bluuebunny/crossref_metadata_2025 huggingface dataset:
Use of digital video technology in an elementary school foreign language methods course
Authors: Chuang Hsueh‐Hua , Rosenbusch Marcia Harmon
Published: August 2005

This article presents a case study of the use of digital video technology with a new pedagogical approach under a constructivist framework in an elementary school foreign language methods course. Data were collected through interviews with the methods course instructor, field notes, analytical notes from videotaped student presentations of their learning from the video clips, students’ mid‐semester evaluation of the use of video clips, and end‐of‐semester student reflections on open‐ended questions regarding the use of video clips. A careful examination of the data identified themes that illustrate the characteristics of the use of digital video technology under a constructivist framework. Those themes include the flexibility and capability of digital video technology, the development of the video clips, students’ ownership of knowledge, feedback from the students, and evaluation of the use of video clips. This case reports the vision of technology integration being realized. It results from the presence of technology, the instructor's pedagogical knowledge, and his or her content expertise.
Performance Pay and Adverse Selection*
Authors: Moen Espen R. , Rosén Åsa
Published: August 2005

It is well known in personnel economics that firms may improve the quality of their workforce by offering performance pay. We analyze an equilibrium model where worker productivity is private information and show that the firms’ gain from worker self‐selection may not be matched by a corresponding social gain. In particular, the equilibrium incentive contracts are excessively high‐powered, thereby inducing the more productive workers to exert too much effort and increasing agency costs stemming from the misallocation of effort.
Experience Rating versus Employment Protection Laws in a Model where Firms Monitor Workers*
Authors: Fath Julia , Fuest Clemens
Published: August 2005

While layoff costs in the U.S. are mostly due to experience‐rated unemployment insurance, layoff costs in European labour markets are primarily a consequence of employment protection laws. In this paper we compare the effects of experience rating and employment protection laws on employment and welfare in a model where unemployment arises due to efficiency wage setting and where labour turnover is inefficiently high. We show that a revenue‐neutral introduction of experience rating reduces labour turnover and increases employment and welfare. The introduction of employment protection laws may also reduce labour turnover but employment declines.
Home versus School Learning: A New Approach to Estimating the Effect of Class Size on Achievement
Authors: Lindahl Mikael
Published: August 2005

The effects of class size on scholastic achievement are estimated using a seasonal feature of the school system. The fact that schools are in session during the school year and out of session during the summer makes it possible to control for non‐school influences on both the level of and changes in achievement. Using Swedish data, smaller classes are found to generate higher test scores and this effect is larger for immigrants. The results are also compared with those from applying the same data to the widely used value‐added model.
Sexuality and sexual activity in pregnancy
Authors: Bartellas Elias , Crane Joan M. G. , Daley Melita , Bennett Kelly A. , Hutchens Donna
Published: August 2005

Objectives
To evaluate women's sexual experience in pregnancy, and to describe their sources of information regarding sexuality during this period.

Design
Cross‐sectional study.

Setting
The offices of obstetricians providing obstetric care in a tertiary care university hospital in St. John's, Newfoundland, Canada.

Population
One hundred and forty‐one pregnant women.

Methods
Pregnant women anonymously completed self‐administered questionnaires regarding sexuality and sexual activity during pregnancy. Responses were summarised using descriptive statistics, and comparisons were made between the trimesters of pregnancy. Multiple logistic regression was performed to assess the influences of a variety of factors on sexual activity.

Results
Vaginal intercourse and sexual activity overall decreased throughout pregnancy (P= 0.004 and 0.05, respectively) with the trimester of pregnancy being the only independent predictor. Most women reported a decrease in sexual desire (58%). Overall, 49% of women worried that sexual intercourse may harm the pregnancy. Concerns regarding sexual activity leading to preterm labour or premature rupture of membranes increased as the pregnancy progressed (P < 0.001 and P= 0.001, respectively). Only 29% of women discussed sexual activity in pregnancy with their doctor and 49% of these women raised the issue first, with 34% feeling uncomfortable in bringing up the topic themselves. Most women (76%) who had not discussed these issues with their doctor felt they should be discussed.

Conclusions
A reduction in sexual activity, vaginal intercourse and sexual desire occurs in many women as pregnancy progresses. Both the woman and her partner have concerns regarding complications in the pregnancy as a result of sexual intercourse. The majority of women wish to discuss these issues with their doctor, but are not always comfortable raising the topic themselves.
Pregnancy outcome in carriers of fragile X
Authors: Kallinen Juuso , Korhonen Kati , Kortelainen Saara , Heinonen Seppo , Ryynänen Markku
Published: August 2005

Objective
To evaluate pregnancy outcome in women who are carriers of fragile X.

Design
Cross‐sectional case‐control study.

Setting
Department of Obstetrics and Gynaecology, Kuopio University Hospital, Finland.

Sample
Sixty‐three singleton pregnancies in carriers of fragile X who were referred for genetic counselling and prenatal diagnosis to Kuopio University Hospital.

Methods
Logistic regression analysis was used to compare pregnancy outcome in women who are fragile X carrier with outcome of the general obstetric population.

Results
Carriers of fragile X often experienced more bleeding in late pregnancy than did the reference group. Otherwise, the course and outcome of pregnancy were comparable in both groups.

