bluuebunny/crossref_metadata_2025 huggingface dataset:
Structural change: The dominant feature in the economic development of the German textile and clothing industries
Authors: Adler Ulrich
Published: August 2004

The textile and clothing industries are good examples to analyse emerging industrial trends in international co‐operation and to map the globalisation effects on outward processing, jobs and technology. The research focuses on the development of economic indicators and is based on the results from consulting and research projects, as well from enquiries in the German textile and clothing industries, which are exposed to intensive cost competition and trying to find a new position within the process of globalisation. A reduction of demand, a change in consumption patterns, the modification in the retailing system, the development of personal income and a global shift of production have triggered the decline of the domestic production of textiles and clothing. Emerging producers from eastern, developing and newly industrialising countries are now the main suppliers for the German textiles and clothing market. The German clothing companies defend a rest market and use intensively the outward processing in low‐wage countries. As a result of the tremendous differences in production costs, the demand for clothing textiles shifted globally towards low‐cost places of clothing production. The outward processing from industrialised countries established a very efficient, well‐organised global production network in low‐wage countries, enabling new potential for economic development. This research focuses on the view of producers in industrialised countries. The analysis shows that the future of textiles and clothing companies is not in producing but in the management of markets, organising a global supply chain of subcontractors and in retailing. The experiences within the global outward processing network shows very high innovation and learning rates in low‐wage countries, enabling a serious potential towards a self‐contained economic development. The economic and social liberalisation within the EU region and the out‐phasing of the WTO in 2005 will give new power to the globalisation process and will influence the structural change of industry. This paper is written as a rational position sensing of the German textile and clothing industries prior to the out phasing of the WTO regulations and the 2005 liberalisation of the EU textile and clothing sector.
Process performance in product development: measures and impacts
Authors: Syamil Ahmad , Doll William J. , Apigian Charles H.
Published: August 2004

The key to successful project management is knowing how well the process is performing to prevent problems rather than fix them after they occur. Success measurement in product development has emphasized end‐result measures of overall project performance or economic value. The product development literature has largely ignored process performance (i.e., the measurement of how effectively the product development process is actually working). Process performance may be an early warning signal of downstream problems in a project's quality, time, or productivity. This paper proposes a model of process performance at the project level during product and process engineering. The model suggests that process performance mediates the influence of concurrent engineering (process choice) on overall project development performance. This process performance model is tested in the automobile industry using a sample of 406 product development projects in Germany and the USA. The theoretical and practical implications of the findings are discussed.
Residents lack knowledge and practical skills in handling the difficult airway
Authors: Rosenstock C. , Østergaard D. , Kristensen M. S. , Lippert A. , Ruhnau B. , Rasmussen L. S.
Published: August 2004

Background:  Full‐scale simulators have been developed in anaesthesia. We aimed at assessing Danish anaesthesia residents' knowledge and management of a standardized difficult airway situation in an advanced airway simulator. The reliability of the assessment was also determined.

Methods:  Thirty‐six residents answered a questionnaire testing their knowledge on difficult airway management and practice patterns. Secondly, all residents attempted management of a standardized ‘cannot ventilate, cannot intubate’ airway scenario. Three observers independently assessed a video recording of the performance.

Results:  Only 17% of the residents passed the written test. Ninety‐seven per cent stated that they had difficulties recalling the American Society of Anesthesiologists'(ASA) difficult airway algorithm and 53% did not know how to oxygenate through the cricothyroid membrane. Seventeen per cent had previously been involved in emergency situations with severe complications due to insufficient airway management. In the scenario 75% of the residents established ventilation using a laryngeal mask airway. After establishing ventilation, 26% would continue with surgery without a definitive airway, despite the risk of aspiration. Analysis of the interobserver agreement showed good (Κ = 0.63) to excellent (Κ = 0.78) consistency for objective parameters in the scoring scheme. Inter‐observer reliability was satisfactory (R = 0.43) for trained Crisis Resource Management evaluators.

Conclusions:  Theoretical and practical education in difficult airway management needs to be improved among Danish anaesthesia residents. Simulator assessment should only be performed using well‐defined objective parameters and trained assessors.
Acute acalculous cholecystitis in critically ill patients
Authors: Laurila J. , Syrjälä H. , Laurila P. A. , Saarnio J. , Ala‐Kokko T. I.
Published: August 2004

Background:  Acute acalculous cholecystitis (AAC) is a serious complication of critical illness. We evaluated the underlying diseases, clinical and diagnostic features, severity of associated organ failures, and outcome of operatively treated AAC in a mixed ICU patient population.

Methods:  The data of all ICU patients who had operatively confirmed AAC during their ICU stay between 1 January 2000 and 31 December 2001 were collected from the hospital records and the intensive care unit's data management system for predetermined variables.

Results:  Thirty‐nine (1%) out of 3984 patients underwent open cholecystectomy for AAC during the two‐year period. Infection was the most common admission diagnosis, followed by cardiovascular surgery. The mean APACHE II score on admission was 25, and 64% of the patients had three or more failing organs on the day of cholecystectomy. The mean length of ICU stay before cholecystectomy was 8 days, and the mean total length of ICU stay was 19 days. Most patients (85%) received norepinephrine infusion, and 90% suffered respiratory failure before cholecystectomy. Hospital mortality was 44%. The non‐survivors had higher Sequential Organ Failure Assessment (SOFA) scores on the day of cholecystectomy compared to the survivors (12.9 vs. 9.5, P = 0.007).

