bluuebunny/crossref_metadata_2025 huggingface dataset:
Left ventricular mass and function in children with GH deficiency before and during 12 months GH replacement therapy
Authors: Salerno Mariacarolina , Esposito Valentina , Spinelli Letizia , Di Somma Carolina , Farina Vincenzo , Muzzica Stefania , De Horatio Laura Tanturri , Lombardi Gaetano , Colao Annamaria
Published: December 2004

objective  This open, prospective study was designed to evaluate the effect of GH deficiency (GHD) on left ventricular (LV) mass (LVM) and performance, by echocardiography, and on lipid profile during childhood.

subjects  Twelve prepubertal children with GHD (eight boys and four girls) aged 8·1 ± 1·7 years were studied before and after 6 and 12 months of GH replacement therapy at a dose of GH of 30 µg/kg/day. Twelve healthy children sex‐, height‐, weight‐ and body surface area‐matched with the patients, served as controls.

methods  Echocardiography was performed at study entry and after 12 months both in GHD children and in controls. Only in GHD children, echocardiography was repeated also after 6 months of GH replacement. In all subjects, we measured LV posterior wall thickness (LVPWT), LV end‐diastolic diameter (LVEDD), LVM index (LVMi), LV systolic and diastolic function.

results  At study entry, LVPWT (5·3 ± 0·8 vs. 6·2 ± 1·1 mm, P < 0·05), LVEDD (34·0 ± 2·4 vs. 36·7 ± 2·1 mm, P < 0·007) and LVMi (47·0 ± 6·9 vs. 59·6 ± 9·5 g/m2, P < 0·005) were significantly lower in GHD children than in controls. Lipid profile, heart rate, blood pressure, LV systolic function and indeces of ventricular filling were similar in patients and controls. After 12 months of GH replacement therapy, LVPWT (6·1 ± 0·7 mm, P < 0·0005), LVEDD (38·8 ± 4·3 mm, P < 0·002) and LVMi (71·5 ± 12·7 g/m2, P < 0·0005) significantly increased in GHD children compared to pretreatment values. In particular, after 12 months of therapy GHD children achieved a normal LVMi when compared to controls (60·7 ± 8·6, P = ns). LVMi increase was significantly correlated with the increase in IGF‐I level (r = 0·49; P < 0·004). LV systolic performance, diastolic filling and blood pressure did not change significantly during GH therapy. After 12 months of treatment, the atherogenic index, measured as total/high‐density lipoprotein‐cholesterol ratio (2·7 ± 0·8) was significantly lower than both pretreatment (3·4 ± 0·3, P < 0·03) and control values (3·8 ± 1·1, P < 0·04).

conclusions  GH deficiency in children affects heart morphology, by inducing a significant decrease in cardiac size, but does not modify cardiac function and lipid profile. Twelve months of GH replacement treatment normalizes cardiac mass, and reduces the atherogenic index.
Exopolysaccharide biosynthesis genes required for social motility in Myxococcus xanthus
Authors: Lu Ann , Cho Kyunyung , Black Wesley P. , Duan Xue‐yan , Lux Renate , Yang Zhaomin , Kaplan Heidi B. , Zusman David R. , Shi Wenyuan
Published: December 2004

Social (S)‐motility in Myxococcus xanthus is a flagellum‐independent gliding motility system that allows bacteria to move in groups on solid surfaces. S‐motility has been shown to require type IV pili (TFP), exopolysaccharide (EPS; a component of fibrils) and lipopolysaccharide (LPS). Previously, information concerning EPS biogenesis in M. xanthus was lacking. In this study, we screened 5000 randomly mutagenized colonies for defects in S‐motility and EPS and identified two genetic regions essential for EPS biogenesis: the EPS synthesis (eps) region and the EPS‐associated (eas) region. Mutants with insertions in the eps and eas regions were defective in S‐motility and fruiting body formation. These mutants failed to bind the dye calcofluor white, indicating that they lacked EPS; however, they retained normal TFP and LPS. Analysis of the eps locus showed several open reading frames (ORFs) that encode homologues to glycosyltransferases, glucanases and EPS transporters as well as regulatory proteins; the eas locus contains two ORFs: one exhibits homology to hypothetical proteins with a conserved domain of unknown function and the other displays no apparent homology to other proteins in the database. Further genetic mutagenesis analysis indicates that the whole eps region is involved in the biosynthesis of fibrils and fibril EPS. The operon at the proximal end of the eps region was analysed by generating in‐frame deletion mutations. These mutants showed varying degrees of defects in the bacterium's ability to produce EPS or perform EPS‐related functions, confirming the involvement of these genes in M. xanthus EPS biogenesis.
BotR/A and TetR are alternative RNA polymerase sigma factors controlling the expression of the neurotoxin and associated protein genes in Clostridium botulinum type A and Clostridium tetani
Authors: Raffestin Stéphanie , Dupuy Bruno , Marvaud Jean Christophe , Popoff Michel R.
Published: December 2004

