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Background:A most important characteristic feature for poor prognosis in colorectal cancer (CRC) is the presence of lymph node metastasis. Determination of carcinoembryonic antigen (CEA) mRNA levels in lymph nodes has proven powerful for quantification of disseminated tumour cells. Here, we investigate the utility of human tissue kallikrein-related peptidase 6 (KLK6) mRNA as a progression biomarker to complement CEA mRNA, for improved selection of patients in need of adjuvant therapy and intensified follow-up after surgery.Methods:Lymph nodes of pTNM stage I-IV CRC- (166 patients/503 lymph nodes) and control (23/108) patients were collected at surgery and analysed by quantitative RT-PCR.Results:Lymph node KLK6 positivity was an indicator of poor outcome (hazard ratio 3.7). Risk of recurrence and cancer death increased with KLK6 lymph node levels. Patients with KLK6 lymph node levels above the 90th percentile had a hazard ratio of 6.5 and 76 months shorter average survival time compared to patients with KLK6 negative nodes. The KLK6 positivity in lymph nodes with few tumour cells, that is, low CEA mRNA levels, also indicated poor prognosis (hazard ratio 2.8).Conclusion:In CRC patients, lymph node KLK6 positivity indicated presence of aggressive tumour cells associated with poor prognosis and high risk of tumour recurrence. [ABSTRACT FROM AUTHOR]

Argues for an evaluation of antenatal care programs of the developed countries. Difficulties in conducting scientific trials to evaluate the programs; Results of some trials on antenatal care from the U.S. and Europe; Reasons for preferring private care to public clinics by women in developed countries; Desirable features of programs of antenatal care.

This paper questions why female circumcision (FC) persists despite eradication interventions and the migration of people to non-practising countries and discusses the reasoning of Somali immigrants on female circumcision. It is based on interviews with diverse groups and individuals in the Somali community, mostly refugees in Sweden. Paradoxes implying denial and avoidance emerged. Female circumcision was described, as just 'a tradition' that has little to do with Islam. The fear of bringing up an uncircumcised daughter in the liberal sexual morality of Sweden was mentioned as a dilemma. Circumcised women said the health care they received during pregnancy and childbirth was poor while the law failed to take account of the experiences of the Somali people. We conclude that rather than eradication, interventions seem to have silenced and stigmatized the practice due to their failure to take account of its meanings, organization and contexts, including the diasporic dynamics within which immigrants negotiate identities. [ABSTRACT FROM AUTHOR]

We conducted this study to explore communication between pregnant women and health care providers at an antenatal clinic in Zimbabwe. We adopted a field research approach using qualitative strategies for data collection and analysis. Using content analysis, we identified impersonal communication, nonprivate communication, rigid communication, uninformed communication, and authoritative communication as characteristic components of the interaction between the pregnant women and the health care providers. The attitudes reflected by the communication styles at the antenatal clinic must be viewed in relationship to the culture and tradition of Zimbabwe. With further research, we may identify obstacles to communication that are not related to culture. This knowledge may lead to a better understanding of appropriate communication strategies to promote healthy pregnancy. [ABSTRACT FROM AUTHOR]

Misoprostrol, a synthetic analogue of prostaglandin E[sub 1] , has been used for cervical preparation. Its ideal dose, route and frequency of administration are still under investigation. We conducted a randomised controlled trial, in a tertiary hospital in a developing country, to compare misoprostol 50 μg (low) and 100 μg (high) for effectiveness and safety in induction of labour at term. Women admitted for induction of labour with a singleton live fetus in cephalic presentation after 37 weeks' gestation were recruited. A misoprostol tablet was inserted in the posterior vaginal fornix at 8-hour intervals. Main outcomes were duration of induction, maternal and fetal complications. The mean duration of induction was 15·4 (SD 10·6) and 14·2 (SD 13·6) h in the low- and high-groups respectively (P = 0·095). There was no difference in need for augmentation with oxytocin (OR 0·82; 95% Cl 0·36-1·86) or operative delivery (OR 1·29; 95% CI 0·26-6·84). There were two uterine ruptures and four intrapartum stillbirths in the high misoprostol group. There was no difference in postpartum haemorrhage, 9·5% vs. 7·9% (P = 1·00) and admissions to the neonatal unit 18·8% vs. 17·0% (P = 0·980) in the 1ow- and high-groups) respectively. Misoprostol 50 μg was as effective as the 100 μg dose for induction of labour whereas the higher dose had an increased risk of serious complications. [ABSTRACT FROM AUTHOR]

