bluuebunny/crossref_metadata_2025 huggingface dataset:
Soil community composition drives aboveground plant–herbivore–parasitoid interactions
Authors: Bezemer T. M. , De Deyn G. B. , Bossinga T. M. , Van Dam N. M. , Harvey J. A. , Van der Putten W. H.
Published: June 2005

Soil organisms can influence higher trophic level aboveground organisms, but only very few studies have considered such effects. We manipulated soil community composition of model grassland ecosystems by introducing nematode communities, microorganisms, neither or both groups. Above ground, aphids (Rhopalosiphum padi) and parasitoids (Aphidius colemani) were introduced, and we measured individual performance and population dynamics of plants, aphids and parasitoids. In microcosms with nematode inoculations either with or without microorganism inoculation, aphids offspring production was significantly reduced by 31%. Aphid populations on both host plants Agrostis capillaris and Anthoxanthum odoratum were lowest in microcosms with combined nematode and microorganism inoculations. Opposite results were found for parasitoids. While the number of emerged parasitoids did not differ between treatments, parasitoid mortality and the proportion of males were significantly lower in microcosms with nematode and microorganism inoculations. Parasitized aphids were significantly larger in microcosms with nematodes inoculated. Plant biomass did not differ, but in the preferred host plant A. odoratum, foliar phenolic content was reduced in the presence of nematodes, and also the concentration of amino acids in the phloem. This study shows that the composition of the soil community matters for aboveground multitrophic interactions.
Environmental and geometric constraints on Indo‐Pacific coral reef biodiversity
Authors: Bellwood D. R. , Hughes T. P. , Connolly S. R. , Tanner J.
Published: June 2005

The Indo‐Australian Archipelago supports the world's richest coral reef biodiversity hotspot. Traditional hypotheses that account for such exceptional biodiversity have highlighted the importance of environmental variables such as habitat area and energy input. Recently, however, an additional explanation has been proposed based on geometric constraints in the placement of geographical ranges within a bounded domain, which cause a mid‐domain peak in species richness; the mid‐domain effect (MDE). Here, for the first time, we examine the relative importance of area, energy and MDE jointly on species richness patterns. Model selection indicates that the best model incorporates MDE and reef area, but no energy effect; moreover, this best‐fit model captures all major features of reef fish and coral species richness patterns. Habitat area is the major environmental factor influencing species richness. The prevention of further fragmentation and loss of habitat area is of critical importance for the conservation of coral reef biodiversity.
Complete rectal prolapse in young patients: psychiatric disease a risk factor of poor outcome
Authors: Marceau C. , Parc Y. , Debroux E. , Tiret E. , Parc R.
Published: June 2005

Objective  Complete rectal prolapse is rare before the age of 50. The aim of our study was to identify the risk factors of total rectal prolapse before this age and to determine the surgical outcome in this specific group of patients.

Patients and methods  The charts of all patients, younger than 50 years old, treated for total rectal prolapse between June 1995 and December 2001 were reviewed. Associated conditions were noted and pre and postoperative functions were compared in regards of constipation and evacuations problems, anal continence (Wexner score), recurrent prolapse and overall satisfaction. All patients underwent an abdominal rectopexy according to the Orr‐Loygue procedure.

Results  During the study period, 28 patients (21 females) with a mean age of 34 ± 9 years were treated for a total rectal prolapse in our institution. Five patient (17.8%) had minor complications. After a mean follow up of 25 months, the global continence improved significantly (Wexner score: 4.9 vs 2; P = 0.014): 8 patients suffering from liquid stools incontinence before surgery were continent after rectopexy, while 2 continent patients became incontinent to liquid stools after surgery. Fourteen patients had chronic psychiatric disease requiring permanent treatment. These patients suffered more frequently from constipation (12/14 vs 5/14; P =0.006) and required more often a digital evacuation before surgery (6/14 vs 1/14; P = 0.07) than non psychiatric patients. They also suffered from more severe constipation and required more enemas after surgery (1/14 vs 6/12; P = 0.03) compared to patients without psychiatric disease. The only two patients, who had recurrence also had psychiatric disease.

Conclusion  Chronic psychiatric disease requiring long‐term medication is observed in 50% of patients with total rectal prolapse under the age of 50 years. Moreover, the medically induced constipation in these patients could represent a cause of poorer functional outcome. Therefore, we recommand the identification of this preoperative risk factor to assess the results of total rectal prolapse treatment in patients younger than 50 years of age.
Jejunal Crohn's disease is associated with a higher postoperative recurrence rate than ileocaecal Crohn's disease
Authors: Keh C. , Shatari T. , Yamamoto T. , Menon A. , Clark M. A. , Keighley M. R.
Published: June 2005

Objective  Crohn's disease is a chronic inflammatory, panintestinal disease of uncertain aetiology. The recurrence rate of Crohn's disease, often taken as the time when further surgical procedure is undertaken, has been reported to be as high as 76% in 10 years. The site of the disease has not yet been associated with the recurrence rate of Crohn's disease. The aim of the study was to compare the outcome of patients who were surgically treated for jejunal Crohn's disease to those whose diseases was confined to the ileocaecal region.

Method  The information was tracked from our database of 724 surgically treated Crohn's disease patients between 1943 and 2002. Twenty‐eight patients with jejunal Crohn's disease at their first operation (12 jejunum alone, 16 also involving other sites) were identified. For each of these patients, 3 patients with ileocaecal Crohn's, matched for age, sex, and smoking habits (n = 84) were identified as controls.