Clostridium botulinum and Clostridium tetani, respectively, produce potent toxins, botulinum neurotoxin (BoNT) and tetanus neurotoxin (TeTx), which are responsible for severe diseases, botulism and tetanus. Neurotoxin synthesis is a regulated process in Clostridium. The genes botR/A in C. botulinum A and tetR in C. tetani positively regulate expression of BoNT/A and associated non‐toxic proteins (ANTPs), as well as TeTx respectively. The botR/A gene lies in close vicinity of the two operons which contain bont/A and antps genes in C. botulinum A, and tetR immediately precedes the tetX gene in C. tetani. We show that BotR/A and TetR function as specific alternative sigma factors rather than positive regulators based on the following results: (i) BotR/A and TetR associated with target DNAs only in the presence of the RNA polymerase core enzyme (Core), (ii) BotR/A and TetR directly bound with the core enzyme, (iii) BotR/A‐Core recognized −35 and −10 regions of ntnh‐bont/A promoter and (iv) BotR/A and TetR triggered in vitro transcription from the target promoters. In C. botulinum A, bont/A and antps genes are transcribed as bi‐ and tricistronic operons controlled by BotR/A. BotR/A and TetR are seemingly related to a new subgroup of the σ70 family that includes TcdR and UviA, which, respectively, regulate production of toxins A and B in C. difficile and bacteriocin in C. perfringens. Sequences of −35 region are highly conserved in the promoter of target toxin genes in C. botulinum, C. tetani, C. difficile and C. perfringens. Overall, a common regulation mechanism probably controls toxin gene expression in these four toxigenic clostridial species.
Erwinia chrysanthemi requires a second iron transport route dependent of the siderophore achromobactin for extracellular growth and plant infection
Authors: Franza Thierry , Mahé Bruno , Expert Dominique
Published: December 2004

Full virulence of the pectinolytic enterobacterium Erwinia chrysanthemi strain 3937 depends on the production in planta of the catechol‐type siderophore chrysobactin. Under iron‐limited conditions, E. chrysanthemi synthesizes a second siderophore called achromobactin belonging to the hydroxy/carboxylate class of siderophore. In this study, we cloned and functionally characterized a 13 kb long operon comprising seven genes required for the biosynthesis (acs) and extracellular release (yhcA) of achromobactin, as well as the gene encoding the specific outer membrane receptor for its ferric complex (acr). The promoter of this operon was negatively regulated by iron. In a fur null mutant, transcriptional fusions to the acsD and acsA genes were constitutively expressed. Band shift assays showed that the purified E. chrysanthemi Fur repressor protein specifically binds in vitro to the promoter region of the acsF gene confirming that the metalloregulation of the achromobactin operon is achieved directly by Fur. The temporal production of achromobactin in iron‐depleted bacterial cultures was determined: achromobactin is produced before chrysobactin and its production decreases as that of chrysobactin increases. Pathogenicity tests performed on African violets showed that achromobactin production contributes to the virulence of E. chrysanthemi. Thus, during infection, synthesis of these two different siderophores allows E. chrysanthemi cells to cope with the fluctuations of iron availability encountered within plant tissues. Interestingly, iron transport mediated by achromobactin or a closely related siderophore probably exists in other phytopathogenic bacterial species such as Pseudomonas syringae.
Heterologous expression of Aquifex aeolicus ribosome recycling factor in Escherichia coli is dominant lethal by forming a complex that lacks functional co‐ordination for ribosome disassembly
Authors: Yamami Tohru , Ito Koichi , Fujiwara Toshinobu , Nakamura Yoshikazu
Published: December 2004

Recycling the post‐termination ribosomal complex requires the co‐ordinated effort of the ribosome, ribosome  recycling  factor  (RRF)  and  elongation  factor EF‐G. Although Aquifex aeolicus RRF (aaRRF) binds Escherichia coli ribosomes as efficiently as E. coli RRF, the resulting complex is non‐functional and dominant lethal in E. coli, even in the presence of homologous A. aeolicus EF‐G. These findings suggest that the E. coli post‐termination ribosomal complex with aaRRF lacks functional co‐ordination with EF‐G required for ribosome recycling. A chimeric EF‐G (E. coli domains I–III, A. aeolicus domains IV–V) or an A. aeolicus EF‐G with distinct mutations in the domain I–II interface could activate aaRRF. Furthermore, novel mutations that localize to one surface of the  L‐shape  structure  of  aaRRF  restored  activity  in E. coli. These aaRRF mutations are spatially distinct from mutations previously described and suggest a novel active centre for coupling EF‐G's G domain motor action to ribosome disassembly.
Reticulocyte‐binding protein homologue 1 is required for sialic acid‐dependent invasion into human erythrocytes by Plasmodium falciparum
Authors: Triglia Tony , Duraisingh Manoj T. , Good Robert T. , Cowman Alan F.
Published: December 2004

The Apicomplexan parasite responsible for the most virulent form of malaria, Plasmodium falciparum, invades human erythrocytes through mutiple ligand–receptor interactions. Some strains of P. falciparum are sensitive to neuraminidase treatment of the host erythrocyte and these parasites have been termed sialic acid‐dependent as they utilize receptors containing sialic acid. In contrast, other strains can efficiently invade neuraminidase‐treated erythrocytes and hence are sialic acid‐independent. The molecular interactions that allow P. falciparum to differentially utilize receptors for merozoite invasion are not understood. The P. falciparum reticulocyte‐binding protein homologue (PfRh or PfRBL) family have been implicated in the invasion process but their exact role is unknown. PfRh1, a member of this protein family, appears to be expressed in all parasite lines analysed but there are marked differences in the level of expression between different strains. We have used targeted gene disruption of the PfRh1 gene in P. falciparum to show that the encoded protein is required for sialic acid‐dependent invasion of human erythrocytes. The ΔPfRh1 parasites are able to invade normally; however, they utilize a pattern of ligand–receptor interactions that are more neuraminidase‐resistant. Current data suggest a strategy based on the differential function of specific PfRh proteins has evolved to allow P. falciparum parasites to utilize alternative receptors on the erythrocyte surface for evasion of receptor polymorphisms and the host immune system.
Precipitation of pyroxenes and Mg2SiO4 from majoritic garnet: simulation of peridotite exhumation from great depth
Authors: Dobrzhinetskaya Larissa F. , Green Harry W. , Renfro Alex P. , Bozhilov Krassimir N. , Spengler Dirk , Van Roermund Herman L. M.
Published: December 2004

