bluuebunny/crossref_metadata_2025 huggingface dataset:
Effect of allowed grazing time, inert rumen bulk and length of starvation before grazing on the weight, composition and dermentative end‐products of the rumen contents of lactating dairy cows
Authors: Chilibroste P. , Tamminga S. , Van Bruchem J. , Van der Togt P. L.
Published: March 2003

The effect of length of the allowed grazing time (Experiment 1), length of starvation time and placement in the rumen of inert bulk material before grazing (Experiment 2) on liquid and particulate rumen pool sizes, composition and fermentability was investigated. In Experiment 1, four lengths of allowed grazing time (1.00, 1.75, 2.50 and 3.25 h) after overnight starvation were compared. The allowed grazing time had no significant effect on total and liquid rumen pool sizes after grazing but did affect (P< 0.05) dry‐matter (DM) and organic matter (OM) rumen pool sizes. The non‐significant diferences between the volatile fatty acid (VFA) rumen pool sizes before and after 1 h of grazing may indicate a delay in the availability of the more rapidly fermentable substrate for the microorganisms. The total VFA remen pool sizes increased significantly (P< 0.01) with the allowed grazing time, which suggests that these fermentation products may be involved in the control of the grazing time in later stages during the day. Experiment 2 consisted of a factorial combination of two lengths of starvation before grazing (16.5 and 2.5 h) and the presence or absence in the rummen of 12.5 kg of a synthetic indigestible material. The duration of starvation before grazing did not affect significantly the particulate, ammonia and VFA rumen pool sizes after grazing except for propionic acid, which was reduced (P < 0.09) by the longer starvation time. The inclusion of inert bulk material in the rumen before grazing significantly reduced (P < 0.05) the total, Liquid DM, OM, and ammonia rumen pool sizes but not the VFA rumen pool sizes after grazing. High levels of ammonia as well as total rumen contents may be involved in the control of the grazing time in this experiment.
The relationship between level of sward height reduction in a rotationally grazed sward and short‐term intake rates of dairy cows
Authors: McGilloway  , Cushnahan  , Laidlaw  , Mayne  , Kilpatrick
Published: March 2003

The objective of this study was to investigate the relationship between level of sward height reduction (SHR) and short‐term intake of herbage by lactating dairy cows offered swards differing in initial bulk density (BD). Three experiments were carried out in which cows were presented with swards representing different levels of SHR (nominally described as ungrazed, low, moderate and high). Experiments 1 and 2 differed with respect to initial sward BD [ungrazed sward 1·7 vs. 2·5 kg dry matter (DM) m−3 respectively]. Experiment 3 investigated the interaction between BD and SHR.

In each experiment, sixteen Holstein/Friesian cows (fitted with excreta collection bags) grazed for a 1‐h period in 200‐m2 plots that had been grazed on the previous day to predetermined sward surface heights (SSH) (= levels of SHR). Herbage intake rates were assessed from changes in live weight, with a correction for insensible weight loss (IWL). Biting rates were recorded from visual observation. High levels of SHR were associated with a significant reduction in SSH, herbage mass and leaf fraction, and a significant increase in sward BD, stem and dead fraction, and DM concentration.

Herbage intake, expressed either as DM intake per bite or DM intake per hour, declined as level of SHR increased from low to high. The level of SHR generally had no effect on biting rate. Intake rates varied from 1·9 to 4·4 kg DM h−1, whereas DM intake bite−1 ranged from 0·5 to 1·3 g. Pooled regression analysis identified SSH (P < 0·001; r2 = 0·94) as the principal determinant of DM intake bite−1. The regression equation was not significantly improved by the addition of terms for leaf fraction, BD, or herbage mass. In Experiment 3, a significant interaction between level of SHR and sward BD was observed. It is concluded that the principal factor controlling intake (g DM bite−1 or kg DM h−1), as swards are progressively grazed down, is SSH, but at a high level of SHR, sward BD also influences intake bite−1.
Long‐term effects of fertilizer on soil nutrient concentration, yield, forage quality and floristic composition of a hay meadow in the Eifel mountains, Germany
Authors: Schellberg  , Möseler  , Kühbauch  , Rademacher
Published: March 2003

A long‐term fertilizer experiment, which was set up in 1941 on extensively grazed heathland, naturally dominated by Calluna vulgaris L. and Nardus stricta L., is presented. The turf layer was grubbed and reseeded with a grass/legume mixture, and plots were fertilized with (a) lime only as calcium (including magnesium), (2) lime and nitrogen (Ca/N), (3) lime, nitrogen and phosphorus (Ca/N/P2O5) and (4) lime, nitrogen, phosphorus and potassium (Ca/N/P2O5/KCl and Ca/N/P2O5/K2SO4). Since 1941 these experimental plots have been mown but not grazed.

After 50 years of imposing the experimental treatments, dry‐matter (DM) yield was found to be positively affected by N, P and K application. Soil N and P concentrations were significantly higher in fertilized than in unfertilized plots. No differences in soil K concentration were found between the two treatments with KCl and K2SO4. Net energy concentration in the plant DM was highest with the Ca/N treatment, but differences were slight. Crude protein concentrations varied from about 110 to 170 g kg–1 DM. In all plots and all years protein concentrations were lower in the first cuts than in the second cuts.