Conclusion:  Acute acalculous cholecystitis was associated with severe illness, infection, long ICU stay, and multiple organ failure. Mortality was related to the degree of organ failure. Prompt diagnosis and active treatment of AAC can be life‐saving in these patients.
Dobutamine compensates deleterious hemodynamic and metabolic effects of vasopressin in the splanchnic region in endotoxin shock
Authors: Martikainen T. J. , Uusaro A. , Tenhunen J. J. , Ruokonen E.
Published: August 2004

Background:  Vasopressin is a potent vasopressor in septic shock, but it may impair splanchnic perfusion. We compared the effects of vasopressin alone and in combination with dobutamine on systemic and splanchnic circulation and metabolism in porcine endotoxin shock.

Methods:  Twelve pigs were randomized to receive either vasopressin (VASO, n = 6) or vasopressin in combination with dobutamine (DOBU, n = 6) during endotoxin shock (E. coli endotoxin infusion). Endotoxin infusion rate was increased to induce hypotension after which vasoactive drugs were started. We aimed to keep systemic mean arterial pressure (MAP) >70 mmHg by vasopressin; the goal of dobutamine infusion was to prevent decrease in cardiac output often associated with vasopressin infusion. Regional blood flows, oxygen delivery and consumption, arterial and regional lactate concentrations were measured.

Results:  Mean arterial pressure >70 mmHg was achieved in both the VASO and DOBU groups. After the primary decrease of cardiac output by vasopressin, systemic blood flow remained stable in vasopressin‐treated animals. However, vasopressin as a monotherapy decreased portal venous blood flow. This was prevented by dobutamine. Vasopressin also induced splanchnic lactate release and arterial hyperlactatemia, which were not observed when dobutamine was combined with vasopressin.

Conclusion:  Dobutamine prevents adverse hemodynamic and metabolic effects of vasopressin in septic shock.
Effect of cardiopulmonary bypass on pulmonary clearance of adrenomedullin in humans
Authors: Kamei M. , Hayashi Y. , Kikumoto K. , Kawai Y. , Kangawa K. , Kuro M. , Minaminoals N.
Published: August 2004

Background:  Adrenomedullin is a potent vasodilatory peptide and its plasma concentration increases after cardiopulmonary bypass. We analyzed the contribution of the lung to the disposition of adrenomedullin before and after cardiopulmonary bypass in humans.

Methods:  Thirty‐five patients undergoing cardiac surgery with cardiopulmonary bypass were studied. Bloods were sampled from the pulmonary artery and left atrium at the following times: prior to systemic heparinization, during pulmonary reperfusion and after cardiopulmonary bypass. Plasma concentrations of total and mature adrenomedullin were measured using an immunoradiometric assay kit specific for human adrenomedullin. Intermediate adrenomedullin was calculated as the difference between total adrenomedullin and mature adrenomedullin.

Results:  Before cardiopulmonary bypass, mature and intermediate adrenomedullin concentrations were reduced by the pulmonary circulation by approximately 30% and 20%, respectively. However, these effects were not observed during pulmonary reperfusion. Mature, but not intermediate, adrenomedullin was reduced after cardiopulmonary bypass. Furthermore, pulmonary clearance quantity of mature adrenomedullin was significantly enhanced after cardiopulmonary bypass.

Conclusion:  These results indicate that cardiopulmonary bypass temporally impairs the pulmonary clearance of mature and intermediate adrenomedullin, but clearance of mature, not intermediate adrenomedullin is enhanced after cardiopulmonary bypass.
Sevoflurane‐induced malignant hyperthermia during cardiopulmonary bypass and moderate hypothermia
Authors: Jonassen A. A. , Petersen A. J. , Mohr S. , Andersson C. , Skattum J. , Kvernebo K. , Paulsen O. G. , Stokland O. , KirkebØen K. A.
Published: August 2004

A 56‐year old man was admitted for elective mitral valve repair and coronary artery bypass surgery due to mitral valve leakage and unstable angina. After induction of anaesthesia he developed a combined metabolic and respiratory acidosis. Different diagnosis were considered and we decided to treat the patient with dantrolene due to suspicion of malignant hyperthermia (MH). The patient received one dose of dantrolene 2,5 mg/kg during cardiopulmonary bypass (CPB) and a second dose of dantrolene 2,5 mg/kg during weaning from CPB. The first arterial blood gas sample taken in the intensive care unit showed relapse of the acidosis and we administered an infusion of 150 mg dantrolene over 3 hours. The patient gradually recovered without sequel and MH was verified by muscle biopsy testing.
Chromosome instability in T‐cells cultured in the presence of pancuronium or fentanyl
Authors: Delogu G. , Antonelli A. , Signore M. , Marcucci L. , Petrinelli P. , Tellan G. , Antonucci A. , Elli R.
Published: August 2004

Background:  Genomic instability is recognized as a cause of cellular apoptosis and certain drugs that exhibit a proapoptotic effect are also able to induce chromosome damage. Since we found in recent experiments that drugs such as pancuronium and fentanyl exerted an apoptogenic effect on T cells, we studied the capacity of those agents to promote chromosome instability, i.e. chromosome aberrations (CA) and telomeric associations (tas) in peripheral blood lymphocytes.