Objective: To compare the effectiveness of vaginally administered misoprostol with extra-amniotic prostaglandin F2α (PGF2α) gel for induction of labor. Method: A randomized controlled trial, with women allocated to receive either misoprostol 50 μg intra-vaginally or extra-amniotic PGF2α gel 5 mg, was conducted in Harare Maternity Hospital. A total of 152 women were admitted for induction of labor with a term singleton, pregnancy and cephalic presentation were recruited. The main outcome was duration of induction. Results: There were no differences in the characteristics of women in the two groups at recruitment. In the misoprostol group there was a significantly reduced need for augmentation of labor with oxytocin (OR=0.36; 95% C.I. 0.17–0.73) and delivery by cesarean section for failure to progress (OR=0.11; 95% C.I. 0.00–0.88). The risk for duration of induction to vaginal delivery exceeding 12, 18 or 24 h was reduced by 18%, 38% and 68%, respectively, but only the risk for duration >24 h was significantly reduced (OR=0.32; 95%C.I. 0.11–0.91). The mean duration of induction was shorter in the misoprostol group, 15.2 vs. 23.6 h (P=0.02). There were no differences in fetal outcome. Conclusion: Misoprostol 50 μg was associated with less use of oxytocin in labor, a shorter induction to delivery interval and fewer cesarean sections for failure to progress when compared with extra-amniotic PGF2α gel. [Copyright &y& Elsevier]

Abstract This study examined health behaviours among nulliparous pregnant Swedish women. Structural equation modelling (N = 350) was used to predict smoking and exercise at gestational weeks 20 and 32 from psychosocial factors measured in early and mid-pregnancy. Although women altered theft lifestyle early in pregnancy, so that by gestational week 20 both smoking and exercise had declined, previous behaviours remained strong and consistent predictors of later behaviours. Hostility and health awareness predicted smoking at both weeks 20 and 32. Smoking at week 32 was also predicted by concurrent perceived stress. Exercise at week 20 was predicted by hostility, social support, stress, and whether or not the pregnancy was planned; and at week 32 only health awareness was significant. Social support had a significant indirect effect on each behaviour, which suggests that social support facilitated compliance with health professionals' recommendations. These results suggest that psychosocial factors previously associated with health outcomes also predict health behaviours throughout pregnancy. [ABSTRACT FROM AUTHOR]

Aim: This study investigates how often bowel continuity was restored after anastomotic leakage in anterior resection for rectal cancer and assesses the clinical factors associated with permanent stoma. Method: The Swedish Colorectal Cancer Registry was used to identify cases of anastomotic leakage registered in southern Sweden between January 2001 and December 2011. Patient characteristics, surgical details and clinical information about the anastomotic leakages were retrieved from medical records. Results: Of the 1442 patients operated on with anterior resection in 11 hospitals, 144 (10%) were diagnosed with anastomotic leakage after anterior resection for rectal cancer. After a median follow‐up of 87 months (range 21–165), the overall rate of permanent stoma among patients with anastomotic leakage was 65%. Age ≥ 70 years (P = 0.02) and re‐laparotomy (P < 0.001) were independently related to permanent stoma. Compared with nondefunctioned patients with anastomotic leakage, defunctioned patients with anastomotic leakage at the index procedure less often required re‐laparotomy at some point during the entire clinical course (P < 0.001), but nondefunctioned and defunctioned patients with anastomotic leakage both had permanent stoma to the same extent (67% and 62%, respectively). Conclusion: Anastomotic leakage is highly associated with permanent stoma after anterior resection, especially in patients aged ≥ 70 years. In this cohort of patients with anastomotic leakage, 65% had permanent stoma at long‐term follow‐up. A defunctioning stoma ameliorates the clinical course but does not affect the end result of bowel continuity in established anastomotic leakage after anterior resection. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Anastomotic leakage (AL) is common after anterior resection (AR). Long term clinical outcomes of AL including late presenting leakage (LL) are not well studied. This study was undertaken to assess clinical features of LL with respect to incidence, association with predisposing factors and need for re‐intervention. Methods: The Swedish Colorectal Cancer Registry (SCRCR) was explored for AL cases after AR for rectal cancer in patients operated in the south of Sweden from 1 January 2001 to 31 December 2011. Demographic data, surgical technical details, number of postoperative days (POD) until diagnosis of AL, presenting symptoms, methods of diagnosis and treatment were retrieved from medical records. LL was defined according to different cut‐offs as leakages occurring after hospital discharge (LLAHD), after 30 POD (LL ≥ POD 30) and after 90 POD (LL ≥ POD 90). Results: In total, 1442 patients were operated on with AR of whom 144 cases of AL (10%) were identified. Median time from operation to follow‐up was 87 months (range 21–162). LLAHD, LL ≥ POD 30 and LL ≥ POD 90 were present in 51%, 24% and 9% respectively. All categories of LL were associated with a defunctioning stoma. Relaparotomy was significantly less often employed in LLAHD, but not in other categories of LL. Conclusion: LL constitutes a substantial portion of all AL after AR for rectal cancer. The large proportion of LLAHD calls for awareness in the outpatient setting. [ABSTRACT FROM AUTHOR]