Results  The median age in both groups was 21 years (range 16–52 years) with a median follow‐up period of 19 years. The 3, 5 and 10 years re‐operation rate for the groups with jejunal disease were 43%, 50% and 61% compared to 22%, 30% and 51% with ileocaecal disease, respectively.

Conclusions  The presence of jejunal Crohn's disease is associated with a higher rate of early disease recurrence compared to ileocaecal disease but long‐term recurrences rate do not differ significantly.
Assessment of long‐term quality of life after laparoscopic and open surgery for Crohn's disease
Authors: Thaler K. , Dinnewitzer A. , Oberwalder M. , Weiss E. G. , Nogueras J. J. , Wexner S. D.
Published: June 2005

Objective  Surgery for Crohn's disease (CD) is associated with a high recurrence rate and quality of life (QOL) in these patients is controversial. The aim of this study was to assess QOL in patients after laparoscopic and open surgery for CD by two different validated instruments, a generic nonspecific score and a specific gastrointestinal QOL index.

Patients and methods  Patients with CD who underwent elective laparoscopic or open ileocaecal resection with primary anastomosis between 1992 and 2000 were followed for recurrence and surgery‐related complications. QOL was assessed by the SF‐36 Health Survey containing a mental (MCS) and a physical (PCS) component summary score and by the Gastrointestinal Quality of Life Index (GIQLI) developed by Eypasch.

Results  Thirty‐seven patients with a mean age of 48.8 ± 18.4 years including 23 females and 14 males were evaluated at a mean follow‐up of 42.6 ±25.8 months (minimum of 8 months). Twenty‐one (57%) patients underwent laparoscopic resection and 16 (43%) open surgery. Both groups were well matched for age, gender, ASA class and body mass index. Fourteen (38%) patients developed recurrent disease and 3 (8%) had postoperative incisional hernias. Overall, QOL scores were 103 ± 26.8 for the GIQLI, 47.2 ± 11.8 for the PCS, and 49.2 ± 11.5 for the MCS. The GIQLI correlated well with the SF36, correlation coefficient = 0.68 for GIQLI vs PCS (95% CI, 0.41,0.95) and 0.67 for GIQLI vs MCS (95%CI, 0.39, 0.95), respectively. When compared to the general US population, mean GIQLI scores (−13.8, P = 0.002) and mean PCS scores (−4.7, P = 0.001) were significantly lower in these patients than in healthy individuals. In a multivariate analysis of impact factors on QOL, recurrence within the follow‐up period was the single significant determinant reducing the PCS (−35.1, P = 0.026) and the GIQLI (−36.1, P =0.018).

Conclusion  QOL is significantly reduced in patients with CD at long‐term follow‐up after both laparoscopic and open surgery. Recurrence is the only factor adversely affecting QOL of CD patients in remission irrespective of the operative technique applied.
Elevated tumour markers prior to complete tumour removal in patients with pseudomyxoma peritonei predict early recurrence
Authors: Alexander‐Sefre F. , Chandrakumaran K. , Banerjee S. , Sexton R. , Thomas J. M. , Tom Cecil  , Moran B.
Published: June 2005

Objective  To assess the potential value of pre‐operative CEA, CA 125 and CA 19–9 in identifying Pseudomyxoma peritonei (PMP) patients at risk of recurrence following complete cytoreductive surgery and intraperitoneal chemotherapy.

Method  Between March 1996 and October 2001, 35 patients, with documented pre‐operative tumour marker measurements, underwent complete cytoreduction. Outcome in the 32 survivors was recorded.

Results  Median age was 53 years (range: 32–74). There were 17[53%] females. In 9/32[28%] all tumour markers were normal. The most common abnormality was elevated CEA level in 14/32[44%]. Median follow up was 23 months (range: 11–74). Recurrence was detected in 8/32[25%]. The 2‐year recurrence free interval was 53% in those with elevated CEA compared with 94% with normal CEA. The 2‐year disease free intervals were 100% in 9 patients with normal preop markers compared with 66% for the group with at least one abnormal marker.

Conclusion  PMP patients with elevated CEA, or more than one abnormal serum tumour maker, are at risk of developing recurrent disease.
Pre‐operative assessment of extramural invasion and sphincteral involvement in rectal cancer by magnetic resonance imaging with phased‐array coil
Authors: Ferri M. , Laghi A. , Mingazzini P. , Iafrate F. , Meli L. , Ricci F. , Passariello R. , Ziparo V.
Published: June 2005

Objective  Pre‐operative staging of rectal cancer should identify patients with extrarectal spread, who might benefit from pre‐operative radiotherapy, and patients with minimal sphincteral involvement, who can avoid permanent colostomy. The aim of this study was to assess the accuracy of Magnetic Resonance Imaging (MRI) to predict tumour stage and sphincter status.

Patients and methods  Thirty‐three patients with a rectal tumour were pre‐operatively assessed by MRI with a phased‐array coil. Imaging results were correlated with the final pathological findings.

Results  The overall accuracy of pre‐operative staging with MRI was 88% (k = 0.75) for extramural tumour invasion and 59% (k = 0.26) for lymph node metastases. MRI correctly evaluated the infiltration of the anal sphincters in 87% of patients (7 of 8 patients with low rectal tumour).