Our experimental simulations of the exhumation path of mantle peridotites show that high‐temperature (1400 °C) decompression of lherzolite from 14 to 13 and 12 GPa results in exsolution of interstitial blebs of diopside and Mg2SiO4 (wadsleyite) lamellae from majoritic garnet. At lower pressures (from 8 to 5 GPa, at T = 1400 °C) only enstatite exsolves as blebs at garnet boundaries. Continuous high‐temperature decompression from 14 to 7 GPa produces zoned majoritic garnet containing blebs of exsolved pyroxenes inside garnet rims. No intracrystalline precipitation of pyroxene was observed in garnet, although such lamellae are found in some natural garnet peridotites. The explanation appears to be the three orders of magnitude difference in grain size between experimental and natural specimens. Our data suggest that Mg2SiO4 and diopside exsolutions reflect the deepest point of the exhumation path of garnet peridotites, whereas enstatite precipitation may be restricted to garnets with less majoritic component at shallower depths.
Organotemplate silica deposition in Neoproterozoic deep‐marine environments: evidence from the Penganga Group, Adilabad, India
Authors: Mukhopadhyay Joydip , Gutzmer Jens , Beukes Nicolas J.
Published: December 2004

Silica in bedded cherts interstratified with manganese carbonates in a deep‐water carbonate ramp succession of the Neoproterozoic Penganga Group, India, displays film‐like, spherical to rod‐shaped, and tubular branching microstructures. The microstructures resemble mineralized extracellular polysaccharides, biofilms and bacterial morphologies. The microstructures suggest silicification by nucleation of silica on organic‐templates or indirectly as sorbed species accumulating on organic templates. Given that similar microstructures have also been documented in Archean cherts it is proposed that organotemplates might have been an important sink for the deposition of silica in Precambrian deep‐water marine environments.
How does micropetrography help us to understand the permeability and poromechanical behaviour of a rock?
Authors: Lion Maxime , Ledésert Béatrice , Skoczylas Frédéric , Recourt Philippe , Dubois Thierry
Published: December 2004

Many poromechanical studies of rocks give little regard to the micropetrographic observation of their constituents. The aim of this study is to show how such a detailed study can help understand and provide more precision on the poromechanical behaviour of the material. The rock studied here is an oolitic limestone. Micropetrography reveals the nature of the constituents (calcite, mostly in the form of fine‐grained micrite), their abundance, their organization (micrite organized in ooids linked by a calcitic cement, small‐sized highly connected isotropic porosity, scarce unconnected porosity) and the structure of the rock (global isotropy, small heterogeneities due to sedimentological phenomena, no microcracks). Micropetrography completes the information obtained by poromechanics in that it allows the observation of elements deduced from macroscopical tests. The aim of this paper is to show the effect of microporosity on permeability and flow in a rock where microporous grains are in contact with each other.
A study on the routes of referral for patients with colorectal cancer and its affect on the time to surgery and pathological stage
Authors: Trickett J. P. , Donaldson D. R. , Bearn P. E. , Scott H. J. , Hassall A. C.
Published: December 2004

Objective  Firstly, to determine the proportion of colorectal cancer (CRC) patients seen within an established two week rule (TWR) system and to observe other routes of referral for CRC patients. Secondly to determine if referral route affects the interval to, and cancer stage at, definitive treatment.

Patients and methods  GP referrals of patients with CRC were divided into direct surgical outpatient referrals (group 1) and indirect referrals to accident and emergency and medical outpatients (group 2). Data were recorded on the time to definitive treatment and the location and stage of tumour.

Results  There were 78 patients in group 1. Thirty (20%) patients were referred by their GP under the TWR, 31 (21%) as urgent and 17 (12%) as nonurgent referrals, to surgical outpatients. There were 69 patients in group 2. Forty‐two (29%) were referred initially to the accident and emergency department and 27 (18%) to general medical outpatients. Group 1 patients were treated within a median of 70.5 days and group 2 patients within 14 days of referral (P < 0.0005). Group 2 contained tumours of a significantly more advanced pathological stage (P = 0.015) and more proximal colonic cancers (P < 0.005).

Conclusion  Fifty‐three percent of patients with CRC were referred directly to surgical outpatients, 20% under the TWR guidelines. Despite having this system in place direct referrals were slower to treatment but the tumours were still of a less advanced pathological stage. Compliance with the TWR should not be used as a means of assessing a colorectal unit's treatment of CRC.
The strength duration test: a novel tool in the identification of occult neuropathy in women with pelvic floor dysfunction
Authors: Telford K. J. , Faulkner G. , Hosker G. L. , Kiff E. S. , Hill J.
Published: December 2004

Objective  The Strength‐duration test (SDT) is a simple minimally invasive measure of muscle innervation, recently adapted for the assessment of the external anal sphincter (EAS). This test can discriminate women with faecal incontinence from controls. The purpose of this study was to determine if the SDT could detect denervation of the EAS in women with weak but anatomically intact EAS and normal pudendal nerve terminal motor latency (PNTML).