Considerable differences in floristic composition were found between different fertilizer treatments. The treatments receiving only Ca contained more than sixty species, many of them representative of oligotrophic extensively managed grassland. In fully fertilized plots, herbs were suppressed by tall‐growing grasses. In these plots the number of species was low.
The effect of N and P fertilizer application and botanical composition on the leaf/stem ratio patterns in spring in Pyrenean meadows
Authors: Calvière  , Duru
Published: March 2003

The effect of botanical composition and nutrient availability on the relative allocation of biomass to stems and leaves in a permanent upland pasture in the central Pyrenees was assessed. Six short‐term and medium‐term fertilizer treatments (nitrogen and phosphorus) were applied to a meadow to create large differences in the proportions of the different species and a wide range of herbage nutrient status. The above‐ground herbage dry‐matter components (green leaves, sheaths and stems for grasses and dicotyledons, and senescent material) were measured for the first growth cycle.

The leaf mass depended mainly on the herbage N status, whereas the stem mass depended both on the botanical composition and on the herbage N and P status. During spring growth, the proportion of leaves in the above‐ground dry matter decreased faster in plots that had the highest nutrient status or that were composed of species characteristic of nutrient‐rich (Festuca‐poor) habitats. Application of fertilizer decreased the proportion of leaves both for grasses and dicotyledons, but to a larger extent for grasses. There was a single relationship between the proportion of leaves in the above‐ground dry matter and the total mass of above‐ground dry matter, irrespective of the sampling date, the botanical composition or the herbage nutrient status. This statistical relationship resulted from (i) a faster increase in stem mass than leaf mass for a given botanical composition when the herbage nutritional status increased, (ii) a greater stem mass when the sward was composed of species usually found in nutrient‐rich habitats.
Sodium fertilizer application to pasture. 10. A comparison of the responses of dairy cows with high and low milk yield potential
Authors: Chiy P. C. , Phillips C. J. C.
Published: March 2003

Current recommendations for the intake of sodium of lactating dairy cows are related to milk yield. A study was conducted to compare the responses of cows of high and low milk production potential to the application of sodium fertilizer to grazed perennial ryegrass pasture. The application of sodium fertilizer increased the intake of herbage dry matter (DM), the time that cows spent grazing and the biting rate. It also increased the concentration of sodium, magnesium and calcium in herbage and decreased the concentration of potassium. Applying sodium fertilizer increased milk yield and milk fat concentration and decreased somatic cell count in the milk of cows of low‐production potential only, whereas it increased persistency of milk production in the cows of high‐production potential. The concentration of lactose in milk increased in both groups after the application of sodium fertilizer. It is concluded that the optimum dietary sodium concentration for grazing cows does not increase with milk yield, and that most immediate advantage will be gained from increasing the sodium concentration in herbage for low‐yielding cows.
How does the vertical and horizontal structure of a perennial ryegrass and white clover sward influence grazing?
Authors: Carrère P. , Louault F. , De Faccio Carvalho P. C. , Lafarge M. , Soussana J. F.
Published: March 2003

Mixtures of perennial ryegrass (Lolium perenne L.) and white clover (Trifolium repens L.) sown in alternate rows or in a thoroughly mixed matrix were grazed by sheep, either continuously or during short grazing tests, and were used to investigate the influence of the vertical and horizontal components of the sward structure on defoliation by sheep.

In an experiment under continuous grazing, the defoliation intensity was greater for white clover compared with perennial ryegrass leaves (0·80 and 0·58 respectively). In spring, perennial ryegrass leaves were more defoliated than white clover leaves, whereas the reverse was observed in summer. The ratio of the proportion of white clover to perennial ryegrass leaves grazed was negatively correlated with the difference between the surface height of the perennial ryegrass and white clover rows in spring. In both spring and summer, white clover leaves of the same extended leaf length had a higher proportion of them grazed than perennial ryegrass leaves.

In another experiment, during short grazing tests with perennial ryegrass–white clover swards that were grazed at the same sward surface height and at the same white clover content as in the previous experiment, there were no significant differences in the proportion of white clover and perennial ryegrass leaves grazed between strips of the two species and thoroughly mixed structures. The proportion of white clover leaves grazed was higher than that of perennial ryegrass leaves.

These results show that the differential defoliation by sheep of perennial ryegrass and white clover leaves varies according to their vertical distribution in the mixed canopy, but is little affected by their horizontal distribution. Even small differences in sward surface height between mixed perennial ryegrass and white clover can affect diet selection by sheep to a rather large extent.
The volatility of components of grass silage on oven drying and the inter‐relationship between dry‐matter content estimated by different analytical methods
Authors: Porter M. G. , Murray R. S.
Published: March 2003

