into risk factors for seroconversion among gay men who test for HIV

OBJECTIVES

The INSIGHT case-control study confirmed that HIV serodiscordant unprotected anal intercourse (SdUAI) remains the primary risk factor for HIV infection in gay men in England. This paper uses qualitative follow-up data to examine the contexts of SdUAI and other risk factors among the case-control study participants.

METHODS

In-depth interviews were conducted with 26 recent HIV seroconverters and 22 non-converters. Purposive selection was used to provide diversity in demographics and sexual behaviour and to facilitate exploration of risk factors identified in the case-control study.

RESULTS

Condoms were perceived as barriers to intimacy, trust and spontaneity. The potential consequences of the loss of these were traded off against the consequences of HIV infection. Previous negative HIV tests and the adoption of risk reduction strategies diminished the perceived threat of HIV infection, supporting beliefs that HIV was something that happened to others. Depression and low self-esteem, often combined with use of alcohol or other drugs, led to further risk taking and loss of control over risk reduction strategies.

CONCLUSIONS

A range of psychosocial reasons led some men to engage in UAI with serodiscordant or unknown partners, despite high levels of risk awareness. Men in their mid-life, those in serodiscordant relationships and men that had experienced bereavement or other significant, negative, life events revealed factors related to these circumstances that contributed to increases in risky UAI. A diverse portfolio of interventions is required to build confidence and control over safer sex practices that are responsive to gay men's wider emotional needs.

Prevalences and correlates of non-viral injecting-related injuries and diseases in a convenience sample of Australian injecting drug users

BACKGROUND

The prevalences and correlates of non-viral injecting-related injuries and diseases (IRIDs) in Australian injecting drug users (IDUs) remain unknown.

METHODS

A cross-sectional survey of IDUs was conducted in six sites across Australia's eastern states to investigate IRID experience among Australian IDU. Correlates of IRIDs were explored using logistic and negative binomial regression analyses.

RESULTS

393 IDUs were recruited. Lifetime experience of non-serious IRIDs was common (e.g., 'dirty hit' 68%); potentially serious and serious IRIDs were less commonly experienced (e.g., abscess 16%; gangrene <1%). Factors independently associated with potentially serious or serious IRIDs in the previous 12 months were: injecting in sites other than arms (Adjusted Odds Ratio 3.0, 95% confidence interval 1.7-5.4), injecting non-powder drug forms (5.0, 2.2-11.2), unstable accommodation (2.0, 1.1-3.5), being aged 25 years or older (4.3, 1.7-10.6) and not always washing hands before injection (9.3, 2.1-41.8). Factors independently associated with multiple IRIDs in the preceding 12 months were using three or more injecting sites (Adjusted Incidence Rate Ratio 1.5, 95% CI 1.1-2.0), injecting in sites other than arms (1.7, 1.3-2.2), using non-powder drug forms (1.9, 1.4-2.5), injecting daily or more often (1.7, 1.3-2.2), current pharmacotherapy experience (1.5, 1.1-1.9), and not always washing hands before injecting (1.9, 1.2-2.9).

DISCUSSION

Some IRIDs are widespread among Australian IDUs. Observed associations, particularly the protective effect of handwashing, have useful public health implications.

A formative evaluation of the potential role of nurse practitioners in a central London HIV outpatient clinic

In-house audit demonstrated that 49% (173/352) of patients attending routine HIV outpatient care are asymptomatic and have needs that could potentially be met by other health care professionals. We therefore evaluated the potential development and acceptability of nurse practitioner roles in contributing to HIV outpatient care. Data were collected through 26 consultation observations, 25 patient interviews, 2 patient focus groups, 22 provider interviews and 8 provider focus groups. Service users were key members of the evaluation team. With increasing HIV incidence and the change in focus of doctor-patient consultations from acute to chronic disease management, there are concerns about the sustainability of easily available routine HIV outpatient appointments using the same model of care that has prevailed over the past 20 years. Nurse practitioner models of care were considered acceptable for asymptomatic patients, including those who do not have complex issues related to highly active antiretroviral therapy (HAART). Key considerations for the role include training, supervision, referral pathways, and a clear understanding of the limitations of nursing practice. There is an emphasis on the need to consider 'new ways of working' throughout the service, rather than merely substituting or transferring clinical roles between professionals. Funding pending, nurse practitioner roles are planned for implementation in late 2004. Evaluation will determine impact on service utilization, health and economic outcomes.

