The gendered nature of South African teachers' discourse on sex education.

In South Africa, high pregnancy and infection rates show that many teenagers are having sex, and that they are not adequately protecting themselves against undesired pregnancies and disease. Sex education is usually taught as part of the subject area Life Orientation. In a qualitative study of 25 Life Orientation teachers in the South African Free State Province, we used semi-structured interviews to explore the ways in which these teachers understand gender to be a factor in learners' experiences of sexuality. Our analysis draws upon the conceptual framework of heteronormativity, a key aspect of which is that girls and boys are socialized into different gender roles in ways that propagate the patriarchy, and these are largely viewed as part of the natural order of things. Our data revealed a tendency for teachers to cast boys as largely predatory and girls as victims of sexual predation, either by their peers or by older boys or men. Although these assumptions reflect some of the everyday experiences in South Africa and many other countries, these expectations may be transmitted and reinforced unconsciously in well-meaning educational interventions meant to protect girls.

Comparison of surgical outcomes between teaching and nonteaching hospitals in the Department of Veterans Affairs.

OBJECTIVE: To determine whether the investment in postgraduate education and training places patients at risk for worse outcomes and higher costs than if medical and surgical care was delivered in nonteaching settings. SUMMARY BACKGROUND DATA: The Veterans Health Administration (VA) plays a major role in the training of medical students, residents, and fellows. METHODS: The database of the VA National Surgical Quality Improvement Program was analyzed for all major noncardiac operations performed during fiscal years 1997, 1998, and 1999. Teaching status of a hospital was determined on the basis of a background and structure questionnaire that was independently verified by a research fellow. Stepwise logistic regression was used to construct separate models predictive of 30-day mortality and morbidity for each of seven surgical specialties and eight operations. Based on these models, a severity index for each patient was calculated. Hierarchical logistic regression models were then created to examine the relationship between teaching versus nonteaching hospitals and 30-day postoperative mortality and morbidity, after adjusting for patient severity. RESULTS: Teaching hospitals performed 81% of the total surgical workload and 90% of the major surgery workload. In most specialties in teaching hospitals, the residents were the primary surgeons in more than 90% of the operations. Compared with nonteaching hospitals, the patient populations in teaching hospitals had a higher prevalence of risk factors, underwent more complex operations, and had longer operation times. Risk-adjusted mortality rates were not different between the teaching and nonteaching hospitals in the specialties and operations studied. The unadjusted complication rate was higher in teaching hospitals in six of seven specialties and four of eight operations. Risk adjustment did not eliminate completely these differences, probably reflecting the relatively poor predictive validity of some of the risk adjustment models for morbidity. Length of stay after major operations was not consistently different between teaching and nonteaching hospitals. CONCLUSION: Compared with nonteaching hospitals, teaching hospitals in the VA perform the majority of complex and high-risk major procedures, with comparable risk-adjusted 30-day mortality rates. Risk-adjusted 30-day morbidity rates in teaching hospitals are higher in some specialties and operations than in nonteaching hospitals. Although this may reflect the weak predictive validity of some of the risk adjustment models for morbidity, it may also represent suboptimal processes and structures of care that are unique to teaching hospitals. Despite good quality of care in teaching hospitals, as evidenced by the 30-day mortality data, efforts should be made to examine further the structures and processes of surgical care prevailing in these hospitals.

Target selection for surgical intervention in severe chronic venous insufficiency: comparison of duplex scanning and phlebography.