This study reviews the volatility coefficients used to convert the oven dry‐matter (DM) content of grass silage to an accepted true DM base, volatile‐corrected oven dry matter (VCODM). The revised coefficients quoted for DM determination at 60°C, 85°C and 100°C are based on 18 grass silages with DM contents in the range 153–365 g kg–1. The volatility coefficients for drying at 60°C, 85°C and 100°C were 0·090, 0·224 and 0·375 for lactic acid and 0·554, 0·716 and 0·892 for total volatile fatty acids respectively. The volatilities of ammonia and total alcohols remained unchanged from previous work and showed no temperature dependences in the range 60°C to 100°C. These revised coefficients were validated using 36 grass silages from three harvests in 1996 and 1997, and no significant differences were found among absolute dry matter (GCDM), alcohol‐corrected toluene dry matter (ATDM) and VCODM contents based on the three drying temperatures (VCODM100, VCODM85 and VCODM60). A series of regression equations relating absolute DM content to oven DM content determined at different temperatures gave coefficients of 1·024, 1·013 and 1·000 and constants of 12·67, 11·43 and 11·16 for oven drying at 60°C, 85°C and 100°C respectively. Mathematical manipulation of these equations enables interconversion of DM contents at the three drying temperatures. A new method is described for the analysis of volatile fatty acid, lactic acid and alcohol concentrations in grass silage by gas–liquid chromatography using a single injection in an automated procedure that makes the routine estimation of VCODM a practical proposition to satisfy routine high‐volume requirements. Finally, in a separate study over 4 years using 2381 grass silages from research and commercial farms throughout Ireland, a simple regression is described, which, for advisory purposes, allows true silage DM content to be estimated from oven dry matter content (ODM) for silages in which ODM is >200 g kg–1.
The effects of feeding selectivity on the estimation of diet composition using the n‐alkane technique
Authors: Bugalho M. N. , Mayes R. W. , Milne J. A.
Published: March 2003

Abstract A limitation to using n‐alkanes in plants as faecal markers for estimating diet composition in herbivores is the small number of dietary components that it is possible to determine. One approach to overcoming this is to group species on the basis of their n‐alkane concentrations and to consider these groups as dietary components. Feeding selectivity within a group, however, may change the proportion of a particular species in the group ingested and hence its n‐alkane contribution to the diet ingested. This could potentially affect estimates of the composition of the diet. Simulations (380) of feeding selectivity within a group of herbage species were undertaken to assess the effects of selectivity on estimates of diet composition. The dataset was from a study whose aim was to estimate the proportions of the herbage component, composed of nineteen species, and of four individual browse species in the diet of red deer grazing a montado ecosystem in S. Portugal in the summer. Simulations were undertaken of total avoidance of each species in the group of herbage species, and selection of each species at 0·5, 1·5, 2·0 and 3·0 of its actual proportion within the group. Feeding selectivity had no effect on 0·36 of the outcomes of the simulations. Over 0·90 of the simulations were within ± 0·05 of the values calculated assuming no selection within the group of herbage species. It is concluded that, in the particular case studied, the effect of selection within a group on the estimates of other dietary components was relatively small and that the group of herbage species could be analysed as a single dietary component.
The Smith Shield: a head box for patient protection and repositioning of the surgeon's camera assistant during laparoscopic surgery
Authors: Choy Cheng C. , M. Clark James T. , Smith David , Frappell Jonathan M.
Published: March 2003

Objective

To reduce the difficulty and fatigue associated with long and complex laparoscopic procedures; to protect the face and airway of the patient from pressure from the surgeon's arms, and to allow easy operating from directly over the head end of the operating table, whilst maintaining access for the anaesthetist and monitoring equipment.

Design

We designed and patented the Smith Shield, a perspex ‘box’ with three rectangular sides that attaches over the anaesthetized patient's head. It functions as a Mayo table and surgeon's arm rest and holds equipment quivers for keeping laparoscopic instruments ready for use.

Subjects and settings

We have used the Smith Shield for all the minimal access procedures performed in our unit between January 1997 and June 1998. Other teams have also used the shield in place of the Mayo table for open procedures, most notably colposuspension.

Results

Most of the surgeons in our directorate now choose to use the shield for all but the most simple of laparoscopic procedures, as they have been so impressed with its advantages. All of our regular anaesthetists, after gaining familiarity with the correct positioning of the patient's arms and intravenous lines, comment that access to the patient for monitoring is satisfactory, and they commend the protection offered to the patient by the shield.

Conclusion

We now regard the Smith Shield as an essential part of our standard laparoscopic equipment as the ability to operate comfortably from the head end of the table has greatly reduced the difficulty of complex procedures.
Laparoscopic pelvic lymphadenectomy and radical vaginal hysterectomy vs. radical abdominal hysterectomy and pelvic lymphadenectomy: a feasibility study
Authors: Tan Ai‐Ling , Mackintosh Andrew R. , Bhat Renuka
Published: March 2003

Objective

To evaluate the feasibility, complications and preliminary results of laparoscopic pelvic lymphadenectomy and radical vaginal hysterectomy for the treatment of early invasive carcinoma of the cervix.

Design

A retrospective randomized clinical study.

Setting

The Gynaecology Oncology Unit at the National Women's Hospital, Auckland, New Zealand.

Subjects

These were 30 women who had presented to the unit with early stage cervical cancer for whom surgery was thought to be the most appropriate primary treatment.

Interventions

The first 15 consecutive patients who were diagnosed in 1997 (group A) underwent a standard class 2 abdominal radical hysterectomy and pelvic lymphadenectomy The first 15 consecutive patients who were diagnosed in 1998 (group B) underwent a laparoscopic pelvic lymphadenectomy and a vaginal radical hysterectomy.

Main outcome measures

These included the clinical factors of operating times, blood loss, complications and hospital stay, and the pathological factors of lymph node yield, surgical margins and residual tumour size.

Results

The operating time was slightly longer in group B (mean = 3.18 h). There were no complications in either group but blood loss was halved in group B (mean = 353 ml). Hospital stay was also shorter (mean = 6 days) compared with group A (mean = 8 days). Lymph node yield was comparable to that obtained in open surgery (mean = 18.1 nodes) and clear margins were obtained in 14 out of 15 patients.