Patients and methods  Thirteen women with weak but intact EAS on endoanal ultrasound (EAUS) with normal maximum resting pressure and PNTML were recruited to undergo the SDT. The results from this group were compared to control data for the SDT previously collected in our unit.

Results  Nine of 13 women were found to have SDT above a 95% confidence interval of the mean curve for controls and six had a SDT outside a 90% confidence interval for individuals derived from control data, suggesting denervation of the EAS. The mean area under the curve was significantly higher in our study group compared to controls (91.0 µsmA vs 72.2 µsmA, P = 0.047) as was the current intensity measured at the 1 ms pulse duration (18.2 mA vs 12.94 mA, P = 0.048), typical of denervation with this test.

Conclusion  The SDT was abnormal in nine of the 13 study patients. This may partly explain reduced maximum voluntary contraction seen in this group of patients. SDT may be a more sensitive tool in detecting neuropathy than latency measurement.
Prospective follow‐up after ambulatory plain midline excision of pilonidal sinus and primary suture under local anaesthesia – efficient, sufficient, and persistent
Authors: Dalenbäck J. , Magnusson O. , Wedel N. , Rimbäck G.
Published: December 2004

Objective  Optimal surgical treatment for chronic pilonidal sinus (PS) disease should be easy and efficient. The purpose of this study was to establish the feasibility of and results after ambulatory simple midline excision and primary wound closure under local anaesthesia.

Patients and methods  The prospective nonrandomised single institution study included 131 consecutive PS patients admitted for surgery. After standardized surgery, all patients were prospectively followed until fully healed. Complications were registered. Results after 41 months (mean, range 36–59) were evaluated by questionnaire.

Results  95% were primary closed. All were ambulatory treated and 98% under local anaesthesia. 88% healed in two weeks. 5.6% exhibited minor wound healing defects and 6.4% demanded full debridement of the wound. Mean delayed healing time was 7.5 weeks (range 3–12). 8% developed a recurrence. 10% of the remainders reported a slight tenderness in the scar area. 90% were symptom‐free.

Conclusion  PS treatment as of above is readily achieved. Wound related complications were reasonably few and in the same magnitude as after more complex excision techniques and induced no significant long‐term sequels. Recurrences could, however, be more common. Prospective randomised studies are warranted to determine if there are any significant differences between excision techniques in and out of the midline.
Scintigraphic assessment of slow transit constipation with special reference to right‐ or left‐sided colonic delay
Authors: Lundin E. , Karlbom U. , Westlin J. E. , Kairemo K. , Jung B. , Husin S. , Påhlman L. , Graf W.
Published: December 2004

Objective  Subtotal colectomy and ileorectal anastomosis for slow transit constipation has several side‐effects. The motor abnormality in some patients may be segmental which could motivate a limited resection of the colon. Therefore a diagnostic tool to identify a segmental colonic motor dysfunction is needed. The aim of this study was to evaluate a scintigraphic method to assess colonic transit with special reference to right‐ or left‐sided delay.

Methods  Twenty‐three constipated patients (19 women, mean age 50 years) with slow colonic transit on radio‐opaque marker studies and 13 healthy individuals (11 women, mean age 46 years) were studied. All subjects were examined with oral 111Indium‐DTPA scintigraphy. The scintigraphic results for patients and controls were presented as geometric centre of radioactivity and percent activity over time in the right, the left and the recto‐sigmoid colon. The inter‐observer variation in the interpretation of the scans was also evaluated.

Results  There was no difference in transit time between the groups of patients and controls in the right colon whereas the patients had a significant delay in the left colon (P < 0.05). Two patients had a marked delay in the right colon followed by relatively rapid transit in the left colon. The inter‐observer correlation was good comparing the right, the left and the recto‐sigmoid colon (r = 0.58–0.98, P < 0.01–0.001).

Conclusion  The results indicate that colonic scintigraphy with oral 111Indium‐DTPA may help to select patients for a left or, in a few cases, a right hemicolectomy for slow transit constipation.
Blood loss and transfusion after total mesorectal excision and conventional rectal cancer surgery
Authors: Mynster T. , Nielsen H. J. , Harling H. , Bülow S. ,   Danish TME‐group and the RANX05‐group
Published: December 2004

Objectives  A recent study showed less bleeding and need of transfusion after total mesorectal excision (TME) compared with conventional rectal cancer surgery. The aim of this study was to evaluate this result in more details.

Patients and methods  Comparison of transfusion history in rectal cancer resections in two different multicentre‐studies. Two hundred and forty‐six patients were operated in the period 1991–93 with a conventional technique and 311 patients were operated with TME‐technique in the period 1996–98. Peri‐operative data, including blood transfusion from one month before until one month after the operation, was recorded prospectively.

Results  The median intra‐operative blood loss was 1000 ml, range 50–6000 ml, before, and 550 ml, range 10–6000 ml (P < 0.001) after introduction of TME. The overall peri‐operative transfusion rate was reduced from 73% to 43% (P < 0.001). When adjusted for blood loss, age, gender, weight, and type of resection, TME significantly reduced the risk of receiving intra or postoperative blood transfusion by 0.4 (CI: 0.3–0.6). The variability in blood loss among 12 TME‐centres was more than 400% and not correlated with transfusion requirements within the centres.