Conclusion
Pregnancy outcome in women who are carriers of fragile X is favourable. There is no need to initiate special fetal monitoring because of the fragile X status of the woman.
Cord blood oxygen saturation in vigorous infants at birth: what is normal?
Authors: Arikan G. M. , Scholz H. S. , Petru E. , Haeusler M. C. H. , Haas J. , Weiss P. A. M.
Published: August 2005

Objective
To define the normal ranges of umbilical cord blood oxygen saturation (SaO2) and acid‐base status at birth and to evaluate the effect of gestational age on cord blood values in vigorous newborn infants following spontaneous vaginal birth from a vertex position.

Design
Prospective study.

Setting
Department of Obstetrics and Gynaecology, University of Graz, Austria.

Sample
Cord blood samples from 1281 vigorous newborn infants.

Methods
Cord blood sampling was performed following on newborn infants following spontaneous vaginal birth in a vertex position. SaO2 was measured directly by a spectrophotometer and pH, base excess, pCO2 and pO2 by a pH/blood‐gas analyser. Infants with a 5‐minute Apgar score ≥ 7 were considered vigorous. Subgroups were classified according to the gestational age: preterm, term and postterm (< 37, 37–42 and > 42 weeks, respectively).

Results
The median umbilical artery SaO2 was 24.3% and the 2.5th centile was as low as 2.7%. The median umbilical artery values were pH = 7.25, base excess =−4.3 mmol/L and pO2= 16 mmHg. The 2.5th centiles were 7.08, −11.1 mmol/L and 5 mmHg, respectively. The median umbilical artery pCO2 was 50 mmHg and the 97.5th centile was 75 mmHg. The mean umbilical artery and vein SaO2 values were not significantly influenced by gestational age. The umbilical artery SaO2 and base excess values were strongly skewed. The mean umbilical artery pH values in preterm infants were higher than in other subgroups. The mean umbilical artery and vein base excess values were lower in post‐term newborn infants than in other subgroups.

Conclusions
The physiological range of oxygen saturation in umbilical cord of vigorous newborn infants at birth is wide and skewed. In contrast to pH and base excess, umbilical cord blood oxygen saturation is not influenced significantly by gestational age at birth.
The impact of adhesions on hospital readmissions over ten years after 8849 open gynaecological operations: an assessment from the Surgical and Clinical Adhesions Research Study
Authors: Lower Adrian M. , Hawthorn Robert J. S. , Emeritus Harold Ellis , O'Brien Fiona , Buchan Scot , Crowe Alison M.
Published: August 2005

Objective
To investigate the epidemiology of, and the clinical burden related to, adhesions following gynaecological surgery.

Population
The Scottish National Health Service Medical Record Linkage Database was used to define a cohort of 8849 women undergoing open gynaecological surgery in 1986.

Methods
All readmissions for potential adhesion related disease in the subsequent 10 years were reviewed.

Main outcome measures
Readmissions and the degree of adhesion involvement gave an indication of clinical burden and workload. The rate of readmission following the initial surgery determined the relative risk of disease related to adhesions.

Results
Two hundred and forty‐five (4.5%) of 5433 readmissions following open gynaecological surgery were directly related to adhesions. 34.5% of patients were readmitted, on average 1.9 times, for a problem potentially related to adhesions or for further intra‐abdominal surgery that could be complicated by adhesions. Readmissions related to adhesions continued throughout the 10 year period of the study. The overall rate of readmission was 64.0/100 initial operations. For readmissions directly related to adhesions, the rate was 2.9/100 initial operations. Operations on the ovary had the highest rate directly related to adhesions (7.5/100 initial operations), with an overall rate of readmission of 106.4/100 initial operations.

Conclusions
Despite the conservative approach taken in this study, the clinical burden, workload and relative risk of readmissions related to adhesions following open gynaecological surgery was considerable. Post‐operative adhesions have important consequences for patients, surgeons and the healthcare system. These results emphasise the need for more effective strategies to prevent adhesions.
A pilot study of Hypericum perforatum for the treatment of premenstrual syndrome
Authors: Stevinson Clare , Ernst Edzard
Published: August 2005

Objective
To investigate whether Hypericum perforatum could relieve symptoms of premenstrual syndrome in a small group of women in order to establish a hypothesis and to test methods for conducting a future randomised controlled trial.

Design
Prospective, open, uncontrolled, observational study.

Setting
Department of Complementary Medicine, University of Exeter.

Population
Nineteen women with premenstrual syndrome who were in otherwise good physical and mental health and not taking other treatments for premenstrual syndrome.

Method
Volunteers underwent a preliminary screening interview, completed Daily Symptom Ratings for one cycle, and attended a medical screening visit before being diagnosed with premenstrual syndrome. Participants took hypericum tablets for two complete menstrual cycles (1 × 300 mg hypericum extract per day standardised to 900 μg hypericin).

Main outcome measures
Symptoms were rated daily throughout the trial using a validated measure. The Hospital Anxiety and Depression scale and modified Social Adjustment Scale were administered at baseline and after one and two cycles of treatment.

Results
There were significant reductions in all outcome measures. The degree of improvement in overall premenstrual syndrome scores between baseline and the end of the trial was 51%, with over two thirds of the sample demonstrating at least a 50% decrease in symptom severity. Tolerance and compliance with the treatment were encouraging.

