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Background Emergency obstetric care training, using Advances in Labour and Risk Management (ALARM) International Program (AIP) was implemented in Ukraine, a country with universal access to skilled perinatal and obstetric care but restricted resources. A total of 577 providers (65.5% of total) from 28 maternal clinics attended a 5-day training session focused on the five main causes of maternal mortality, with hands-on skill workshops, pre- and post- tests, and an objective structured clinical examination. The effects of this emergency obstetric care training on maternal outcomes is the subject of this paper. Methods A non-randomized controlled trial was conducted. The pilot areas where the training was implemented consisted of 64 maternity clinics of which 28 were considered as cases and 36 non-participating clinics were the referents. Data on maternal outcomes were collected for a 2-year span (2004-2005) prior to the trainings, which took place 2006-2007 and again after implementation of the trainings, from 2008 to 2009. Information was collected from 189,852 deliveries. Outcomes for the study were incidences of operative delivery and postpartum hemorrhage. Non-parametric statistics, meta-analyses, and difference in difference (DID) estimation were used to assess the effect of the AIP on maternal indices. Results DID analysis showed that after the training, compared to the referents, the cases had significant reduction of blood transfusions (OR: 0.56; 95%CI: 0.48-0.65), plasma transfusions (OR: 0.70; 95%CI: 0.63-0.78), and uterus explorations (OR: 0.64; 95%CI: 0.59-0.69). We observed a non-significant reduction of postpartum hemorrhage >= 1000 ml (OR: 0.92; 95%CI: 0.81-1.04; P = 0.103). Utilization of vacuum extraction for vaginal delivery increased (OR: 2.86; 95%CI: 1.80-4.57), as well as forceps assisted delivery (OR: 1.80; 95%CI: 1.00-3.25) and cesarean section (OR: 1.11; 95%CI: 1.06-1.17). There was no change in the occurrence of postpartum hysterectomy and

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.

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.

Objective: To assess the quality of partograms used to monitor tabor in Dar es Salaam hospitals, Tanzania. Methods: The study team reviewed the records of the parameters of tabor, 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 tabor. 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 tabor and indicate urgent in-service training to address the importance of documentation and regular partogram audit in order to reduce maternal and perinatal deaths. (c) 2007 International Federation of Gynecology and Obstetrics.

Objective: Poor obstetric care in low income countries has been attributed to a wide range of factors. We conducted a perinatal care needs assessment in Dar es Salaam health institutions to assess the factors underlying the present poor perinatal outcome. Methods: A cross sectional study was conducted in 2005 in all four public hospitals and all five public health centres purposively selected, and in six dispensaries selected using simple random sampling method. WHO Safe Motherhood needs assessment instruments were used to assess structural, systemic and process needs for quality perinatal care. Health care providers, administrators and clients were interviewed about perinatal care services in their respective health institutions. Results: The majority (72%) of all deliveries in Dar es Salaam took place in the four available public hospitals. The potential coverage of comprehensive and basic emergency obstetric care(EmOC) services were 360% and 350% of the United Nations minimum recommended health institution categories per 500,000 population respectively. The coverage for health centres and dispensaries based on Tanzanian standards were 20% and 24% respectively. Two of the hospitals did not provide theatre and blood transfusion services for 24 hours per day. Two public health centres did not provide delivery services at all and 83% of the dispensaries had poorly established obstetric services. There was only one public neonatal unit that served as a referral institution for all sick newborns delivered in public health institutions in the region. Conclusion: This paper reveals the state of inadequate infrastructure, equipments and supplies for perinatal care in Dar es Salaam public health institutions. A major investment is needed to establish new public infrastructure for maternal and neonatal care, upgrade and optimize use of the existing ones, and improve supply of essential material resources in order to achieve the Millennium Development Goals set for maternal

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 per cent. The 5-year relative survival rate was 70·1 per cent 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 II, 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.

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.

Biallelic germline mutations in the base excision repair gene MYH have been shown to predispose to a proportion of multiple colorectal adenomas and cancer. To evaluate the contribution of MYH mutations to non-FAP, non-HNPCC familial colorectal cancer, 84 unrelated Swedish individuals affected with colorectal cancer from such families were screened for germline mutations in the coding sequence of the gene. None of the cases was found to carry any pathogenic sequence change. We then determined the prevalence of the two most common pathogenic MYH mutations found in Caucasians, Y165C and G382D, in 450 Swedish sporadic colorectal cancer cases and 480 Swedish healthy controls. The frequency of both variants in Swedish cases and controls was similar to those previously reported. In addition, we found that previously unknown sequence variations at the position of amino acid 423 (R423Q, R423P, and R423R) appear to occur more frequently in cases than in controls (p = 0.02), a finding that warrants future studies. © Mary Ann Liebert, Inc.