Survivorship of the Charnley Elite Plus cemented femoral stem

We report the results of the Charnley Elite Plus femoral stem in multiple surgeons' hands at a minimum of 3 years after implantation. Over a 4-year period, 244 patients underwent 268 primary hip arthroplasty procedures using this particular stem. Patients underwent postal and radiographic review at a mean of 4.5 (3.0--6.8) years following their arthroplasty. There were five revision procedures for aseptic loosening (5/268; 1.9%). Radiological assessment revealed gross radiological failure in a further 12 femoral stems (12/208; 5.8%). In the best case scenario, using revision for aseptic loosening as the endpoint, the survivorship for this period was 98.1%. If radiographic failures are incorporated into this endpoint, survivorship is 93.1%. This failure rate at an early stage raises concerns as to the long-term survivorship of this prosthesis.

Developing complex interventions for rigorous evaluation--a case study from rural Zimbabwe

Much attention has been placed on the need to develop and evaluate complex interventions targeting public health issues, such as reproductive health. However, and as has been the case in the recent past, even well-designed trials will be flawed unless meticulous attention is paid to ensuring the most appropriate intervention is designed and developed. This requires a well-resourced and carefully planned feasibility study, incorporating both formative and process evaluation, with particular attention being paid to the context of the proposed intervention. In this paper, we describe the way in which a feasibility study helped redesign and shape a complex intervention targeting adolescent sexual health in rural Zimbabwe. By using a mixture of in-depth interviews, focus groups and participant observation with pupils, parents, teachers and education officers, we were able to show that the intervention as originally conceived was unlikely to be deliverable. Process evaluation findings from the feasibility study led to substantial changes to both the content and delivery of the proposed intervention, which is now subject to testing for effectiveness in a large community randomized trial.

An agenda for future research on HIV and sexual behaviour among African migrant communities in the UK

The epidemiology of the recent rise in HIV cases in Britain highlights the need for more research among the heterosexual African migrant population. New research should not, however, only extend the limited number of studies that describe observable patterns in sexual health but should also seek to determine their underlying social causation. To achieve this, both methodological and ontological shifts are necessary in the existing research paradigm; we advocate that a broad range of qualitative techniques be deployed both to uncover the empirical details of specifically African sexual behaviours and to highlight and explore the 'relational' nature of sexual decision-making. Rather than fixing on individuals, analysis must situate them within the broader discursive and material frames that structure the boundaries of decision-making. In addition, researchers need to utilise the parallel literature on the social embeddedness of HIV in Africa to inform analysis of the British context. It would then be possible to address the crucial question of whether the social conditions known to cause high-risk behaviours and facilitate transmission in Africa persist, or are transformed, after migration to the UK. A key, and neglected, dimension of this is the role of spatial context in relational sexual decision-making and the constitution of social relationships in particular arenas. This needs further thought, particularly in relation to domestic space and gender identities. We believe that the research agenda proposed herein has much to contribute to interventions and service provision. Nevertheless, we are mindful of the need for self-reflexivity about our role in the production of powerful knowledges about sex. Our final proposal is that researchers seek ways to work with, not on, African communities in order to facilitate their own informed management of sexual health.

A qualitative study of the psychosocial implications of lipodystrophy syndrome on HIV positive individuals

OBJECTIVES

To investigate the psychosocial impact of lipodystrophy on the lifestyles of HIV positive patients on highly active antiretroviral therapy (HAART).

METHODS

In-depth interviews were conducted with 14 HIV positive patients on HAART at an outpatient sexually transmitted infections (STI) and HIV clinic in central London. Qualitative data from interview transcripts were analysed using grounded theory to elicit key categories and subcategories.

