bluuebunny/crossref_metadata_2025 huggingface dataset:
A Prospective Study of Two Conservative Treatments for Ganglia of the Wrist
Authors: STEPHEN A. B. , LYONS A. R. , DAVIS T. R. C.
Published: December 2003

This randomized prospective study assessed whether multiple puncture of the ganglion wall improves the results of simple ganglion aspiration. We found that 32% of ganglia resolved after aspiration alone in comparison with 22% after aspiration and multiple puncture. This difference was not significant. However, only 18% of patients requested formal surgical excision, suggesting that aspiration allays fears of malignancy and allows the patient to accept a minor cosmetic embarrassment.
The Effect of Dorsal Carpal Ganglion Excision on the Scaphoid Shift Test
Authors: HWANG J. J. , GOLDFARB C. A. , GELBERMAN R. H. , BOYER M. I.
Published: December 2003

A clinical and radiographic review was performed on 18 patients (19 wrists) with dorsal carpal ganglia and associated positive scaphoid shift test. All patients underwent excision of the ganglion followed by 2 weeks of postoperative immobilization with the wrist in 20° extension. All patients had wrist pain, a painful clunk on the Watson scaphoid shift test, localized tenderness on palpation of the scapholunate articulation and normal radiographs. Patients were assessed postoperatively by questionnaire and physical examination. Improved functional activity and decreased pain were noted in all patients. In 17 of 19 wrists, the positive preoperative Watson scaphoid shift test become negative. We believe that dorsal wrist ganglia are frequently associated with a positive scaphoid shift test and that excision of the ganglion followed by 2 weeks immobilization may lead to resolution of the signs and symptoms of instability, at least in the short term.
Withdrawal of TNF‐α after the fifth day of differentiation of CD34+ cord blood progenitors generates a homogeneous population of Langerhans cells and delays their maturation
Authors: Noirey N. , Staquet M.‐J. , Gariazzo M.‐J. , Serres M. , Dezutter‐Dambuyant C. , André C. , Schmitt D. , Vincent C.
Published: December 2003

Abstract: Human cord blood CD34+ progenitors cultured in the presence of granulocyte‐macrophage colony‐stimulating factor (GM‐CSF), tumor necrosis factor‐α (TNF‐α) and transforming growth factor‐β (TGF‐β) generate a heterogeneous population of dendritic cells (DC), including Langerhans cells (LC). This combination of cytokines has been shown to be crucial for differentiation into LC. After day 5 of culture, TNF‐α has been maintained in the medium in most studies despite the observation of spontaneous maturation of LC after day 12. Five‐day samples of in vitro differentiated LC were cultured in parallel with or without TNF‐α. The absence of TNF‐α was shown to: (1) slow down proliferation without triggering apoptotic cell death, (2) enhance the percentage of LC, (3) delay or abrogat the expression of CD83, CD86, HLA‐DR and CD208 molecules, and (4) maintain endocytosis by receptor and macropinocytosis. The withdrawal of TNF‐α abrogated the spontaneous synthesis of matrix metalloproteinases. At day 12, TNF‐α‐deprived LC were less efficient in allogeneic T cell activation than LC cultivated with TNF‐α. These data indicate that the suppression of TNF‐α after day 5 maintains cells in an immature state and provides a population with 80% of LC at day 12.
Biological response modifiers and their potential use in the treatment of inflammatory skin diseases
Authors: Villadsen Louise S. , Skov Lone , Baadsgaard Ole
Published: December 2003

Abstract: In recent years, a more detailed understanding of the pathogenesis of several inflammatory skin diseases, combined with the developments within biotechnology, has made it possible to design more selective response modifiers. Biological response modifiers hold the potential for greater effectiveness and fewer side‐effects than the current systemic therapies now used for severe psoriasis, contact dermatitis and atopic dermatitis. In the pathogenesis of inflammatory skin diseases, the immune system plays a pivotal role, and this is where biological response modifiers such as monoclonal antibodies, recombinant cytokines, or fusion proteins may be effective. Several biological response modifiers have already shown positive results in phase II/III clinical trials in skin diseases, and many new biological response modifiers are in progress.
Alteration in the production of IL‐10 and  IL‐12 and aberrant expression of CD23, CD83 and CD86 by monocytes or  monocyte‐derived dendritic cells from atopic dermatitis patients
Authors: Aiba Setsuya , Manome Hideaki , Yoshino Yumiko , Tagami Hachiro
Published: December 2003

Abstract: Atopic dermatitis (AD) is characterized by the presence of Th2‐type cells in the skin infiltration as well as in the peripheral blood, although a predominant infiltration of interferon‐γ (IFN‐γ)‐producing cells is also reported in the chronic skin lesions of AD. Recently it has become clear that the development of Th1 or Th2 is strongly influenced by factors produced by the antigen presenting cells (APCs). To clarify whether APCs from AD patients play a favorable role in the differentiation of Th2 cells, we compared the production of cytokines and the expression of co‐stimulatory molecules by monocytes (MOs) and monocyte‐derived DCs (MoDCs) after stimulations with various reagents between 13 AD patients and 13 age‐matched healthy controls. We examined their production of IL‐1β, IL‐10, IL‐12p40, and IL‐12p70, and their expression of CD23, CD40, CD54, CD80, CD83, CD86 and HLA‐DR. We stimulated them with superantigens, lipopolysaccharide (LPS), agonistic anti‐CD40 antibody, phytohemagglutinins (PHA), IL‐1β/TNF‐α, IL‐4, or IFN‐γ. The following results were obtained (1): IL‐10 production was significantly enhanced in AD MOs after LPS stimulation. In contrast, IL‐12p40 production was significantly lower in AD MOs than in HC MOs after a variety of stimulations (2). IL‐12p40 was also significantly lower in AD MoDCs after LPS stimulation (3). The induction of CD23 with IL‐4 was significantly higher in AD MOs. and finally (4), AD MoDCs augmented the expression of CD83, CD86, and HLA‐DR less significantly than HC MoDCs after anti‐CD40 Ab stimulation. These data indicate that AD APCs show some responses different from those observed in HC APCs after several stimulations, such as LPS, IL‐1β/TNF‐α, IL‐4, or anti‐CD40 Ab, and that these responses might play a role in the polarizing process of helper T cells into Th2 cells as recognized in AD patients.
Metabolism and residue depletion of albendazole and its metabolites in rainbow trout, tilapia and Atlantic salmon after oral administration
Authors: Shaikh B. , Rummel N. , Gieseker C. , Serfling S. , Reimschuessel R.
Published: December 2003