Conclusion
The results of this pilot study suggest that there is scope for conducting a randomised, placebo‐controlled, double‐blind trial to investigate the value of hypericum as a treatment for premenstrual syndrome.
Epilepsy and pregnancy: effect of antiepileptic drugs and lifestyle on birthweight
Authors: Hvas Christian Lodberg , Henriksen Tine Brink , østergaard John R. , Dam Mogens
Published: August 2005

Objective
To investigate the impact of epilepsy and antiepileptic drugs on length of gestation and anthropometric measures of the newborn.

Design
Cohort study based on questionnaires mailed to all pregnant women who attended for prenatal care at our department from August 1989 to January 1997.

Setting
Department of Obstetrics and Gynaecology at Aarhus University Hospital, Denmark.

Participants
One hundred and ninety‐three singleton pregnancies in women with epilepsy were compared with 24,094 singleton pregnancies in women without epilepsy.

Main outcome measures
Preterm delivery, small for gestational age, mean gestational age, gestational age‐adjusted birthweight, head circumference, and body length.

Results
Children of women with epilepsy who smoked had lower gestational age and were at increased risk of preterm delivery (OR 3.4; 95% CI 1.8–6.5), compared with children born by nonepileptic women who smoked. Birthweight adjusted for gestational age was reduced by 102 g (95% CI 40–164) in women with epilepsy, and the risk of delivering a child who was small for gestational age was increased (adjusted OR 1.9, 95% CI 1.3–2.7), compared with women without epilepsy. Newborn babies of women with epilepsy treated by drugs had a reduced adjusted birthweight (208 g, 95% CI 116–300), head circumference (0.4 cm, 95% CI 0.0.0.7), and body length (0.5 cm, 95% CI 0.1–1.0), compared with the newborn infants of women without epilepsy.

Conclusions
Women with epilepsy who smoked were at increased risk of preterm delivery compared with healthy smokers. Children of women with drug treated epilepsy had lower birthweight, length, and head circumference than children of women without epilepsy.
A randomised controlled trial and meta‐analysis of active management of labour
Authors: Sadler L. C. , Davison T. , McCowan L. M. E.
Published: August 2005

Objective
To test whether a policy of active management of nulliparous labour would reduce the rate of caesarean section and prolonged labour without influencing maternal satisfaction.

Design
Randomised controlled trial.

Setting
Tertiary referral obstetric unit, Auckland, New Zealand.

Population
Nulliparous women in spontaneous labour at term with singleton pregnancy and cephalic presentation and without fetal distress.

Methods
After the onset of active labour, previously consented women were randomly assigned to active management (n= 320) or to routine care (n= 331). Active labour was defined as regular painful contractions, occurring at least once in five minutes, lasting at least 40 seconds, accompanied by either spontaneous rupture of the membranes, or full cervical effacement and dilatation of at least two centimetres. Active management included early amniotomy, two‐hourly vaginal assessments, and early use of high dose oxytocin for slow progress in labour. Routine care was not prespecified. Prolonged labour was > 12 hours duration. Maternal satisfaction with labour care was assessed by postal questionnaire at six weeks postpartum.

Main outcome measures
Mode of delivery, duration of labour, and maternal satisfaction.

Results
Active management of labour did not reduce the rate of caesarean section 30/320 (9.4%), compared with 32/331 (9.7%) for routine care, but did shorten the length of first stage of labour (median 240 min vs 290 min; P= 0.02), and reduce the relative risk of prolonged labour (RR 0.39; 95% CI 0.22, 0.71). There were no differences between groups in the rates of newborn nursery admission, neonatal acidosis, low Apgar scores, or postpartum haemorrhage. Satisfaction with labour care was high (77%) and did not differ between groups.

Conclusions
Active management of labour reduced the duration of the first stage of labour without affecting the rate of caesarean section, maternal satisfaction, or other maternal or newborn morbidity.
Outcome of the next labour in women who had a vaginal delivery in their first pregnancy
Authors: Mawdsley S. D. , Baskett T. F.
Published: August 2005

This study reviews the outcome of the next labour in women who are delivered vaginally in their first pregnancy. The influence of the method of delivery in the first pregnancy and of factors in both the first and next labour on the type of delivery in the second pregnancy, are recorded in a group of 13,813 women. Those delivered spontaneously and by vacuum, low forceps and mid‐forceps in their first pregnancy had a 96%, 91%, 88% and 82% chance, respectively, of spontaneous delivery in their next pregnancy. The type of labour (spontaneous, induced or augmented) in the first pregnancy had minimal influence on the method of delivery in the second pregnancy. Compared with spontaneous onset, induction and augmentation of labour in the second pregnancy reduced the chance of spontaneous delivery by 6% and 18%, respectively.
How can the incidence of negative specimens resulting from large loop excision of the cervical transformation zone (LLETZ) be reduced? An analysis of negative LLETZ specimens and development of a predictive model
Authors: Howells R. E. J. , O'Mahony F. , Tucker H. , Millinship J. , Jones P. W. , Redman C. W. E.
Published: August 2005

Objective
To analyse biopsies of large loop excision of the transformation zone of the cervix; to identify factors associated with negative histology; and to develop predictive models in order to reduce the number of negative loop excisions.