Conclusion  MRI provides the surgeon with valuable information regarding extramural tumour spread and sphincteral involvement, enabling appropiate selection of patients for pre‐operative adjuvant therapy or sphincter‐saving surgery.
The prevalence of iron deficiency among patients presenting with colorectal cancer
Authors: L Beale A. , Penney M. D. , Allison M. C.
Published: June 2005

Objectives  To examine prospectively the prevalence of iron deficiency among new patients presenting with colorectal cancer and to compare transferrin saturation and serum ferritin as markers of iron deficiency in this group of patients.

Patients and methods  Data were gathered on all patients presenting with a new diagnosis of colorectal cancer over a 12‐month period. Iron status was estimated and, when possible, confirmed by measurement of serum ferritin concentration and transferrin saturation. Iron status was further examined in relation to tumour site and Dukes' stage.

Results  During the study 157 patients presented with a new colorectal cancer. Of these, 130 could be evaluated and 78[60%] had evidence of iron deficiency. Transferrin saturation was below the reference range in 55 patients, but serum ferritin was below in only 18 patients. Among the 49 patients with right‐sided cancers, 39[80%] were iron deficient. Iron deficiency was significantly more likely in patients with right sided cancers compared with those with cancers at or distal to the splenic flexure (χ2 = 13, P < 0.001).

Conclusion  The majority of patients with a new diagnosis of colorectal cancer are iron deficient at presentation. In such patients transferrin saturation measurement is a more sensitive marker of iron deficiency than serum ferritin. The potential role of measuring serum transferrin saturation as an adjunct to faecal occult blood screening should be explored further.
The impact of bone marrow micrometastases on metastatic disease‐free survival in patients with colorectal carcinoma
Authors: O'Connor O. J. , Cahill R. A. , Kirwan W. O. , Redmond H. P.
Published: June 2005

Aims  The biological relevance of bone marrow micrometastases (BMM) in colorectal cancer remains unknown. Here, we investigate their nature by examining the impact of the presence of BMM on metastatic disease‐free survival in a cohort of patients with this disease.

Methods  Sixty‐three consecutive patients undergoing surgery for colorectal cancer of any stage were studied after approval of the study protocol by the local ethics committee and with full individual informed consent. All had bilateral iliac crest bone marrow aspirates prior to operation. Aspirates were then examined for the presence of aberrant cytokeratin‐18‐positive cells by a blinded observer using both flow cytometric and APAAP immunohistochemical techniques.

Results  Mean follow‐up after surgery was 4.6 years (range 1.9–6.9) for those without hepatic metastases at diagnosis. Seven of 34 patients with Dukes’ stage A or B developed metastatic disease after a mean interval of 4.7 years (range 3.8–6.8). However, only 2 of these patients demonstrated BMM at the time of surgery. Nine of 15 patients with Dukes’ C carcinoma at the time of surgery subsequently developed metastases after a mean interval of 4.4 years (range 1.9–6.9). Again, only two of these patients had BMM detectable initially. In only three of the 14 patients known to have metastases at the time of operation (i.e. Dukes’‘D’ disease) were BMM found.

Conclusion  The presence of BMM as detected by this methodology was not predictive of tumour recurrence or metastasis. This study does not support the consideration of adjuvant therapy based on the presence of BMM at a single pre‐operative time point in patients with colorectal cancer.
Is it possible to predict or prevent third degree tears?
Authors: Byrd L. M. , Hobbiss J. , Tasker M.
Published: June 2005

Objectives  This paper reviews the causes anal sphincter injury during vaginal delivery. It emphasises that they are not usually the result of poor obstetric care. The role of the colorectal surgeon in their management is discussed.

Methods  Medline was searched using the key words third degree tears, pregnancy, risk factors, prevention and recurrence risk. A hand search of journals and located articles was made. Two hundred and twenty three papers were identified, 84 are referenced.

Results  The reported incidence of anal sphincter tears is usually between 0.5% and 2.5% of vaginal deliveries. Maternal factors such as parity and age and obstetric factors such as mode of presentation, the use of forceps and the size of the baby all influence the incidence of sphincter tears. Predicting tears in individual women is inaccurate and midwifery practices can do little to prevent them. Reducing pelvic floor morbidity by increasing the caesarean section rate would require that a large number of caesarean sections be done to prevent a small number of tears. The recognition of perineal trauma is improved by training. Accurate apposition of the sphincters with antibiotic cover and post‐operative laxatives are the important technical aspects of the repair. Colorectal follow up helps to identify those women with symptoms and allows advice about the advisability of subsequent vaginal deliveries. A previous third degree tears increases the risk of a subsequent one, although the overall risk remains low. A second vaginal delivery after a third degree tear that has resulted in a functional deficit predisposes to worsening function. When there is no residual anatomical defect and no functional loss, there is no evidence of increased risk of incontinence following another vaginal delivery.

Conclusion  Vaginal delivery will continue to be the main method of delivery and will continue to generate a low incidence of pelvic floor morbidity. The management of injury to the anal sphincter is facilitated by close co‐operation between obstetricians and colorectal surgeons.
Pre‐operative mechanical bowel cleansing or not? an updated meta‐analysis
Authors: Wille‐Jørgensen P. , Guenaga K. F. , Matos D. , Castro A. A.
Published: June 2005

Objectives  Pre‐operative mechanical bowel preparation has been considered an efficient regimen against leakage and infectious complications, after colorectal resections. This dogma is based only on observational data and experts' opinions. The aim of this study was to evaluate the efficacy and safety of prophylactic pre‐operative mechanical bowel preparation before elective colorectal surgery.

