While some speculation surrounds annual private practice incomes of anaesthetists, little is known of the hours of work needed to generate any presumed income (the hourly rate). The benefit maxima of five private medical insurers are published in fee schedules and data on the duration of common operations are now also known. In this study we combined these to generate estimates for hourly rates of reimbursement across 78 common operations in eight surgical subspecialties, for anaesthetists and surgeons. We expected to find significant differences between insurers as a result of market competition, and we expected differences between anaesthetists and surgeons. The median (IQR [range]) rate of reimbursement for anaesthetists was £167 (132–211 [68–570]).h−1 with significant variation across subspecialties (p < 0.001); for example, cardiac surgery was best reimbursed at £283 (257–308 [229–398]).h−1 and orthopaedics the least at £146 (133–159 [81–246]).h−1. Contrary to expectations, the rates of payment to anaesthetists by insurers were similar (p > 0.17). Patterns of reimbursement for surgeons were similar to those for anaesthetists, except that surgeons were reimbursed at about twice the rate. We conclude there is a confluence of insurer reimbursement levels and we discuss potential implications of this finding. Our results also have implications for how incentives between the NHS and private practice, or within a private practice group, might be optimally managed.

BACKGROUND Tigecycline is a minocycline derivative, belonging to a chemical class prone to oxidation and to medium-related effects on susceptibility. We therefore studied the effect of medium type and age on the tigecycline MICs found in broth and on agar by the Clinical Laboratory Standards Institute and British Society for Applied Chemotherapy methods. METHODS MICs of tigecycline, minocycline and tetracycline were determined for 96 non-fastidious bacteria and 20 streptococci using Mueller-Hinton broth (MHB), Mueller-Hinton agar (MHA), Iso-Sensitest broth (ISB) and Iso-Sensitest agar (ISA) as: (i) freshly-prepared media; (ii) fresh media but with the antibiotic added 1 day before inoculation and (iii) media stored for 7 days before antibiotic addition and use. RESULTS MICs of tigecycline in fresh MHB were up to two doubling dilutions higher than on or in MHA, ISA or ISB. Media with tigecycline or classical tetracyclines added a day before use gave raised MICs, though rarely by more than one dilution. MICs of tigecycline (less so classical tetracyclines) were increased in 7-day-old MHB or ISB, even though the antibiotic was freshly added. This latter effect was greatest for the most susceptible strains and was absent or much reduced for organisms with MICs > or = 8 mg/L; it did not occur in the corresponding agar dilution tests. Addition of blood to MHB largely abrogated the effect, as did steaming the broth before adding the antibiotic. CONCLUSIONS The raised MICs of tigecycline in aged broth probably reflect inactivation by dissolved oxygen. This accords with the lack of any MIC increase in newly-steamed (i.e. degassed) MHB or on aged agar (which is melted at 100 degrees C before use). Blood, which also abrogated the effect, may increase reducing capacity, protecting the tigecycline. At a practical level, broth MIC determinations for tigecycline should always employ fresh media.

OBJECTIVES During 2003, the Health Protection Agency's Antibiotic Resistance Monitoring and Reference Laboratory began to receive isolates of Escherichia coli for confirmation of extended-spectrum beta-lactamase production with a phenotype implying a CTX-M-type beta-lactamase, i.e. MICs of cefotaxime > or = 8-fold higher than MICs of ceftazidime. Many were referred as being from community patients. We examined 291 CTX-M-producing isolates from the UK and investigated the genetic basis of their phenotype. METHODS PCR was used to detect alleles encoding CTX-M enzymes and to assign these to their blaCTX-M phylogenetic groups. Selected alleles were sequenced. Producers were compared by analysis of banding patterns generated by pulsed-field gel electrophoresis of XbaI-digested genomic DNA. MICs were determined by an agar dilution method or by Etest. RESULTS Of 291 CTX-M-producing E. coli isolates studied from 42 UK centres, 70 (24%) were reportedly from community patients, many of whom had only limited recent hospital contact. Community isolates were referred by 12 centres. Two hundred and seventy-nine (95.9%) producers contained genes encoding group 1 CTX-M enzymes and 12 contained blaCTX-M-9-like alleles. An epidemic CTX-M-15-producing strain was identified, with 110 community and inpatient isolates referred from six centres. Representatives of four other major strains also produced CTX-M-15, as did several sporadic isolates examined. Most producers were multi-resistant to fluoroquinolones, trimethoprim, tetracycline and aminoglycosides as well as to non-carbapenem beta-lactams. CONCLUSIONS CTX-M-producing E. coli are a rapidly developing problem in the UK, with CTX-M-15 particularly common. The diversity of producers and geographical scatter of referring laboratories indicates wide dissemination of blaCTX-M genes. Because of the public health implications, including for the treatment of community-acquired urinary tract infections, the spread of these strains--and CTX-M-15 beta-lactamase in particular--merits close monitoring.