Metabolic and residue depletion profiles of albendazole (ABZ) and its major metabolites in three fish species, rainbow trout, tilapia and Atlantic salmon are reported. Based on these profiles, similarities (or dissimilarities) between species will determine the potential to group fish species. ABZ at 10 mg/kg body weight was incorporated into fish food formulated in a gelatin base or in gel capsule and fed as a single dose to six fish from each species. Rainbow trout were held three each in a partitioned 600‐L tank. Tilapia and Atlantic salmon were housed in separate 20‐L tanks. Samples of muscle with adhering skin were collected at 8, 12, 18, 24, 48, 72, and 96 h postdose from trout kept at 12 °C, at 4, 8, 12, 24, 48, 72, 96, 120, and 144 h postdose from tilapia kept at 25 °C and at 8, 14, 24, 48, 72, and 96 h postdose from Atlantic salmon kept at 15 °C. The samples were homogenized in dry ice and subjected to extraction and cleanup procedures. The final extracts were analyzed for parent drug ABZ and its major metabolites, albendazole sulfoxide (ABZ‐SO), albendazole sulfone (ABZ‐SO2) and albendazole aminosulfone using high‐performance liquid chromatography with fluorescence detection. ABZ was depleted by 24 h in trout and tilapia and by 48 h in salmon; ABZ‐SO, a pharmacologically active metabolite, was depleted by 48 h in tilapia, by 72 h in rainbow trout and was present until 96 h in salmon; and low levels of ABZ‐SO2 and albendazole aminosulfone, both inactive metabolites, were detectable at least till 96 h in all three fish species.
Thalidomide for the treatment of idiopathic myelofibrosis
Authors: Strupp C. , Germing U. , Scherer A. , Kündgen A. , Mödder U. , Gattermann N. , Haas R.
Published: December 2003

Except rare instances of allogeneic stem cell transplantation, treatment of idiopathic myelofibrosis (IMF) is only palliative and based on cytostatic treatment (hydroxyurea and anagrelide), androgen therapy, steroids and splenectomy. Thalidomide is an anti‐angiogenic and immunmodulatory drug with a wide spectrum of activities, which are not clearly understood. Current data suggest that the action of thalidomide is related to several different mechanisms, including suppression of tumor necrosis factor, effects on basic fibroblast growth factor, vascular endothelial growth factor, interleukins and interferons, downregulation of selected cell surface adhesion molecules, and changes in the lymphocyte subsets.

We administered thalidomide to 16 patients with IMF (15 men, one women) who had transfusion‐dependent anemia, thrombocytopenia or symptomatic splenomegaly. Median age was 59 yr (range: 52–78). Patients received thalidomide at an escalating dose from 100 to 400 mg/d (median 300 mg). The drug was discontinued in four patients because of progressive disease (two) or polyneuropathy (two). Other adverse effects were obstipation (10), fatigue (eight) and edema (two). Clinical response has now been observed for a median duration of 9 months (range: 3–20). Fifteen patients are evaluable. Anemia improved in six of 10 patients who were anemic. Platelet counts improved in five of seven patients with thrombocytopenia. Splenomegaly regressed in three of 13 patients. Lactate dehydrogenase (LDH) decreased in seven of 12 patients, but increased in four patients. LDH levels were not correlated with clinical response. In summary, thalidomide appears useful in the treatment of IMF.
Clinicopathological correlations of TIMP‐1 and TIMP‐2 in Hodgkin's lymphoma
Authors: Pennanen Heli , Kuittinen Outi , Soini Ylermi , Turpeenniemi‐Hujanen Taina
Published: December 2003

Objectives:  The influence of matrix–tumour interactions in Hodgkin's lymphoma is poorly characterised, although a large part of the tumour often consists of reactive tissue. The aim of the present study was to assess the clinicopathological role of two main inhibitors of matrix metalloproteinases, TIMP‐1 and TIMP‐2, in Hodgkin's lymphoma.

Materials and methods:  The TIMP‐1 and TIMP‐2 protein expressions were studied from paraffin‐embedded tumour sections of 68 patients with Hodgkin's lymphoma by using immunostaining with TIMP‐1 and TIMP‐2‐specific antibodies. The results of the stainings were compared with the clinicopathological disease characteristics.

Results:  A total of 33.3% of the tumour tissue sections expressed TIMP‐1 and 46.8% expressed TIMP‐2. The expression of the TIMP‐1 protein was found to be strongly associated with the nodular sclerosis subtype (P = 0.015) and the existence of a bulky tumour (P = 0.004) in Hodgkin's lymphoma. The expression of the TIMP‐2 protein, on the other hand, correlated with the occurrence of B symptoms (P = 0.032).

