Impact of the introduction of fee for service payments on types of minor surgical procedures undertaken by general practitioners: observational study

The 1990 general practitioners (GPs) contract introduced item of service payment for minor surgery, payable for six categories of procedure. Early review showed no substitution of cheaper procedures for more expensive treatments. Detailed payment data from six Health Authorities for the period 1993-2000 show an 11 per cent increase in claims, largely accounted for by the rise in cautery, incorporating cryotherapy. Cryotherapy is no more effective at treating warts than cheap commercially available products, but is quite profitable for GPs. This is yet another example of item of service payment distorting treatment priorities. The new GP contract, and the initiative to develop GPs with special interests in dermatology and minor surgery, will allow primary care trusts to develop minor surgery undertaken by appropriately skilled and experienced GPs, and which reflects the needs of the population.     

Elevated sperm chromosome aneuploidy and apoptosis in patients with unexplained recurrent pregnancy loss

OBJECTIVE: To evaluate sperm chromosome aneuploidy and semen quality in 24 partners of women with unexplained recurrent pregnancy loss and to analyze the data in relation to sperm apoptosis data. METHODS: Semen quality parameters and sperm chromosome aneuploidy for chromosomes X, Y, 13, 18, and 21 were evaluated in the recurrent pregnancy loss patients, fertile controls, and a control group of men from the general population. RESULTS: The mean aneuploidy rate in the recurrent pregnancy loss group was 2.77 +/- 0.22, significantly higher (P <.005) than in either the general population (1.48 +/- 0.12) or in fertile (1.19 +/- 0.11) control groups. In the recurrent pregnancy loss patients, the percentage of aneuploid sperm was correlated to the percentage of apoptotic sperm (r =.62, P <.001). Normal morphology was diminished in the patient group, compared with the general population group (P <.01) and the donor group (P <.001). CONCLUSIONS: These data indicate that some recurrent pregnancy loss patients have a significant increase of sperm chromosome aneuploidy, apoptosis, and abnormal sperm morphology. This study demonstrates a new possible cause of recurrent pregnancy loss.     

Increased biliary fistulas after liver resection with the harmonic scalpel

The Harmonic Scalpel (HS) is frequently used for hepatic resection. Yet, no current study addresses its utility compared to conventional methods. We reviewed our experience with this device to determine if it decreased perioperative complications when compared to the traditional clamp crushing technique. One hundred forty-nine anatomic hepatic resections were performed at our institution from September 1992 to February 2002. Patients were divided into two groups based on the technique of resection: HS [53% (n = 79)] versus clamp crushing [47% (n = 70)]. Use of the HS was associated with a shorter mean operative time (357 +/- 15.0 vs. 404 +/- 19.1 min; p = 0.05) and a trend toward decreased blood loss (1211 +/- 125.5 vs. 1411 +/- 180.7 mL; P = NS) and transfusion requirements (2.6 +/- 0.5 vs. 1.7 +/- 0.3 units; P = 0.10). However, use of the HS was associated with a significant increase in biliary fistulas [24% (n = 19) vs. 7% (n = 5); P = 0.01]. Use of the Harmonic Scalpel was associated with decreased operative time and a trend toward decreased blood loss and transfusion requirements. Its use was also associated with a significant increase in the incidence of postoperative bile leaks, and, therefore, surgeons must be vigilant during liver parenchymal transection when using this device.     

NHPV16 VLP vaccine induces human antibodies that neutralize divergent variants of HPV16

Genital HPV genotypes are generally distinct serotypes, but whether variants within a genotype can represent serologic subtypes is unclear. In this study we used serum from human volunteers vaccinated with HPV16 L1 VLPs from variant 114K, to examine cross-neutralization of variants from each of the five major phylogenetic branches of HPV16. Recombinant Semliki Forest virus-derived pseudovirions for each variant were generated and combined with serum from vaccines, and the mixture was monitored for infectivity in a standard C127 cell focal transformation assay. Sera from all 10 VLP-immunized individuals had neutralizing activity against each of the variant pseudovirions. For each of the sera, variant titers differed by only fourfold or less from the median titer. Therefore, from a vaccine perspective, HPV16 variants belong to a single serotype. Vaccination with HPV16 114K L1 VLPs generates antibodies that should confer a similar degree of protection against all known phylogenetic branches of HPV16.     

