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Understanding synergies between neurodegenerative and cerebrovascular pathologies that modify dementia presentation represents an important knowledge gap.This multi-site, longitudinal, observational cohort study recruited participants across prevalent neurodegenerative diseases and cerebrovascular disease and assessed participants comprehensively across modalities. We describe univariate and multivariate baseline features of the cohort and summarize recruitment, data collection, and curation processes.We enrolled 520 participants across five neurodegenerative and cerebrovascular diseases. Median age was 69 years, median Montreal Cognitive Assessment score was 25, median independence in activities of daily living was 100% for basic and 93% for instrumental activities. Spousal study partners predominated; participants were often male, White, and more educated. Milder disease stages predominated, yet cohorts reflect clinical presentation.Data will be shared with the global scientific community. Within-disease and disease-agnostic approaches are expected to identify markers of severity, progression, and therapy targets. Sampling characteristics also provide guidance for future study design.

Ultraviolet radiation (UVR) has been an effective treatment for a number of chronic skin disorders, and its ability to alleviate these conditions has been well documented. Although nonionizing, exposure to ultraviolet (UV) radiation is still damaging to deoxyribonucleic acid integrity, and has a number of unpleasant side effects ranging from erythema (sunburn) to carcinogenesis. As the conditions treated with this therapy tend to be chronic, exposures are repeated and can be high, increasing the lifetime probability of an adverse event or mutagenic effect. Despite the potential detrimental effects, quantitative ultraviolet dosimetry for phototherapy is an underdeveloped area and better dosimetry would allow clinicians to maximize biological effect whilst minimizing the repercussions of overexposure. This review gives a history and insight into the current state of UVR phototherapy, including an overview of biological effects of UVR, a discussion of UVR production, illness treated by this modality, cabin design and the clinical implementation of phototherapy, as well as clinical dose estimation techniques. Several dose models for ultraviolet phototherapy are also examined, and the need for an accurate computational dose estimation method in ultraviolet phototherapy is discussed.

Background Homeopathy is a system of complementary and alternative medicine based on a belief that a malady can be treated by the administration of an extreme dilution of an agent thought to cause the physical signs of that malady. Homeopathy enjoys popular support from the general public and advocates of alternative medicine, but most large-scale clinical trials show no homeopathy to be no more effective than placebo treatment. Objectives To explore the chemical and physical plausibility of homeopathic treatments. Methods Homeopathic claims were put into a physical context and analysed using the laws of basic physics and chemistry. Results Through the laws of physics, homeopathic medicines appear to have zero chance of containing any biologically active component. Evidence from physical chemistry also rules out the plausibility of mechanisms such as water memory. Conclusions The proposed mechanisms of homeopathy are shown to be implausible when analysed from a physical and chemical perspective, and thus it is of no surprise that the biological effects of homeopathy cannot be measured in large-scale clinical trials.

Background Acne is a common skin disorder among women. Although no uniform approach to the management of acne exists, combination oral contraceptives (COCs), which contain an estrogen and a progestin, often are prescribed for women. Objectives To determine the effectiveness of combined oral contraceptives (COCs) for the treatment of facial acne compared to placebo or other active therapies. Search strategy We searched for randomized controlled trials of COCs and acne in the computerized databases of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, and LILACS. We also searched for clinical trials in ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP). We wrote to authors of identified trials to seek any unpublished or published trials that we might have missed. Selection criteria All randomized controlled trials reported in any language that compared the effectiveness of a COC containing an estrogen and a progestin to placebo or another active therapy for acne in women were eligible. Data collection and analysis We extracted data on total and specific (i.e., open or closed comedones, papules, pustules and nodules) facial lesion counts; acne severity grades; global assessments by the clinician or the participant and discontinuation due to adverse events. Data were entered and analyzed in RevMan. Main results The search yielded 25 trials: 7 placebo-controlled trials made 4 different comparisons, 17 trials made 13 comparisons between 2 different COC regimens, and 1 additional trial compared a COC to an antibiotic. COCs reduced acne lesion counts, severity grades and self-assessed acne compared to placebo. Differences in the comparative effectiveness of COCs containing varying progestin types and dosages, though, were less clear. COCs that contained chlormadinone acetate or cyproterone acetate improved acne better than levonorgestrel, although this apparent advantage was based on limited data. A COC with cyproterone acetate might result in better acne outcomes than one with desogestrel; however, the three studies comparing these COCs produced conflicting results. Likewise, levonorgestrel showed a slight improvement over desogestrel in acne outcomes in one trial, but a second trial found the COC groups were similar. Authors' conclusions The four COCs evaluated in placebo-controlled trials are effective in reducing inflammatory and non-inflammatory facial acne lesions. Few important differences were found between COC types in their effectiveness for treating acne. How COCs compare to alternative acne treatments is unknown since limited data were available regarding this question. Plain Language Summary Effect of birth control pills on acne in women Acne is a common skin problem for women. Several treatments are available. Combined birth control pills, which have the hormones estrogen and progestin, are often prescribed for women with acne. This review looked at how well birth control pills worked to treat facial acne. We did a computer search for studies of birth control pills and acne treatment. Outcomes could be the amount of acne, how severe the acne was, and how many women dropped out early due to problems. We wrote to researchers to find other trials. We included randomized trials in any language that compared two types of birth control pills, a pill and a placebo or 'dummy,' or a pill and another acne treatment. We found 25 trials: 7 trials used 'dummies,' 17 compared different types of birth control pills, and 1 compared a pill and an antibiotic. The three pills studied in trials with dummies worked well to reduce facial acne. In comparing pills with different hormones, no important differences were seen. The conclusions did not change when we added trials in this update to the other studies. Most trials compared two types of pills for acne treatment. Better quality studies are needed to compare one birth control pill with another. How birth control pills compare to other acne treatments like antibiotics is unclear. Since birth control pills improve acne, they can be used to treat women with acne who also want birth control.