Conclusions:  These results provide the first clinical evidence suggesting that TIMP‐1 could promote growth of Hodgkin's lymphoma, and may be linked to connective tissue turnover in the nodular sclerosis subtype. However, TIMP‐2 is shown to correlate with systemic symptoms.
Successful treatment of chemotherapy‐refractory Sézary syndrome with alemtuzumab (Campath‐1H)
Authors: Gautschi O. , Blumenthal N. , Streit M. , Solenthaler M. , Hunziker T. , Zenhäusern R.
Published: December 2003

Introduction:  Sézary syndrome (SS) is a cutaneous T‐cell lymphoma characterized by erythroderma, lymphadenopathy and circulating atypical T cells. Median survival after diagnosis is 10 yr, with chemotherapy resistance being a major problem in advanced disease. Alemtuzumab (Campath‐1H) is a monoclonal antibody directed against the lymphocytic antigen CD52, expressed on B‐ and T‐cells. Alemtuzumab is approved for relapsing chronic B‐cell leukemia and seems to be active also in T‐cell lymphomas such as T‐cell prolymphocytic lymphoma, SS and mycosis fungiodes.

Case history:  A 32‐yr‐old male patient presented with advanced stage, extensively pretreated SS with heavily itching erythroderma, peripheral lymphadenopathy, circulating Sézary cells and bone marrow infiltration. The disease had not responded to PUVA/interferon‐α and progressed on chemotherapy with CHOP, 2‐CDA, vinorelbine, etoposide and liposomal doxorubicin. Following treatment with alemtuzumab (30 mg i.v. three times per week for 10 wk), itching resolved rapidly and an almost complete remission was achieved within 3 months after starting this treatment. At 12‐month follow up, no disease progression was present.

Conclusion:  In accordance with previous data, this single case underlines the potent activity of alemtuzumab in advanced, chemotherapy‐refractory SS.
Salvage therapy with an outpatient DHAP schedule followed by PBSC transplantation in 79 lymphoma patients: an intention to mobilize and transplant analysis
Authors: Olivieri Attilio , Brunori Marino , Capelli Debora , Montanari Mauro , Massidda Danilo , Gini Guido , Lucesole Moira , Poloni Antonella , Offidani Massimo , Candela Marco , Centurioni Riccardo , Leoni Pietro
Published: December 2003

Chemotherapy followed by autologous transplantation may be an efficient salvage treatment in malignant lymphomas. We investigated the feasibility, tolerability and efficacy of an outpatient schedule of dexamethasone, cytarabine and cisplatin (DHAP), followed by peripheral blood progenitor cell autografting as salvage treatment in patients with high grade (HG), low grade (LG) non‐Hodgkin's lymphoma (NHL) and Hodgkin's Disease (HD). A total of 159 DHAP courses (median: 2, range: 1–5), was administered on outpatient basis to 79 patients (31 LG‐NHL, 28 HG‐NHL and 20 HD), with the intention to mobilize and to transplant. A successful collection was not achieved in 40% LG‐NHL, 10% HD and 20% HG‐NHL patients. The risk to fail the collection was significantly related to the number of previous chemotherapy courses (>6) (P = 0.005, RR = 1.4), to the pretransplant status (P = 0.04, RR = 13.5) and to the previous fludarabine administration (P = 0.01, RR = 20). High dose therapy (HDT) was feasible in 60 patients (76%). The overall treatment related mortality was 3.8%. The overall response rate (ORR) was 81% with a 57.6% overall survival (OS) at 62 months (95% CI: 45–69.3%) and a progression free survival (PFS) of 42% at 74 months (95% CI: 26.7–58%). The diagnosis of HG‐NHL and the non‐response to DHAP resulted to reduce respectively the OS (P = 0.007, RR = 2.8) and PFS probability (P = 0.01, RR = 4.1). In conclusion this outpatient schedule of DHAP is a well tolerated, efficient salvage and mobilizing regimen not only in HG‐NHL, but also in LG‐NHL and in HD. Randomized studies are needed to better define the role of DHAP in LG‐NHL and HD patients.
Effect on yield and dry‐matter distribution of the stay‐green characteristic in cultivars of forage maize grown in England
Authors: Wilkinson J. M. , Hill J.
Published: December 2003

To test whether or not the ‘stay‐green’ (SG) characteristic confers benefits in terms of crop yield or distribution of dry matter (DM) in selected forage maize cultivars, an experiment was conducted in 1998 and 1999 at two sites in England: Writtle College, Essex and the University of Leeds, West Yorkshire. Five SG and five conventional (C) cultivars of forage maize were grown in replicated field‐scale plots at each site in both years. One‐metre lengths of single rows in each plot were harvested by hand, leaving a 20‐cm stubble, on four occasions each year over 3‐week periods (harvest 1 to harvest 4), prior to the harvest of the remainder of the fields. Plants were chopped, mixed and a subsample taken for determination of DM content by oven‐drying. Mean yields of whole plant DM were similar between SG and C cultivars. Both yield of DM and proportion of ear in the total plant DM increased from harvest 1 to harvest 4 (P < 0·01). The increase in DM yield between harvest 1 and harvest 4 was greater for C than for SG cultivars (P < 0·05). Within sites there were no differences in the concentration of whole plant DM between SG and C cultivars, which increased from harvest 1 to harvest 4 (P < 0·001). The proportion of ear DM in the whole plant DM tended to be higher for C than for SG cultivars in both years and increased (P < 0·001) from harvest 1 to harvest 4. The concentration of DM in the ear fraction was higher (P < 0·05) for C than for SG cultivars. We conclude that differences between SG and C cultivars of forage maize are likely to be relatively small when grown in the English climate and harvested after the same growing period.
Productivity and nutritive value of some cultivated perennial grasses and mixtures in the alpine region of the Tibetan Plateau
Authors: Dong S. K. , Long R. J. , Hu Z. Z. , Kang M. Y. , Pu X. P.
Published: December 2003