PURPOSE: The goal of this study was to determine whether duplex scanning (DS) alone, compared with ascending phlebography (AP) and descending phlebography (DP), would have been sufficient to guide treatment of severe chronic venous insufficiency (CVI), CEAP Clinical Classes 5 and 6. METHODS: Beginning in 1994, patients presenting to the VA Sierra Nevada Vascular Clinic with ulceration due to CVI, CEAP Clinical Classes 5 and 6, were examined with DS, AP, and DP. Phlebography mainly guided surgical interventions. The ability of DS findings to select surgical interventions, with the aims of diversion of reflux from area of trophic skin or reduction of global venous hypertension was compared with phlebography. Of the 33 male patients (age, 29-70 years; average, 55 years) considered for operative interventions between January 1994 and November 1999, 30 were selected for operative treatment. RESULTS: DS was 100% sensitive and specific for detection of complete occlusion of the superficial femoral vein (10/10) and for saphenous incompetence; sensitivity was 95% (19/20); and specificity was 100%. However, DS failed to reveal subtle changes in recanalized femoral veins because of prior thrombophlebitis, which was uncovered by AP in six of 23 patent femoral veins. There were 16 positive findings on AP of residual thrombophlebitis, of which six were not read on DS. Sensitivity was 63%, specificity was 100%, the positive predictive value was 100%, and the negative predictive value was 53%. Reflux grading with DP agreed with DS in 23 of 33 cases or varied by one grade in five of 33 cases: sensitivity, 82%; specificity, 75%; positive predictive value, 96%; and negative predictive value, 37%. Kistner grade 4 reflux involving the superficial femoral and popliteal veins was noted by DP in five of the 33 cases when DS described reflux as "moderate." Incompetent superficial femoral vein valve stations in the upper third of the vein, which caused primary reflux, were clearly defined by DP in four of 33 cases; valve location was not well defined by DS. Below-knee perforator identification with DS was difficult; this was related to the severity of lipodermatosclerosis and the presence of ulceration. The number of perforators described at operation with subfascial endoscopic perforator surgery (n = 13) averaged 6 +/- 2, whereas AP identified an average of 4 +/- 2 in supramalleolar area. In four men, two previously undiagnosed caval and two iliac obstructions were detected with AP; one was corrected with Palma bypass grafting. Follow-up at 4 to 60 months (average, 40 months) showed four ulcer recurrences among 30 patients who were operated on. Two patients underwent repeat operations on the basis of repeated phlebographic study and are cured at this time, one patient was healed with conservative therapy, and one patient is lost to follow-up. CONCLUSIONS: DS would have been inadequate for identifying surgical targets in CVI, CEAP Clinical Classes 5 and 6. DS overlooked iliac and caval lesions. Potential valveplasty sites, which were only delineated on DP, resulted in four valveplasties in the upper third of the superficial femoral vein for grade 4 reflux. AP localized mid- to upper-leg perforators, but neither AP nor DP detected perforators in the range of 5 to 10 cm above the calcaneus. The net effect of phlebography was a choice for deep interventions in five (17%) of 30 cases, which would not have been possible with DS alone. The identification of iliocaval occlusion influenced the decision, based on prior experience, not to perform distal procedures in three cases.

A flavonoid sulfate antigen activates human alphabeta CD8+ Th2 lymphocytes in pollen allergy.

Cellular immune responses are initiated when T lymphocytes expressing alphabeta TCR recognize peptide antigens bound to MHC molecules or, less frequently, double-stranded glycolipid antigens bound to CD1 molecules. In the allergy to Parietaria judaica, human alphabeta CD8+ Th2 lymphocytes react to a non-peptide pollinic antigen presented by B cells. The environmental allergen was purified and identified as a new flavonoid pigment: 2'-O-sulfate, 6-O-betaD-glucuronopyranosyl, 2',5,6-trihydroxy-isoflavone. Its specific recognition by alphabeta CD8+ Th2 T cells (1) depends upon an MHC- and CD1-independent presentation mediated by B cells, (2) is determined by the flavonoid carbohydrate and sulfate groups and (3) leads to positive skin prick test in allergic patients. Hence, an unusual mode of aromatic sulfated antigen recognition by alphabeta CD8+ Th2 T lymphocytes might underlie the cellular mediation of human allergy to plant allergens.

A new approach to an old and vexing problem: subfascial endoscopic perforator surgery.