RESULTS

Three main themes relating to lipodystrophy emerged: effect on the individual; impact on the social world of the individual; responses of the individual. Lipodystrophy had physical and psychological effects, ranging from bodily discomfort to low self esteem and depression. Owing to its physical manifestations it was viewed as a visible marker of HIV disease. At the level of social functioning, lipodystrophy led to problems with personal and family relationships, although having a partner was protective. Individuals reported narrowing their social world, in some cases to degrees of social isolation. Individual responses included changes in diet, increased exercise regimes, steroid use and plastic surgery (mainly collagen injections to the face). For those who had experienced serious illness related to HIV, there was a more sanguine acceptance of lipodystrophy as an unfortunate consequence of longevity and drug therapy

CONCLUSIONS

Health professionals need to address the psychosocial implications of lipodystrophy, including the ways in which it may affect different groups and their adherence to therapy. Formative evaluations are needed to assess the potential for targeted interventions.

Improving young people's access to reproductive health care in rural Zimbabwe

The aim of this study was to explore ways to improve the accessibility of clinics for young people with reproductive health problems in rural Zimbabwe. This study, which took place in rural Masvingo, was part of a project to develop a comprehensive adolescent reproductive health intervention for Zimbabwean youth. Six focus group discussions were held with secondary school pupils aged 16-19; four focus group discussions were held with nurses. Additionally, 16 community meetings with parents of adolescents were observed. The data were analyzed using the principles of grounded theory: three main categories and several sub-categories emerged from the data. The accessibility of existing services for young people was poor, partly because nurses were reluctant to provide such services due to lack of clarity in legislation and also through fear of condoning adolescent sexual activity. Although the clinical acumen of staff was recognized as sound, service delivery was perceived to be judgemental and lacking in confidentiality and privacy. This reflects the cultural context in which services are delivered. Culturally, adolescents are deemed to be children and as such to have few rights. There is a widely held belief that teaching young people about sex will promote sexual activity. Our findings suggested that staff training should focus on attitudinal rather than medical issues.

Sexual health clinics for women led by specialist nurses or senior house officers in a central London GUM service: a randomised controlled trial

OBJECTIVES

To assess the care process and clinical outcomes for two different models of GUM clinic for women: one led by specialist nurses and the other by senior house officers (SHOs).

METHOD

An open randomised controlled trial was carried out in a central London genitourinary medicine (GUM) women's clinic. Of 1172 women telephoning for an appointment, 880 were randomised to provide 169 eligible patients in the specialist nurse arm and 178 in the SHO arm. Of the eligible patients a total of 224 attended their appointment. The clinical records of the randomised women were audited for adequacy of care according to local guidelines. 30 key variables were objectively assessed and recorded on a standard audit form. An overall unitary index score (%) was calculated for each patient. The main variables associated with the outcome of specialist nurse and SHO decision making (diagnostic test request, preliminary diagnosis, and treatment provided) were then analysed independently.

RESULTS

The median documentation audit scores for specialist nurses (n=103) and SHOs (n=121) were 92% and 85% respectively (p<0.0001). The specialist nurses' documentation was significantly (p<0.05) more complete than the SHOs' for five variables: details of menstrual cycle, physical examination, medication instructions given to patients, health promotion discussion, and provision of condoms. Specialist nurses performed equally to the SHOs with regard to requesting the correct diagnostic tests, providing the correct preliminary diagnosis, and providing the correct treatment.

CONCLUSIONS

A model of care using trained GUM nurses working within agreed protocols can provide comprehensive patient care for female patients that is equal to care provided by SHOs. Our results raise important issues regarding advanced GUM nursing education and training, protocol development, and accountability.

A postal survey to identify and describe nurse led clinics in genitourinary medicine services across England

BACKGROUND

Nurses in genitourinary medicine (GUM) services are progressively extending their roles to conduct "comprehensive care" nurse led clinics. In such roles the nurse coordinates the first line, comprehensive care of patients presenting with sexual health conditions and issues.