The productivity and nutritive value of some cultivated perennial grasses, Bromus inermis (B), Elymus sibricus (S), E. nutans (N), Agropyron cristatum (A), Poa crymophila (P) and mixtures B + N, S + A, B + S + A, S + B + N, N + S + A, B + S + N + A, B + N + A + P, B + S +A + P and S + N + A + P, in the alpine region of the Tibetan Plateau were investigated. Elymus nutans and E. sibricus and the mixtures, B + S + N + A, B + S +A + P and S + N + A + P, were most productive with yields of dry matter (DM) of between 11 000 and 14 000 kg−1 of biomass annually in the second harvest year. Acid‐detergent fibre (ADF) concentrations increased (P < 0·05), and crude protein (CP) concentrations and in sacco DM degradability values decreased (P < 0·05) with the maturity of the cultivated grasses. Swards, based on these species and mixtures, have the potential to be the main choices for cultivation in the Tibetan Plateau because they produce more nutrients than other grass species and mixtures. Late August (flowering stage of dominant grasses) is the optimum time for harvesting as the yield of rumen‐degradable CP is highest that of DM relatively high and the DM degradability is satisfactory.
Adnexectomy for benign pathology at vaginal hysterectomy without laparoscopic assistance
Authors: Sheth Shirish S.
Published: December 2003

Of 166 consecutive women with a benign adnexal mass scheduled for vaginal hysterectomy with adnexectomy, the operation was successful in 158 (95%). Preoperatively, attempts were made to ascertain that adnexal mass was benign and either freely mobile or with only slightly restricted mobility. Laparotomy was required in eight women, in five for adhesions and in three for malignancy detected during the operation. No woman required laparoscopic‐assisted surgery. The 158 women who had successful vaginal hysterectomy with adnexectomy were compared with 100 similar women who had a laparotomy performed by same single operator. The vaginal group had a lower morbidity, speedier recovery and shorter hospital stay.
Elevated tissue plasminogen activator as a potential marker of endothelial dysfunction in pre‐eclampsia: correlation with proteinuria
Authors: Belo Luís , Santos‐Silva Alice , Rumley Ann , Lowe Gordon , Pereira‐Leite Luís , Quintanilha Alexandre , Rebelo Irene
Published: December 2003

Objective
To clarify the role played by endothelial cell production of fibrinolytic factors in normal pregnancy and pre‐eclampsia.

Design
A longitudinal study performed during normal pregnancy and a cross sectional study performed in healthy and pre‐eclamptic pregnant women in the third trimester of pregnancy.

Setting
Department of Obstetrics and Gynaecology, University Hospital of S. João, Porto, Portugal.

Population
Fourteen normal pregnant women followed through the three trimesters of gestation. Two groups of women (normal, n= 56; pre‐eclamptic, n= 37) evaluated at the third trimester of gestation.

Methods
Measurement of platelet number, plasma levels of fibrinogen, tissue plasminogen activator (t‐PA) antigen, plasminogen activator inhibitor‐1 (PAI‐1) activity, and fibrin fragment D‐dimer.

Main outcome measures
Pre‐eclampsia, proteinuria.

Results
All the substances, except platelet count, increased significantly throughout normal pregnancy. Comparison of the values in the third trimesters of normal and pre‐eclamptic pregnancies showed similar values for the fibrinogen and platelet counts, and higher values of t‐PA (almost twice normal median value; P < 0.0001), PAI‐1 and D‐dimer in the pre‐eclamptic women. t‐PA correlated positively and significantly with the degree of proteinuria in pre‐eclamptic women (r= 0.575, P= 0.0002).

Conclusion
These findings suggest that elevated t‐PA antigen may reflect endothelial disturbance in pre‐eclampsia, and may be a potential biomarker of risk.
Does fear of childbirth during pregnancy predict emergency caesarean section?
Authors: Johnson Rebecca , Slade Pauline
Published: December 2003

Objective
Caesarean section rates are rising dramatically in the UK. It has been estimated that they have increased from 10% to 22% of all births over 15 years. A Swedish study has suggested that fear of childbirth during pregnancy may increase the risk of emergency caesarean section. The aim of this study is to identify whether fear of childbirth can predict the occurrence of emergency caesarean section in a UK sample.

Design
A prospective design using between‐group comparisons.

Setting
Sheffield, S. Yorkshire, UK.

Sample
Four hundred and forty‐three pregnant women, recruited at 32 weeks of gestation, over 16 years of age.

Methods
Participants completed self‐assessment, postal questionnaires assessing fear of labour and anxiety using the Wijma Delivery Expectancy Scale (W‐DEQ) and the Speilberger State Trait Anxiety Scale (STAI), together with their expectations about their mode of delivery. Delivery information was gathered via birth summary sheets.

Main outcome measure
Mode of delivery.

Results
Emergency caesarean section was associated with previous caesarean section, parity, age and a score reflecting medical risk, but not fear of childbirth or anxiety measures. There were no differences in fear between women experiencing spontaneous‐vertex, forceps/ventouse, emergency or elective caesarean deliveries. The W‐DEQ was factor analysed and was found to measure four distinct domains: fear, lack of positive anticipation and the degree to which women anticipate isolation and riskiness in childbirth. However, these individual factors also failed to contribute to the prediction of mode of delivery. Primiparous women in the UK sample showed highly elevated fear scores when compared with a Swedish sample. Such discrepancies were not found for the multiparous sample.