Chronic venous insufficiency with venous hypertension causes leukocyte trapping, lipodermatosclerosis, and finally, skin ulceration involving the lower extremity. Perforator vein incompetence has been identified as an important contributing factor to ulceration when abnormally elevated pressure is transmitted to areas of affected skin, usually at the ankle medially. Surgical techniques for ligation of incompetent communication veins were first popularized by Linton and Dodd from 1940 to 1950. Early techniques used extensive longitudinal incisions for subfascial ligation through indurated skin. These procedures were plagued with wound complications: delayed healing, skin necrosis, and infection. Techniques continued to evolve that used minimally invasive incisions and avoided zones of affected skin. With the availability of endoscopic, fiberoptic, and laparoscopic advances in surgery, instrumentation has been developed for minimally invasive endoscopic approach to accomplish subfascia endoscopic perforator surgery (SEPS) under direct vision. SEPS is now used alone and in combination with other venous interventions to reduce transmission of venous hypertension to affected skin areas. The SEPS procedure, its indications, and the history of surgical treatment of perforator vein incompetence are discussed. Unique problems related to short hospital stays and postoperative care are outlined. This review will help the vascular nurse understand the rationale and techniques of SEPS. This comprehension will enable provision of accurate information to the patient and a knowledge-based plan of care.

Venous thromboembolism in trauma patients: standardized risk factors.

PURPOSE: This study was done to evaluate the use of published standardized risk factors for venous thromboembolism (VTE) in patients admitted to a trauma intensive care unit (ICU) and to derive guidelines for the use of low molecular weight heparin (LMWH) and surveillance venous Doppler ultrasound scanning (VDUS). METHODS: Patients were admitted to a regional trauma center ICU. Two periods were studied. Period 1 was a retrospective analysis of documented cases of VTE in the trauma registry from 1993 to 1995 (n=39). The period was also a review of all patients admitted to a trauma ICU in 1994 without VTE who met the following criteria: age greater than 11 years, ICU stay of more than 36 hours, and survival of more than 72 hours (n=227). Period 2 was a concurrent analysis of 1996 documented cases of VTE and similarly selected ICU admissions (VTE, n=10; no VTE, n=224). Risk factor scores (R1, admitting; R2, total) were calculated from the International Society for Cardiovascular Surgery/Society for Vascular Surgery reporting standards. The scores were cumulative by category and over time. The suitability of such standards was determined in period 1. The resulting therapeutic and surveillance guidelines were evaluated in period 2. RESULTS: Period 1 risk factor scores, R1 and R2, were correlated with the occurrence of VTE from chi2 test (P < .05 and P < .01, respectively). Risk categories were grouped as low, moderate, and high. VTE was not observed in the low-risk group (0 to 2). Among all VTE (n=49), 11 cases occurred in patients with moderate-risk scores and 38 in patients with high-risk scores. In 1994 and 1996, the selected groups were analyzed and the incidence rate of VTE was 4.7% in both years for the moderate-risk group and 2.5% and 4.8% for the high-risk group, respectively. Most VTE cases (78%) received some form of prophylaxis (PRx), and 26% of cases had multiple methods of prophylaxis (MPRx). This included 80% of the cases that received unfractionated heparin. In period 2, no pulmonary emboli (PE) occurred, in contrast to period 1, in which 16 of 39 cases of VTE (41%) were first seen with PE. In period 2, no patient receiving MPRx, including compression and LMWH, had VTE develop. Surveillance VDUS discovered 60% of 1996 cases in period 2. No PE were seen in period 2. CONCLUSION: Standard risk factors were easily applied to the trauma patient at the bedside. Patients at low risk needed no PRx. Patients at high risk did best with both compression devices and LMWH. VDUS was recommended selectively in patients at high risk in whom multiple-method PRx could not be achieved. Patients at moderate risk required further study to define optimal PRx and need for surveillance VDUS. Intracaval devices were used prophylactically only twice.

Vascular surgery for impotence: a review.

Progress in treatment of impotence in the past two decades has resulted in impressive advances. While most men respond to medical therapy including prostaglandin E1 injection or the more recent use of urethral alprostadil, 6-7% of men fail to respond to these treatments or vacuum devices. This review considers current and past results of vascular surgery in this group of men. Guidelines for case selection for vascular interventions as well as reporting criteria are suggested. Vascular surgery as a logical first step in selected patients may offer an advantage in men failing conservative therapy and for those not desiring prosthetic implantation.

Comparative sexual side effects of bupropion, fluoxetine, paroxetine, and sertraline.