Methods:  Lymphocytes from healthy donors were cultured with pancuronium or fentanyl, using two different concentrations for each drug: 20 and 200 ng/ml for pancuronium and 10 and 30 ng/ml for fentanyl, respectively. Cells were exposed to each concentration of these drugs either for 24 or 48 h. The higher concentration chosen was the same at which we detected the proapoptotic effect in our previous works. Cytogenetic analysis was performed by means of a standard technique and chromosome aberrations or telomeric associations were blindly evaluated by two independent observers.

Results:  The chromosome aberrations we observed in treated cells were not significantly different from control lymphocytes. However, an unusual rate of telomeric associations (P < 0.001) was detected in cells exposed to both pancuronium and fentanyl, at each concentration tested and at each exposure time of the study.

Conclusions:  Fentanyl and pancuronium do not have a direct clastogenic effect on T cultures, but at the same concentrations at which we demonstrated their apoptogenic power, these drugs are able to increase genomic instability through inducing an elevated rate of telomeric associations. Such a capacity could exploit in peripheral T cells the same mitochondrion‐mediated signal pathway of apoptosis death.
Primary sepsis in a university hospital in northern Sweden: A retrospective study
Authors: Jacobson S. , Johansson G. , Winsö O.
Published: August 2004

Background:  Severe sepsis and septic shock are associated with high mortality rates. Data on sepsis outcome from Scandinavian countries are sparse. The aim of this study was to examine the length of stay (LOS) in the ICU, ICU mortality and costs of care for adult patients with primary sepsis in a university hospital in northern Sweden.

Methods:  We performed a retrospective data analysis of records of 92 patients admitted over a 3‐year period, under the diagnosis of sepsis or urosepsis. Demographic data, admission category, APACHE II score, aetiology and severity of sepsis, ICU LOS, mortality and TISS were analyzed.

Results:  Eighty‐one adult patients were identified by standard definitions as suffering from sepsis. The median ICU length of stay was 4.2 days, 6 days for survivors and 2.1 days for non‐survivors. Thirteen out of 20 deaths occurred within the first 3 days after admission. Overall ICU mortality rate was 24.7% while the ICU mortality for patients with septic shock was 57.7%. The mean costs of care for patients with sepsis were 3139 Euros day−1 and the cost of care per patient surviving sepsis was 38 494 Euros.

Conclusion:  The incidence of primary sepsis in our ICU was low. Previous reports on high mortality in association with severe sepsis and septic shock are valid also at our hospital. The ICU‐LOS was shorter than previously reported, while our costs of care were in the same range as stated by others. This retrospective analysis is valid for interpretation of the applicability of currently available sepsis therapies.
Hyperoxic ventilation at the critical hematocrit: Effects on myocardial perfusion and function
Authors: Kemming G. I. , Meisner F. G. , Meier J. , Tillmanns J. , Thein E. , Eriskat J. , Habler O. P.
Published: August 2004

Background:  Hemodilution reduces hematocrit (Hct) and blood oxygen content. Tissue oxygenation is mainly preserved by increased cardiac output. As myocardial O2‐demands increase, coronary vasodilatation becomes necessary to increase myocardial blood flow. Myocardial ischemia occurs at a critical Hct‐value (Hctcrit), with accompanying exhaustion of coronary reserve. Hyperoxic ventilation is known to both reverse peripheral tissue hypoxia at Hctcrit and also to induce coronary vasoconstriction. This study aimed to determine whether hyperoxic ventilation at Hctcrit further exacerbates myocardial ischemia and dysfunction.

Methods:  Nine anesthetized pigs ventilated on room air were hemodiluted by 1 : 1 exchange of blood with pentastarch (6%HES) to Hctcrit , defined as onset of myocardial ischemia (ECG changes). At Hctcrit , hyperoxic ventilation was started. Measurements were performed at baseline, at Hctcrit, and after 15 min of hyperoxic ventilation. We determined myocardial blood flow (microsphere method), arterial O2‐content, subendocardial O2‐delivery and myocardial function (left ventricular pressure increase).

Results:  At Hctcrit 7 (6;8)%, O2‐content was reduced [3.7 (3.1;3.9) ml dl−1]. Despite a compensatory increase of myocardial blood flow [531 (449;573), ml min−1100 g−1], all pigs displayed myocardial ischemia and compromised myocardial function (P < 0.05). Hyperoxic ventilation produced increased coronary vascular resistance secondary to vasoconstriction, and reduced myocardial blood flow [426 (404;464), ml min−1100 g−1; P < 0.05]. Myocardial oxygenation was found to be maintained by increased O2‐content [4.4 (4.2;4.8), ml dl−1; P < 0.05], the contribution of dissolved O2 to subendocardial O2‐delivery increased (32 vs. 8%; P < 0.05), which preserved myocardial function.

Conclusion:  Hyperoxic ventilation at Hctcrit is followed by coronary vasoconstriction and reduction of coronary blood flow. However, myocardial oxygenation and function is maintained, as increased O2‐content (in particular dissolved O2) preserves myocardial oxygenation.
Comparative analysis of in vitro contracture tests with ryanodine and a combination of ryanodine with either halothane or caffeine: a comparative investigation in malignant hyperthermia
Authors: Bendahan D. , Guis S. , Monnier N. , Kozak‐Ribbens G. , Lunardi J. , Ghattas B. , Mattei J‐P. , Cozzone P. J.
Published: August 2004

Background:  The diagnosis of susceptibility to malignant hyperthermia (MH) is currently performed on muscle biopsies subjected to halothane‐caffeine in vitro contracture tests (IVCTs). There is a consensus on our need to improve the diagnostic potential of IVCTs if we are to maximize the information available for research and diagnosis in MH. This study was designed as a pilot comparative study and we aimed at comparing the ryanodine test and new tests using a combination of ryanodine, halothane and caffeine.