Independent influences of central fat and skeletal muscle lipids on insulin sensitivity

OBJECTIVE: Insulin resistance is closely associated with two disparate aspects of lipid storage: the intracellular lipid content of skeletal muscle and the magnitude of central adipose beds. Our aim was to determine their relative contribution to impaired insulin action. RESEARCH METHODS AND PROCEDURES: Eighteen older (56 to 75 years of age) men were studied before elective knee surgery. Insulin sensitivity (M/Delta I) was determined by hyperinsulinemic-euglycemic clamp. Central abdominal fat (CF) was assessed by DXA. Skeletal muscle was excised at surgery and assayed for content of metabolically active long-chain acyl-CoA esters (LCAC). RESULTS: Significant inverse relationships were observed between LCAC and M/Delta I (R(2) = 0.34, p = 0.01) and between CF and M/Delta I (R(2) = 0.38, p = 0.006), but not between CF and LCAC (R(2) = 0.0005, p = 0.93). In a multiple regression model (R(2) = 0.71, p < 0.0001), both CF (p = 0.0006) and LCAC (p = 0.0009) were independent statistical predictors of M/Delta I. Leptin levels correlated inversely with M/Delta I (R(2) = 0.60, p = 0.0002) and positively with central (R(2) = 0.41, p = 0.006) and total body fat (R(2) = 0.63, p = 0.0001). DISCUSSION: The mechanisms by which altered lipid metabolism in skeletal muscle influences insulin action may not be related directly to those linking central fat and insulin sensitivity. In particular, it is unlikely that muscle accumulation of lipids directly derived from labile central fat depots is a principal contributor to peripheral insulin resistance. Instead, our results imply that circulating factors, other than nonesterified fatty acids or triglyceride, mediate between central fat depots and skeletal muscle tissue. Leptin was not exclusively associated with central fat, but other factors, secreted specifically from central fat cells, could modulate muscle insulin sensitivity.     

Inequalities in provision of systematic care for patients with diabetes

BACKGROUND: GPs are now playing a greater role in the care of people with diabetes; however, the level of performance in primary care is variable. Practices with a recall system and diabetes mini-clinic have been shown to achieve better outcome of care of patients with diabetes. Systematic care also requires effective community-based diabetes services and access to primary care diabetes teams including dieticians, chiropodists, and optometrists and ophthalmologists. OBJECTIVES: The aims of this study were to determine how services for people with diabetes are organized in primary care and whether there are inequalities in systematic care of people with diabetes. METHODS: A piloted postal questionnaire was sent to all 327 general practices in three health authorities in England serving a population of >2 million people. The three health authorities provided practice-based routine data relating to all general practices. RESULTS: A total of 264 (80.7%) practices replied; 236 (89.4%) employed a diabetes recall system and 196 (74.2%) reviewed their patients in a diabetes mini-clinic. Multiple regression showed that having a recall system was associated independently with a GP [odds ratio (OR) 6.2; 95% confidence interval (CI) 2.6-14.9] or a practice nurse (OR 3.5; 1.4-8.7) with an interest in diabetes. Having a diabetes mini-clinic was associated independently with a GP with an interest in diabetes (OR 4.1; 2.1-7.8), a practice nurse having attended a diabetes course (OR 2.8, 1.3-6.2), practices with more partners (OR 1.2 per additional partner; 1.0-1.4) and fundholding practices (OR 2.6; 1.2-5.5). One hundred and sixteen (43.9%) practices had a chiropodist present in the practice, and 90 (34.1%) had a practice-based dietician. A chiropodist and a dietician were significantly more likely to be attached in training practices and in less deprived areas. A practice-based dietician was significantly associated with larger practices. CONCLUSIONS: Providing high quality primary care is essential to meeting the government's agenda of reducing inequalities. This study shows high levels of structured diabetes care which are not related to deprivation. However, practices in more deprived areas still lag behind practices in more affluent areas in terms of access to members of the diabetes team. To improve care of people with diabetes in primary care, deficiencies and inequalities highlighted in our survey must be addressed. The results of this survey will be valuable to primary care groups and organizations responsible for commissioning diabetes services.