Design
Retrospective analysis of patient notes and audit database.

Setting
Colposcopy clinic of a large district general hospital in North Staffordshire.

Population
Four hundred and fifty‐two women who underwent a large loop excision of the transformation zone (LLETZ) procedure for suspected cervical intraepithelial neoplasia.

Methods
Women who underwent a LLETZ procedure were placed in two different groups, one positive for cervical intra epithelial neoplasia and the other negative for cervical intra epithelial neoplasia. Information was obtained on a number of clinical and colposcopic variables. Analysis was undertaken to determine if there were any differences between the two groups. These factors were then identified and three predictive models generated. Receiver‐operator characteristic curves were used to assess and test these models.

Main outcomes measures
To identify factors associated with negative histology on a LLETZ specimen. To predict how to reduce the number of negative LLETZ specimens.

Results
Four hundred and fifty‐two women underwent a LLETZ procedure, 88 were negative (19%) and 364 were positive (81%). In women who were treated at their first visit, 56/316 (18%) had negative histology. There were significant associations between negative histology in the LLETZ and negative or low grade cytological atypia, negative colposcopic findings and years of age > 50 in both bivariate analysis and stepwise logistic regression. In the predictive models, the sensitivity ranged between 72% and 80%, the specificity 59%–72%, and the area under the receiver‐operator characteristic was 0.75–0.77. If we had used the predictor models and managed women with negative or low grade cervical atypia and negative colposcopy findings conservatively, we would have reduced the negative biopsy rate from 19% to 14%, but five cases of high grade disease and 25 cases of low grade disease would have been missed. If we had also included women aged > 50 years in this model, the negative biopsy rate would have dropped from 19% to 15%, with only one case of high grade disease and 11 cases of low grade disease missed. All these women would require continued cytological and colposcopic surveillance. Importantly, no cases of invasion would have been missed.

Conclusion
Using a predictive model can reduce the number of negative LLETZ specimens, but at the expense of continued cytological and colposcopic surveillance and cannot be recommended in normal practice. This raises the question whether current standards for negative histology in LLETZ specimens are set unrealistically high.
A discrepancy between gestational age estimated by last menstrual period and biparietal diameter may indicate an increased risk of fetal death and adverse pregnancy outcome
Authors: Nguyen Tri huu , Larsen Torben , Engholm Gerda , Møller Henrik
Published: August 2005

Objective
To determine if the discrepancy between gestational age estimated by last menstrual period and by biparietal diameter (GALMP− GABPD) is associated with adverse pregnancy outcome.

Design
Population‐based follow up study.

Population
Singleton pregnancies were studied when a reliable date of last menstrual period and biparietal diameter measured between 12 and 22 weeks of gestation was available (n= 16,469).

Methods
Logistic regression analysis and Kaplan‐Meier survival analysis were used to analyse the association between GALMP− GABPD and adverse pregnancy outcome.

Main outcome measures
Adverse outcome was defined as abortion after 12 weeks of gestation, stillbirth or postnatal death within one year of birth, delivery < 37 weeks of gestation, a birthweight < 2500 g or a sex‐specific birthweight lower than 22% below the expected.

Results
The risk of death was more than doubled if GALMP− GABPD of ≥ 8 days was compared with GALMP− GABPD of < 8 days (OR 2.2; 95% CI 1.6–3.1). The risk of death was a factor of 6.1 higher if GALMP− GABPD of ≥ 8 days was combined with increased (> 2 × multiple of median) maternal alphafetoprotein measured in the 2nd trimester.

Conclusions
A discrepancy between GALMP and GABPD generally reflects the precision of the two methods used to predict term pregnancy. However, a positive discrepancy of more than seven days, particularly with high maternal alpha‐fetoprotein, might indicate intrauterine growth retardation and an increased risk of adverse perinatal outcome.
Evaluation of a human papillomavirus assay in cervical screening in Zimbabwe
Authors: Womack Sharita D. , Chirenje Z. M. , Blumenthal Paul D. , Gaffikin Lynne , McGrath John A. , Chipato T. , Ngwalle E. , Shah Keerti V.
Published: August 2005

Objective
To determine the utility of an assay for high risk genital human papillomavirus (HPV) in cervical screening in Zimbabwe, Africa.

Design
Cross‐sectional study.

Setting
Harare, Zimbabwe.

Population
Zimbabwe women (n= 2140), 25 to 55 years old, recruited in clinics in Chitungwiza and Greater Harare.

Methods
Genital specimens were assessed for HPV, using the HPV DNA test Hybrid Capture II (probe B). Further assessment of the women was conducted using colposcopy and biopsy as indicated. High grade squamous intraepithelial lesions were diagnosed in 215 women. Colposcopy and/or biopsy showed low grade lesions in 346 women.

Results
The overall prevalences were: 42.7% for HPV, 10% for high grade squamous intraepithelial lesions and 16% for low grade lesions. Prevalence for HPV decreased significantly with increase in age (P for trend < 0.0001) and increased significantly with increasing disease severity, from 35% in normal women, to 53% in women with low grade lesions and 81% in women with high grade lesions (P for trend < 0.001). In specimens positive for HPV, the amount was 14‐fold higher in women with high grade lesions compared with normal women. In screening for high grade lesions the assay for HPV had a sensitivity of 81% (CI 75%–86%); sensitivity for low grade lesions was 64% (CI 60%–68%). Specificity was 62% (CI 59%–64%) for high grade lesions and 65% (CI 62%–67%) for low grade lesions. The positive predictive value was 19% (CI 17%–22%) for high grade lesions and 39% (CI 36%–42%) for low grade lesions.