Methods:  One hundred and thirty‐two subjects (52 MHS and 80 MHN) were included in this study and new IVCTs were performed in additional muscle biopsy specimens. The contracture time‐course was compared considering the onset time of contracture (OT) and the time to reach a 10 mN contracture (10T). Cut‐off values were determined using ROC analyses.

Results:  For the ryanodine test, sensitivity and specificity calculated for OT were 84.6% and 90.4%, respectively, and were better than those obtained using 10T. Combined tests using either caffeine and ryanodine or halothane and ryanodine did provide higher sensitivities (from 85.3 to 93.9%). A better specificity was only observed for the IVC tests combining halothane (cumulated) and caffeine both with ryanodine (93.9% for both). The largest sensitivity was observed when halothane was used as a bolus and combined with ryanodine. The specificity was always larger with the combined tests as compared to the test using ryanodine alone (from 79.1 to 90.9%). This superiority was confirmed, at least in part, when comparing genetic investigations and the results of new tests in a subgroup of subjects.

Conclusions:  This pilot study showed a clear diagnostic potential for new IVC tests combining halothane, the triggering agent of MH, and ryanodine acting at the calcium release channel, and should be considered as a first step in the investigation of combined tests.
Is the ARX index a more sensitive indicator of anesthetic depth than the bispectral index during sevoflurane/nitrous oxide anesthesia?
Authors: Nishiyama T. , Matsukawa T. , Hanaoka K.
Published: August 2004

Background:  During general anesthesia, hypnotic components have been monitored with electroencephalogram. The bispectral index is derived from a cortical electroencephalogram, but the A‐line ARX index is the electroencephalographic response to auditory stimuli. The purpose of this study was to compare the changes of the A‐line ARX index and the bispectral index during sevoflurane – nitrous oxide anesthesia.

Methods:  One hundred females aged 30–60 years, and scheduled for partial mastectomy, were divided into two groups. Anesthesia was induced with sevoflurane 5% and nitrous oxide in oxygen for 3 min. A laryngeal mask airway was inserted, and anesthesia was maintained with sevoflurane 1–2% and nitrous oxide in oxygen. During surgery, the sevoflurane end‐tidal concentration was kept at 0.5%, 1%, or 2% for 5 min before each measurement. Blood pressure, heart rate, and the A‐line ARX index (n = 50), and the bispectral index (n = 50) were measured.

Results:  Blood pressure and heart rate increased following laryngeal mask airway insertion and blood pressure decreased at 2% sevoflurane in both groups similarly. The A‐line ARX index, but not the bispectral index, increased significantly by laryngeal mask airway insertion and skin incision. The A‐line ARX index decreased at 2% sevoflurane compared with 0.5%, while the bispectral index remained unchanged.

Conclusion:  During sevoflurane‐nitrous oxide anesthesia, the A‐line ARX index might be a more sensitive indicator of anesthetic depth than the bispectral index.
Changes in visual and auditory response time during conscious sedation with propofol
Authors: Kim K. M. , Jeon W. J. , Lee D. H. , Kang W. C. , Kim J. H. , Noh G. J.
Published: August 2004

Background:  Using a push‐button device, we investigated whether visual or auditory response time would increase with increasing sedation, and assessed the responsiveness score of the Observer's Assessment of Alertness/Sedation (OAA/S) scale at the point of first loss of response to visual or auditory stimulation.

Methods:  In experiment 1 we applied visual and auditory stimulation to 19 patients as the propofol target plasma concentration (CPT) was increased to determine whether the visual or auditory response would be lost first. Thirty patients were each then infused with propofol, starting at a CPT of 0.3 µg ml−1 and increasing by increments of 0.2 µg ml−1, during which visual (experiment 2) or auditory (experiment 3) stimulation was applied when the effect‐site concentration (CE) of propofol reached CPT. Visual response time (VRT), auditory response time (ART), CE and total amounts of propofol, and OAA/S score at the first loss of visual/auditory response were measured.

Results:  Visual response disappeared earlier than auditory response in 84.2% of the patients. Visual response time and ART were linearly prolonged as the CE of propofol increased. The CE and total amounts of propofol at the first loss of visual response were 1.2 ± 0.4 µg ml−1 and 57.9 ± 16.7 mg, compared with 1.4 ± 0.5 µg ml−1 and 71.6 ± 26.1 mg, respectively, at the first loss of auditory response. The median (range) OAA/S scores at the first loss of visual and auditory response were 4 (3–4) and 3 (2–4), respectively.

Conclusion:  VRT and ART were linearly prolonged with increasing sedation. Visual response may be useful in monitoring conscious sedation.
Nursing staff resources in direct patient care: comparison of TISS and ICNSS
Authors: Pyykkö A. K. , Ala‐Kokko T. I. , Laurila J. J. , Miettunen J. , Finnberg M. , Hentinen M.
Published: August 2004

Background:  The aim was to study the variation in the nursing workload and nursing staff resources in direct patient care.