Conclusions
Fear of childbirth during the third trimester is not associated with mode of delivery in a UK sample. Possible cross‐cultural differences are discussed.
Reproductive performance after hysteroscopic metroplasty in the hypoplastic uterus: a study of 29 cases
Authors: Barranger Emmanuel , Gervaise Amélie , Doumerc Séverin , Fernandez Hervé
Published: December 2003

Objective
To evaluate the reproductive performance after hysteroscopic metroplasty performed for hypoplastic uterus.

Design
Crossover study (15 patients) and descriptive analysis (14 patients).

Setting
Tertiary care university hospital.

Population
Twenty‐nine women (mean age: 31.4 years; range: 27–38.5 years) with a hypoplastic malformed uterus and a history of primary infertility and/or recurrent abortion and/or preterm delivery were included in this study. Fourteen women suffered from primary infertility and 15 women had previous pregnancies. Twenty‐three women had been exposed to diethylstilboestrol in utero.

Methods
Women underwent hysteroscopic metroplasty between January 1996 and May 1999.

Main outcome measures
Rate of pregnancies and live births, anatomical results.

Results
The mean follow up was 40 months (range: 13–67 months). Twenty‐one women (72.4%) experienced 30 pregnancies. Thirteen women gave birth to 16 live infants. At the time of the follow up, four women were pregnant in the second trimester. Compared with previous pregnancies, the rate of deliveries increased from 3.8% to 63.2%. No complications occurred during metroplasty. The hysteroscopic anatomical results were good in all cases.

Conclusions
Our results suggest that hysteroscopic metroplasty, with its simplicity and minimal post‐operative sequelae, seems to be an operation of choice in women with a hypoplastic malformed uterus and a history of severe infertility and/or recurrent pregnancy loss.
A randomised study of misoprostol and gemeprost in combination with mifepristone for induction of abortion in the second trimester of pregnancy
Authors: Bartley Julia , Baird David T.
Published: December 2003

Objective
To compare the effectiveness of gemeprost and misoprostol as prostaglandins used in combination with mifepristone for induction of mid‐trimester termination.

Design
Randomised trial.

Setting
Scottish teaching hospital.

Sample
One hundred women undergoing abortion between 12 and 20 weeks.

Methods
Each woman received 200 mg mifepristone and 36–48 hours later either 1 mg gemeprost vaginal pessary every 6 hours for 18 hours or 4 × 200 μg misoprostol tablets vaginally followed by 2 × 200 μg misoprostol tablets orally every 3 hours for 12 hours. Success was defined as the percentage of women aborted within 24 hours of the first administration of prostaglandin.

Main outcome measures
Prostaglandin–abortion interval and side effects.

Results
There were no significant differences in median prostaglandin–abortion interval between gemeprost (6.6 hours 95% CI 6.0–10.7) and misoprostol (6.1 hours 95% CI 5.5–7.5) (P= 0.22). The cumulative abortion rates at 24 hours (96%vs 94%, respectively), the surgical evacuation rates (12% and 10%) and the incidence of vomiting, diarrhoea and pain were similar.

Conclusion
Two hundred milligrammes of mifepristone followed 36–48 hours later by either vaginal gemeprost or misoprostol is a highly effective way of inducing abortion in the second trimester of pregnancy.
Influence of the subpubic arch angle on anal sphincter trauma and anal incontinence following childbirth
Authors: Frudinger Andrea , Halligan Steve , Spencer John A.D. , Bartram Clive I. , Kamm Michael A. , Winter Raimund
Published: December 2003

Objective
To assess the relationship between the subpubic arch angle, anal sphincter and perineal trauma, and anal incontinence after childbirth in nulliparous women.

Design
Prospective cohort study.

Setting
University teaching hospital.

Sample
One hundred thirty‐four low risk nulliparous women.

Methods
Measurements of the bony pelvic outlet were made to calculate the subpubic arch angle. Endosonographic assessment of the perineum and anal sphincter was made before and after delivery. A specific bowel function questionnaire was completed before and after delivery.

Main outcome measures
Perineal and anal sphincter trauma, and deteriorating anal continence after delivery.

Results
Thirty‐two women with a subpubic arch angle of less than 90° had significantly prolonged first and second stages of labour when compared with 102 women whose subpubic arch was wider. Following delivery, anal continence deteriorated in more women with a narrow subpubic angle (69%vs 21%, P < 0.001) but this was unrelated to the incidence of anal sphincter and perineal trauma.

Conclusions
A narrow subpubic arch is strongly associated with prolonged labour and postpartum anal incontinence in nulliparous women. However, perineal and anal sphincter trauma, assessed by ultrasound, does not account for the higher rate of postpartum anal incontinence in women with a narrow subpubic arch angle.
The management of symptomatic hydronephrosis in pregnancy
Authors: Fainaru Ofer , Almog Beny , Gamzu Ronni , Lessing Joseph B. , Kupferminc Michael
Published: December 2003

Objective
To present and to evaluate the conservative and surgical management of hydronephrosis in pregnancy.

Design
Retrospective analysis of an interventional cohort.

Setting
A tertiary maternity ward.

Sample
Of the 30,552 women delivering in our institution between January 1998 and June 2001, 56 women (0.2%) were admitted to the prenatal care unit due to symptomatic hydronephrosis.