Methods  EMBASE, LILACS, MEDLINE and The Cochrane Library and abstracts from major gastroenterological congresses were searched. No language restrictions were applied. The selection criterion used was randomised clinical trials (RCT) comparing any kind of mechanical bowel preparation with no preparation in patients submitted to elective colorectal surgery and where anastomotic leakage, mortality, and wound infection were outcome measurements. Data were independently extracted by the reviewers and cross‐checked. The methodological quality of each trial was assessed by the same reviewers. For meta‐analysis the Peto‐Odds ratio was used.

Results  Of 1592 patients (9 RCTs), 789 were allocated to mechanical bowel preparation (Group A) and 803 to no preparation (Group B) before elective colorectal surgery. Anastomotic leakage developed in 48 (6%) of 772 patients in A compared with 25 (3.2%) of 777 patients in B; Peto OR 2.03, 95% (CI: 1.28–3.26; P = 0.003). Wound infection occurred in 59 (7.4%) of 791 patients in A and in 43 (5.4%) of 803 patients in B; Peto OR 1.46, 95% (CI: 0.97–2.18; P = 0.07);

Five (1%) of 509 patients died in group in A compared with 3 (0.61%) of 516 patients in group B; Peto OR 1.72, 95% (CI: 0.43–6.95; nonsignificant).

Conclusion  There is no evidence that patients benefit from mechanical bowel preparation. On the contrary taking colorectal surgery as a whole, pre‐operative bowel cleansing leads to a higher rate of anastomotic leakage. The dogma that mechanical bowel preparation is necessary before elective colorectal surgery has to be reconsidered.
Management of pilonidal sinus using fibrin glue: a new concept and preliminary experience
Authors: Seleem M. I. , Al‐Hashemy A. M.
Published: June 2005

Background  There is a multiplicity of treatment techniques described for pilonidal sinus. However none of the methods has emerged as being superior to the others. A ideal treatment should be simple, lead to minimal disability and a rapid return to normal activity. We present the preliminary finding an operative technique using fibrin glue in patents with pilonidal sinus.

Patients and methods  The study was carried out in the surgical unit of the Armed Forces Hospital, Khamis Mushayt, Kingdom of Saudi Arabia. From September 2001 to February 2004, 25 consecutive patients with primary pilonidal sinus, were prospectively submitted to tension free excision and fibrin glue injection under local anaesthesia as day surgery cases. There were 23 males and 2 females with a mean age of 26.4 years (range 17–50 years). The data recorded included the duration of the disease symptoms, operative time, duration of hospital stay, postoperative analgesia, and return to work. All excised specimens were sent to histopathology. The postoperative disability and the social disruption were evaluated by indirect questions about the ability to drive a car and the position assumed while at home in the outpatient follow‐up.

Results  The mean duration of the symptoms was 15.4 months (range 4–36 months). Mean operative time including local anaesthetic time was 19.3 min (range 15–50 min). The mean hospital stay was 7.5 h (range 6–10 h). All patients were discharged home on the day of surgery. Mean follow‐up was 10.8 months (range 4–36 months). Primary healing was achieved in 24 (96%) patients within two weeks. One (4%) patient had a breakdown of the fibrin glue and the open wound managed with daily betadine dressings.

Conclusion  The management of pilonidal sinus with excision under local aaesthesia and application of a fibrin glue is simple and reduces postoperative disability and disruption of patient social life.
Colorectal adenomas with a low frequency of ki‐ras mutations: a sample from a population with a low mortality rate from colorectal cancer
Authors: Kornaros S. , Liloglou T. , Politou M. , Elemenoglou I.
Published: June 2005

Objective  To detect and analyse ki‐ras point mutations in colorectal adenomas and carcinomas in patients from Greece, where mortality rate from colorectal cancer is lower than that in other European countries and the USA.

Patients and methods  As a method we used PCR‐RFLP technique, to examine ki‐ras codons 12 and 13 mutations in 450 paraffin embedded tissues, consisting of 141 normal mucosas, 165 adenomas and 144 sporadic colorectal cancers taken from 141 patients.

Results  Frequency of ki‐ras mutations was 3.2% (3/93) in small adenomas, 5.2% (3/57) in greater than 1 cm adenomas, 20% (3/15) in tissues where adenoma and cancer coexisted and 39.5% (57/144) in colorectal cancer.

Conclusion  These data showed that the frequency of ki‐ras mutations was low in all sizes of polyps and high in carcinomas in a sample of a population, characterized by a low mortality rate from colorectal cancer. Ki‐ras mutations were not an early event of colon carcinogenesis in these patients and the low frequency of ki‐ras mutations in adenomas may probably have some relevance to the low mortality rate. Our findings could be explained, not by the dietary habits of this population, but by the presence of other hitherto unknown environmental factors.
Is prophylactic colectomy indicated in patients with MYH‐associated polyposis?
Authors: Leite J. S. , Isidro G. , Martins M. , Regateiro F. , Albuquerque O. , Amaro P. , Romãozinho J. M. , Boavida G. , Castro‐Sousa F.
Published: June 2005

Objectives  The MYH gene has recently been associated with multiple colorectal tumours. It participates in the DNA base‐excision‐repair, avoiding mutations in other genes, namely the APC and Ki‐ras. Recently, biallelic MYH mutations have been described in patients with attenuated polyposis and in 7.5% with classic polyposis and no detectable APC mutation. The aim of this study was to analyse the incidence of germ‐line MYH mutations in selected Portuguese families recorded in a hereditary tumour registry and to evaluate the risk of colorectal cancer in this syndrome.