Methods:  Nursing staff resources and the patient‐nurse ratio (P/N) were compared between postoperative and mixed‐type intensive care units (ICUs) using the Therapeutic Intervention Scoring System (TISS) and the Intensive Care Nursing Scoring System (ICNSS) during a 4‐month period.

Results:  A total of 832 patients were treated. In the postoperative ICU, the mean daily TISS score per nurse was 41.1, corresponding to a P/N of 1 : 1, and the mean ICNSS score was 33.8, corresponding to a P/N of 1 : 1.5. In the mixed‐type ICU, the mean TISS score per nurse was 34.7, corresponding to a P/N of 2 : 1, and the mean ICNSS score was 27.7, corresponding to a P/N of 1 : 1. In the postoperative unit, 50.4% of the patients would have required a 1 : 1 P/N ratio based on their TISS scores and 47.5% would have required 1.5 or two nurses as estimated by the ICNSS score. In the mixed ICU 57.1% of the patients would have required a P/N ratio of 1 : 1 based on TISS scores and 61.3% a ratio of 1 : 1.5 or 1 : 2 according to the ICNSS score.

Conclusion:  Intensive Care Nursing Scoring System gives additional information about the nursing staff resources and yields a higher number of nurses needed in direct patient care even when TISS scores show the number of nurses to be adequate.
Body fat patterning in polycystic ovary syndrome women as a predictor of the response to clomiphene
Authors: Douchi Tsutomu , Oki Toshimichi , Yamasaki Hideki , Nakae Mitsuhiro , Imabayashi Akiko , Nagata Yukihiro
Published: August 2004

Background.  To investigate the difference in the response to clomiphene citrate (CC) based on body fat distribution in women with polycystic ovary syndrome (PCOS).

Methods.  Ninety anovulatory PCOS women were divided into two subgroups based on treatment response: women who ovulated with CC (CC responders, n = 49) and those who did not ovulate with CC (CC nonresponders, n = 41). Baseline characteristics included age, age at menarche, height, weight and body mass index [BMI; weight/(height)2]. Percentage of body fat, body fat mass and the ratio of trunk fat to leg fat mass amount (trunk–leg fat ratio) were measured by dual‐energy X‐ray absorptiometry (DEXA).

Results.  Age, age at menarche and height did not differ between the two groups. However, trunk–leg fat ratio in CC responders (0.9 ± 0.4) was significantly lower than that in CC nonresponders (1.3 ± 0.4) (p < 0.001). Percentage of body fat, body fat mass and BMI were also lower in CC responders (p < 0.01). On multiple regression analysis, however, trunk–leg fat ratio proved to be a superior predictor of CC responder to percentage of body fat, BMI or body fat mass (standardized regression coefficient ≥ 0.510; t‐values ≥ 3.432; p < 0.001).

Conclusions.  Response to CC in anovulatory PCOS women differs with body fat distribution.
Genetic influence on dystocia
Authors: Algovik Michael , Nilsson Emma , Cnattingius Sven , Lichtenstein Paul , Nordenskjöld Agneta , Westgren Magnus
Published: August 2004

Background.  Dystocia—prolonged and difficult labor—is a common and worldwide problem during parturition. Epidemiological studies have suggested a familial aggregation. This study aimed to quantify the genetic influence (i.e. the heritability) on dystocia.

Methods.  A retrospective study of all births in Sweden from 1973 through 1997 was undertaken. Data from the population‐based Swedish Birth, Twin and National Family Registers were linked on an individual basis. In total, 2 539 534 births were analyzed. Relationships between sibling and mother–daughter pairs were established. The relative risk for dystocia was calculated. Model‐fitting (Mx) was used to estimate the relative contribution of genetic and environmental factors for liability to dystocia.

Results.  In all, 190 747 women were diagnosed with dystocia. Measures of familial similarity (relative risks and correlation of liability) for dystocia were higher in monozygotic than in dizygotic twins, other sibling pairs and mother–daughter pairs. Correlation of liability was also higher in full‐sisters than in half‐sisters. Model‐fitting suggested that genetic effects accounted for 28%[95% confidence interval (CI) 21–32] of the susceptibility for dystocia.

Conclusion.  Dystocia is a complex disorder of poor uterine action that is influenced by a significant genetic component as well as environmental factors. The amount of genetic influence makes it interesting to study the gene expression in these patients. Detection of the genes related to dystocia might lead to better pathophysiological understanding of this condition and the possibility of detecting these mothers before parturition.
Review of epidemiological evidence for reproductive and hormonal factors in relation to the risk of epithelial ovarian malignancies
Authors: Riman Tomas , Nilsson Staffan , Persson Ingemar R.
Published: August 2004