Methods
For each patient, renal sonography, urinalysis, serum creatinine levels, white blood cell counts and urine culture were obtained. All patients were treated conservatively by analgesics, intravenous fluids and antibiotics. Failure of these measures: non‐resolving infection, deteriorating renal function, absence of Doppler sonographic evidence of ureteral flow or intractable pain led to instrumental drainage of the affected kidney. A double pigtail polyurethane ureteric stent was passed under cystoscopic vision and sonographic guidance.

Main outcome measures
Resolution of clinical symptoms.

Results
Conservative treatment led to resolution in 52 women (92.9%), whereas four women (7.1%) failed to respond and were treated successfully and without complications by pigtail insertion. Early induction of labour was unnecessary and good perinatal outcome was the rule.

Conclusions
Although the vast majority of cases of symptomatic hydronephrosis in pregnancy may be treated conservatively, pigtail insertion is an efficient and safe modality for the rare patient with refractory symptoms.
The effect of the publication of a major clinical trial in a high impact journal on clinical practise: the ORACLE Trial experience
Authors: Kenyon Sara , Taylor David J.
Published: December 2003

Objective
To estimate the short term effect of the publication of a major clinical trial on clinical practise.

Design
Questionnaire survey of clinical practise.

Setting
UK.

Population
All maternity units in the UK.

Method
A self‐administered questionnaire completed by lead consultants on delivery suite of maternity units.

Main outcome measures
Changes in antibiotic prescription.

Results
Within six months of publication, approximately 50% of maternity units had changed their guidelines for the care of women with preterm prelabour rupture of the fetal membranes.

Conclusion
Publication of a major clinical trial does impact on clinical practise but the impact is heterogeneous in terms of time and consistency.
Active management of term prelabour rupture of membranes with oral misoprostol
Authors: Shetty A. , Stewart K. , Stewart G. , Rice P. , Danielian P. , Templeton A.
Published: December 2003

Objective
To compare the active management of term prelabour rupture of membranes with oral misoprostol with conservative management for 24 hours followed by induction with oxytocin or prostaglandin E2 (PGE2) gel.

Design
A non‐blinded randomised controlled trial.

Setting
Induction and labour wards, Aberdeen Maternity Hospital.

Population
Sixty‐one women with confirmed prelabour rupture of the membranes at ≥36 weeks of gestation.

Methods
The women were randomised to 50 μg of oral misoprostol repeated every 4 hours, if required, to a maximum of five doses (active group), or to induction of labour with PGE2 gel or oxytocin only if not in spontaneous labour 24 hours after prelabour rupture of membranes (conservative group).

Main outcome measures
Number of women in active labour within 24 hours of the prelabour rupture of membranes, preference of women for any one particular method of management in any subsequent pregnancy with prelabour rupture of membranes.

Results
93.3% of the active group and 54.8% of the conservative group were in spontaneous labour within 24 hours of the prelabour rupture of membranes (RR 1.7, 95% CI 1.2 to 2.4). Of those achieving a vaginal delivery, 72% of the active group did so within 24 hours of the prelabour rupture of membranes as compared with 26.9% of the conservative group (RR 2.7, 95% CI 1.4 to 5.3, P= 0.002). There were no significant differences in the neonatal or maternal outcomes. In the active group, 78% felt they would have the same method of induction as compared with 40% in the conservative group (RR 1.9, 95% CI 1.1 to 3.3, P= 0.03).

Conclusions
Active management with oral misoprostol resulted in more women going into labour and delivering within 24 hours of the prelabour rupture of membranes with no increase in maternal or neonatal complications. Women tended to view active management of prelabour rupture of membranes more positively. Oral misoprostol might be an option to consider in those wishing active management.
A randomised clinical trial comparing the effects of delayed versus immediate pushing with epidural analgesia on mode of delivery and faecal continence
Authors: Fitzpatrick Myra , Harkin Rosemary , McQuillan Katherine , O'Brien Conor , O'Connell P. Ronan , O'Herlihy Colm
Published: December 2003

Objective
To assess the effects of delayed vs immediate pushing in second stage of labour with epidural analgesia on delivery outcome, postpartum faecal continence and postpartum anal sphincter and pudendal nerve function.

Design
Prospective, randomised, controlled trial.

Setting
Tertiary referral maternity teaching hospital.

Population
One hundred and seventy nulliparous women randomised at full dilatation to immediate or delayed pushing.

Methods
A total of 178 nulliparous women, all with continuous epidural analgesia, were randomised at full cervical dilatation, but before the fetal head had reached the pelvic floor, to either immediate pushing or 1 hour delayed pushing. Labour outcome was analysed and all women underwent postpartum assessment of anal sphincter function, including anal manometry. Those women who had a normal delivery underwent neurophysiology studies, while those women who had an instrumental delivery underwent endoanal ultrasound.

Main outcome measures
Mode of delivery; altered faecal continence.

Results
Ninety women were randomised to immediate pushing and 88 to delayed pushing. The spontaneous delivery rate was 56% (50/90) in the immediate pushing group and 52% (46/88) in the delayed pushing group. Mean duration of labour for the immediate pushing group was 427 minutes compared with 480 minutes for the delayed pushing group (P= 0.005). Eighty‐four percent (76/90) of women in the immediate pushing group received oxytocin to augment labour, 21/76 (28%) in the second stage only. Eighty‐one percent (71/88) of women in the delayed pushing group received oxytocin to augment labour, 22/71 (31%) in the second stage only. Fetal outcome did not differ between the two groups. Episiotomy rates were 73% and 69% in the immediate pushing and delayed pushing groups, respectively. 26% (23/90) of the immediate pushing group and 38% (33/88) of the delayed pushing group complained of altered faecal continence after delivery (NS). Manometry, ultrasound and neurophysiology studies did not differ significantly between the two groups. Overall, 55% of women after instrumental delivery had endosonographic evidence of damage to the external anal sphincter, while 36% of women after spontaneous delivery had abnormal neurophysiology studies.