Conclusion
For high grade squamous intraepithelial lesions the sensitivity of the Hybrid Capture II HPV DNA test was high, but the specificity was relatively low. The test may therefore be most useful in conjunction with other screening tests.
Quality of medical information about menorrhagia on the worldwide web
Authors: Latthe Pallavi M. , Latthe Manish , Khan Khalid S.
Published: August 2005

Objective
To evaluate the quality of medical information on the management of menorrhagia on the worldwide web.

Design and procedures
An on‐line search of the Internet, locating relevant web sites by using key phrases ‘heavy periods’ and ‘patient information’ in seven search engines. Quality was defined as the extent to which the characteristics of a web page satisfied its stated and implied objectives. Assessment focused on credibility and content of each web page. Source, currency and editorial review process assessed credibility and hierarchy and accuracy of evidence assessed content of the web pages.

Main outcome measures
Rate of compliance with preset criteria for quality of health information on the Internet.

Results
Nine relevant web pages were located, none of which complied with all of the criteria for quality. Seven of these pages displayed the source and five showed the currency of the information, while none described an editorial review process. Four web pages displayed a hierarchy of evidence and one web page depicted all the criteria for accuracy of its contents.

Conclusion
None of the web pages provided complete information to women on heavy periods according to the quality criteria. This makes it difficult for the user without medical knowledge to determine which web page is credible and useable and which should be ignored or rejected. There is a need to be vigilant about the quality of information on the Internet.
Postpartum depression: identification of women at risk
Authors: Nielsen D. , Videbech P. , Hedegaard M. , Dalby J. , Secher N. J.
Published: August 2005

Objective
To identify and test the predictive power of demographic, obstetric, and psychosocial risk factors of postpartum depression.

Design
Community‐based, prospective follow up study based on questionnaires on past history of psychiatric disease, psychological distress and social support during pregnancy and depression at four months after delivery. Obstetric files were collected at time of birth.

Setting
Antenatal care clinic and delivery ward, Aarhus University Hospital, Denmark.

Population
6790 women giving birth between 1 January 1994 and 31 December 1995, who attended the antenatal clinic during pregnancy; 5252 (78%) completed all questionnaires. The validation population comprised 528 women enrolled immediately prior to and after the study period.

Main outcome measure
Postpartum depression four months after giving birth assessed by the Edinburgh Postnatal Depression Scale.

Results
5.5% of the women suffered from postpartum depression, corresponding to a score of 13 or higher on the Edinburgh Postnatal Depression Scale. Risk factors identified by multivariate logistic regression analysis included psychological distress in late pregnancy (OR 6.3 [95% CI 4.4–9.1]), perceived social isolation during pregnancy (OR 3.6 [95% CI 1.9–7.0]); high parity (OR 3.8 [95% CI 1.8–8.0]); and a positive history of prepregnant psychiatric disease (OR 2.1 [95% CI 1.4–3.2]). No association was found between pregnancy or delivery complications, and postpartum depression. The maximum predictive power of the identified risk factors was 0.3. According to these results, one out of three women who suffers from psychological distress in late pregnancy with perceived social isolation will develop postpartum depression.

Conclusion
Antenatal focus on psychosocial wellbeing may help to identify women at risk of postpartum depression.
The views and anticipated needs of women in early pregnancy
Authors: Jewell David , Sanders Julia , Sharp Debbie
Published: August 2005

Objective
To assess the expectations of antenatal care of pregnant women at the outset of pregnancy.

Design
Questionnaire study within a randomised controlled trial, comparing traditional antenatal care with a more flexible schedule.

Setting
Eleven primary care centres providing midwifery care in Avon.

Population
Five hundred and ninety‐three pregnant women at low risk of obstetric complications presenting for antenatal care.

Methods
A questionnaire was completed by women who agreed to participate in the trial shortly after antenatal booking. The questionnaire explored women's views on their attitudes to pregnancy and antenatal care, the locus of control related to pregnancy, the planning of the pregnancy and expectations of care.

Main outcome measures
Comparisons between nulliparous and multiparous women in terms of their views of antenatal care, and their stated preference for a particular package of care.

Results
There was no difference in their views of pregnancy as an event entailing risk. On a locus of control scale that measured women's perceptions of factors which might affect their babies’ health, nulliparous women rated antenatal care higher than multiparous women (P= 0.0001). However, this was not associated with any difference between the two groups in their stated preference for traditional or flexible care. Approximately half of the women expressed no preference, and of those who did 61% would opt for traditional care. Almost one‐fifth of the whole sample welcomed the idea of flexible care.

Discussion
These data support the evidence of previous studies that there remains a strong desire among pregnant women to receive a ‘traditional’ pattern of care, even among those who have previously experienced normal pregnancy. However, a minority can be identified at the outset of pregnancy who may welcome a change to a more flexible pattern of care.
Subcutaneous versus intracutaneous injections of sterile water for labour analgesia: a comparison of perceived pain during administration
Authors: Mårtensson Lena , Nyberg Karin , Wallin Gunnar
Published: August 2005

Objective
To investigate whether, during injections of sterile water, there is any difference in perceived pain between intracutaneous and subcutaneous injections.