Ovarian cancer is the leading cause of mortality related to gynecologic malignancies in Sweden but there is no current screening program. Based upon epidemiological research there is evidence that certain reproductive factors are associated with ovarian cancer risk. Most studies generally indicate that each childbirth incurs a 15–20% risk reduction. Women who have used oral contraceptives for 5 years or longer experience about half the risk of ovarian cancer compared with never users. Breastfeeding seems to be protective while age at menarche and at menopause are less consistent risk predictors. Tubal ligation and hysterectomy seem to reduce ovarian cancer risk by up to 80%. Although some studies found endometriosis, polycystic ovarian syndrome (PCOS) and pelvic inflammatory disease (PID) to be positively related to ovarian cancer, the role of these factors is not yet established. Most recent studies observed an approximately 50% ovarian cancer risk increase among ever users of hormone replacement therapy (HRT) compared with never users, and the risk increased further with long‐term use. There is less information concerning separate estrogen and progestin effects of HRT and ovarian cancer risk. Although the cause of ovarian cancer remains obscure, hypotheses relating to “incessant” ovulation, excessive gonadotropin secretion, retrograde carcinogen transportation, apoptosis and estrogen/progestin imbalance have been invoked as etiological explanations. All these hypotheses find various epidemiological support. The aim of this review is to summarize the epidemiological findings on reproductive factors and ovarian cancer risk. These findings are considered in the context of etiologic hypotheses and some new research areas are suggested.
Cholestasis of pregnancy, pruritus and 5‐hydroxytryptamine 3 receptor antagonists
Authors: Schumann Roman , Hudcova Jana
Published: August 2004

Pruritus, an early symptom of intrahepatic cholestasis of pregnancy, may be severe. Conventional treatment includes ursodeoxycholic acid and cholestyramine. Ondansetron, a 5‐hydroxytryptamine 3 receptor antagonist antiemetic, has been shown to reduce pruritus of different etiologies including cholestasis. We now report the successful preoperative use of ondansetron in a patient with pruritus from intrahepatic cholestasis of pregnancy. While the mechanism for our patient's response is poorly understood, 5‐hydroxytryptamine 3 receptor antagonists should be further evaluated and possibly considered as a treatment option for intrahepatic cholestasis of pregnancy‐related pruritus.
Side‐effects of hormone replacement therapy and influence on pattern of use among women aged 45–64 years.  The Norwegian Women and Cancer (NOWAC) study 1997
Authors: Bakken Kjersti , Eggen Anne Elise , Lund Eiliv
Published: August 2004

Background.  Use of hormone replacement therapy (HRT) increased considerably in Norway during the 1990s. The aim of this study was to investigate reasons for starting and discontinuing HRT use and examine the prevalence of side‐effects and what impact they had on pattern of use.

Methods.  The Norwegian Woman and Cancer (NOWAC) study is a population‐based, prospective study based on mailed questionnaires to women 30–70 years. This report is limited to a random sample of 4996 Norwegian women aged 45–64 years who participated in 1997 (response rate 62%). The questionnaire included detailed questions about HRT: reasons for starting and stopping, type of preparation, duration of use and side‐effects experienced.

Results.  Most women started HRT to ameliorate climacteric complaints (75.9%). Only 8.7% had prevention of osteoporosis as the only reason for therapy. Mean duration of use was 4.9 years among current users. Side‐effects were reported by 43% of the ever users, nearly half of them reporting more than one side‐effect. Weight gain was the most frequent stated side‐effect (56.3%), although not statistically significant in association with HRT. Among ever users 28.2% discontinued therapy, more than half of them because of side‐effects.

Conclusions.  The women's primary reason for starting HRT was climacteric complaints. Side‐effects were common and constituted the major reason for discontinuation of therapy. The women perceived weight gain as a side‐effect.
High frequency of congenital thrombophilia in women with pathological pregnancies?
Authors: Rasmussen Åse , Ravn Pernille
Published: August 2004

The obstetrical complications preeclampsia, intrauterine growth restriction (IUGR), placental abruption and fetal loss are major causes of maternal and fetal morbidity and mortality. Much recent research has focused on to what extent congenital thrombophilia contributes to these obstetrical complications. Combined with the hypercoagulable state of pregnancy, thrombophilia has the potential to induce placental thrombosis and cause placental insufficiency with subsequent obstetrical complications. This article aims to review and discuss published clinical studies of the relationship between congenital thrombophilia and preeclampsia, IUGR, placental abruption and fetal loss. In addition, the few published clinical trials of prophylactic antithrombotic treatment to prevent severe obstetrical complications in thrombophilic women are discussed. The studies have shown variable results evaluated mainly as a result of the limited number of case reports published. However, the strongest association was found to be between congenital thrombophilia and preeclampsia and late fetal loss. Early fetal loss was not found to be associated with congenital thrombophilia. At present, the question remains open as to whether IUGR and placental abruption is directly associated with thrombophilia or mediated through preeclampsia. In conclusion, the associations between congenital thrombophilia and preeclampsia, IUGR, placental abruption and fetal loss only reaches evidence grade 4. Present recommendations and clinical guidelines are thus based on weak scientific proof.
A population‐based case–control study of oral griseofulvin treatment during pregnancy
Authors: Czeizel Andrew E. , Métneki Júlia , Kazy Zoltán , Puho Elisabeth
Published: August 2004

Aim:  To study the teratogenicity of oral griseofulvin during pregnancy.

Methods:  The data of the population‐based Hungarian Case–Control Surveillance of Congenital Abnormalities between 1980 and 1996 and the Hungarian Congenital Abnormality Registry between 1970 and 2002 were evaluated.

Results:  In total, 38 151 pregnant women who delivered newborn infants without any defects (control group) and 22 843 pregnant women who had fetuses or newborns with congenital abnormalities were included in the study. Seven (0.03%) case and 24 (0.06%) control pregnant women were treated with the griseofulvin (crude odds ratio with 95% confidence interval: 0.49, 0.21–1.13). A teratogenic potential of griseofulvin was not indicated by a comparison of the expected and observed number of different congenital abnormalities. A higher mean birth weight was found in control newborn infants born to mothers with griseofulvin treatment compared with the data of control newborn infants without this treatment. In addition, 55 conjoined twins were evaluated in the data set of the Hungarian Congenital Abnormality Registry, and no conjoined twins had mother with griseofulvin treatment during pregnancy.