Background: During rectal cancer surgery the bowel may contain viable, exfoliated cancer cells, a potential source for local recurrence (LR). The amount and viability of these cells can be reduced using intraoperative rectal washout, a procedure that reduces the LR risk after anterior resection. The aim of this study was to analyse the impact of washout on oncological outcome when performed in Hartmann's procedure (HP) for rectal cancer. Methods: A national cohort study on data for patients registered from 1995 to 2007 in the Swedish Colorectal Cancer Registry was carried out. The final analysis included patients belonging to TNM stages I-III who had undergone R0 HP with a registered 5-year follow-up. Multivariate analysis was performed. Results: A total of 1188 patients were analysed (686 washout and 502 no washout). No differences were detected between the washout group and the no washout group concerning rates of LR [7% (49/686) vs. 10% (49/502); p = 0.13], distant metastasis (DM) [17% (119/686) vs. 18% (93/502); p = 0.65], and overall recurrence (OAR) [21% (145/686) vs. 24% (120/502); p = 0.29]. For both groups, the 5-year cancer-specific survival was below 50%. In multivariate analysis, washout neither decreased the risk of LR, DM, or OAR nor increased overall or the cancer-specific 5-year survival. Conclusions: The oncological outcome did not improve when washout was performed in HP for rectal cancer. [ABSTRACT FROM AUTHOR]

Aim The main aims were to explore time trends in the management and outcome of patients with rectal cancer in a national cohort and to evaluate the possible impact of national auditing on overall outcomes. A secondary aim was to provide population-based data for appraisal of external validity in selected patient series. Method Data from the Swedish ColoRectal Cancer Registry with virtually complete national coverage were utilized in this cohort study on 29 925 patients with rectal cancer diagnosed between 1995 and 2012. Of eligible patients, nine were excluded. Results During the study period, overall, relative and disease-free survival increased. Postoperative mortality after 30 and 90 days decreased to 1.7% and 2.9%. The 5-year local recurrence rate dropped to 5.0%. Resection margins improved, as did peri-operative blood loss despite more multivisceral resections being performed. Fewer patients underwent palliative resection and the proportion of non-operated patients increased. The proportions of temporary and permanent stoma formation increased. Preoperative radiotherapy and chemoradiotherapy became more common as did multidisciplinary team conferences. Variability in rectal cancer management between healthcare regions diminished over time when new aspects of patient care were audited. Conclusion There have been substantial changes over time in the management of patients with rectal cancer, reflected in improved outcome. Much indirect evidence indicates that auditing matters, but without a control group it is not possible to draw firm conclusions regarding the possible impact of a quality control registry on faster shifts in time trends, decreased variability and improvements. Registry data were made available for reference. [ABSTRACT FROM AUTHOR]

The impact of anastomic leakage (AL) on the oncological outcome after anterior resection (AR) for rectal cancer is still controversial. We explored the impact of AL regarding local recurrence (LR), distant metastasis and overall recurrence (OAR). Overall and cancer-specific survival was analysed. Patients undergoing AR for rectal cancer with a registered AL between 1995 and 1997 and a control group were identified in the Swedish Rectal Cancer Registry. The medical records were retrieved for additional data and validation. Differences in the oncological outcome at 5-year follow-up were analysed with multivariate methods. After validation, 114 patients with AL and 136 control patients with locally radical surgery for tumours in tumour-node-metastasis stages I-III were analysed. There was no difference detected between patients with AL and control patients regarding rates of LR [8% (9 of 114) vs 9% (12 of 136); P = 0.97], distant metastasis [18% (20 of 114) vs 23% (31 of 136); P = 0.37] and OAR [19% (22 of 114) vs 28% (38 of 136); P = 0.15]. The 5-year cancer-specific survival was almost 80% in both groups. In multivariate analysis, AL was not a risk factor of LR, distant metastasis or OAR and had no impact on 5-year overall or 5-year cancer-specific survival. Irrespective of the occurrence of AL, preoperative radiotherapy ( P = 0.055) and rectal washout ( P = 0.046) reduced the LR rate, but did not influence survival. Anastomotic leakage was not proved to be a risk factor of worse oncological outcome. Hence, additional adjuvant treatment or extended follow-up on the basis of the occurrence of AL after AR might not be justified. [ABSTRACT FROM AUTHOR]