Patients and methods  Nineteen APC mutation negative patients, 13 presenting attenuated polyposis and 6 with classic familial adenomatous polyposis (> 100 adenomas), were screened for germline biallelic MYH mutations.

Results  Biallelic germline mutations in MYH were identified in 9 of the attenuated polyposis and in one of the classic polyposis patients. The mean age at the clinical diagnosis was 50.6 years (from 35 to 69 years); six were men and four women. Five patients belonged to families with affected siblings; three showed evidence for vertical transmission and two had no evidence for familial transmission of the disease. No extra‐colonic manifestations were reported. All patients had surgical resections: five total colectomies, four reconstructive proctocolectomies and one left hemicolectomy. Eight patients had associated malignant degeneration: three T3N+, four T3N0 and one T1N+. In the follow‐up two patients died due to tumour recurrence.

Conclusion  A large frequency of biallelic MYH mutations (69%) was found in APC mutation negative patients belonging to families with attenuated polyposis; the highest percentage was observed in families presenting evidence for horizontal transmission of the disease. The high percentage of degeneration found in these patients suggests that colonoscopy with polypectomies is not sufficient and prophylactic colectomy is recommended. The identification of MYH associated polyposis is important to evaluate the level of risk, particularly for the siblings.
A prospective analysis of extended endoscopic mucosal resection for large rectal villous adenomas: an alternative technique to transanal endoscopic microsurgery
Authors: Hurlstone D. P. , Sanders D. S. , Cross S. S. , George R. , Shorthouse A. J. , Brown S.
Published: June 2005

Introduction  Endoscopic mucosal resection is a safe resection tool for selected flat, sessile and lateral spreading tumours of the colon. Transanal microsurgical resection of select rectal neoplastic lesions is another accepted modality. Recent data suggests transanal microsurgery may have high complication rates. We conducted a prospective clinicopathological evaluation of an extended endoscopic mucosal resection technique for highly selected lesions of the rectum and assessed outcome data over a maximal 24‐month period.

Patients and methods  Eighty‐three patients with known rectal neoplastic lesions underwent chromoscopic colonoscopy and on‐table staging using a high‐frequency (12.5 MHz) mini‐probe EUS by a single endoscopist. Patients with T2 or node positive disease were referred for surgery. Following extended endoscopic mucosal resection patients were followed‐up at 3, 6, 12 and 24 months post ‘index’ resection with chromoscopic endoscopy and EUS. Procedural complications, recurrence rates and outcome data were collected.

Results  Sixty‐two patients fulfilled inclusion criteria. Median procedure time was 48 mins (range32–126). Lateral spreading tumours (median diameter 30 mm; range 18–42 mm) and sessile lesions (median diameter 38 mm; range 25–86 mm) accounted for 19% and 81% of lesions, respectively. Ninety‐seven percent of patients undergoing EMR were discharged within 6‐h of procedure. Thirty‐day re‐admission and death rate was 0%. Bleeding complications occurred in 5/62 (8%) of patients with all achieving complete haemostasis using endo clips. None required transfusion. There were no procedural related complications or perforations. Overall ‘cure’ rate at a median follow‐up of 16 months was 98%.

Conclusions  Extended endoscopic mucosal resection for rectal neoplastic lesions can achieve superior results to those of per‐anal excision and trans‐anal microsurgery with regard to complications and recurrence rates. Extended endoscopic mucosal resection may be an alternative therapeutic modality in selected patients.
Error and objectivity: cognitive illusions and qualitative research
Authors: Paley John
Published: June 2005

Abstract Psychological research has shown that cognitive illusions, of which visual illusions are just a special case, are systematic and pervasive, raising epistemological questions about how error in all forms of research can be identified and eliminated. The quantitative sciences make use of statistical techniques for this purpose, but it is not clear what the qualitative equivalent is, particularly in view of widespread scepticism about validity and objectivity. I argue that, in the light of cognitive psychology, the ‘error question’ cannot be dismissed as a positivist obsession, and that the concepts of truth and objectivity are unavoidable. However, they constitute only a ‘minimal realism’, which does not necessarily bring a commitment to ‘absolute’ truth, certainty, correspondence, causation, reductionism, or universal laws in its wake. The assumption that it does reflects a misreading of positivism and, ironically, precipitates a ‘crisis of legitimation and representation’, as described by constructivist authors.
Time, human being and mental health care: an introduction to Gilles Deleuze
Authors: Roberts Marc
Published: June 2005