Design
Blind controlled trial with cross‐over design.

Setting
Göteborg and Skövde, Sweden.

Participants
One hundred healthy female volunteers.

Methods
The women were randomised into two groups and subjected to two trials, within one week of each other. During the first trial one group (n= 50) received the intracutaneous injection first, followed by the subcutaneous injection. The second group (n= 50) was given the subcutaneous injection first, followed by intracutaneous injection. In both groups all the injections were given in reverse order during the second trial.

Main outcome measures
Experienced pain during the administration of sterile water injections, measured by visual analogue scale.

Results
The analysis showed intracutaneous injections to be significantly more painful than subcutaneous injections, even after adjusting for injection day and for left/right site of injection (mean 60.8 vs 41.3, P < 0.001).

Conclusions
The findings suggest that the less painful subcutaneous injection technique should be used.
A comparison of bladder neck movement and elevation after tension‐free vaginal tape and colposuspension
Authors: Atherton Michelle J. , Stanton Stuart L.
Published: August 2005

Objective
To compare elevation and movement of the bladder neck after tension‐free vaginal tape and open Burch colposuspension, using transperineal ultrasound.

Design
Prospective, non‐randomised study using pre‐ and post‐operative transperineal ultrasound of the bladder neck.

Setting
Tertiary referral urogynaecology unit at a London teaching hospital.

Sample
Thirty consecutive women who underwent tension‐free vaginal tape or colposuspension for primary genuine stress incontinence between March 1998 and June 1999.

Methods
Women underwent transperineal ultrasound of the bladder neck prior to and three to four weeks after surgery.

Main outcome measures
Bladder neck elevation, angle and movement in relation to the pubic symphysis.

Results
For both tension‐free vaginal tape and colposuspension the post‐operative bladder neck angles at rest and valsalva were more acute than pre‐operatively. The post‐operative linear movement on valsalva was less than pre‐operatively. For colposuspension the rotational movement on valsalva was significantly less post‐operatively, but for tension‐free vaginal tape there was only a trend towards less post‐operative rotational movement. Post‐operative angles and movement were significantly less for colposuspension. The resting bladder neck position was elevated significantly more by colposuspension.

Conclusion
Both tension‐free vaginal tape and colposuspension decrease bladder neck angles at rest and valsalva, linear movement on valsalva and elevate the bladder neck. The colposuspension causes significantly more change than the tension‐free vaginal tape. This suggests the mechanism of continence for the tension‐free vaginal tape is less dependent on bladder neck change than the colposuspension.
A randomised comparison and economic evaluation of laparoscopic‐assisted hysterectomy and abdominal hysterectomy
Authors: Lumsden M. A. , Twaddle S. , Hawthorn R. , Traynor I. , Gilmore D. , Davis J. , Deeny M. , Cameron I. T. , Walker J. J.
Published: August 2005

Objectives
To determine the safety, cost effectiveness and effect on quality of life of laparoscopicassisted vaginal hysterectomy (LAVH) compared with total abdominal hysterectomy (TAH) in the management of benign gynaecological disease.

Design
Randomised controlled trial and economic evaluation.

Setting
Three hospitals in the West of Scotland.

Participants
Two hundred women scheduled for an abdominal hysterectomy for benign gynaecological disease.

Main outcome measures
Conversion rate of LAVH to TAH, complication rates, NHS resource use and costs, quality of life using EuroQol 5 D visual analogue scale, and achievement of milestones.

Results
The overall incidence of operative complications was 14% in the TAH group and 8% in the LAVH group, with an 8% conversion rate. Length of operation was significantly greater in the women having LAVH at 81 ±30 min vs 47 ±16 min (P < 0.001). There was no difference in analgesic requirements between the groups although there was a significantly shorter hospital stay for those having LAVH. The rate of post‐surgery recovery, satisfaction with operation and quality of life at four weeks post‐operative were similar in the two groups of women. LAVH was significantly more expensive than TAH and remained more expensive for all but the most extreme scenario.

Conclusions
This study demonstrates that despite the decreased length of hospital stay, LAVH is more expensive than TAH. In addition, recovery following operation and patient satisfaction were not affected by the route chosen. It is unlikely that LAVH represents an efficient use of NHS resources.
The endometrial response to sequential and continuous combined oestrogen‐progestogen replacement therapy
Authors: Sturdee David W. , Ulrich Lian G. , Barlow David H. , Wells Michael , Campbell Michael J. , Vessey Martin P. , Nielsen Bjarne , Anderson Malcolm C. , Bragg Anthony J.
Published: August 2005

Objectives
1. To determine the prevalence of endometrial hyperplasia in postmenopausal women taking standard proprietary regimens of sequential oestrogen/progestogen; 2. to determine the effects of nine months treatment with an oral continuous combined regimen of 2 mg 17ß‐oestradiol and 1 mg norethisterone acetate (Kliofem [Kliogest outside the UK]; Novo Nordisk, Denmark) on endometrial histology in postmenopausal women.