The article presents a study which examines the impact of rectal washout on local recurrence following surgery for rectal cancer. An overview of the methodology used for the study is provided, along with information on rectal washout and treatment of rectal cancer. Results showed a consistent difference in local recurrence rates between rectal washout and no-washout groups. Researchers recommends rectal washout distal to tumour due to its simplicity and inexpensiveness.

Aim Despite advances in rectal cancer treatment, local recurrence (LR) remains a significant problem. To select high-risk patients for different treatment options aimed at reducing LR, it is essential to identify LR risk factors. Method Local recurrence and survival rates of 4153 patients registered 1995–1997 in the Swedish Rectal Cancer Registry were analysed. LR risk factors were analysed by multivariate methods. For LR patients the registry was validated and additional data retrieved. Results The 5-year overall and cancer-specific survival rates were 45% and 62% respectively. LR was registered in 326 (8%) patients. After R0-resections for tumours in TNM stages I–III, LR developed in 10% of tumours at 0–5 cm, 8% at 6–10 cm and 6% at 11–15 cm above the anal verge. Preoperative radiotherapy (RT) reduced the LR rate irrespective of height [0–5 cm: OR 0.50 (0.30–0.83), 6–10 cm: OR 0.42 (0.25–0.71), and 11–15 cm: OR 0.29 (0.13–0.64)]. Patients without preoperative RT had significantly higher LR risk after rectal perforation [OR 2.50 (1.48–4.24)], and almost significantly decreased LR risk when rectal washout was performed [OR 0.65 (0.43–1.00)]. Preoperative RT prolonged time to LR but did not significantly influence the survival among LR patients. LR was an isolated tumour manifestation in 103 (39%) patients with validated LR. Conclusion Preoperative RT should be considered for rectal cancer also in the upper third of the rectum. Intraoperative perforation should be avoided, and rectal washout is indicated as valuable. Follow-up for the detection of isolated LR is important. Extended follow up should be considered for patients treated with RT. [ABSTRACT FROM AUTHOR]

Through in-depth interviews, this study explored perceptions and experiences of key players handling child sexual offense cases in Dar es Salaam, Tanzania. The informants included public police investigators, magistrates, legal workers, and social workers working with nongovernmental organizations. The interviews were recorded, transcribed verbatim, and analyzed using qualitative content analysis. Five themes emerged summarizing factors associated with sexual offenses, including community passivity, legal system weaknesses, legal framework inadequacy, and key players' vulnerabilities. Addressing the identified weaknesses may promote justice, while changes in attitudes and norms are needed for the prevention of sexual offenses to children. [ABSTRACT FROM AUTHOR]

Objective: To assess the quality of partograms used to monitor labor in Dar es Salaam hospitals, Tanzania.Methods: The study team reviewed the records of the parameters of labor, and maternal and fetal conditions in 367 partograms, and interviewed 20 midwives.Results: All midwives interviewed had been previously trained to use the partogram. Of all partograms reviewed, 50% had no records of duration of labor. Although cervical dilation and fetal heart rates were recorded in 97% and 94% of the partograms respectively, 63% and 91% of these were judged to be substandard. Substandard monitoring of fetal heart rates was strongly associated with poor fetal outcome (P<0.001). Blood pressure, temperature, and pulse rates were not recorded in 47%-76% of partograms.Conclusion: These findings reflect poor management of labor and indicate urgent in-service training to address the importance of documentation and regular partogram audit in order to reduce maternal and perinatal deaths. [ABSTRACT FROM AUTHOR]