Divisions of Neuroanaesthesia and Critical Care Medicine Montreal Neurological Institute and Royal Victoria Hospital McGill University, Montreal, Quebec

OBJECTIVE:To determine the circumstances, incidence, and outcome of cardiopulmonary resuscitation in British hospitals.DESIGN:Hospitals registered all cardiopulmonary resuscitation attempts for 12 months or longer and followed survival to one year.SETTING:12 metropolitan, provincial, teaching, and non-teaching hospitals across Britain.SUBJECTS:3765 patients in whom a resuscitation attempt was performed, including 927 in whom the onset of arrest was outside the hospital.MAIN OUTCOME MEASURE:Survival after initial resuscitation, at 24 hours, at discharge from hospital, and at one year, calculated by the life table method.RESULTS:There were 417 known survivors at one year, with 214 lost to follow up. By life table analysis for every eight attempted resuscitations there were three immediate survivors, two at 24 hours, 1.5 leaving hospital alive, and one alive at one year. Survival at one year was 12.5% including out of hospital cases and 15.0% not including these cases. Each hospital year averaged 30 survivors at one year: three who had an arrest outside hospital, seven who had one in the accident and emergency department, seven in the cardiac care unit, 10 in the general wards, and three in other, non-ward areas. Within the hospitals survival rates were best in those who had an arrest in the accident and emergency department, the cardiac care unit, or other specialised units. Outcome varied 12-fold in subgroups defined by age, type of arrest, and place of arrest.CONCLUSION:71% of the mortality at one year in patients undergoing attempted resuscitation occurred during the initial arrest. Hospital resuscitation is life saving and cost effective and warrants appropriate attention, training, coordination, and equipment.

The Journal of PathologyVolume 144, Issue 3 p. 221-221 Book Review The determinants of viral and bacterial pathogenicity. Edited by H. Smith, J.P. Arbuthnott and C. A. Mims. The Royal Society, London, 1983. No. of pages: viii + 163. Price: £24.75 (clothbound). ISBN: 0 85403 216 9 M. E. Ward, M. E. Ward Southampton General HospitalSearch for more papers by this author M. E. Ward, M. E. Ward Southampton General HospitalSearch for more papers by this author First published: November 1984 https://doi.org/10.1002/path.1711440310AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume144, Issue3November 1984Pages 221-221 RelatedInformation

The mechanism by which Chlamydia trachomatis is endocytosed by host cells is unclear. Studies of the kinetics of chlamydial attachment and uptake in the susceptible HeLa 229 cell line showed that chlamydial endocytosis was rapid and saturable but limited by the slow rate of chlamydial attachment. To overcome this limitation and to investigate the mechanism of endocytosis, chlamydiae were centrifuged onto the host cell surface in the cold to promote attachment. Endocytosis of the adherent chlamydiae was initiated synchronously by rapid warming to 36 degrees C. Electron micrographs of chlamydial uptake 5 min after onset showed that chlamydial ingestion involves movement of the host cell membrane, leading to interiorization in tight, endocytic vacuoles which were not clathrin coated. Chlamydial ingestion was not inhibited by monodansylcadaverine or amantadine, inhibitors of receptor-mediated endocytosis and chlamydiae failed to displace [3H]sucrose from micropinocytic vesicles. Chlamydial endocytosis was markedly inhibited by cytochalasin D, an inhibitor of host cell microfilament function, and by vincristine or vinblastine, inhibitors of host cell microtubules. Hyperimmune rabbit antibody prevented the ingestion of adherent chlamydiae, suggesting that endocytosis requires the circumferential binding of chlamydial and host cell surface ligands. These findings were incompatible with the suggestion that chlamydiae enter cells by taking advantage of the classic mechanism of receptor-mediated endocytosis into clathrin-coated vesicles, used by the host cell for the internalization of beta-lipoprotein and other macromolecules, but were consistent with the hypothesis that chlamydiae enter cells by a microfilament-dependent zipper mechanism.

Journal Article CHLAMYDIAL CLASSIFICATION, DEVELOPMENT AND STRUCTURE Get access M E WARD, PhD M E WARD, PhD Department of Microbiology University of Southampton Search for other works by this author on: Oxford Academic PubMed Google Scholar British Medical Bulletin, Volume 39, Issue 2, 1983, Pages 109–115, https://doi.org/10.1093/oxfordjournals.bmb.a071800 Published: 01 June 1983

In an attempt to exploit the benefits and to reduce the incidence of side-effects of etomidate during intravenous sedation for nervous patients undergoing oral surgery under local analgesia, a series of four clinical trials were undertaken: a pilot study in which etomidate was preceded by a combination of pentazocine and diazepam; a double-blind study in which saline was randomly substituted for the etomidate, and two further studies in which the administration of etomidate was preceded by that of either pentazocine or diazepam alone. The combination of a small dose of diazepam (0.1 mg/kg) with an initial dose of etomidate (0.1 mg/kg) followed by increments of the latter as necessary proved to be most successful in reducing the severity of unwanted reactions while retaining the unique advantages of etomidate.