Conclusion

Our preliminary results demonstrate the feasibility and safety of laparoscopic pelvic lymphadenectomy and vaginal radical hysterectomy as an alternative to open radical hysterectomy and pelvic lymphadenectomy.
An unusual clinical and histological consequence of uterine arterial embolization of a fibroid
Authors: Burnham Annabelle , Crystal Alan , Torrie E. Peter H.
Published: March 2003

Objective Case report of an unusual clinical and histological consequence of uterine arterial embolization of a fibroid.

Subject A 33‐year‐old patient with a large intramural fibroid causing menorrhagia who wished to avoid a myomectomy and/or hysterectomy.

Interventions Uterine artery embolization was performed. The fibroid was partially resected from a submucosal location 6 weeks later, and a further 2 weeks later the remainder of the necrotic fibroid was removed from the uterine cavity.

Results Histological examination showed that the fibroid was completely infarcted following uterine arterial embolization, and the gel foam particles were identified in the blood vessels of the fibroid. This intramural fibroid was subsequently extruded to a submucosal position where it could be resected and removed.

Conclusion Uterine arterial embolization is used increasingly in the management of symptomatic uterine fibroids in women who wish to avoid a myomectomy and/or hysterectomy. We draw attention to this interesting case of sequestration and extrusion of a large intramural fibroid, with notable histological evidence of embolization.
The effect of paracervical adrenaline on blood loss in patients undergoing transcervical resection of the endometrium
Authors: Roberts Mark , Walton Stuart M.
Published: March 2003

Objective To determine the effect of pretreatment paracervical adrenaline on blood loss in patients undergoing transcervical resection of the endometrium (TCRE).

Design A double‐blind randomized controlled trial in 102 women, using adrenaline 1:200 000. To collect lost blood, a soft Malecot catheter was placed through the cervical os and connected to a drainage bag.

Results Paracervical adrenaline was associated with a small reduction in blood loss that was not statistically significant and an increase in operative heart rate.

Conclusions Our data do not support the routine use of paracervical adrenaline for endometrial resection. The use of a Malecot catheter to collect post‐TCRE blood loss is a new and effective method.
Endometriomas: a review of modern management
Authors: Dover Richard W. , Torode Hugh
Published: March 2003

Objective 

To review the available therapeutic options for the treatment of endometriomas with an emphasis on laparoscopic management.

Design 

A review of the current literature.

Main outcome measures 

The recurrence rate of endometriomas as assessed with the use of ultrasound or second‐look laparoscopy.

Results 

Medical therapy alone, or ultrasound‐guided drainage offer, a poor response rate, and should not be considered as first‐line options. Surgery has the potential to achieve good results, irrespective of whether an open or laparoscopic approach is used. In view of the recognized benefits of laparoscopic methods compared with open surgery, an endoscopic approach is recommended. The choice of laparoscopic procedure is unclear, although simple drainage alone is inadequate. Removal of the cyst lining, by either stripping the capsule, or sharp excision, has the capacity to produce a good outcome, although there are some concerns about the damage that this technique may cause to the underlying ovary. The use of electrical or laser energy to ablate the lining also has the ability to produce good outcomes, although there is no evidence from a prospective study that it leads to a lower recurrence rate than excision/stripping.

Conclusions 

Laparoscopic treatment is the preferred management for endometriomas, although in the absence of good clinical trials, the choice of procedure performed remains based upon clinician preference.
Adaptation of the Filshie clip applicator port to carry 5‐mm instruments without gas escape. A useful technique when unexpected pathology is encountered at laparoscopic sterilization
Authors: Clark James T. M. , Byrne Dominic L.
Published: March 2003

Introduction 

Incidental findings of pelvic pathology at the time of laparoscopic sterilization are not uncommon, and may necessitate additional instrumentation through a 5‐mm port. We describe a simple and inexpensive method of adapting the Filshie clip applicator port to carry 5‐mm instruments without losing gas pressure. When 5‐mm instrumentation is required, the instrument is placed within the digit of a sterile glove and then inserted through the 7.5‐mm Filshie clip applicator port. The glove digit remains within the port preventing gas escape whilst the instrument punctures the tip to emerge through the port to be used in the normal way.

Results 

We report the results of a prospective study of 50 consecutive laparoscopies. Ease of use, gas leakage rates and complications are recorded. Having demonstrated the effectiveness of this technique, we evaluated its usefulness, by performing a retrospective case review of the operating notes of 50 consecutive laparoscopic sterilizations, recording the incidence of documented pelvic pathology and instrument use. Unexpected pathology was encountered in 13 cases (26%), and instruments were required in five (10%).

Conclusions 

Incidental abnormalities within the pelvis are not uncommonly encountered at laparoscopic sterilization. Where instrumentation is required, our method allows utilization of the Filshie clip applicator port as an alternative to using a new 5‐mm port. The system is cheap, safe and effective. One glove can provide digits for five separate insertions if necessary. We have found this temporary laparoscopic port‐reducing method to be a simple and useful technique which meets the unexpected short‐term need for instrument use at the time of laparoscopic sterilization.
No difference found in survival using carbon dioxide laparoscopy, helium laparoscopy, or laparotomy in an adenocarcinoma nude mouse model
Authors: Narducci Fabrice , Lanvin Dominique , Occelli Bruno , Miannay Emmanuel , Danet Sandrine , Querleu Denis
Published: March 2003

Objective

To evaluate the impact of surgical approach on tumour growth and survival of xenografted nude mice.