Design
An open, prospective study in postmenopausal women.

Setting
Fifty‐four menopause clinics in the UK.

Participants
2028 postmenopausal women: 1312 (Group A) taking sequential oestrogen‐progestogen hormone replacement therapy (HRT), and 716 (Group B) not taking HRT, were recruited. In Group A, 388 women took preparations containing 10 days of progestogen, 921 had 12 days, and 3 had 13 days per cycle.

Methods
Endometrial aspiration biopsies were taken towards the end of a three‐month run‐in period (Group A) or at study entry (Group B), before administration of the continuous combined HRT regimen. Biopsies were repeated at the end of the nine month treatment period.

Main outcome measure
Endometrial histology.

Results
Initial endometrial biopsy data were available for 1106 women in Group A, who by the time of endometrial investigation had been taking HRT for a median duration of 2.56 years (5th to 95th centiles: 0.77 to 8.49 years). Data were available for 661 untreated women, who had no bleeding and had not taken HRT within the last year (Group B). Complex hyperplasia was found in 59 women (5.3%), and atypical hyperplasia in a further eight (0.7%) in Group A. In Group B there were no cases with complex hyperplasia, but one woman showed atypical hyperplasia (0.2%). At the end of the nine months of continuous combined therapy there was no case of hyperplasia among 1196 biopsies (upper 95% confidence limit of risk 0.31%) in women completing the study. Within this Group all of the women with complex hyperplasia arising during previous sequential HRT and who completed the study (n= 38) reverted to normal endometrial patterns. There was no case of endometrial carcinoma during the study.

Conclusions
Despite taking standard regimens of sequential HRT containing at least 10 days of progestogen, there was a 5.3% prevalence of complex endometrial hyperplasia, and a 0.7% prevalence of atypical hyperplasia. However, continuous combined HRT (Kliofem) containing daily progestogen is not associated with an increased risk of hyperplasia and will convert the endometrium to normal in those with complex hyperplasia arising during previous sequential HRT.
A randomised controlled trial of vaginal clindamycin for early pregnancy bacterial vaginosis
Authors: Kurkinen‐Räty Merja , Vuopala Salme , Koskela Markku , Kekki Minnamaija , Kurki Tapio , Paavonen Jorma , Jouppila Pentti
Published: August 2005

Objective
To determine whether treatment of bacterial vaginosis (BV) with vaginal clindamycin affects pregnancy outcome.

Materials and methods
Mothers with singleton pregnancies and without previous preterm delivery in 17 health centres in Oulu from March 1996 Until March 1998, in whom BV was diagnosed by Gram stain of a vaginal swab at the first antenatal visit (at the 12th gestational week) were randomised at Oulu University Hospital to have a one‐week course of vaginal clindamycin, or placebo. A follow up sample of Gram stain was taken two weeks after randomisation and at the 30th gestational weeks. Pregnancy outcome data was obtained from hospital records. Primary outcome was preterm birth, and puerperal infectious morbidity the other outcome measure.

Results
During the study period 1956 women were screened, of whom 143 (7.3%) were BV‐ positive. One hundred and one were randomised. The total preterm birth rate of BV+ women randomised was 9.9% (10/101). Preterm birth occurred in 20.7% (6/29) vs 0% (0/26) according to whether BV persisted or not (P < 0.01). The preterm birth rate was 13.7% (7/51) in the clindamycin group vs 6.0% (3/50) in the placebo group (OR 2.5, 95% CI 0.6–10). BV was cured just after treatment in 17 out of 51 (33%) of the clindamycin‐ treated patients vs 17 out of 50 (34%) of the placebo‐ treated patients (OR 1.0, 95% CI 0.4–2.2). There was a difference in puerperal infectious morbidity in patients where BV persisted (31%, 9/29) compared with those in which BV did not persist (7.7%, 1/26) (OR 5.4, 95% CI 1.04–28). Infections were seen in 4/51 (8%) of the clindamycin treated vs 10/50 (20%) of the placebo treated cases, (OR 0.3, 95% CI 0.1–1.2).

Conclusion
The prevalence of BV was lower than expected in this low risk population, but nevertheless it increased the risk of preterm birth and puerperal infectious morbidity, the risk being highest in cases where BV persisted during pregnancy. Vaginal clindamycin treatment for BV in the first trimester of pregnancy did not appear to reduce the risk of preterm birth or puerperal infections.
Naegele's rule: a reappraisal
Authors: Baskett Thomas F. , Nagele Fritz
Published: August 2005

The origin of Naegele's rule to calculate the expected date of confinement is reviewed. It is possible that the rule has been misinterpreted, resulting in an earlier estimated date of delivery with implications for induction of labour for post dates pregnancy.
Accuracy and limitations of transabdominal fetal echocardiography at 12–15 weeks of gestation in a population at high risk for congenital heart disease
Authors: Simpson John M. , Jones Annette , Callaghan Nicky , Sharland Gurleen K.
Published: August 2005

Objective
Evaluation of transabdominal fetal echocardiography at 12–15 weeks of gestation.

Design
Retrospective analysis.

Setting
Tertiary fetal cardiology unit.

Sample
Two hundred twenty‐nine consecutive fetuses imaged at 12–15 weeks of gestation over a 45‐month period.