Chlamydia trachomatis causes common infections of the eyes and genital tract in man. The mechanism by which this obligate intracellular bacterium is taken into epithelial cells is unclear. The results described here support the concept that chlamydial infections of HeLa cells is under bidirectional cyclic nucleotide control, with guanosine 3':5'-cyclic monophosphate (cGMP) acting as a stimulator, and adenosine 3':5'-cyclic monophosphate (cAMP) as an inhibitor. Treatment of the HeLa cells with the divalent cation ionophore A23187, with carbamoylcholine, or with prostaglandins known to increase the concentration of endogenous cGMP, also increased host cell susceptibility to chlamydial infection. Cyclic GMP was only effective if added at or before chlamydial inoculation, suggesting that its main effect was on chlamydial uptake. The stimulatory effect of cGMP, but nt antagonism, by cAMP, was abolished if the cells were first treated with any of four different inhibitors of prostaglandin synthesis, suggesting a critical role for endogenous prostaglandin synthesis. Centrifugation of chlamydiae on to host cells was followed by a rapid increase in the mobility of Ca2+ across the cell membrane. The interrelationships of these observations and the possibility that chlamydiae and other intracellular pathogens might evoke alterations in host cell prostaglandin and cyclic nucleotide concentrations to aid their own uptake are discussed.

AnaesthesiaVolume 36, Issue 2 p. 205-206 Free Access A safety valve for pollution control systems M.E. WARD, M.E. WARD M.E. Ward Esq, MB, BS, FFARCS, Consultant Anaesthetist, Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford.Search for more papers by this author M.E. WARD, M.E. WARD M.E. Ward Esq, MB, BS, FFARCS, Consultant Anaesthetist, Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford.Search for more papers by this author First published: February 1981 https://doi.org/10.1111/j.1365-2044.1981.tb08726.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume36, Issue2February 1981Pages 205-206 ReferencesRelatedInformation

Monovalent rabbit antisera were prepared to highly purified gonococcal lipopolysaccharide (LPS), to pili and to two major purified outer envelope proteins. All these antisera were free from significant specific IgM antibody and were standardized to 4 microgram specific IgG antibody per test, permitting accurate comparisons between the different gonococcal surface antigens as triggers of the complement-dependent bactericidal reaction. LPS was the most effective antigen at inducing a bactericidal response to homologous and heterologous gonococci, followed by the two individual outer envelope proteins. Pili were relatively ineffective. Strain P9 gonococci grown in vivo or which possessed a 'capsule' in vitro were more resistant to serum killing than the non-capsulated parent strain. One highly susceptible strain, F62, which was killed by complement in the absence of any LPS antibody, was able to directly activate complement by the alternative pathway.

Pili have been isolated from Neisseria gonorrhoeae by controlled homogenization followed by selective disaggregation in sucrose and purification by CsCl density gradient centrifugation. Pili from six gonococcal strains had buoyant densities of 1-30 to 1-31 g ml-1 on CsCl. The pili were immunologically distinct when tested with rabbit antisera to purified pili. The amino acid composition of pilin from strains P9 and 201 was very similar, consisting of 208 and 212 amino acid residues respectively giving molecular weights of 22 600 and 22352. The pili contained a high proportion (46%) of non-polar amino acids. Further analysis of strain P9 pili revealed the presence of 1 to 2 phosphate groups and 1 to 2 hexose groups per pilin subunit; no amino sugars were detected. Pili from strain P9 were resolved into two bands by equilibrium density gradient centrifugation or column isoelectric focusing, suggesting the presence of more than one kind of pilus.

Isoelectric focusing showed that Neisseria gonorrhoeae has an overall negative surface charge. Chemical modification of protein amino or carboxyl groups changed the surface charge and thereby altered the ability of the organisms to attach to human amnion cells grown in tissue culture. Attachment of modified and unmodified N. gonorrhoeae was increased by the presence of pili only when the bacteria bore a negative surface charge. Thus an important factor in the pathogenesis of gonorrhoea may be the ability of pili to facilitate attachment of N. gonorrhoeae by overcoming the initial electrostatic repulsive barrier which exists between it and the host cell.

Lipopolysaccharides, extracted by phenol-water from five strains fo Neisseria gonorrhoeae, were purified by treatment with ribonuclease followed by multiple washes. These preparations were fatal to mice when administered in submicrogram amounts with actinomycin D, the LD50 values varying from 4 to 16 mug/kg. Analyses showed that all preparations contained glucose, galactose, glucosamine, heptose, 2-keto-3-deoxyoctonic acid and phosphate. All the lipopolysaccharides contained the same fatty acids, namely beta-OH-10:0, beta-OH-12:0, beta-OH-14:0, 12:0, 14:0,16:0, 16:1, 18:0 and 18:1. We were unable to detect significant differences between the lipopolysaccharides of virulent and avirulent gonococci or between penicillin-sensitive and resistant strains. Gonococcal lipopolysaccharides appeared to lack O-antigen side chains.

This family demonstrates once again the well-known latency of gonorrhoea in women, and it also seems very likely that the condition had remained latent in the husband until septicaemia ensued though no proof of this can be obtained The most unusual finding was the development of one of the rarest of the complications of gonorrhoeanamely, gonococcal septicaemia in both husband and wife. We have not been able to find a similar example recorded in the literature.-We are, etc., J. K. OATES V. H. PATTERSON