Conclusion:  Our data do not indicate a detectable teratogenic risk of oral griseofulvin treatment during pregnancy; however, the numbers of cases and controls were limited. Therefore, international collaboration is needed for the final conclusion.
Restricted fetal growth in sudden intrauterine unexplained death
Authors: Frøen J. Frederik , Gardosi Jason O. , Thurmann Anne , Francis André , Stray‐Pedersen Babill
Published: August 2004

Background.  Unexplained antepartum stillbirth is a common cause of perinatal death, and identifying the fetus at risk is a challenge for obstetric practice. Intrauterine growth restriction (IUGR) is associated with a variety of adverse perinatal outcomes, but reports on its impact on unexplained stillbirths by population‐based birthweight standards have been varying, including both unexplained and unexplored stillbirths.

Aim.  We have studied IUGR, assessed by individually adjusted fetal weight standards, in antepartum deaths that remained unexplained despite thorough postmortem investigations.

Methods.  Antenatal health cards from a complete population‐based 10‐year material of 76 validated sudden intrauterine unexplained deaths were compared to those of 582 randomly selected liveborn controls. Birthweight <10th percentile of the individualized standard adjusted for gestational age, maternal height, weight, parity, ethnicity, and fetal gender was defined as growth restriction.

Results.  52% of unexplained stillbirths were growth restricted, with a mean gestational age at death of 35.1 weeks. Suboptimal growth was the most important fetal determinant for sudden intrauterine unexplained death (odds ratio 7.0, 95% confidence interval 3.3–15.1). Concurrent maternal overweight or obesity, high age, and low education further increase the risk. Overweight and obesity increase the risk irrespective of fetal growth, and while high maternal age increases the risk of the normal weight fetus, it is not associated to growth restriction as a precursor of sudden intrauterine unexplained death.

Conclusions.  IUGR is an important risk factor of sudden intrauterine unexplained death, and this should be excluded in pregnancies with any other risk factor for sudden intrauterine unexplained death.
Decreased fetal movements: background, assessment, and clinical management
Authors: Olesen Anette G. , Svare Jens A.
Published: August 2004

A reduction or cessation of fetal movements (FMs) is frequently reported by pregnant women and causes concern and anxiety. However, the clinical significance of a history of reduced FMs remains unclear, and the assessment and management of these pregnancies is controversial. This article is a review of the literature on decreased FMs found in medline and the cochrane library using the search phrases: decreased FMs, perinatal outcome, FM monitoring, and fetal assessment. Formal counting of FMs by the pregnant woman could possibly identify the fetuses, which are at risk of compromise, thus allowing for appropriate action. However, the benefit of this intervention has not been definitely proven. Cardiotocography, umbilical/uterine artery Doppler velocimetry, and ultrasonography have been used for antepartum fetal assessment in pregnancies with decreased FMs, but the evidence of a clinical benefit is limited. The effects of fetal assessment with vibroacoustic stimulation and biophysical profile are unknown and should be further evaluated. Present recommendations on the management of pregnancies with decreased FMs are based on limited and inconsistent scientific evidence. There is a need for further well‐designed studies in order to provide evidence‐based guidelines in the future.
Comparison of protein carbonyl and total plasma thiol concentrations in patients with complete hydatidiform mole with those in healthy pregnant women
Authors: Harma Mehmet , Harma Muge , Kocyigit Abdurrahim
Published: August 2004

Background.  Normal pregnant women are known to have increased oxidative stress and lipid peroxidation (which can be estimated by protein carbonyl concentration) but offsetting antioxidant protection (of which plasma thiols are an important component).

Aim.  This study set out to compare levels of these markers in normal pregnant women and patients with complete hydatidiform mole (CHM).

Methods.  Blood was taken from 41 healthy pregnant women and 39 patients with CHM attending a university hospital, and protein carbonyl and thiol levels determined spectrophotometrically on plasma. Statistical analysis of the results was performed using Student's t‐test and Pearson's correlation.

Results.  Patients with CHM were found to have significantly higher levels of protein carbonyls and lower (but non‐significant) levels of thiols.

Conclusion.  The results may indicate oxidative stress as a feature of CHM.
Pregabalin Pharmacology and Its Relevance to Clinical Practice
Authors: Ben‐Menachem Elinor
Published: August 2004