Conclusion  TME results in a reduced blood loss and a reduction of blood transfusion, but additional factors others than blood loss seems to influence the decision of transfusion.
Absence of socioeconomic variation in survival from colorectal cancer in patients receiving surgical treatment in one health district: cohort study
Authors: Lyratzopoulos G. , Sheridan G. F. , Michie H. R. , McElduff P. , Hobbiss J. H.
Published: December 2004

Objective  To examine whether there is an association between patient deprivation status and survival from colorectal cancer among patients receiving treatment of the same type and quality.

Patients and methods  A survival study was conducted of all colorectal cancer patients diagnosed between 1991 and 1997 who received surgery either in the NHS district general hospital or the private hospital of one UK health district. The five‐year survival rates, both all cause and colorectal cancer specific, were calculated for subgroups defined by patient age, gender, stage and deprivation status using Kaplan‐Meier curves. Cox proportional hazards models were used to examine the influence of deprivation on five‐year survival after adjusting for age, gender and stage.

Results  There were 603 consecutive colorectal patients during the study period. Five‐year all‐cause and colorectal cancer‐specific survival rates were 41% and 53%, respectively. There was no association between deprivation status and stage at diagnosis (P = 0.308). Multivariable proportional hazards modelling (adjusting for gender, age and tumour stage) demonstrated no association between deprivation status and survival.

Conclusion  In this single district study, no relationship between patient socioeconomic status and survival from colorectal cancer could be demonstrated. Consistency in the type and quality of treatment offered to patients by the same clinical teams may have been responsible for the equitable survival outcomes.
Flunarizine Effects on Oxidative Stress in Migraine Patients
Authors: Ciancarelli I , Tozzi-Ciancarelli MG , Di Massimo C , Marini C , Carolei A
Published: December 2004

Prophylactic activity of flunarizine in migraine is attributed to its antioxidant properties and to the relief of cerebral vasospasm in which nitric oxide (NO) is involved. We investigated the antimigraine activity of flunarizine and its influence on NO and oxidative marker bioavailability in 25 subjects suffering from migraine without aura and in 25 healthy controls. Urinary samples collected before and after treatment with flunarizine (5 mg orally per day for 6 months) were assayed for NO stable metabolites (NOx) and thiobarbituric acid reactive substances (TBARS). Urinary levels of NOx and TBARS were higher in migraine sufferers before treatment than in healthy controls. No differences were observed in NOx levels in migraine sufferers, before and after flunarizine treatment; urinary TBARS levels were decreased after flunarizine treatment ( P < 0.05) and remained persistently higher than in healthy controls ( P < 0.05). Our results suggest that flunarizine did not prevent NO-mediated vasodilatation, while it proved effective in limiting the oxidative reactions occurring in migraine sufferers.
Hemicrania Continua Postpartum
Authors: Spitz M , Peres MFP
Published: December 2004

Hemicrania continua is a common, but unrecognized headache disorder. We describe two patients with hemicrania continua whose symptoms started in the postpartum period, coined as hemicrania continua postpartum.
Effects of mode of delivery and infant feeding on the risk of mother‐to‐child transmission of hepatitis C virus
Authors:   European Paediatric Hepatitis C Virus Network
Published: December 2004

Objective
To investigate the effects of mode of delivery and infant feeding on the risk of mother‐to‐child transmission of hepatitis C virus.

Design
Pooled retrospective analysis of prospectively collected data.

Sample
Data on hepatitis C virus seropositive mothers and their children identified around delivery were sent from 24 centres of the European Paediatric Hepatitis C Virus Network.

Main outcome measures
Hepatitis C virus infection status of children born to hepatitis C virus infected women.

Results
A total of 1,474 hepatitis C virus infected women were identified, of whom 503 (35%) were co‐infected with HIV. Co‐infected women were more than twice as likely to transmit hepatitis C virus to their children than women with hepatitis C virus infection alone. Overall 9.2% (136/1474) of children were hepatitis C virus infected. Among the women with hepatitis C virus infection‐only, multivariate analyses did not show a significant effect of mode of delivery and breastfeeding: caesarean section vs vaginal delivery OR=1.17, P=0.66; breastfed versus non‐breastfed OR=1.07, P=0.83. However, HIV co‐infected women delivered by caesarean section were 60% less likely to have an infected child than those delivered vaginally (OR=0.36, P=0.01) and those who breastfed were about four times more likely to infect their children than those who did not (OR=6.41, P=0.03). HIV infected children were three to four times more likely also to be hepatitis C virus infected than children without HIV infection (crude OR=3.76, 95% CI 1.89–7.41).

Conclusions
These results do not support a recommendation of elective caesarean section or avoidance of breastfeeding for women with hepatitis C virus infection only, but the case for HIV infected women undergoing caesarean section delivery and avoiding breastfeeding is strengthened if they are also hepatitis C virus infected.
A randomised controlled trial comparing abdominal and vaginal prolapse surgery: effects on urogenital function
Authors: Roovers Jan‐Paul W.R. , van der Vaart C. Huub , van der Bom Johanna G. , Schagen van Leeuwen Jules H. , Scholten Piet C. , Heintz A. Peter M.
Published: December 2004

Objective  To compare the effects of vaginal hysterectomy (combined with anterior and/or posterior colporraphy) and abdominal sacro‐colpopexy (with preservation of the uterus) on urogenital function.

Design  Randomised trial.

Setting  Three teaching hospitals in The Netherlands.

Population  Eighty‐two patients undergoing surgical correction of uterine prolapse stages II–IV.