OBJECTIVE: To investigate patient reported prosexual side effects of the aminoketone antidepressant bupropion (INN, amfebutamone) and to compare directly the sexual side effects of bupropion and the selective serotonin reuptake inhibitor (SSRI) antidepressants fluoxetine, paroxetine, and sertraline. METHODS: One hundred seven psychiatric outpatient respondents receiving current treatment with one of the above antidepressants anonymously completed questionnaires that allowed reporting of both decreases and increases in sexual function. The main outcome measures were antidepressant-associated changes in libido, arousal, duration of time from arousal to orgasm, intensity of orgasm, and duration of orgasm relative to that experienced before the onset of the patients' psychiatric illnesses. RESULTS: Bupropion-treated patients reported significant increases in libido, level of arousal, intensity of orgasm, and duration of orgasm beyond levels experienced premorbidly. The three SSRIs to an equal degree significantly decreased libido, arousal, duration of orgasm, and intensity of orgasm below levels experienced premorbidly. Overall, 27% of the SSRI-treated patients had no adverse sexual side effects; in contrast, 86% of patients treated with bupropion had no adverse sexual effects, and 77% of bupropion-treated patients reported at least one aspect of heightened sexual functioning. CONCLUSIONS: SSRI-induced adverse sexual effects appear to be the rule rather than the exception and may be substantially underreported unless patients are specifically asked about the effects of these medications on various aspects of sexual function. In contrast, prosexual effects were reported by the majority of patients treated with bupropion. The findings are reviewed in light of the neurochemistry of these agents and the sexual response.

Safety, feasibility, and early efficacy of subfascial endoscopic perforator surgery: a preliminary report from the North American registry.

PURPOSE: The North American Subfascial Endoscopic Perforator Surgery (NASEPS) Registry was established to evaluate the safety, feasibility, and efficacy of minimally invasive endoscopic Linton operations for treatment of chronic venous insufficiency. METHODS: Retrospective analysis was performed on the clinical data of 151 patients who underwent attempt at 158 SEPS in 17 medical centers in the United States and Canada between June 1993 and February 1996. RESULTS: SEPS was completed on 155 limbs of 148 patients, 81 male and 67 female (mean age, 56 years; range, 27 to 87 years). Three procedures were aborted. Seven patients had bilateral procedures (data from one limb were analyzed). One hundred four limbs (70%) had active ulcers, and 22 (15%) had healed ulcers. A single endoscopic port without insufflation was used in 66 procedures (45%) and laparoscopic instrumentation, with two or three ports, in 82 (55%), with CO2 insufflation in 78 (53%). A tourniquet was used on 112 patients (76%). Concomitant venous procedures were performed in 106 patients (72%; saphenous stripping in 71, high ligation in 17, varicosity avulsion in 85). No early deaths or thromboembolism occurred. Complications included wound infections (9), superficial thrombophlebitis (5), cellulitis (4), and saphenous neuralgia (10). Seven patients with wound infection had open ulcers; nine of 10 with neuralgia had concomitant procedures. A roll-on tourniquet caused skin necrosis in one patient. The clinical score improved from 9.4 to 2.9 after surgery (p < 0.0001). Mean follow-up was 5.4 months; 31 patients had > or = 6 months follow-up. Ulcers healed in 88% (75 of 85); recurrence or new ulcer was reported in 3% (4 of 120). CONCLUSIONS: The SEPS modified Linton operation appears safe, with no postoperative deaths or early thromboembolism. Wound infection after SEPS remains important. Early results indicate rapid ulcer healing. Prospective evaluation of long-term results is warranted.

Venous ulceration: a cross-over study from nonoperative to operative treatment.