Materials and methods

237 mice which had received 106 SKOV‐3 (human ovarian adenocarcinoma) cells subcutaneously and intraperitoneally, were anaesthetized for 60 min. The animals were randomly allocated to one of four groups: control group (n = 57), laparotomy (n = 61), CO2 laparoscopy (n = 62), or He laparoscopy (n = 57).

Results

Scar tumour grafts were found in 83.6% in the laparotomy group and in 64.5% in the group which underwent CO2 laparoscopy (P = 0.02). No significant differences were observed between any of the groups in relation to subcutaneous tumour volume at day 30 (P = 0.95), the intraperitoneal tumour volume (P = 0.70), the frequency of peritoneal carcinomatosis (P = 0.55), mesocolic and submesocolic tumour location (P = 0.52) or diaphragmatic metastases (P = 0.97). Moreover, no effect was found on the period of survival of the animals (P = 0.83). The average duration of survival was 63.4 ± 18.2 days (control), 64.2 ± 13.2 (laparotomy), 65.2 ± 16.9 (CO2) and 64.9 ± 16.5 (helium).

Conclusion

In the model used, CO2 laparoscopy is not associated with increased risk of tumour dissemination, scar implantation or death.
Adelaide laparoscopic hysterectomy audit (1991–1998): realistic complication rates!
Authors: O'shea Robert T. , Petrucco Oswald , Gordon Simon , Seman Elvis
Published: March 2003

Objective

To review complications of laparoscopic hysterectomy occurring in a citywide population of approximately 1 million people.

Design

All laparoscopic hysterectomy cases were analysed retrospectively independently of the surgeons involved.

Setting

All private and public hospitals (n = 19) in metropolitan Adelaide, South Australia.

Subjects

1904 patients over the period 1991–98.

Interventions

The majority of cases involved a combined laparoscopic and vaginal approach with a proportion of total laparoscopic hysterectomies (n = 33). Surgical techniques involved both staples and diathermy.

Main outcome measures

Rates of major complications such as haemorrhage, haematoma formation, laparotomy and urinary tract injury.

Results

Significant haemorrhage occurred in 3.7% (n = 70) of cases with a haematoma incidence of 3.2% (n = 60). Laparotomy rates reduced from 5% (1991–93) to 1.7% (1996–98) with an overall incidence of 3.4% (n = 64). Overall urinary tract injury rates remained constant over the survey period, i.e. 3.3% (1991–93) vs. 3.1% (1996–98). However there was a significant reduction in ureteral damage but this was countered by an increasing cystotomy rate.

Conclusions

Laparotomy rates were comparable to those in published data but reduced significantly over the audit period. The incidence of haematoma formation was significantly greater than that in published data, but reduced over the period 1991–98. Urinary tract damage and haemorrhage exceeded expectations. This audit once again has suggested that the true rate of major complications with laparoscopic hysterectomy is higher than the literature suggests.
Early experience with the vaginoscopic approach to outpatient microhysteroscopy
Authors: Okeahialam Majella G. , Jones Sian E. , O'Donovan Peter
Published: March 2003

Objective

To assess the outcome of the vaginoscopic approach to outpatient microhysteroscopy using a 2.5‐mm semi‐rigid hysteroscope without using a speculum, tenaculum or analgesia.

Design 

A prospective observational study.

Setting 

Outpatient hysteroscopy unit of a large district general hospital.

Subjects 

24 women referred to the outpatient hysteroscopy unit with abnormal uterine bleeding.

Results 

A total of 24 women had vaginoscopic outpatient microhysteroscopy. Of the procedures, 20 (83.4%) were successful using the technique and four (16.6%) failed procedures occurred. Pain was not encountered during the procedure.

Conclusion 

Outpatient hysteroscopy with a semi‐rigid 2.5‐mm microhysteroscope using the vaginoscopic approach is a well‐tolerated and successful technique for the evaluation of abnormal genital tract bleeding.
Do not catheterize the bladder at operative laparoscopy
Authors: Miskry Tariq , Cumbis Athanasios , Apostolidis Petros , Eleftheriou Marios , Magos Adam
Published: March 2003

Objective

Bladder catheterization at operative laparoscopy is currently routine, although this may be associated with an increased risk of urinary tract infection and urethral trauma. We wanted to establish whether non‐catheterization is practical or whether it results in problems with operative view or postoperative urinary retention.

Design

Prospective study with historical controls.

Setting

Minimal‐access surgery unit at a tertiary referral centre.

Subjects

40 consecutive women undergoing operative gynaecological laparoscopy.

Interventions

Patients were only catheterized intraoperatively if bladder filling interfered with surgery, or postoperatively if they failed to pass urine within 6 h. The rate of urinary infection was compared with 40 historical controls who were routinely catheterized.

Results

There were no cases of intraoperative bladder trauma. In total, five patients (12.5%) required a urinary catheter, three intraoperatively and two postoperatively. The likelihood of catheterization was significantly associated with an operating time >100 min (P < 0.01). One woman (2.5%), who was not catheterized had positive urine microbiology findings compared with five (12.5%) in the control group (P = 0.2). Although this was not statistically significant, this was not the main aim of our study. In fact, a total of 160 patients would be required to confirm a reduction in infection by 10%.