Summary:  Pregabalin is a potent ligand for the alpha‐2‐delta subunit of voltage‐gated calcium channels in the central nervous system that exhibits potent anticonvulsant, analgesic, and anxiolytic activity in a range of animal models. In addition, pregabalin has been shown to be a highly effective adjunctive therapy for partial seizures in clinical trials. Potent binding to the alpha‐2‐delta site reduces depolarization‐induced calcium influx with a consequential modulation in excitatory neurotransmitter release. Pregabalin has no demonstrated effects on GABAergic mechanisms. Pregabalin demonstrates highly predictable and linear pharmacokinetics, a profile that makes it easy to use in clinical practice. Absorption is extensive, rapid, and proportional to dose. Time to maximal plasma concentration is ∼1 h and steady state is achieved within 24–48  h. These characteristics reflect the observed onset of efficacy as early as day two in clinical trials. High bioavailability, a mean elimination half life (t1/2) of 6.3  h, and dose‐proportional maximal plasma concentrations and total exposures predict a dose–response relationship in clinical practice and allow an effective starting dose of 150 mg/day in clinical practice without need for titration. Administration with food has no clinically relevant effect on the amount of pregabalin absorbed, providing for a dosing regimen uncomplicated by meals. Pregabalin does not bind to plasma proteins and is excreted virtually unchanged (<2% metabolism) by the kidneys. It is not subject to hepatic metabolism and does not induce or inhibit liver enzymes such as the cytochrome P450 system. Therefore, pregabalin is unlikely to cause, or be subject to, pharmacokinetic drug–drug interactions—an expectation that has been confirmed in clinical pharmacokinetic studies. However, dose adjustment may be necessary in patients with renal insufficiency. Thus, the pharmacological and pharmacokinetic profiles of pregabalin provide a predictable basis for its use in clinical practice.
The Use of Antiepileptic Drugs—Principles and Practice
Authors: Sander Josemir W.
Published: August 2004

Summary:  Up to 70% of people developing epilepsy may expect to become seizure free with optimum antiepileptic drug (AED) therapy. The remaining 30% are the most difficult to treat. Most patients are controlled on a single AED, but a small proportion requires a combination of two agents. Add‐on therapy with a second drug, rather than substitution, may be a viable and rational approach in some patients, particularly if the first drug is relatively well tolerated. Precise classification of the type of seizures, as well as the epilepsy syndrome, together with careful recording of both seizures and adverse effects, are essential if rational management decisions are to be made. The goal of therapy should be complete seizure freedom with a single drug taken once or twice a day and without adverse effects. If control is difficult to achieve, the maximum tolerated dose of each drug should be explored, but a balance needs to be struck between adverse effects and control of seizures. In patients in whom treatment appears to be ineffective, the diagnosis of epilepsy and adherence to therapy should be reviewed. Drugs used in combination must be carefully selected, as poor adherence, drug interactions, and toxicity are more likely if more than one drug is prescribed. Agents are usually chosen according to seizure type, patient characteristics, and often by clinician preference. Those that are better tolerated have a low potential for pharmacokinetic and pharmacodynamic interactions, and those that can be easily introduced without any complicated titration schedule have an advantage.
Narcissistic disorders in clinical practice
Authors: Britton Ronald
Published: August 2004

Abstract:  In this paper1, the concept of narcissism in the psychoanalytic literature is reviewed and three uses of the term are defined, firstly, clinical narcissism, secondly, an innate force or tendency opposed to relationships and thirdly, narcissistic personality disorders. The latter can be further differentiated on the basis of the transference/countertransference into borderline (thin‐skinned), aloof (thick‐skinned) and as‐if (false‐self) narcissistic disorders. The characteristics of each of these patterns are described. The author suggests that narcissistic disorders arise when there is a failure of containment in infancy and childhood that gives rise to an ego‐destructive super‐ego leading to the evolving of a narcissistic organization. The libidinal defensive organization arises when parental failure of containment is the primary factor and destructive organization when the infant has an excess of object‐hostility.

Two case descriptions are given to illustrate the distinction between a predominantly destructive and a predominantly libidinal narcissistic disorder and the author suggests that both arise from the production, by projective identification, of a narcissistic relationship with an ego ideal in order to evade a relationship with a destructive parental super‐ego.
Autism, early narcissistic injury and self‐organization: a role for the image of the mother’s eyes?
Authors: McDowell Maxson J.
Published: August 2004

Abstract:  Holland elucidated the new paradigm of self‐organization in complex adaptive systems. This paradigm holds for all living systems, including the personality. In conjunction with the theory of archetypes, self‐organization suggests two radical hypotheses, one about early development, the other about the origins of autism. Autism is associated with several medical conditions, with genetic markers, and with infant visual deprivation. However none of these factors is either necessary or sufficient to cause autism. It is hypothesized that each of these factors increases the likelihood of a primary psychological deficit: failure to acquire, or retain, the image of the mother’s eyes. This hypothesis was initially derived from analytic work with patients who have early narcissistic injury and with patients who have mild autistic traits. Both diagnoses may arise from the same initial disturbance: Symington argued that autism is an extreme form of infantile narcissism. Indirect evidence for the image‐of‐the‐eyes hypotheses comes from the evolution of primates, from infant‐mother observations, from observations of infant vision, and from experiments on vision in other vertebrates. Byrd recently confirmed that the incidence of autism is increasing dramatically. The image‐of‐the‐eyes hypotheses suggest that this increase may be linked to increased use of non‐maternal childcare for young infants.
The mythic function of narcissism
Authors: Aversa G. Luigi , Baldieri Vittoria , Marozza Maria Ilena
Published: August 2004

Abstract:  The paper1 makes some critical comments on the use Freud makes of myth and examines some of the inconsistencies and contradictions in his conceptualization of narcissism. Using some of the ideas of Bachelard and Hillman on the role of the imaginary, the authors theorize a function of myth that is independent of and not subordinated to the reality function. They suggest that narcissism must be seen not only in terms of individual history but that it has a mythic function; narcissism facilitates the creation of a relationship between the ego and the Self through the mediation of the imaginal world and through the prospective value of images.