OBJECTIVES

To identify and describe comprehensive care nurse led clinics in GUM services across England.

METHODS

A postal questionnaire consisting of 17 closed response questions was sent to 209 GUM services across England. A second questionnaire was sent to non-responders to increase the response rate. Data were single entered and analysed using SPSS.

RESULTS

Of the 190 GUM clinic respondents (91% response rate), 44 (23%) reported providing some form of comprehensive care nurse led clinic, 90% of which were initiated since 1995. Key results show staff development featured as the main reason for initiating such services and there was general consistency in the aspects of care undertaken by these nurses. There was evidence of guideline development specific to nurse led care and some patient group direction use for supplying medication. The level of support from medical staff while nurse led clinics were being conducted varied between services. Few services have conducted any audit or research to monitor/evaluate nurse led care. There was little consistency in the clinical experience and educational prerequisites to undertake comprehensive care nurse led clinics. Continuing professional development opportunities also varied between services.

CONCLUSIONS

The steady growth of comprehensive care nurse led clinics indicates that the skills of GUM nurses are being recognised. Nurses working in advanced practice roles now require courses and study days reflecting these changes in practice. Locally agreed practice guidelines can define nursing practice boundaries and ensure accountability, as will the development of patient group directions to supply medication. Monitoring and evaluation of nurse led clinics also require attention.

The application of qualitative research methods to the study of sexually transmitted infections

Qualitative methods have gained support in health sciences research and have a role to play in STI studies. This article reviews the main techniques used by qualitative researchers, with illustrations taken from the field of STIs.

Combination therapy with low dose sirolimus and tacrolimus is synergistic in preventing spontaneous and recurrent autoimmune diabetes in non-obese diabetic mice

AIMS/HYPOTHESIS

Sirolimus and tacrolimus are immunosuppressive drugs that prevent rejection of pancreatic islet allografts transplanted into patients with Type I (insulin-dependent) diabetes mellitus. This study aimed to determine whether sirolimus and tacrolimus can prevent autoimmune beta-cell destruction, and if so, what the mechanisms of action are.

METHODS

Sirolimus and tacrolimus were given separately and together to female non-obese diabetic (NOD) mice from age 12 to 35 weeks. Diabetes incidence was determined and pancreatic insulitis and insulin content were measured. Sirolimus and tacrolimus were also given separately and together to diabetic NOD mice from the time of syngeneic islet transplantation until the reappearance of hyperglycaemia. Islet grafts were examined by RT-PCR assay for expression of interferon (IFN)- gamma, interleukin (IL)-2, IL-4, IL-10 and transforming growth factor (TGF)- beta1.

RESULTS

Low doses of sirolimus (0.1 mg/kg) and tacrolimus (0.1 mg/kg) were synergistic in reducing insulitis, preserving pancreatic insulin content and preventing diabetes in female NOD mice (8 % diabetes incidence at 35 weeks vs 66 % in vehicle-treated mice). Also, the combination of sirolimus and tacrolimus prolonged syngeneic islet graft survival (median 34 days vs 13 days for vehicle-treated mice). Islet grafts from sirolimus plus tacrolimus-treated mice expressed significantly decreased mRNA contents of Th1-type cytokines (IFN- gamma and IL-2) and the highest ratio of TGF- beta1/IFN- gamma mRNA.

CONCLUSION/INTERPRETATION

These findings suggest that combination therapy with sirolimus and tacrolimus prevent autoimmune beta-cell destruction by upregulating expression of the immunoregulatory cytokine, TGF- beta1 and reducing Th1 cytokines (IFN- gamma and IL-2) expressed in the islets. Low-dose sirolimus and tacrolimus combination therapy could warrant consideration for prevention or early treatment of human Type I diabetes.