Background: An audit of all patients with rectal cancer in Sweden was launched in 1995. This is the first report from the Swedish Rectal Cancer Registry (SRCR). Methods: Between 1995 and 2003, 13 434 patients treated for adenocarcinoma of the rectum were registered with the SRCR; there were approximately 1500 new patients annually. Results: Approximately half had an anterior resection, a quarter an abdominoperineal resection and 15 per cent a Hartmann's procedure. The median 30-day postoperative mortality rate was 2.4 per cent and the overall postoperative morbidity rate was 35-0 per cent. The 5-year cancer-specific survival rate was 62.3 percent. The 5-year relative survival rate was 70.1 percent after anterior resection, 59.8 per cent after abdominoperineal resection and 39.8 per cent after a Hartmann's procedure. The crude 5-year local recurrence rate was 9.5 per cent overall, 6.1 per cent after preoperative radiotherapy and 11.4 per cent after surgery alone. For 3868 patients who had a locally curative procedure the local recurrence rate was 7.4 per cent overall, 5.9 per cent for those who had radiotherapy and 10.2 per cent for those who did not. The local recurrence rate was 2.9 per cent (28 of 968) for stage I disease, 7.9 per cent (112 of 1418) for stage 1I, 13.9 per cent (188 of 1357) for stage III and 8.5 per cent (45 of 532) for stage IV. Conclusion: These good population-based results are due, in part, to the nationwide prospective quality assurance registration. [ABSTRACT FROM AUTHOR]

Objective To compare a five-visit antenatal care (ANC) model with specified goals with the standard model in a rural area in Zimbabwe. Design Cluster randomised controlled trial with the clinic as the randomisation unit. Setting Primary care setting in a developing country where care was provided by nurse-midwives. Population Women booking for ANC in the clinics were eligible. Main outcome measures Number of antenatal visits, antepartum and intrapartum referrals, utilization of health centre for delivery and perinatal outcomes. Methods Twenty-three rural health centres were stratified prior to random allocation to the new ( n= 11) or standard ( n= 12) model of care. Results We recruited 13 517 women (new, n= 6897 and standard, n= 6620) in the study, and 78% (10 572) of their pregnancy records were retrieved. There was no difference in median maternal age, parity and gestational age at booking between women in the standard model and those in the new model. The median number of visits was four for both models. The proportion of women with five or less visits was 77% in the new and 69% in the standard model (OR 1.5; 95% CI 1.08–2.2). The likelihood of haemoglobin testing was higher in the new model (OR 2.4; 95% CI 1.0–5.7) but unchanged for syphilis testing. There were fewer intrapartum transfers (5.4 versus 7.9% [OR 0.66; 95% CI 0.44–0.98]) in the new model but no difference in antepartum or postpartum transfers. There was no difference in rates of preterm delivery or low birthweight. The perinatal mortality was 25/1000 in standard model and 28/1000 in new model. Conclusion In Gutu district, a focused five-visit schedule did not change the number of contacts but was more effective as expressed by increased adherence to procedures and better use of institutional health care. [ABSTRACT FROM AUTHOR]

Accurate identification of lymph node involvement is critical for successful treatment of patients with colorectal carcinoma (CRC). Real-time quantitative RT-PCR with a specific probe and RNA copy standard for biomarker mRNA has proven very powerful for detection of disseminated tumour cells. Which properties of biomarker mRNAs are important for identification of disseminated CRC cells? Seven biomarker candidates, CEA, CEACAM1-S/L, CEACAM6, CEACAM7-1/2, MUC2, MMP7 and CK20, were compared in a test-set of lymph nodes from 51 CRC patients (Dukes' A-D) and 10 controls. Normal colon epithelial cells, primary tumours, and different immune cells were also analysed. The biomarkers were ranked according to: (1) detection of haematoxylin/eosin positive nodes, (2) detection of Dukes' A and B patients, who developed metastases during a 54 months follow-up period and (3) identification of patients with Dukes' C and D tumours using the highest value of control nodes as cutoff. The following properties appear to be of importance; (a) no expression in immune cells, (b) relatively high and constant expression in tumour tissue irrespective of Dukes' stage and (c) no or weak downregulation in tumours compared to normal tissue. CEA fulfilled these criteria best, followed by CK20 and MUC2. [ABSTRACT FROM AUTHOR]

We conducted a population-based cohort study to determine the prevalence of antenatal and intra-partum referrals, compliance with advice and perinatal outcomes in referred pregnant women in Gutu district, Zimbabwe. The cohort was composed of 10,572 women who received antenatal care in 23 rural health centres (RHC) in Gutu district between January 1995 and June 1998. Pregnancy records of women with antenatal or intra-partum referral were analysed for indication, compliance and perinatal outcomes. Using women who had no antenatal referral or those who complied as referents, the association of referral with perinatal outcome was expressed as relative risk (RR) with 95% confidence intervals (CI). A total of 30% of women (3,094/10,572) had an antenatal referral. Among women attending RHC in labour, 13% (694/5,338) were referred intra-partum. Nulliparous and women younger than 20 years were more likely to be referred. Nurse – midwives' compliance with referral recommendations was low as 59% women with historical risk factors and 52% with raised blood pressure (>140/90 mmHg) were not referred. Women complied with referral advice except when indication was high parity. Women with antenatal referral were more likely to have hospital delivery, 70% vs 18% ( p [ABSTRACT FROM AUTHOR]