Conclusions
Rates of instrumental delivery were similar following immediate and delayed pushing, in association with epidural analgesia. Delayed pushing prolonged labour by 1 hour but did not result in significantly higher rates of altered continence or anal sphincter injury, when compared with immediate pushing.
Olfactory modulation of nausea during early pregnancy?
Authors: Hummel T. , von Mering R. , Huch R. , Kölble N.
Published: December 2003

Objectives
To investigate whether nausea and vomiting and olfactory sensitivity are correlated, we determined whether subjects with little or no nausea and vomiting are less sensitive to odours than subjects who indicate a high degree of nausea and vomiting, and whether subjects with relatively low olfactory sensitivity are less prone to nausea and vomiting than subjects with relatively higher olfactory sensitivity.

Design
Cross sectional study.

Setting
The Unit of Perinatal Physiology, Department of Obstetrics, University Hospital, Zurich, Switzerland.

Population
Fifty‐three women in early pregnancy.

Methods
Following a detailed history related to olfaction and nausea and vomiting, subjects filled in a nausea profile which provided a ‘general nausea score’ comprised of the factors ‘somatic distress’, ‘gastrointestinal distress’, and ‘emotional distress’. Olfactory function was assessed using pen‐like odour dispensing devices (‘sniffin’ sticks’). Tests included n‐butanol odour threshold, odour discrimination and odour identification.

Main outcome measures
Olfactory function assessed by means of the sniffing sticks nausea profile.

Results
Correlational analyses between results of olfactory sensitivity and scores from the nausea questionnaire were not significant. Further, when subjects were divided into groups with relatively low or relatively high overall scores in the nausea profile, olfactory sensitivity did not differ between groups. Similarly, other analyses did not indicate a modulation of nausea and vomiting through olfactory sensitivity.

Conclusions
These findings do not support the hypothesis that higher olfactory sensitivity relates to an increase of nausea. However, they do support the idea that olfactory‐induced nausea is independent of subjectively perceived intensity. Olfactory‐induced nausea appears to be due to the cognitive processing of olfactory information which, in early pregnancy, is reported to be altered in an unsystematic fashion.
Side effects of oral misoprostol during the first 24 hours after administration in the third stage of labour
Authors:   For the WHO Collaborative Group to Evaluate Misoprostol in the Management of the Third Stage of Labour, Lumbiganon Pisake , Villar José , Piaggio Gilda , Metin Gülmezoglu A. , Adetoro Lekan , Carroli Guillermo
Published: December 2003

Objective
To evaluate the side effects of 600 μg misoprostol orally during the first 24 hours after administration in the third stage of labour.

Design
Double blind randomised controlled trial.

Setting
Tertiary care hospitals in Nigeria and Thailand.

Sample
All women participating in the WHO Misoprostol trial in these two hospitals between January 1, 1999 and June 17, 1999.

Methods
All women were followed up during the first 24 hours postpartum to evaluate the occurrence of shivering, nausea, vomiting, diarrhoea and other misoprostol‐related side effects.

Main outcome measures
Rates of shivering, nausea, vomiting, diarrhoea and pyrexia within 1 hour and in the intervals 2–6, 7–12, 13–18 and 19–24 hours after delivery.

Results
A total of 1686 women were enrolled. Women who received misoprostol had higher incidence than the oxytocin group of ‘any’ shivering in the first hour (RR 6.4, 95% CI 3.9 to 10.4) and the period covering 2–6 hours following delivery (RR 4.7, 95% CI 1.9 to 11.2). Pyrexia was also more common in the misoprostol group in both the same time intervals (RR 2.8, 95% CI 1.4 to 5.3 and RR 6.3, 95% CI 3.7 to 10.8, respectively). Diarrhoea was not present in the first hour in either group but appeared in the second time period (2–6 hours) and third time period (7–12 hours) more frequently in the misoprostol group than with oxytocin.

Conclusion
The increased incidence of shivering and pyrexia that occurs with postpartum use of misoprostol persists up to 6 hours following delivery. Approximately 5% of women experience diarrhoea that starts after 1 hour and subsides within 12 hours.
Neonatal complications following preterm birth
Authors: Ward Robert M. , Beachy Joanna C.
Published: December 2003

Improvements in neonatal intensive care during the last 20 years have increased the survival of the most immature newborns at 23 weeks from 0% to 65% at some centres, although rates vary widely among neonatal care centres. University of Utah, USA data show that each week in utero after week 23 raises survival by 6–9%, to 90% by 27–28 weeks and 95% by 33 weeks. Provision of care in specialised centres to provide high‐risk obstetric and neonatal intensive care, prenatal treatment with corticosteroids, postnatal treatment with surfactant and nitric oxide, and improvements in respirators and equipment to care for extremely immature infants all contribute to these changes. The increased rate of survival for extremely premature newborns has not been accompanied by an increased rate of severe intraventricular haemorrhage or neurological impairment, such as cerebral palsy. Regardless, intraventricular haemorrhage remains a significant problem, especially if associated with post‐haemorrhagic hydrocephalus, leading to long‐term neurological impairment and decreased survival. Necrotising enterocolitis (NEC) is more common in premature than in term newborns and is the most frequent cause of short bowel syndrome in infancy. Survival after surgery for NEC has improved during the last two decades, but complications of nutritional support produce many long‐term problems. Retinopathy of prematurity (ROP) remains a frequent cause of neurosensory impairment for extremely premature newborns. Laser photocoagulation for advanced ROP is more effective than cryotherapy for preventing retinal detachment and improving visual outcomes. Despite prenatal corticosteroid treatment and postnatal surfactant administration, many extremely premature newborns still develop bronchopulmonary dysplasia. Abnormal pulmonary function may persist into adulthood, but newer ventilators and management schemes appear to be reducing this long‐term morbidity. Many changes in neonatal care occur each year, but carefully controlled outcome studies are needed to evaluate the effectiveness of these newer styles of neonatal intensive care.
The role of oxytocin in parturition
Authors: Blanks Andrew M. , Thornton Steven
Published: December 2003