Sociodemographic characteristics associated with medical appointment adherence among HIV-seropositive patients seeking treatment in a county outpatient facility

BACKGROUND

Adherence is a major problem facing HIV-seropositive patients. Low adherence has been associated with faster disease progression as well as development of drug-resistant strains of HIV. Thus it is critical to understand factors associated with treatment compliance. This study examined the independent contributions of disease severity, age, gender, household income, homelessness, ethnicity, and sexual orientation on appointment adherence.

METHODS

Participants (n = 671) scheduled for appointments in an outpatient county treatment facility for HIV-related medical care completed demographic questionnaires and clinic staff collected appointment attendance data.

RESULTS

Multiple regression analyses indicated that patients diagnosed with AIDS, older in age, and receiving a higher income were more likely to keep medical appointments. Additionally, African American ethnicity and identifying as heterosexual were associated with missing scheduled medical appointments.

CONCLUSIONS

These data suggest that cultural and sociodemographic characteristics influence patients' adherence to outpatient services. Implications for interventions aimed at increasing medical adherence are discussed.

Mapping as a method for analysing policy response in the management of health services

Health services are susceptible to changes in health need, resource allocation, public-health debates and health policies. Service mapping is considered a useful tool for analysing complex issues, monitoring changes over time and facilitating change. It also enables one to describe pathways of care and the relationships between services. This article centres on two projects--a London-wide project 'Service networks for HIV Care' and a local survey 'Mapping of HIV-related services for illicit drug users'--and demonstrates the usefulness of mapping for both studies. Mapping of service networks allowed exploration of a variety of connections between treatment centres, and led to recommendations for a model of HIV service networks across London. The mapping of HIV-related services for illicit drug users confirmed that the service provision was balanced in time, space and target groups, but also identified gaps showing that services were not very successful in attracting women and members of ethnic minority groups. It is clear from both studies that mapping provides an overview of existing services, describing details of services, their target groups or links. It can assist to monitor changes over time, to reconfigure services according to need, and to target resources where need becomes apparent. Mapping exercises also can be useful in identifying new areas for collaboration and interagency work.

Developing a strategy for community-based health promotion targeting homeless populations

There is a need for targeted health promotion aimed at homeless populations. A survey of 100 Big Issue newspaper vendors was conducted, along with in-depth interviews and focus groups, in order to identify health promotion needs. Drug and alcohol problems, the effects of cold weather, nutritional deficiencies, and poor personal hygiene were reported as the main health concerns. However, health was not always an immediate priority for the homeless, with daily concerns predominating, such as shelter and getting money for food. A range of information needs were highlighted and a number of key health promotion topics identified. Social network and social activity data were collected from 14 Big Issue vendors to assess their penetration of groups of homeless people. Both generic and targeted health promotion activities are recommended, and the role of health advocacy and peer education should be further explored.

Testicular sertoli cells protect islet beta-cells from autoimmune destruction in NOD mice by a transforming growth factor-beta1-dependent mechanism

Testicular Sertoli cells protect pancreatic islet grafts from allo- and autoimmune destruction; however, the mechanism(s) of protection is unclear. The aim of this study was to determine whether Fas ligand (FasL) and/or transforming growth factor (TGF)-beta, immunoregulatory proteins produced by Sertoli cells, might mediate the protective effects of these cells against autoimmune destruction of islet beta-cells. Sertoli cells were purified from testes of NOD mice and implanted under the right renal capsule of diabetic NOD mice, whereas NOD islets were implanted under the left renal capsule. Of the mice that received islet and Sertoli cells grafts, 64% (9 of 14) remained normoglycemic at 60 days posttransplantation compared with 0% (0 of 6) of the mice that received islet grafts alone. Immunohistochemical examination of Sertoli cell grafts in normoglycemic mice revealed that TGF-beta1 expression by Sertoli cells remained high, whereas FasL expression by Sertoli cells decreased progressively posttransplantation. Also, plasma levels of TGF-beta1 were significantly elevated in mice that received Sertoli cells and islet grafts, and anti-TGF-beta1 antibody administration completely abrogated the protective effect of Sertoli cells on islet graft survival, whereas anti-FasL antibody did not. Islet graft destruction in anti-TGF-beta1-treated mice was associated with increases in interferon (IFN)-gamma-producing cells and decreases in interleukin (IL)-4-producing cells in the islet grafts. We conclude that 1) Sertoli cell production of TGF-beta1, not FasL, protects islet beta-cells from autoimmune destruction and 2) TGF-beta1 diverts islet-infiltrating cells from a beta-cell-destructive (IFN-gamma+) phenotype to a nondestructive (IL-4+) phenotype.