Methods
Retrospective analysis of echocardiography and autopsy reports.

Main outcome measures
Accuracy of early echocardiography for the detection of abnormalities of the cardiac connections.

Results
Diagnostic images were obtained in 226/229 fetuses (98.7%). Abnormalities of the cardiac connections were detected in 13 fetuses (5.7%) on the initial scan. Where information was available (n= 11), the echocardiographic findings were confirmed at autopsy or postnatally. In two of the 13 cases of congenital heart disease, repeat echocardiography was necessary to provide additional cardiological information. Of the 213 cases in whom a normal initial report was issued, four (1.7%) had congenital heart disease diagnosed later in pregnancy (n= 3) or postnatally (n= 1). Three of these fetuses had haemodynamically insignificant ventricular septal defects and one developed a dilated cardiomyopathy later in gestation.

Conclusions
Transabdominal fetal echocardiography can be performed at 12–15 weeks of gestation permitting accurate early detection of major congenital heart defects in a high risk population. Some forms of congenital heart disease, usually minor, may not be detectable at such an early stage.
Performance of ultrasound as a second line test to serum CA125 in ovarian cancer screening
Authors: Menon Usha , Talaat Ahmed , Rosenthal Adam N. , Macdonald Nicola D. , Jeyerajah Arjun R. , Skates Steven J. , Sibley Karen , David H. , Jacobs Ian J.
Published: August 2005

Objective
To assess the performance of ultrasonography in a multimodal ovarian cancer screening strategy.

Design
Prospective ovarian cancer screening trial between December 1986 and June 1993.

Setting
General practice, occupational health departments and an ovarian cancer screening clinic at a London teaching hospital.

Population
Postmenopausal women, ≥ 45 years with a raised CA125.

Methods
Volunteers with a CA125 ≥ 30 U/mL underwent a pelvic ultrasound. Scans were classified as normal, abnormal (ovarian volume ≥ 8.8 mL) or equivocal (normal volume with abnormal morphology). Abnormal ovarian morphology was subclassified as simple cyst (single, thin walled cyst with no septa or papillary projections) or complex (all other abnormalities). Volunteers with abnormal scans were referred for a gynaecological opinion. Follow up was via the cancer registry and postal questionnaires.

Main outcome measures
Sensitivity, specificity and positive predictive value of different ultrasound criteria for detection of index cancer (e.g. primary invasive epithelial carcinoma of the ovary and fallopian tube).

Results
Seven hundred and forty‐one women underwent 1219 scans and 20 index cancers occurred during a median follow up of 6.8 years. The sensitivity for detection of ovarian cancer of different ultrasound criteria was 100% for abnormal morphology, 89.5% for abnormal volume and 84% for complex morphology. The highest specificity (97%) and positive predictive value (37.2%) was achieved using complex morphology.

Conclusion
A variety of ultrasound criteria can achieve high sensitivity, specificity and positive predictive value for index cancers in postmenopausal women with an elevated CA125. Use of ovarian morphology to interpret ultrasound may increase sensitivity and use of complex ovarian morphology may increase the positive predictive value.
Can diagnostic laparoscopy be avoided in routine investigation for infertility?
Authors: Johnson N. P. , Taylor K. , Nadgir A. A. , Chinn D. J. , Taylor P. J.
Published: August 2005

Objective
To determine whether routine testing for serum Chlamydia trachomatis antibodies, considered in combination with a woman's clinical features, may avoid the need for diagnostic laparoscopy in routine investigation for infertility.

Design
Retrospective case notes analysis.

Setting
Secondary level care infertility clinic.

Population
Eighty women who had undergone both laparoscopy and serum Chlamydia trachomatis antibody testing.

Methods
Ascertainment of any history of suspected pelvic inflammatory disease, pelvic pain, cervical intraepithelial neoplasia, pelvic surgery or appendicectomy; any abnormality on clinical pelvic examination; the findings at laparoscopy; the result of serum Chlamydia trachomatis antibody testing by enzyme‐linked immunosorbent assay (ELISA) screening with microimmunofluorescence (MIF) confirmatory diagnostic testing. The usefulness of clinical features, the serum Chlamydia trachomatis antibody test and these two variables combined in the detection of tubal disease and pelvic pathology of relevance to infertility were measured statistically.

Main outcome measures
Specificity, sensitivity, positive predictive value, negative predictive value and likelihood ratio for each of the tests.

Results
The combination of any positive clinical feature with a positive test for serum Chlamydia trachomatis antibodies detects tubal disease with sensitivity 92%, specificity 70%, positive predictive value 72%, negative predictive value 91% and likelihood ratio 3.1; it detects bilateral tubal obstruction with sensitivity 84%, specificity 51%, positive predictive value 35%, negative predictive value 91% and likelihood ratio 1.7; it detects pelvic pathology relevant to infertility with sensitivity 76%, specificity 71%, positive predictive value 80%, negative predictive value 65% and likelihood ratio 2.6. The negative predictive value for pelvic pathology from the use of clinical features in addition to the chlamydia antibody test is not significantly higher than that from the chlamydia antibody test alone (53%).

Conclusions
A policy of selective laparoscopy in routine investigation for infertility, based on the result of the test for serum Chlamydia trachomatis antibodies and a woman's clinical features, is not supported.