PURPOSE: This study compared 3 years of nonoperative therapy in a vascular clinic (1991 to 1993) with a proactive approach to diagnosis and operative treatment (1994 to 1995). METHODS: In the first period, 11 compliant men 48 to 69 years of age (average, 55 years) were treated without surgery using Unna's boot dressing, compression wound care, and patient education. In the second period, after duplex scans and venographic examinations when appropriate, operative interventions were performed in 10 patients. RESULTS: In period 1 there were 44 occurrences of ulceration (range, 3 to 8 per individual), with an average time to heal of 13 weeks (range, 7 to 28 weeks per individual). Beginning in January 1994 (period 2), 11 patients who had current active ulceration underwent duplex scans and venographic examinations to detect correctable lesions, including deep, superficial, or perforator incompetence, or deep venous occlusions. Ten became candidates for surgery. One patient was not a candidate for venous surgery because of extensive caval thrombosis. Operations included extrafascial perforator division in nine patients; long saphenous stripping with submalleolar saphenous and perforator interruption in seven; one Palma crossover venous graft; and one superficial femoral valvuloplasty. In period 2 (24 months), there were two recurrent ulcers, one related to failure to use adequate compression and one related to infection of an incision. Nine of 10 patients remained healed at 24 months. Average time to heal was 4 weeks. Clinical severity score as described in the Consensus Statement of the American Venous Forum was reduced from 12 (range, 9 to 17) in period 1 to a mean of 3.5 (range, 2 to 8) in period 2 (p < 0.01 by paired t test). CONCLUSION: Improved diagnostic and operative techniques make possible more active approaches to venous ulceration. Nonoperative treatment, even in skilled hands, is associated with prolonged disability and ulcer recurrence. The condition of selected patients in whom nonoperative treatment fails can be improved substantially with operative intervention.

Infrainguinal reconstruction in diabetes.

Dramatic changes have occurred in the efficacy of infrainguinal reconstruction in diabetic patients. Enhanced limb salvage resulted from comprehensive understanding of patterns of macrovascular involvement, better perioperative control of sepsis and hyperglycemia, and advances in techniques for limb salvage. This report summarizes the applicability of recently evolving surgical techniques. Advances in pattern recognition have eliminated the misconception that microvascular involvement of the foot precludes successful reconstruction. A decreasing incidence of amputation in diabetic patients is currently seen. Interventions applicable to the usual patterns of diabetic macroangiopathy include femorodistal bypass to ankle or foot and popliteal distal bypass using autogenous vein usually in situ. In the absence of usable vein (a rare occurrence), the authors have observed intermediate patency using polytetrafluoroethylene to a vein cuff and anticoagulation. Initially, successful bypasses in diabetic and nondiabetic patients exhibit comparable longterm patency. Local toe or foot amputations are used more frequently to maintain bipedal gait. With careful management, a high rate of limb salvage is practical for nonsmoking, nonuremic diabetic patients.

The protective effect of vein cuffed anastomoses is not mechanical in origin.

PURPOSE: Intimal hyperplasia (IH) is a proliferative process of vascular smooth muscle cells that occurs after an arterial injury, particularly at outflow anastomoses of prosthetic bypass grafts. IH causes stenosis that leads ultimately to graft flow reduction and thrombosis. We have demonstrated previously that vein cuff interposition between an expanded polytetrafluoroethylene (e-PTFE) graft and artery at distal anastomoses diminished IH formation in the arterial outflow as compared with noncuffed anastomoses. Improved long-term patency rates associated with the placement of an interposition vein cuff at the distal anastomosis of e-PTFE grafts to infrageniculate arteries have also been demonstrated clinically. This study examined the mechanical factors that may contribute to the protective effect of cuffed anastomoses. These factors include the expansibility of the vein cuff as compared with e-PTFE, as well as the angle of the cuffed anastomosis. METHODS: Compatible animals were selected by use of platelet aggregation studies. Nine dogs, group A, received a 4 mm e-PTFE graft plus a 1 cm long interposition vein cuff at the distal anastomosis in the left carotid artery. The same procedure was done on the right side, and in addition the vein cuff was encircled by an e-PTFE jacket incorporated into the anastomosis to prevent the expansion of the vein cuff with arterial pulsation. To study the effect of distal anastomotic angle and geometry on the formation of IH, five dogs, group B, received a 4 mm e-PTFE graft in both sides. On the left, the distal anastomosis was performed between the graft and the artery at an acute angle as it is commonly done when a bypass graft is placed. On the right side a 1 cm long, 6 mm diameter e-PTFE segment was interposed between the artery and the graft at a perpendicular angle. This geometry mimicked the right angle of a vein cuff-to-artery anastomosis. After 10 weeks the grafts were harvested, and the thickness of IH was measured with an ocular micrometer under light microscopy. RESULTS: In group A, one dog had bilateral graft thrombosis (12%), and these grafts were discarded. In the remaining eight dogs there was no statistically significant difference in the thickness of IH between the right (jacketed group) and the left side (nonjacketed/control group), showing that vein cuff expansibility did not play a role in protecting against the formation of IH. In group B, bilateral graft thrombosis occurred in four of five dogs (80%), suggesting that the perpendicular anastomotic angle was not protective. CONCLUSION: These results suggested that the protective effect of the vein cuff is not mechanical in origin.