AIM: This paper reports a study evaluating the sensitivity of a semi-structured interview schedule and card sort methods in assessing postpartum concerns of women. BACKGROUND: Several methods have been used to assess postpartum maternal concerns and the process of becoming a mother, but few studies have evaluated the methods with respect to their sensitivity for obtaining information. METHOD: A cohort of mothers was followed-up at one (n = 110) and 6 weeks (n = 83) after childbirth in Dar es Salaam, Tanzania. Women with a minimum of 7 years of primary education were interviewed and they also sorted cards. Those with less fewer than 7 years of primary education were interviewed only. The methods were used in alternate order to assess method interaction. RESULTS: In the interviews at 1 week, mothers more often expressed worry and interest related to the baby or themselves when they had sorted cards first. The extent to which women expressed worry and interest about specific baby- and mother-related topics was generally higher for women who had sorted cards before the interview at both 1 and 6 weeks. Independent of whether they were interviewed only, interviewed after sorting cards or before, mothers more often expressed a higher degree of interest than of worry about the baby and self at both 1 and 6 weeks. The order of the data collection methods did not influence the way women sorted cards as being worries and interests. CONCLUSION: Compared to interview using a semi-structured interview schedule, our findings suggest that the card sort is more sensitive in obtaining information about women's concerns. Although the interview method has the advantage of reaching less educated people, the card sort is a technique that is associated with fewer barriers and is a more participatory method for those who can use it. [ABSTRACT FROM AUTHOR]

Over 10% of current births in all countries of the world are delivered by caesarean section. Single-dose ampicillin or cefazolin administered after cord clamping has been proven to be effective for the prevention of post-caesarean infections as indicated in many randomised trials and reviews in the Cochrane Library. This study aimed to determine three determinants of behavioural intention using the theory of planned behaviour: attitudes, subjective norms, and perceived controls. Intentions were examined for five aspects of the use of antibiotic prophylaxis, namely whether or not antibiotics were used, used in all caesarean sections, after rather than before cord clamping, whether ampicillin/cefazolin or broader-spectrum antibiotics were used, and whether single or multiple doses were given. Fifty obstetricians selected from university, regional, and general hospitals in southern Thailand, were surveyed using a questionnaire and in-depth interview. Their intentions to use a single dose and to use in all cases were low, and this was related to negative attitudes and reference groups who did not approve of the single dose. The negative attitude was based on scepticism concerning the applicability of well-equipped trials from the developed world and fear of consequences of post-caesarean infections. Norms carried over from residency training had more long-term influence in their practice than newer information from books or journals. Perceived external controls on their practice were less predictive of intentions. Intentions were only partly predictive of behaviour. Changing attitudes, introducing evidence-based information into residency training and strengthening control systems in the hospital are essential to improve intentions. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate and compare the three most commonly used perinatal death classification systems: (1) the Nordic–Baltic; (2) the Aberdeen; and (3) the Wigglesworth, and assess their applicability in a developing country (Sudan) with a high perinatal mortality rate, and their justification for practical use in quality assurance and audit activities. Methods: At Omdurman Maternity Hospital (OMH), Khartoum, Sudan, 166 perinatal deaths were prospectively assessed during a 3-month period (May–August 2000) with a total of 2260 births. Narratives of 166 perinatal deaths were prepared for the purpose of audit. A panel of two Danish and one Sudanese obstetrician categorized the cases according to: (1) the Nordic–Baltic; (2) the Aberdeen; and (3) the Wigglesworth classification. Results: By all three classifications a similar fraction of cases (approx. 85%) were allocated to one category only, and in 15% of cases the assessors were in doubt into which of two categories the cases should be allocated. The necessary information is often not available, giving at least 40% classified as ‘unknown’ in the Aberdeen classification, whereas the Wigglesworth classification results in an even larger group of unspecified asphyxia. Conclusion: Classification of perinatal deaths in developing countries is associated with problems regarding application, validity and usefulness. The Nordic–Baltic classification seems to be most suitable for appropriate stratification using routinely recorded variables and providing categories associated with specific levels of care. [Copyright &y& Elsevier]