Conclusions

Bladder catheterization should not be routine prior to operative laparoscopy. Not only can most procedures be completed without catheterization, but it is likely that the risk of urinary infection would be reduced and there would be cost savings to the hospital.
Adhesion prevention in the surgical treatment of pelvic endometriosis
Authors: Canis M. , Botchorishvili R. , Tamburro S. , Safi A. , Wattiez A. , Mage G. , Pouly J. L. , Bruhat M. A.
Published: March 2003

Objective

To review and to discuss the current approaches which may be proposed to prevent adhesions in the surgical management of pelvic endometriosis.

Methods

The current literature was reviewed using a Medline search and data from the Cochrane Library.

Results and conclusions

Although not demonstrated in adequately designed prospective randomized trials, laparoscopy is considered to be less adhesiogenic than laparotomy. Adhesion re‐formation is still a major problem after laparoscopy. The use of barrier agents, such as Interceed, or solutions such as Intergel should be considered in patients treated for moderate or severe endometriosis. Although effective, these products are not substitutes for a good surgical technique. As the treatment of adhesions is difficult, every effort should be made to prevent adhesion formation. To prevent severe postoperative adhesion formation, the following rules are proposed. Laparotomy should be avoided whenever possible. When the surgical treatment appears too difficult, a preoperative medical treatment may be used to delay the treatment, to facilitate the procedure, and to avoid a laparotomy. Laparoscopic procedures should be performed according to the principles of microsurgery which have been demonstrated to reduce adhesion formation at laparotomy.
Ambulatory endoscopic treatment of symptomatic benign endometrial polyps: a feasibility study
Authors: Clark T. Justin , Godwin Jan , Khan Khalid S. , Gupta Janesh K.
Published: March 2003

ObjectiveTo determine the feasibility (potential efficacy and cost‐effectiveness) of ambulatory endoscopic polypectomy in the treatment of symptomatic endometrial polyps.

DesignCohort study comparing ambulatory (intervention group) with inpatient treatment (control group).

Methods58 women with symptomatic intrauterine polyps were identified on outpatient hysteroscopy. The experimental group underwent outpatient endoscopic polypectomy using a bipolar intrauterine system (31/58, 53%) and the control group underwent traditional inpatient polypectomy under general anaesthesia (27/58, 47%). The main outcomes compared between the two treatment groups were: uterine bleeding symptoms; patient satisfaction; quality of life (EuroQol); time off work, and use of health service resources at 6 months.

Results18/31 (58%) women treated as outpatients and 16/27 (59%) women treated as inpatients returned completed outcome questionnaires. There was no difference in the effectiveness of outpatient endoscopic polypectomy compared with inpatient treatment, in terms of improvement of abnormal uterine bleeding (11/12 (92%) vs. 13/14 (93%);P = 1.0); patient satisfaction (14/18 (78%) vs. 14/16 (88%);P = 0.7) and quality of life measured by EuroQol (median score 1.0 vs. 0.93;P = 0.1). Patients who underwent inpatient therapy did however, visit their general practitioner more frequently than those who received outpatient therapy (20 visits vs. seven visits, respectively;P = 0.005). The mean cost of outpatient treatment was 37% less than that of inpatient therapy (£490 vs. £781;P = 0.0001).

ConclusionAmbulatory endoscopic therapy for symptomatic endometrial polyps appears to be efficacious and cost‐effective. The launch of a randomized controlled trial to confirm these provisional results seems feasible.
Increased bleeding in HIV‐positive Haemophiliacs treated with antiretroviral protease inhibitors
Authors: Stanworth  , Bolton  , Hay  , Shiach
Published: March 2003

Seventeen HIV‐positive patients with congenital Haemophilia, one with von Willebrand’s disease, and one with acquired Haemophilia in remission, were treated with antiretroviral protease inhibitors. Clear increases in the frequency of bleeds or changes in the bleeding pattern were documented in 10 individuals taking HIV protease inhibitors. Blood product requirements were increased in eight individuals with severe Haemophilia over the 6 months after starting HIV protease inhibitors. Therapy with the HIV protease inhibitor was discontinued in two patients in whom the increased bleeding was severe. No haeostatic cause for the increased bleeding tendency could be identified. Patients with bleeding disorders should be warned about this potential complication of HIV protease inhibitor therapy, and should be closely monitored.
Pharmacokinetics, efficacy and safety of Humate‐P® in von Willebrand disease
Authors: Dobrkovska  , Krzensk  , Chediak
Published: March 2003