Abstract  The French philosopher, Gilles Deleuze, is emerging as one of the most important and influential philosophers of the 20th century, having published widely on philosophy, literature, language, psychoanalysis, art, politics, and cinema. However, because of the ‘experimental’ nature of certain works, combined with the manner in which he draws upon a variety of sources from various disciplines, his work can seem difficult, obscure, and even ‘willfully obstructive’. In an attempt to resist such impressions, this paper will seek to provide an accessible introduction to Deleuze's work, and to begin to discuss how it can be employed to provide a significant critique and reconceptualization of the theoretical foundations and therapeutic practices of psychiatry, psychotherapy, and mental health nursing. In order to do this, the paper will focus upon Deleuze's masterwork, and the cornerstone to his philosophy as a whole, Difference and Repetition; in particular, it will discuss how his innovative and challenging account of time can be employed to provide a conception of human life as a ‘continuity’, rather than as a series of distinct ‘moments’ or ‘events’. As well as discussing the manner in which his work can provide us with an understanding of how life is different and significant for each human being, this paper will also highlight the potential importance of Deleuze's work for logotherapy, for the recent ‘turn’ to ‘narrative’ as a psychotherapeutic approach and for contemporary mental health care's growing interest in ‘social constructionism’. As such, this paper also seeks to stimulate further discussion and research into the importance and the relevance of Deleuze's work for the theory and practice of psychiatry, psychotherapy, and mental health nursing.
Social Protection and the Labour Market in Latin America: What can be Learned from Household Surveys?
Authors: Gasparini Leonardo , Bertranou Fabio M.
Published: June 2005

Most social protection is provided through contribution‐based programmes, which means that protection is usually linked to employment conditions in the formal economy. This article describes the levels, trends and structure of social protection for workers in Latin America, highlighting the relationship between protection and employment conditions. The study is based on a selection of household surveys carried out in various countries in the region: Argentina, Brazil, Bolivia, Chile, Ecuador, Guatemala, Mexico, Nicaragua and Peru. It emphasizes the usefulness of household surveys as sources of information for representative studies on social protection and employment, in spite of the problems of coverage and comparability that they raise.
The Role of Insurance in Social Protection in Latin America
Authors: Titelman Daniel , Uthoff Andras
Published: June 2005

Social protection schemes in Latin America face serious short falls in the financial resources available to meet their needs. New types of insurance envisaged in reforms should help to contain costs and increase coverage. However, in strengthening schemes' coverage it is highly probable that considerable demand for additional financial resources will arise to address the need to introduce the principle of solidarity into the system. This article examines reforms in the financing of social security for healthcare and pensions, highlighting the implications of various public‐private combinations for financial management and coverage.
Assessing the World Bank Report Keeping the Promise
Authors: Mesa‐Lago Carmelo
Published: June 2005

A new report of the World Bank released in 2004 evaluates the performance of structural pension reforms in several Latin American countries, ratifying some fundamental issues of the Bank's previous report of 1994 but contesting others, acknowledging serious problems and recommending new policies. In the light of available data from ten countries with structural reforms in the region, as well as the author's own research, this article discusses nine key elements of the new report: coverage, compliance, competition among administrators, managerial costs, capital accumulation, effects on capital and financial markets, fiscal costs, general and gender equity, and isolation from politics.
Occupational Risks in Latin America
Authors: Gutiérrez Alvaro Castro
Published: June 2005

Protection against employment accidents and occupational diseases, also known as occupational risks, has a long history in Latin America. There have been very few studies of this branch of social security, despite the fact that as a vehicle of social protection it is of the greatest importance for any society. In view of its implications in terms of improved worker protection and greater productivity in the economy, this form of insurance deserves greater attention. This article attempts to give an overview of the evolution of occupational risk insurance in Latin America, as well as its current problems and status. It discusses specific aspects of selected schemes, with concluding observations on the challenges now faced by such schemes in the region.
Correlation of birth injury with maternal height and birthweight
Authors: Gudmundsson Saemundur , Henningsson Anne‐Charlotte , Lindqvist Pelle
Published: June 2005

Background  Infant or maternal injury during vaginal delivery is a constant threat to all involved, but difficult to predict.

Objective  To estimate the risk of birth injuries in an institution favouring trial of vaginal birth when there was doubt of the best mode of delivery.

Design  A retrospective cohort study.

Setting  University Hospital.

Population  Singleton 14,359 vaginal deliveries in cephalic presentation during 5½ years.

Methods  The total caesarean section rate during this period was 9%. The likelihood of injury was evaluated by logistic regression analysis with injury as the dependent variable and maternal height and child birthweight as explanatory variables in birth injury risk estimation.

Main outcome measures  Infant injury defined as one of the following: shoulder dystocia, clavicle fracture or brachial plexus injury; and maternal injury as anal sphincter rupture (ASR).

Results  There were a total of 318 infant injuries in 282 infants and 423 ASRs. A strong correlation was found between injury and both fetal macrosomia and short maternal stature, but macrosomia was a stronger indicator of injury. Birth injury risk estimation curves were constructed based on maternal height and birthweight.

Conclusions  The present results confirm a strong correlation between fetal macrosomia and short maternal stature and the likelihood of injury during vaginal birth. Risk estimation curves were constructed that might be of great value for the obstetrician in choosing the mode of delivery in these cases.
Outcome of pregnancy in a woman with an increased body mass index
Authors: Usha Kiran T.S. , Hemmadi S. , Bethel J. , Evans J.
Published: June 2005

Objective  To show the increased risk of adverse outcomes in labour and fetomaternal morbidity in obese women (BMI > 30).

Design  A population‐based observational study.