An evaluation of peer-led STD/HIV prevention work in a public sex environment

This paper describes an independent evaluation of a peer-led STD/HIV prevention intervention conducted by Gay Men Fighting AIDS (GMFA) in a public sex environment (PSE). A variety of quantitative and qualitative research methods were employed to collect data on the intervention process as well as its outcomes. The main aim of the intervention was the distribution of condoms and safer sex literature to PSE users. During a five-month period, over 100,000 condoms and 2,200 safer sex information packs were distributed by GMFA volunteers to the PSE users. Condom provision was identified as the most needed health promotion activity in PSEs in a survey of gay and bisexual men (n = 688) conducted by the evaluators. Data collected showed that condoms provided by GMFA, as well as from other sources, were being used in the PSE. The peer-led focus of the intervention was acceptable to the PSE users. In addition, high levels of commitment and input from the volunteers contributed considerable added value to the intervention. The evaluation found that GMFA was successful in reaching the target population and addressing their needs and demands.

The empirical and methodological comparative value of the rapid assessment of drug use patterns

This paper examines the comparative value of rapid assessment in the field of illicit drug use. Three aims of rapid assessment are highlighted: one, to collect quality data to inform policy and practice; two, to encourage a multi-method research approach; and three, to promote and support greater local involvement and ownership of the project itself. A number of manuals and guidelines have been produced for rapid assessment. A key issue to address, therefore, is the extent to which a structured and standardised approach can provide sufficient flexibility to take into account the political, social and cultural differences in the respective countries in which assessment takes place. Using the empirical experience derived from four rapid assessment projects, a four-phase strategy is outlined: developing infrastructure and formative evaluation; research training and mapping exercises; data collection; and report writing and dissemination. In place of the current reactive approach, we need more strategic thinking at the macro-level. To enable comparison between projects we should move towards basic methodological standardisation, but this should be accomplished without stifling the sociological imagination, which is a crucial ingredient to successful rapid assessment.

The drug-use situation in the Czech Republic

This article reports on a rapid assessment conducted in the Czech Republic during the second half of 1995. The main aim of the assessment was to describe patterns of illicit drug use, particularly in the capital, Prague. A Rapid Assessment Board was established to oversee the study, and both secondary and original data were collected from a range of sources. Illicit drug use was found to have increased throughout the country in the preceding five years, with amphetamines being the most popular substance. Polydrug use is common. There has been an increase in the use of the so-called "dance drugs", especially lysergic acid diethylamide (LSD), among younger people, and heroin, especially in the main urban areas. Injecting is on the increase, too. There is an urgent need to expand both fixed-site and community-based services.

Rapid assessment of the drug-injecting situation at Hanoi and Ho Chi Minh City, Viet Nam

This paper describes a rapid assessment of the drug-injecting situation in Viet Nam. The study, which was carried out over a five-week period during October and November 1993, focused on the cities of Hanoi and Ho Chi Minh City. A multi-indicator inductive methodology was adopted that mixed qualitative and quantitative measures. As only limited background epidemiologic and official statistics were available, the study involved the generation of original data, through, for example, the construction of "cognitive maps" describing broad patterns of drug use, semi-structured interviews (for the collection of baseline data), focus groups, in-depth interviews and ethnographic observations. The study revealed that the injection of "blackwater" opium proliferated, often in combination with a range of pharmaceutical preparations. High-risk injecting practices were common at both Hanoi and Ho Chi Minh City, drug scenes and congregation sites being more public and visible at Ho Chi Minh City. The implications for policy and practice are discussed, emphasis being placed on the need for outreach and peer intervention.