In a pharmacokinetic study with Humate‐P® including six patients with various types of von Willebrand disease, a median half‐life of 11.3 h for vWF:RCoF and of 15.2 h for vWF:Ag was found. The median value of in vivo recovery (IVR) was estimated for vWF:RCoF as 2.10 IU dL−1 plasma per 1 substituted IU kg−1 b.w. (or 73%), for vWF:Ag as 1.88 IU dL−1 plasma per 1 substituted IU kg−1 b.w. (or 69%); and for FVIII:C as 2.69 IU dL−1 plasma per 1 IU kg−1 b.w. (or 99%). Transient postinfusion shortening or normalization of previously prolonged bleeding time was observed in all patients. In a retrospective study involving 97 patients with various von Willebrand disease types, clinical efficacy and safety of treatment with Haemate‐P® in 73 surgical interventions, 344 separate bleeding events, 93 other events and 20 cycles of prophylactic treatment were evaluated. The clinical efficacy was rated good to excellent in 99% of the surgeries, in 97% of the bleeding episodes, in 86% of the other events, and in all prophylactic treatments. The overall tolerability was good. Adverse events possibly or probably associated with use of Humate‐P®/Haemate‐P® were rare, of non‐serious nature and mild to moderate in their intensity.
Unsolved problems in haemophilia
Authors: Lee C. A. , Kessler C. M. , Varon D. , Martinowitz U. , Heim M. , ALEDORT L. M.
Published: March 2003

Summary. Diagnosis and therapy for the vast majority of haemophiliacs in the world remain beyond their reach. Health care costs for hemophilia replacement products keep rising. Global inequities for financing health care result in most hemophiliacs being undertreated. The transfusion‐transmitted disease, factor VIII inhibitors, is common. Its predictability escapes detection. Management has progressed substantially and offers many therapeutic modalities. Programs for prophylaxis or immune tolerance induction are impossible for most patients. Thus, the challenge for haemophiliacs is to attain these goals.
Treatment of acute and chronic synovitis by non‐surgical means
Authors: Lee C. A. , Kessler C. M. , Varon D. , Martinowitz U. , Heim M. , FERNANDEZ‐PALAZZI F.
Published: March 2003

Summary. This paper reviews personal experience in the treatment of recurrent haemarthrosis and chronic synovitis by non‐surgical means. Experience with synoviorthesis with rifampicine and radioactive colloids is analyzed, and a multiple chromosomal study to demonstrate safety of radioactive injections is described. The results obtained are so very satisfactory as to recommend non‐aggressive synoviorthesis as the treatment of choice to prevent recurrence of bleeding. Long experience in the treatment of chronic arthropathy with intrarticular corticosteroids and hyaluronic acid has shown very promising results.
Management of haemophilia B patients with inhibitors and anaphylaxis
Authors: Lee C. A. , Kessler C. M. , Varon D. , Martinowitz U. , Heim M. , WARRIER I.
Published: March 2003

Summary. The development of inhibitor antibodies is a serious complicaiton of haemophilia in young children. Occurrence of anaphylaxis at the time of inhibitor development is a recently described complication unique to haemophilia B. Management of these inhibitor patients with allergy is complicated due to the absence of any readily available products for treatment of acute bleeding episodes. Clinical experience suggests that recombinant activated factor VII is the most appropriate and logical treatment for acute bleeding episodes in these patients. From the limited information available regarding immune tolerance induction (ITI) in these patients, it appears that ITI regimens have been only minimally successful and are associated with a high rate of complication (nephrotic syndrome).
Therapy for chronic hepatitis B and C infection in haemophilia
Authors: Lee C. A. , Kessler C. M. , Varon D. , Martinowitz U. , Heim M. , DUSHEIKO G. M.
Published: March 2003

Summary. Haemophiliacs, until recently, have been at risk of hepatitis B and C infection. Substantial numbers of patients remain persistently infected. Several lines of evidence suggest that these diseases will cause considerable morbidity unless therapy can successfully reduce viraemia and prevent disease progression. Cessation of viral replication may prevent progression to hepatic fibrosis.
In vivo recovery with products of very high purity — assay discrepancies
Authors: Lee C. A. , Kessler C. M. , Varon D. , Martinowitz U. , Heim M. , LUSHER J. M. , HILLMAN‐WISEMAN C. , HURST D.
Published: March 2003

Summary. In view of reports of FVIII assay discrepancies in post‐infusion plasma samples depending on methods used, we compared FVIII results run by each of four different methods following infusion of rFVIII (Kogenate®). Nine persons with haemophilia A were infused with each of two lots of product. Plasma samples were obtained at baseline, and at 10 min, 30 min, 1, 2, 4, 8, 12, 14, 30 and 48 h post‐infusion for measurement of FVIII. FVIII assay methods were chromogenic, and one‐stage APTT using three different types of activators: micronized, silica, ellagic acid, and kaolin. The same reference plasma standard was used throughout. Results demonstrated a consistent difference in FVIII values, with chromogenic assays being considerably higher than those run by one‐stage assays. The discrepancy was greatest when kaolin was the activator. These results point out the problems in attempting to determine the “correct” FVIII level in patient plasma samples following infusion of high purity FVIII preparations. Potential “pitfalls” include the standard used for defining product potency, the methods, reagents, instrumentation and standards used in assaying plasma samples and, in some instances, the characteristics of the product itself. This situation has considerable cost implications, potential impact on patient care, and makes it difficult to compare results between laboratories.
Complications associated with the treatment of haemophiliacs with inhibitors
Authors: Green
Published: March 2003