Oxytocin and the oxytocin receptor have two important roles in labour. Evidence in all mammalian species suggests that neurohypophysical oxytocin plays a role in the expulsive phase and, although there are less supporting data, a role for oxytocin in the initiation of labour is likely. The initiation of labour may be mediated in women and rhesus monkeys by paracrine rather than endocrine mechanisms. Although initial characterisation of the oxytocin knockout mouse suggested that oxytocin is not important in this species, subsequent investigations have demonstrated that oxytocin is important for the precise timing of the onset of labour. Studies in knockout mice also confirm important interrelationships between oxytocin and prostaglandins. Oxytocin stimulates prostaglandin release in many species, mainly in the decidua/uterine epithelium. The effects of oxytocin are mediated by tissue‐specific oxytocin receptor expression, which leads directly to contraction in the myometrium and prostaglandin formation in the decidua. There is a dramatic increase in oxytocin receptor expression in these tissues in late pregnancy and pharmacological inhibition delays delivery, which suggests that, in contrast to oxytocin, the oxytocin receptor is essential for normal labour.
The role of infection in preterm labour
Authors: Friese Klaus
Published: December 2003

Although there are many maternal characteristics associated with preterm birth, the aetiology in most cases is poorly understood. Our research demonstrates that multiple risk factors, such as maternal age and especially infection, are associated with preterm birth. Bacterial vaginosis and intrauterine infection are now believed to be an important risk factor for preterm delivery.
Socio‐economic and psychosocial factors in the management and prevention of preterm labour
Authors: Moutquin Jean‐Marie
Published: December 2003

Socio‐economic factors associated with preterm labour include social class, (usually assessed by earnings and education), working conditions (professional status, ergonomic environment, working hours), physical and travelling activities, daily life activities, lifestyle, family status and psychosocial state as related to past and current pregnancy history together with current stress factors. A review of the association of these factors with preterm birth will be reported with an emphasis of the biological plausibility linking mostly emotional, and at a lesser degree, physical and psychological stress to the occurrence of preterm labour. A case control study, carried out in Quebec City among 101 women in preterm labour and 202 matched pregnancies for parity and gestational age, identified 7 risk factors in an explanatory multivariate model among 117 variables: Body mass index (BMI) <20 (OR; 95% CI: 3.96; 2.61–7.09), previous preterm labour (OR; 95% CI: 3.61; 1.12–11.65) previous low birth weight (OR; 95% CI: 2.24; 1.05–7.71), standing at work >2 hours (OR; 95% CI: 3.90; 1.53–9.91), Abruptio placentae (OR; 95% CI: 5.88; 1.20–28.76), urinary tract infection (UTI) (OR; 95% CI: 4.4.3; 1.47–13.34), and stress score >5 (OR; 95% CI: 2.56; 1.20–5.54). The most stressful events were related to family illness, mortality, disruption, violence or financial distress. Some risk factors cannot be modified (previous preterm labour, low birth weight and UTI), while preventive efforts should be directed towards attaining BMI >20 before conception, modifying working conditions during current pregnancy and appropriate management of acute emotional stress.
Cervical length assessment by ultrasound as a predictor of preterm labour—is there a role for routine screening?
Authors: Hoesli Irene , Tercanli Sevgi , Holzgreve Wolfgang
Published: December 2003

Transvaginal ultrasonography has recently been shown to be an objective, reproducible and reliable method to assess the cervix and predict the risk of preterm delivery in high‐risk pregnancies. Assessment of the cervix includes cervical length measurement (CLM) and measurement of dilatation of the internal os in a dynamic functional examination. There is an inverse correlation between cervical length and the frequency of preterm delivery. The high negative predictive value avoids unnecessary interventions such as tocolysis or cerclage in high‐risk pregnancies. In contrast, a length of 25 mm or less at 28–30 weeks of gestation is associated with a significantly increased incidence of preterm delivery. Studies in women with high risk for preterm delivery, i.e. contractions, premature rupture of the membranes and history of preterm delivery, have shown a high sensitivity and a high positive predictive value, however in low‐risk groups they have failed to show a high sensitivity. From large observational studies in low‐risk populations we know that the 50th percentile of the cervical length is 35 mm at 24 weeks of gestation3. Advantages of CLM as a screening test include the fact that sonographical assessment of the cervix is a widely accepted and well‐standardised method, which requires only a relatively short period of training. Disadvantages of screening are two factors, the first being the low sensitivity of the test and the low prevalence of preterm deliveries in a low‐risk population, resulting in cut off values being set at a very low level (i.e. 5th percentile) in order to get acceptable specificity. Secondly, screening is only worthwhile if an effective preventive therapy is available. The debate about tocolysis and cerclage is not yet concluded. Therefore we would not currently recommend cervical length measurement as a screening tool—but as a routine method in high risk gravidas with or without symptoms. Further interest should be focused on scoring systems combining ultrasound with biochemical, endocrinological and maybe molecular cell methods such as the measurement of fetal DNA in maternal blood to prevent preterm deliveries in the general population.