Setting  University Hospital of Wales. The study sample was drawn from the Cardiff Births Survey, a population‐based database comprising of a total of 60,167 deliveries in the South Glamorgan area between 1990 and 1999.

Population  Primigravid women with a singleton uncomplicated pregnancy with cephalic presentation of 37 or more weeks of gestation with accurate information regarding height and weight recorded at the booking visit (measured by the midwives) were included in the study.

Methods  Comparisons were made between women with a body mass index of 20–30 and those with more than 30. SPSS version 10 was used for statistical analysis. Student's t test, χ2 and Fisher's exact tests were used wherever appropriate.

Main outcome measures  Labour outcomes assessed were risk of postdates, induction of labour, mode of delivery, failed instrumental delivery, macrosomia and shoulder dystocia. Maternal adverse outcomes assessed were postpartum haemorrhage, blood transfusion, uterine and wound infection, urinary tract infection, evacuation of uterus, thromboembolism and third‐ or fourth‐degree perineal tears. Fetal wellbeing was assessed using Apgar <7 at 5 minutes, trauma and asphyxia, cord pH < 7.2, babies requiring neonatal ward admissions, tube feeding and incubator.

Results  We report an increased risk [quoted as odds ratio (OR) and confidence intervals CI)] of postdates, 1.4 (1.2–1.7); induction of labour, 1.6 (1.3–1.9); caesarean section, 1.6 (1.4–2); macrosomia, 2.1 (1.6–2.6); shoulder dystocia, 2.9 (1.4–5.8); failed instrumental delivery, 1.75 (1.1–2.9); increased maternal complications such as blood loss of more than 500 mL, 1.5 (1.2–1.8); urinary tract infections, 1.9 (1.1–3.4); and increased neonatal admissions with complications such as neonatal trauma, feeding difficulties and incubator requirement.

Conclusion  Obese women appear to be at risk of intrapartum and postpartum complications. Induction of labour appears to be the starting point in the cascade of events. They should be considered as high risk and counselled accordingly.
TOCOX—A randomised, double‐blind, placebo‐controlled trial of rofecoxib (a COX‐2‐specific prostaglandin inhibitor) for the prevention of preterm delivery in women at high risk
Authors: Groom Katie M. , Shennan Andrew H. , Jones Bryony A. , Seed Paul , Bennett Phillip R.
Published: June 2005

Objective  To assess the safety and efficacy of the long term prophylactic use of rofecoxib (a COX‐2‐specific inhibitor) in women at high risk of preterm delivery.

Design  A randomised, double‐blind, placebo‐controlled trial.

Setting  Queen Charlotte's and Chelsea Hospital, London and Guys and St Thomas' Hospitals, London.

Population  Ninety‐eight singleton pregnancies at high risk of preterm labour.

Methods  Treatment from 16 to 32 weeks. Weekly ultrasound surveillance.

Main outcome measures  Fetal renal function and ductus arteriosus blood flow changes. Preterm delivery rates and neonatal outcome.

Results  Rofecoxib caused a reduction in hourly fetal urine production rates (−34%, 95% CI −13 to −50%, P= 0.004) and amniotic fluid index (−2.2, 95% CI −3.2 to −1.2, P < 0.001). This effect did not increase with time on treatment and reversed in all cases on discontinuation of treatment. Rofecoxib had an effect on the ductus arteriosus, increasing maximum systolic velocity (0.1 m/s, 95% CI 0.03–0.16, P= 0.02) and minimum diastolic velocity (0.007 m/s, 95% CI 0.0007–0.013, P= 0.03). This effect increased with time on treatment but was reversed with discontinuation of treatment and had no long term clinical sequelae. There was no difference in preterm delivery rates <30 weeks (28% on placebo vs 33% on rofecoxib, Mantel–Haensel [M–H]‐adjusted risk 1.11, 95% CI 0.67–1.87). There were more deliveries <37 weeks in those on rofecoxib (40%vs 67%, M–H‐adjusted risk 1.59, 95% CI 1.09–2.32). Rates of preterm prelabour rupture of membranes (PPROM) were higher in those on rofecoxib (RR 2.5, 95% CI 1.3–4.7).

Conclusion  Rofecoxib has a significant but reversible effect on fetal renal function and the ductus arteriosus. It does not reduce the incidence of early preterm delivery <30 weeks and is associated with an increased risk of delivery before 37 weeks in women at high risk.
Editorials: Will Peritoneal Dialysis be Left Behind?
Authors: Prichard Sarah
Published: June 2005

Peritoneal dialysis (PD) enjoyed huge growth in the 1980s, followed by a rapid decline in the late 1990s, and a now persistently low utilization rate in many countries, including the United States. Recent clinical data indicate a survival advantage for patients started on PD. Residual renal function is better preserved with PD. Adequacy targets are being revised and will likely allow PD prescriptions to be simplified. The physiology of the peritoneum is better understood and treatment strategies reflect that understanding. New solutions have been developed in response to studies that have assessed the impact of conventional PD dialysate on the structure and function of the peritoneum. A remaining challenge is to ensure that nephrology trainees and nephrologists in practice are fully informed of the advantages of PD for many patients and of the advances in the therapy. If this can be achieved, PD should start to grow again.
Editorial Focus: Transplant Nephrectomy: At the Peril of Dialysis Patients: Ignoring the Failed Transplant
Authors: Ayus Juan Carlos , Achinger Steven G.
Published: June 2005