To examine the safety profile of products used to treat inhibitor patients unresponsive to factor VIII, a review of published clinical experience was performed. The products evaluated were activated prothrombin complex concentrates (aPCCs), such as AUTOPLEX® T, porcine factor VIII and recombinant activated factor VII (rVIIa). Safety characteristics included potential for transmission of infectious agents, anamnesis, thrombogenicity, thrombocytopenia and allergic reactions. While viral transmission has been virtually eliminated, the risk is theoretically higher with plasma‐derived products such as aPCC and porcine factor VIII than with rVIIa, although contamination of cultured cells is a concern. Anamnesis occurs with aPCCs and porcine factor VIII, and may induce resistance to further therapy with porcine factor VIII. Thrombosis and disseminated intravascular coagulation are very infrequently reported in patients exposed to aPCCs and rVIIa, and never with porcine factor VIII. The latter is occasionally associated with thrombocytopenia, but this uncommonly limits treatment with this agent. Lastly, allergic reactions occur with about equal frequency with all products, but anaphylaxis is mainly a concern after administration of porcine factor VIII. In conclusion, products currently available are reasonably safe. Considerations such as efficacy, availability, ease of administration and cost must also be considered in making treatment choices.
Acquired von Willebrand syndrome – report of 10 cases and review of the literature
Authors: Nitu‐Whalley  , Lee
Published: March 2003

Acquired von Willebrand syndrome (AvWS) is a rare bleeding disorder with clinical and laboratory features closely resembling hereditary von Willebrand disease (vWD), arising in previously haemostatically normal individuals.

We present a retrospective review of 10 cases with AvWS diagnosed over 17 years. The severity of the bleeding tendency varied from mild to severe forms. Multimers electrophoresis showed that 8/10 patients had a normal pattern similar to type 1 vWD, 1/10 had a type 2A vWD pattern (with absence of high and intermediate molecular weight multimers) and 1/10  had a type 3 vWD pattern. An inhibitor screen was performed in 6/10 patients and autoantibodies against von Willebrand factor were found in only two cases. The underlying cause/associated conditions were identified in 8/10 patients. Treatment of the bleeding diathesis was successfully achieved with desmopressin or clotting factor concentrates. Resolution of underlying hypothyroidism (in two cases) and multiple myeloma (in one case) led to normalization of the coagulation parameters.

The report on this cohort of 10 patients with AvWS illustrates the complexity of AvWS and its multifactorial aetiology.

A brief review of the recent literature on AvWS is also presented, with emphasis on the current opinions in pathogenesis and treatment.

Acquired von Willebrand syndrome (AvWS) is an acquired bleeding disorder, characterized by a phenotype similar to the inherited von Willebrand disease (vWD), with a prolonged bleeding time and low plasma levels of factor VIII – von Willebrand factor (vWF) measurements. It occurs in patients with no family history of vWD, who present with recent onset of bleeding symptoms. AvWS appears to be associated mainly with lymphoproliferative disorders, immunological conditions and neoplasia.

AvWS is a rare condition and it is difficult to conduct prospective studies, therefore it is important to document the experience with such cases. The aim of this paper is first, to report 10 cases of AvWS identified at our Haemophilia Centre during the past 17 years. Second, to present a brief review of the recent literature on AvWS – outlining the salient features, associated disorders, mechanisms of acquisition and the available options of treatment.
Probabilities, costs, and outcomes: methodological issues in modelling haemophilia treatment
Authors: Bohn  , Colowick  , Avorn
Published: March 2003

Economic analyses in haemophilia care are at present limited, but are increasingly being used to examine the costs and outcomes associated with various treatment regimens. The assignment of probabilities and costs in these models can be challenging, and the use and development of new quality‐of‐life instruments for haemophilia have yet to be fully investigated. These methodological issues need to be addressed to expand research in the area of the economics of haemophilia care.
Treatment of patients with inhibitors: cost issues
Authors: Goudemand
Published: March 2003

The management of bleeding episodes and surgery in haemophilia patients who develop inhibitors is specially difficult and also has major impact on therapeutic costs. We assessed the costs of coagulation factors in noninhibitor haemophilia A and B patients (0 Inh; n=103), patients with low responding inhibitors (LR; n=24), patients with high responding inhibitors (HR; n=17) in our centre between 1988 and 1998 during two periods: 1988–1995 and 1996–1998, before and after the introduction of recombinant factor VIIa in France (1996). From 1988 to 1995 the mean annual cost of 0 inh and LR patients was
43 234 and
49 422, respectively, with more than 90% as home treatment, whereas the mean cost of HR patients was
56 262 (1.3 time more than 0 Inh), half of this cost being related to treatment administered in hospital. From 1996 to 1998, the mean cost of HR patients was
186 482, approximately three times more than that of 0 Inh (
59 887) and LR patients (
54 226) with half of the cost due to treatment administered in hospital. So rFVIIa seems to exert a major economic effect on both the cost of home treatment and treatment administered in hospital. It must be pointed out that particularly severe bleeding episodes were effectively treated with rFVIIa during this period and that rFVIIa allowed surgery to be undertaken: including two elective orthopaedic surgeries. So there is no doubt that rFVIIa offers new perspectives in the therapeutic management of HR patients, but creates a new economic situation which needs further evaluation.

image
Non‐operative treatment of flexion contracture of the knee in haemophilia
Authors: Fernandez‐Palazzi F. , Battistella L.R.
Published: March 2003

For the non‐operative treatment of flexion contracture of the haemophilic knee we have used serial casting and wedging in 58 patients, and extension/de‐subluxation orthoses in 13 patients. On average it was possible to achieve ‐5° of extension by 4 weeks, with only a little improvement in the following 4 weeks. The short‐to medium‐term results using either the extension/de‐subluxation hinges or serial casting were similar. Both methods have been shown to result in significant improvement in joint contracture.