Methods  Participating patients completed the urogenital distress inventory (UDI), before and at six weeks, six months and one year after surgery, to measure discomfort of prolapse and micturition symptoms. Domain scores of the UDI (ranging from 0 to 100, higher scores indicating more discomfort) were compared between groups at all time points. Findings at pelvic examination, number of doctor visits within the first year after surgery because of pelvic floor symptoms and performed or planned surgery of recurrent genital prolapse were also compared.

Main outcome measure  Domain scores of the UDI at one year after surgery.

Results  At one year after surgery, scores on the discomfort/pain domain (mean difference 7.1, 95% confidence interval [CI] 1.1–13.2), overactive bladder domain (mean difference 8.7, 95% CI 0.5–16.9) and obstructive micturition domain (mean difference 10.3, 95% CI 0.6–20.1) of the UDI were significantly higher in the abdominal group than in the vaginal group. Findings at pelvic examination were similar in both groups. Doctor visits because of pelvic floor symptoms were more frequent in the abdominal group than in the vaginal group. Re‐operation was performed or planned in 9 of the 41 patients who underwent abdominal surgery and in 1 of the 41 patients who underwent vaginal surgery (odds ratio [OR] = 11.2, 95% CI 1.4–90.0).

Conclusions  Our findings suggest that vaginal hysterectomy with anterior and/or posterior colporraphy is preferable to abdominal sacro‐colpopexy with preservation of the uterus as surgical correction in patients with uterine prolapse stages II–IV.
Routine ultrasound for pregnancy termination requests increases women's choice and reduces inappropriate treatments
Authors: McGalliard Catherine , Gaudoin Marco
Published: December 2004

This prospective observational study aimed to determine the correlation between gestational age based on menstrual dates and ultrasound scan in women requesting pregnancy termination and the proportion of cases where first trimester medical termination might be offered.

Two hundred and sixty‐two women (93%) had ongoing pregnancies. Two hundred and thirty‐seven women (90%) were certain of their menstrual dates but there was a discrepancy of more than one week in gestational age in 38%. Calculated from their menstrual dates, 138 women might have been offered first trimester medical termination but this rose to 173 if gestation was based on ultrasound scan.

From this study, we believe ultrasound should be performed routinely for all women requesting pregnancy termination.
The importance of genetic and environmental effects for pre‐eclampsia and gestational hypertension: a family study
Authors: Nilsson Emma , Salonen Ros Helena , Cnattingius Sven , Lichtenstein Paul
Published: December 2004

Objectives  To determine the importance of genetic effects in the aetiology of pre‐eclampsia and gestational hypertension and to investigate whether pre‐eclampsia and gestational hypertension share genetic aetiology.

Design  Individual record linkage between the population‐based Swedish Multi‐Generation and the Medical Birth Registers.

Setting  Sweden.

Population  1,188,207 births between 1987 and 1997 and their parents.

Methods  Similarities in relatives were measured by the number of pairs concordant and discordant for disease, the odds ratio (OR) and tetrachoric correlations. Estimates of genetic and environmental effect for gestational hypertension, pre‐eclampsia and pregnancy‐induced hypertension were calculated from structural equation model fitting.

Main outcome measures  Pre‐eclampsia and gestational hypertension.

Results  Full sisters and mother–daughters were more similar for pre‐eclampsia (OR 3.3, 95% confidence interval [CI] 3.0–3.6 and OR 2.6, 95% CI 1.6–4.3, respectively) than half‐sisters (maternal half‐sisters OR 1.4, 95% CI 0.9–2.2 and paternal half‐sisters OR 1.0, 95% CI 0.6–1.6). Full sisters and mother–daughters were also more similar for gestational hypertension than half‐sisters. A full sister to a woman with pre‐eclampsia also had a significantly increased risk of gestational hypertension (OR 2.5, 95% CI 2.2–2.8). In contrast, the risk for half‐sisters was not increased. Model fitting suggested heritability estimates for pre‐eclampsia of 31%, for gestational hypertension 20% and for pregnancy‐induced hypertension 28%.

Conclusions  There is a genetic component in the development of pre‐eclampsia and gestational hypertension and the pattern of co‐morbidity suggests that they may share part of their genetic aetiology. This could be important for studies of potential susceptibility genes for these diseases.
No association between hepatitis B or C viruses and vulval lichen planus in a UK population
Authors: Cooper S.M. , Kirtschig G. , Jeffery K.J.M. , Wojnarowska F.
Published: December 2004

The aim of the study was to investigate the prevalence of hepatitis C (HCV) antibodies, hepatitis B surface antigen (HBsAg) carriage and liver disease in 100 females with genital lichen planus (LP) in Oxfordshire. Sera were screened for HCV antibodies (AxSYM HCV 3.0 Abbott), HBV surface antigen (AxSYM HBsAg V2 Abbott), mitochrondrial and anti‐smooth muscle antibodies. Liver function tests were undertaken. All sera were negative for HCV antibody and HBsAg. Transiently abnormal liver function tests (2) and liver specific antibodies (2) were detected in four patients with no underlying liver disease. We found no association between HBV or HCV and genital LP in this population.
Thiol status and antioxidant capacity in women with a history of severe pre‐eclampsia
Authors: Raijmakers Maarten T.M. , Roes Eva Maria , Zusterzeel Petra L.M. , Steegers Eric A.P. , Peters Wilbert H.M.
Published: December 2004

Objective  To investigate a possible mechanism that could lead to the subsequent development of cardiovascular diseases (CVD) in women with a history of severe pre‐eclampsia.

Design  Case–control study.

Setting  University Medical Centre Nijmegen, The Netherlands.