Recently it has been shown that patients returning to hemodialysis (HD) following kidney transplant loss have poor survival, though the factors responsible for these poor outcomes remain largely unknown. In the past, we have shown that occult infection of clotted arteriovenous grafts (AVGs) leads to a chronic inflammatory state characterized by erythropoietin resistance, hypoalbuminemia, elevated C‐reactive protein (CRP), and poor outcomes. It is well known that failed renal allografts induce graft intolerance syndrome, a clinical syndrome of pain, fever, and anemia, in the majority of patients. Similarly we have shown that failed renal allografts, by their nature as a nidus of chronic immunoreactivity, also induce a chronic inflammatory state. We speculate that this chronic inflammatory state, characterized by biochemical markers of poor HD outcomes, may be responsible for the excess mortality in this group. It is currently standard practice to leave failed kidney transplants in place upon return to HD and to treat symptomatic graft intolerance syndrome with immunosuppression. While this approach may reduce clinical symptoms in the short term, treatment failure and ultimately transplant nephrectomy occur in the majority of cases. There is also evidence that continued immunosuppression can even be dangerous. It should be noted that medical treatment of graft intolerance syndrome has not been shown to reduce chronic inflammation or decrease mortality. Similarly embolization of failed kidney transplants, another option for handling failed kidney transplants, has a high rate of treatment failure, has not been shown to reduce chronic inflammation, and nothing is known about the long‐term safety of this approach. Therefore failed kidney transplants in patients with biochemical markers of chronic inflammation (as is the case for infected, clotted AVGs) should be removed prior to the development of clinical symptoms in order to eliminate the chronic inflammatory state.
The Management of the Failed Renal Allograft: An Enigma with Potential Consequences
Authors: Langone Anthony J. , Chuang Peale
Published: June 2005

The number of patients returning to dialysis after their renal allograft fails is increasing in absolute numbers year after year. The management of the failed allograft that is not immediately symptomatic remains controversial. Surgical mortality and morbidity, a rising number of circulating antibodies, reduced erythropoietin, and diuresis are among the arguments to support simply observing the failed allograft. Chronic inflammation, potential for malignancy, infection, and the need for low‐dose immunosuppression are concerns that might goad one into performing a preemptive nephrectomy. Based on the current literature and our own clinical experience, we believe allograft nephrectomies should not be routinely performed. They should be reserved for those patients who develop particular symptoms attributable to the allograft or those who require space for retransplantation. Future studies that address this issue in addition to testing various immunosuppression attrition rates may be able to discern a protocol that minimizes drug exposure while leading to reduced nephrectomy rates after returning to dialysis.
Reviews: Uremic Toxins: A New Focus on an Old Subject
Authors: Yavuz Asuman , Tetta Ciro , Ersoy F. Fevzi , D’intini Vincent , Ratanarat Ranistha , De Cal Massimo , Bonello Monica , Bordoni Valeria , Salvatori Gabriella , Andrikos Emilio , Yakupoglu Gulsen , Levin Nathan W. , Ronco Claudio
Published: June 2005

The uremic syndrome is characterized by an accumulation of uremic toxins due to inadequate kidney function. The European Uremic Toxin (EUTox) Work Group has listed 90 compounds considered to be uremic toxins. Sixty‐eight have a molecular weight less than 500 Da, 12 exceed 12,000 Da, and 10 have a molecular weight between 500 and 12,000 Da. Twenty‐five solutes (28%) are protein bound. The kinetics of urea removal is not representative of other molecules such as protein‐bound solutes or the middle molecules, making Kt/V misleading. Clearances of urea, even in well‐dialyzed patients, amount to only one‐sixth of physiological clearance. In contrast to native kidney function, the removal of uremic toxins in dialysis is achieved by a one‐step membrane‐based process and is intermittent. The resulting sawtooth plasma concentrations of uremic toxins contrast with the continuous function of native kidneys, which provides constant solute clearances and mass removal rates. Our increasing knowledge of uremic toxins will help guide future treatment strategies to remove them.
Renal Replacement Therapy in Patients with Chronic Liver Disease
Authors: Howard Clancy S. , Teitelbaum Isaac
Published: June 2005

As the prevalence of chronic liver disease and chronic kidney disease (CKD) increase, clinicians are likely to be increasingly faced with difficult diagnostic, treatment, and ethical challenges when facing both of these diseases in a single patient. Alterations in creatinine formation and elimination in cirrhotic patients render creatinine‐based estimates of glomerular filtration rate and dialysis adequacy less accurate in this population. Furthermore, differentiating signs and symptoms of uremia from hepatic disease may be difficult and clear indications for renal replacement therapy (RRT) in these patients have not been defined. Hemodialysis is associated with a high rate of complications and has not been shown to prolong life in cirrhotic patients with acute renal failure (ARF), but has not been carefully examined in those with CKD. Peritoneal dialysis is, similarly, unhelpful in chronic liver disease complicated by ARF, but has been found to be a viable option in some cirrhotic patients with CKD. Continuous RRT is generally tolerated by patients with decompensated cirrhosis and either acute or chronic renal failure and may act to bridge patients to liver transplantation. Given the poor underlying survival of cirrhotic patients with renal failure, clinicians should carefully consider the utility of RRT in each patient.