Purpose: Ultraviolet phototherapy is a widely used treatment which has exceptional success with a variety of skin conditions. Over-exposure to ultraviolet radiation (UVR) can however be detrimental and cause side effects such as erythema, photokeratisis, and even skin cancer. Quantifying patient dose is therefore imperative to ensure biologically effective treatment while minimizing negative repercussions. A dosemodel for treatment would be valuable in achieving these ends. Methods: Prior work by the authors concentrated on modeling the output of the lamps used in treatment and it was found a line source model described the output from the sources to a high degree. In practice, these lamps are surrounded by reflective anodized aluminum in patient treatment cabins and this work extends the model to quantify specular reflections from these planes on patient dose. Results: The extension of the model to allow for reflected images in addition to tube output shows a remarkably good fit to the actual data measured. Conclusions: The reflection model yields impressive accuracy and is a good basis for full UVR cabin modeling.

Purpose: Ultraviolet phototherapy is widely used in the treatment of numerous skin conditions. This treatment is well established and largely beneficial to patients on both physical and psychological levels; however, overexposure to ultraviolet radiation (UVR) can have detrimental effects, such as erythemal responses and ocular damage in addition to the potentially carcinogenic nature of UVR. For these reasons, it is essential to control and quantify the radiationdose incident upon the patient to ensure that it is both biologically effective and has the minimal possible impact on the surrounding unaffected tissue. Methods: To date, there has been little work on dose modeling, and the output of artificial UVR sources is an area where research has been recommended. This work characterizes these sources by formalizing an approach from first principles and experimentally examining this model. Results: An implementation of a line source model is found to give impressive accuracy and quantifies the output radiation well. Conclusions: This method could potentially serve as a basis for a full computational dose model for quantifying patient dose.

Objective To test the feasibility of mounting a randomised controlled trial comparing mifepristone–misoprostol versus dilation and evacuation (D&E) for midtrimester abortion. Design Pilot randomised controlled trial. Setting University of North Carolina Hospitals, Chapel Hill, North Carolina. Population Women aged 18 years or older and without prior uterine operations who requested abortion at 14–19 menstrual weeks of gestation from January 2002 to January 2003. Methods Participants received either mifepristone 200 mg by mouth followed in two days by vaginal then oral misoprostol (Aberdeen regimen) or D&E after one or two days of laminaria preparation. Care was provided by residents under faculty supervision. Main outcome measures Enrolment rate and acceptability of and adverse events associated with methods. Results The trial was stopped at one year because of slow enrolment. Of 47 women eligible for the trial, 29 (62%) declined participation, primarily because of a preference for D&E abortion. Among the 18 participants enrolled, nine were randomised to treatment with mifepristone–misoprostol and 9 to D&E. Compared with D&E, mifepristone–misoprostol abortion caused more pain and adverse events, although none was serious. Conclusions Our findings concerning acceptability and adverse events should be considered hypothesis-generating; they may prove useful in planning a larger randomised controlled trial. Such a trial will be difficult to mount in the US. Hence, we suggest that it be done in a setting where labour-induction abortion is the norm.