Vascular interventions for impotence: lessons learned.

PURPOSE: The purpose of this study was to analyze the results of vascular interventions for impotence in men with this complaint. METHODS: Between September 1983 and March 1993, 1094 men with the chief complaint of impotence (average age 54.5 years) were screened by use of penile plethysmography and penile brachial indexes: 635 were considered to have normal flow, and 459 were considered to have abnormal arterial flow, 12.2% of whom were found to have aortoiliac disease. Based on negative neural screening results, absence of erectile responses on increasing doses of intracavernously injected papaverine or prostaglandin E1 (ICI), surgical candidates for microvascular procedures were referred for dynamic infusion cavernosography (DICC) and pudendal arteriography. Operations for men discovered to have aortoiliac disease were based on conventional indications including aneurysm size or limb ischemia. None of the subjects had diabetes. Only those patients without diabetes and those not requiring blood pressure medications were selected for microvascular procedures. We report our experience and surgical outcomes at average follow-ups of 33 to 48 months. Four types of operations were performed on 67 men (age 18 to 79 years). These included 17 aortoiliac reconstructions, 11 dorsal penile artery bypasses, 12 dorsal vein arterializations, and 27 venous interruptions. Follow-up data were obtained by direct examination and noninvasive Doppler examinations; repeat arteriography (4 of 11); repeat DICC after venous ablation procedures (18 of 27) and postoperative ICI response. Mail questionnaires completed postoperative surveillance. RESULTS: Among 17 men undergoing aortoiliac intervention for aneurysms in eight and occlusive disease in nine, 58% functioned spontaneously after operation and 18% used ICI or vacuum constrictor devices at an average follow-up time of 38 months. Among 11 men with dorsal penile artery bypasses, 27% functioned spontaneously and 45% used ICI at an average follow-up time of 34.5 months. Among 12 men with dorsal vein arterialization, 33% functioned spontaneously, and 47% used ICI at an average follow-up time of 48 months. Among 27 with venous interruption, 33% functioned spontaneously and 44% used ICI. In seven of eight aneurysms of 4.5 to 6.0 cm in size, impotence workup led to discovery; probable embolic mechanisms existed in three. Venous interruption efficacy correlated with postoperative DICC results when flow to maintain erection was 40 ml or less. Apart from two cases of glans hyperemia, no surgical complications occurred in the microvascular procedures. There was one episode of bleeding caused by DICC after aortic reconstruction. There were no deaths. CONCLUSIONS: With prospective screening criteria, 6% to 7% of impotent men became candidates for vascular intervention. Including those functioning with ICI or vacuum constriction devices, about 70% of these men were functional after operation. Men undergoing aortoiliac reconstruction has a significantly higher rate (58%) of spontaneous function as compared with those undergoing microvascular procedures.

A simplified phenytoin regimen for preeclampsia.

The objective of this study was to assess the feasibility of giving phenytoin to a group of mild preeclamptic women in a universal dosing scheme comparable to that typical of magnesium sulfate administration. Serum phenytoin levels were measured at regular intervals for 32 hours following a 1 g intravenous loading dose in 14 patients. A second group of 14 women received 500 mg orally to supplement the 1 g initial dose and had serum levels similarly measured. The resultant serum levels are described, and the effect of maternal weight analyzed. The average serum phenytoin level in the first 14 women given the 1 g loading dose fell to 10 micrograms/mL approximately 12 hours after treatment. Serum levels plateaued above this threshold in the 14 women given 500 mg of additional medication orally 10 hours after treatment initiation and were maintained for an additional 14 hours before decline was observed. The serum levels resulting from the initial 1 g loading dose were analyzed 8 hours after treatment initiation in the entire group of 28 women according to body weight, and a clinically significant effect of weight on serum level was observed only at the extremes of weight. We conclude that a universal dosing scheme comparable to that typically used for magnesium sulfate is feasible for phenytoin administration to preeclamptic women.