Sample  Non‐pregnant women with a history of severe pre‐eclampsia (n= 131) and women with an uncomplicated obstetric history (n= 94).

Methods  Total plasma levels of cysteine (tCys), homocysteine (tHcy), cysteinylglycine (tCysGly) and glutathione (tGSH), the free‐to‐oxidised ratio of these thiols in whole blood, the glucose‐6‐phosphate dehydrogenase (G6PDH) enzyme activity and antioxidant capacity were assessed at least 6 months following last pregnancy.

Main outcome measure  Oxidative stress and antioxidant status.

Results  Women with a history of severe pre‐eclampsia showed higher levels (mean [SD]) of tHcy (13.1 [5.0] versus 11.5 [4.8] μmol/L; P= 0.018) and tCysGly (37.5 [5.6] versus 34.0 [5.8] μmol/L; P= 0.0001) compared with controls, whereas tCys was lower (232 [31] versus 242 [39]; P= 0.029). The lower free‐to‐oxidised ratio of homocysteine (2.3 [0.8] versus 2.9 [1.0], P= 0.0001) among women with a history of severe pre‐eclampsia as compared with control subjects might indicate a higher oxidant status for homocysteine. Previous severe pre‐eclamptic patients had also a higher antioxidant capacity as compared with controls (0.79 [0.14] versus 0.74 [0.11] mmol Fe2+/L, P= 0.002).

Conclusion  Since women with a history of severe pre‐eclampsia showed elevated total homocysteine levels, which is an independent risk factor for CVD, and higher oxidised homocysteine levels in whole blood, these women may have an enhanced risk for the subsequent development of cardiovascular‐related problems in later life.
How should randomised trials including multiple pregnancies be analysed?
Authors: Gates Simon , Brocklehurst Peter
Published: December 2004

Objective  To compare the effects of four methods of analysis on the results of randomised controlled trials that recruit women with multiple pregnancies and measure outcomes on their babies.

Design  Analysis of one real and two simulated data sets.

Setting  Secondary analysis of perinatal randomised controlled trials.

Population  Randomised controlled trials including women with multiple pregnancies.

Methods  The analytical methods compared were (a) assuming independence among babies, (b) analysing outcomes per women, counting a woman as having an outcome if any of her babies had it (equivalent to selecting the worst outcome among any of a woman's babies), (c) randomly selecting one baby from each set of multiples for inclusion in the analysis, (d) adjustment of the analysis to take account of non‐independence of babies from multiple pregnancies, using methods developed for analysis of cluster randomised trials.

Main outcome measures  Odds ratios for trials' main outcomes.

Results  Results from application of cluster trial methods were similar to those from assuming independence among babies, but with slightly wider confidence intervals, reflecting the reduced effective sample size caused by non‐independence between babies from the same pregnancy. Results were more variable using the other two methods, and in some cases, departed markedly from the results of the cluster trial methods.

Conclusions  Cluster trial methods provide a simple way of adjusting the analysis to take account of non‐independence between babies from the same pregnancy. Random selection and analysis by pregnancy (methods (b) and (c)) have disadvantages and do not report outcomes for all of the babies in the trial. This may cause problems with incorporating trials analysed using these methods into systematic reviews.
Isolated oligohydramnios is not associated with adverse perinatal outcomes
Authors: Zhang Jun , Troendle James , Meikle Susan , Klebanoff Mark A. , Rayburn William F.
Published: December 2004

Objective  To examine fetal growth and perinatal outcomes in pregnancies with isolated oligohydramnios.

Design  A cohort study.

Setting  Multiple clinics and hospitals.

Population  Low risk pregnant women.

Methods  We used data from the multicentre clinical trial of Routine Antenatal Diagnostic Imaging with UltraSound (RADIUS), in which 15,151 low risk pregnant women were randomly assigned to the ultrasound screening group or the control group. Women in the screening group underwent sonographic exams at 15–22 and 31–35 weeks of gestation. Both groups could have clinically indicated sonographic exams at any time.

Main outcome measures  We used changes of fetal weight z‐score to assess whether fetal growth was compromised from the diagnosis of oligohydramnios until delivery, using a repeated‐measures regression. We used a combined perinatal index as an indicator of adverse perinatal outcome, which consisted of severe perinatal morbidity and mortality.

Results  Oligohydramnios (amniotic fluid index ≤5 cm) was diagnosed in 1.5% (113/7617) of women with ultrasound screening compared with 0.8% (57/7534) among the controls. Approximately half of the oligohydramnios cases in the screening group were isolated with no clearly associated factors (e.g. premature rupture of the fetal membranes, congenital anomalies, diabetes, hypertension, postdate and intrauterine growth restriction). Fetal weight centiles in isolated oligohydramnios cases did not change significantly from diagnosis until delivery. Pregnancies with isolated oligohydramnios had perinatal outcomes similar to pregnancies with a normal amniotic fluid index.

Conclusion  Isolated oligohydramnios is not associated with impaired fetal growth or an increased risk of adverse perinatal outcomes.
Antenatal screening and intrapartum management of Group B Streptococcus in the UK
Authors: Kenyon Sara , Brocklehurst Peter , Blackburn Ann , Taylor David J.
Published: December 2004

Objective  To determine whether there has been any change in UK policy for the screening and intrapartum management of Group B Streptococcus in pregnancy over a two year period.

Design  Two national survey's of practice carried out in 1999 and 2001.

Setting  All obstetric units in the UK.

Population  Clinical directors of maternity services.