Antenatal care (ANC) attempts to screen and provide surveillance and treatment to individuals according to the level of need. We assessed the value of antenatal risk allocation made at the first visit in identifying women who will experience pregnancy complications in a rural area in Zimbabwe. As part of an ANC trial women were allocated into low- and high-risk categories based on medical, demographic and obstetric history. All highrisk women were recommended hospital delivery. This evaluation is based on 5223 women who received traditional care from nurse-midwives in 12 rural health centres, of whom 2890 (55%) were classified as high risk by the traditional risk markers, including 1618 nulliparous women. Complications occurred in 924 (17·7%) women 577 (62·4%) of whom had risk markers identified at booking. Twenty per cent (577/2890) of women classified as high risk developed complications. There was a high recurrence of complications, such as hypertensive disorders, operative delivery and preterm delivery. Nulliparity was a risk for low birth weight, operative delivery and hypertensive disorders, whereas grandmultiparity (≥6) was a risk for hypertension in pregnancy. Young age (≤16 years) was)a risk factor for low birth weight and perinatal death. Age above 35 years was not an independent risk factor. The traditional risk allocation system, with a likelihood ratio of 1·16, was not effective in identifying women at risk of pregnancy complications and resulted in too large a risk group for referral. [ABSTRACT FROM AUTHOR]

Objective: A national audit on perinatal deaths was performed to assess the quality of antenatal care, and to suggest measures for improved antenatal care.Material and Methods: Medical records of all the perinatal deaths in Latvia in the years 1995-1996 have been studied. Non-attenders and attenders of antenatal care were characterized by socio-economic and medical variables: maternal age, parity, history of perinatal outcome, health status and behavioral hazards during the index pregnancy, length of gestation and birth weight. The Nordic-Baltic perinatal death classification was used.Results: In 85 of 442 cases (19%) of perinatal deaths women had not taken advantage of antenatal care provided for them. Non-attenders were more likely to be smokers (p<0.001) and alcohol abusers (p<0.005), above 35 years of age (p<0.005), and had higher parity (p<0.001). Non-attenders more often had systemic diseases and pregnancy complications. Neonatal complications, such as congenital syphilis (p<0.05) and other infections (p<0.05), were more common among non-attenders. There was no difference in rates of preterm birth and low birth weight between attenders and non-attenders.Conclusions: One fifth of mothers with perinatal death did not attend ANC, and in some women who attended ANC, lack of intervention was related to the perinatal death. [ABSTRACT FROM AUTHOR]

Background: There is current interest in symptoms during pregnancy, but yet little is known about their prevalence and how often they are experienced across pregnancy. The reasons why some women experience more symptoms or experience them more often than others has received limited research attention.Objective: To document the prevalence and frequency of 27 pregnancy symptoms and to systematically investigate, cross-sectionally and prospectively, the effect of psychosocial factors on the prevalence and frequency of these symptoms, while controlling for biomedical factors.Methods: Four hundred and seventy-six nulliparous Scandinavian women who attended routine prenatal care in Uppsala county, Sweden, were studied six times during pregnancy (gestational weeks 10, 12, 20, 28, 32, and 36).Results: The prevalence of symptoms was high, but only a smaller portion of these symptoms were experienced frequently. Psychological stress particularly contributed to the prevalence and frequency of concurrent symptoms and predicted symptoms up to 16 weeks later, independent of medical risk, smoking, and weight gain.Conclusions: Prevalence rates may be inflated, because many symptoms were experienced only 'occasionally' during each of the 4-week periods we sampled. By examining how frequently symptoms were experienced, we gained an indication of which symptoms are more likely to be bothersome or intrude upon daily activities. Psychosocial variables accounted for individual differences in symptom reports after taking biomedical factors into account. Attention to psychosocial variables in future studies will aid in our understanding of the etiology of pregnancy symptoms. [ABSTRACT FROM AUTHOR]