Methods  A questionnaire was sent to all clinical directors of maternity services in the UK requesting information about their policy and practice with respect to antenatal screening for Group B Streptococcus colonisation. Reminders were sent after one month.

Main outcome measures  Number of maternity units in the UK screening and offering intrapartum antibiotic prophylaxis for Group B Streptococcus colonisation in pregnancy.

Results  The response rates were 84% in 1999 and 82% in 2001. Of the responding units, six (3%) in 1999 and four (2%) in 2001 used vaginal swab based screening for Group B Streptococcus colonisation in the antenatal period. In 1999, intrapartum antibiotic prophylaxis was offered to women with a previous baby affected by Group B Streptococcus in 85% (176/207) of maternity units and in 2001 this had risen to 95% (193/203). Similarly, in 1999 intrapartum antibiotic prophylaxis was offered to women who were known carriers of Group B Streptococcus in 87% (179/207) of maternity units and in 2001 this had risen to 95% (193/203). Appropriate dosage of a recommended antibiotic was prescribed in 7% (9/123) units in 1999 and in 20% (35/178) units in 2001.

Conclusions  Although intrapartum antibiotic prophylaxis for women at high risk of giving birth to babies with Group B Streptococcus is widely practiced in the UK, a programme of antenatal screening for Group B Streptococcus colonisation has not been adopted along the lines advocated in the USA. There therefore remains an opportunity to evaluate such a screening programme in a randomised trial.
Maternal morbidity during labour and the puerperium in rural homes and the need for medical attention: A prospective observational study in Gadchiroli, India
Authors: Bang Rani A. , Bang Abhay T. , Reddy M. Hanimi , Deshmukh Mahesh D. , Baitule Sanjay B. , Filippi Veronique
Published: December 2004

Objectives  To estimate the incidence of maternal morbidity during labour and the puerperium in rural homes, the association with perinatal outcome and the proportion of women needing medical attention.

Design  Prospective observational study nested in a neonatal care trial.

Setting  Thirty‐nine villages in the Gadchiroli district, Maharashtra, India.

Sample  Seven hundred and seventy‐two women recruited over a one year period (1995–1996) and followed up from the seventh month in pregnancy to 28 days postpartum (up to 10 visits in total).

Methods  Observations at home by trained village health workers, validated by a physician. Diagnosis of morbidities by computer program.

Main outcomes  Direct obstetric complications during labour and the puerperium, breast problems, psychiatric problems and need for medical attention.

Results  The incidence of maternal morbidity was 52.6%, 17.7% during labour and 42.9% during puerperium. The most common intrapartum morbidities were prolonged labour (10.1%), prolonged rupture of membranes (5.7%), abnormal presentation (4.0%) and primary postpartum haemorrhage (3.2%). The postpartum morbidities included breast problems (18.4%), secondary postpartum haemorrhage (15.2%), puerperal genital infections (10.2%) and insomnia (7.4%). Abnormal presentation and some puerperal complications (infection, fits, psychosis and breast problems) were significantly associated with adverse perinatal outcomes, but prolonged labour was not. A third of the mothers were in need of medical attention: 15.3% required emergency obstetric care and 24.0% required non‐emergency medical attention.

Conclusions  Nearly 15% of women who deliver in rural homes potentially need emergency obstetric care. Frequent (43%) postpartum morbidity, and its association with adverse perinatal outcome, suggests the need for home‐based postpartum care in developing countries for both mother and baby.
Delivering an effective outpatient service in gynaecology
Authors: Marsh Fiona , Kremer Christian , Duffy Sean
Published: December 2004

Objective  To examine the cost implications of outpatient versus daycase hysteroscopy to the National Health Service, the patient and their employer.

Design and interventions  Randomised controlled trial.

Setting  The gynaecology clinic of a large teaching hospital.

Participants  Ninety‐seven women with abnormal uterine bleeding requiring investigation.

Methods  Women were randomly allocated to either outpatient or daycase hysteroscopy. They were asked to complete diaries recording expenses and time off work. The National Health Service costs were calculated for a standard outpatient and daycase hysteroscopy.

Main outcome measures  Costs to the National Health Service, costs to the employer, loss of income, childcare costs and travel expenses.

Results  The outpatient group required significantly less time off work compared with the daycase group (0.8 days vs 3.3 days), P < 0.001. Of those women who lost income due to the hysteroscopy, the average loss of income was twice as much in the daycase group (£20.40 in the outpatient group vs£50.60 in the daycase group). The average cost of childcare required to cover the time spent in hospital undergoing the hysteroscopy was similar in both groups, however, the number of women requiring childcare was small. Travel costs incurred by the women were 74% more in the daycase group compared with the outpatient group—with an average cost of £3.46 in the outpatient group and £6.02 in the daycase group. Daycase hysteroscopy costs the National Health Service approximately £53.88 more per patient, than performing an outpatient hysteroscopy. Purchasing the hysteroscopes necessary to perform an outpatient hysteroscopy is a more expensive outlay than those required for daycase hysteroscopy. However, there are so many other savings that only 38 patients need to undergo outpatient hysteroscopy (even with a 4% failure rate) rather than daycase hysteroscopy in order to recoup the extra money required to set up an outpatient hysteroscopy service.

Conclusion  Outpatient hysteroscopy offers many benefits over its traditional counterpart including faster recovery, less time away from work and home and cost savings to the woman and her employer and the National Health Service. Resources need to be made available to rapidly develop this service across the UK in order to better serve both patient and taxpayer.