This study investigated the association between maternal cigarette smoking and fetal growth, evaluated by longitudinal ultrasound examinations and by neonatal anthropometric measurements. The investigation was carried out in a healthy population of affluent Scandinavian women, parity 1 and 2, who were selected consecutively and prospectively, and with term, normal pregnancies. Three hundred and six non-smoking, 242 light-smoking and 308 heavy-smoking mothers and their newborns were examined. Ultrasound measurements were performed in pregnancy weeks 17, 25, 33 and 37. Biparietal diameter (BPD), mean abdominal diameter (MAD) and femur length were recorded. The negative effect on fetal growth from maternal smoking was found to affect the male fetus proportionally more than the female. Boys born to heavy-smoking mothers had a weight reduction of 8.2% and a lower fat accretion (as measured by subscapular skinfold) of 12%, whereas girls had a weight and fat reduction of 4.8% and 2% respectively. In boys (but not girls) born to smokers, head circumference was significantly smaller, also reflected by significantly smaller mean BPD measurements recorded from pregnancy week 18 onwards. The MAD measurements became successively more negatively affected in the second half of pregnancy in both males and females. A greater intrauterine growth velocity and a different hormonal milieu are suggested as possible explanations of the greater male susceptibility. [ABSTRACT FROM AUTHOR]

Hereditary non-polyposis colorectal cancer (HNPCC) is linked to an inherited defect in the DNA mismatch repair system. DNA from HNPCC tumours shows microsatellite instability (MSI). It has been reported that HNPCC patients have a better prognosis than patients with sporadic colorectal cancer. We examined whether the presence of MSI in a series of unselected colorectal tumours carries prognostic information. In a series of 181 unselected colorectal tumours, 22 tumours (12%) showed MSI. Survival analysis at 5-10 years follow-up showed no statistically significant difference in prognosis between MSI-positive and -negative tumours. Our results suggest that the MSI phenotype as such is not an independent prognostic factor. [ABSTRACT FROM AUTHOR]

A hospital-based study was undertaken in Harare, Zimbabwe to estimate the proportion of unplanned or unintended pregnancy among mothers who delivered at the referral hospital and to analyse their socio-demographic pattern and sexual relationships. A case-referent study design was used with systematic sampling of maternity records of mothers who had delivered. Interviews were performed before discharge using a semi-structured questionnaire. Mothers who reported that the index pregnancy was unplanned or unintended constituted the cases, and the referents were those reporting the pregnancy as planned. Out of 923 deliveries, 41% were unplanned and 9% unwanted. The mean age of the mothers was 25 years and women aged 19 or below [Odds Ratio (OR) = 2.2, 95% CI = 1.5-3.2] and 35 or above (OR = 2.8, 95% CI = 1.7-4.6) were significantly more likely to present with unplanned pregnancy. Nulliparous women (OR = 2.4) and mothers with five or more pregnancies (OR = 8.2) had a significantly increased likelihood of the pregnancy being unplanned. Level of education in the mothers studied had no independent association to planning of pregnancy. Unemployed (OR = 14) and single (OR = 7.8), or divorced/separated/widowed (OR = 5.1) women as well as those with low income (OR = 2.1) and whose partner earned no income (OR = 2.2), were more at risk of unplanned pregnancy. Those living with their own parents despite being pregnant were also more likely to report an unplanned pregnancy. In conclusion, there are documentable social and reproductive factors underlying unwanted pregnancy. Risk factors for unplanned pregnancy form a pattern similar to those for maternal mortality. Thus unplanned pregnancy is a major indicator of the presence of factors known to increase the risk of maternal death. Policy makers and health education should address factors contributing to unplanned pregnancy and its prevention in order to prevent reproductive mortality and morbidity. The presence of those factors associated with unplanned pregnancy at booking or delivery should also alert service providers to the need for appropriate contraceptive counselling as part of post delivery care. [ABSTRACT FROM AUTHOR]

Background: We previously reported that the alpha-1 chain of type 11 collagen (COL11A1), not normally expressed in the colon, was up-regulated in stromal fibroblasts in most sporadic colorectal carcinomas. Patients with germline mutations in the APC gene show, besides colonic polyposis, symptoms of stromal fibroblast involvement, which could be related to COL11A1 expression. Most colorectal carcinomas are suggested to be a result of an activated Wnt- pathway, most often involving an inactivation of the APC gene or activation of beta-catenin.Methods: We used normal and polyp tissue samples from one FAP patient and a set of 37 sporadic colorectal carcinomas to find out if the up-regulation of COL11A1 was associated with an active APC/beta-catenin pathway.Results: In this study we found a statistically significant difference in COL11A1 expression between normal tissue and adenomas from one FAP patient, and all adenomas gave evidence for an active APC/beta-catenin pathway. An active Wnt pathway has been suggested to involve stromal expression of WISP-1. We found a strong correlation between WISP-1 and COL11A1 expression in sporadic carcinomas.Conclusions: Our results suggest that expression of COL11A1 in colorectal tumors could be associated with the APC/beta-catenin pathway in FAP and sporadic colorectal cancer. [ABSTRACT FROM AUTHOR]