Background Steroidal contraceptive use has been associated with changes in bone mineral density in women. Whether such changes increase the risk of fractures later in life is not clear. Osteoporosis is a major public health concern. Age-related decline in bone mass increases the risk of fracture, especially of the spine, hip, and wrist. Concern about bone health influences the recommendation and use of these effective contraceptives globally. Objectives Our aim was to evaluate the effect of using hormonal contraceptives before menopause on the risk of fracture in women. Search methods Through April 2014, we searched for studies of fracture or bone health and hormonal contraceptives in MEDLINE, POPLINE, CENTRAL, EMBASE, and LILACS, as well as ClinicalTrials.gov and ICTRP. We examined reference lists of relevant articles for other trials. For the initial review, we wrote to investigators to find additional trials. Selection criteria Randomized controlled trials (RCTs) were considered if they examined fractures, bone mineral density (BMD), or bone turnover markers in women with hormonal contraceptive use prior to menopause. Eligible interventions included comparisons of a hormonal contraceptive with a placebo or with another hormonal contraceptive that differed in terms of drug, dosage, or regimen. They also included providing a supplement to one group. Data collection and analysis We assessed all titles and abstracts identified through the literature searches. Mean differences were computed using the inverse variance approach. For dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) was calculated. Both included the 95% confidence interval (CI) and used a fixed-effect model. Due to differing interventions, no trials could be combined for meta-analysis. We applied principles from GRADE to assess the evidence quality and address confidence in the effect estimates. In addition, a sensitivity analysis included trials that provided sufficient data for this review and evidence of at least moderate quality. Main results We found 19 RCTs that met our eligibility criteria. Eleven trials compared different combined oral contraceptives (COCs) or regimens of COCs; five examined an injectable versus another injectable, implant, or IUD; two studied implants, and one compared the transdermal patch versus the vaginal ring. No trial had fracture as an outcome. BMD was measured in 17 studies and 12 trials assessed biochemical markers of bone turnover. Depot medroxyprogesterone acetate (DMPA) was associated with decreased bone mineral density (BMD). The placebo-controlled trials showed BMD increases for DMPA plus estrogen supplement and decreases for DMPA plus placebo supplement. COCs did not appear to negatively affect BMD, and some formulations had more positive effects than others. However, no COC trial was placebo-controlled. Where studies showed differences between groups in bone turnover markers, the results were generally consistent with those for BMD. For implants, the single-rod etonogestrel group showed a greater BMD decrease versus the two-rod levonorgestrel group but results were not consistent across all implant comparisons. The sensitivity analysis included 11 trials providing evidence of moderate or high quality. Four trials involving DMPA showed some positive effects of an estrogen supplement on BMD, a negative effect of DMPA-subcutaneous on lumbar spine BMD, and a negative effect of DMPA on a bone formation marker. Of the three COC trials, one had a BMD decrease for the group with gestodene plus EE 15 μg. Another indicated less bone resorption in the group with gestodene plus EE 30 μg versus EE 20 μg. Authors' conclusions Whether steroidal contraceptives influence fracture risk cannot be determined from existing information. The evidence quality was considered moderate overall, largely due to the trials of DMPA, implants, and the patch versus ring. The COC evidence varied in quality but was low overall. Many trials had small numbers of participants and some had large losses. Health care providers and women should consider the costs and benefits of these effective contraceptives. For example, injectable contraceptives and implants provide effective, long-term birth control yet do not involve a daily regimen. Progestin-only contraceptives are considered appropriate for women who should avoid estrogen due to medical conditions.

Background Weight gain is often considered a side effect of combination hormonal contraceptives, and many women and clinicians believe that an association exists. Concern about weight gain can limit the use of this highly effective method of contraception by deterring the initiation of its use and causing early discontinuation among users. However, a causal relationship between combination contraceptives and weight gain has not been established. Objectives The aim of the review was to evaluate the potential association between combination contraceptive use and changes in weight. Search methods In November 2013, we searched the computerized databases CENTRAL (The Cochrane Library), MEDLINE, POPLINE, EMBASE, and LILACS for studies of combination contraceptives, as well as ClinicalTrials.gov and International Clinical Trials Registry Platform (ICTRP). For the initial review, we also wrote to known investigators and manufacturers to request information about other published or unpublished trials not discovered in our search. Selection criteria All English-language, randomized controlled trials were eligible if they had at least three treatment cycles and compared a combination contraceptive to a placebo or to a combination contraceptive that differed in drug, dosage, regimen, or study length. Data collection and analysis All titles and abstracts located in the literature searches were assessed. Data were entered and analyzed with RevMan. A second author verified the data entered. For continuous data, we calculated the mean difference and 95% confidence interval (CI) for the mean change in weight between baseline and post-treatment measurements using a fixed-effect model. For categorical data, such as the proportion of women who gained or lost more than a specified amount of weight, the Peto odds ratio with 95% CI was calculated. Main results We found 49 trials that met our inclusion criteria. The trials included 85 weight change comparisons for 52 distinct contraceptive pairs (or placebos). The four trials with a placebo or no intervention group did not find evidence supporting a causal association between combination oral contraceptives or a combination skin patch and weight change. Most comparisons of different combination contraceptives showed no substantial difference in weight. In addition, discontinuation of combination contraceptives because of weight change did not differ between groups where this was studied. Authors' conclusions Available evidence was insufficient to determine the effect of combination contraceptives on weight, but no large effect was evident. Trials to evaluate the link between combination contraceptives and weight change require a placebo or non-hormonal group to control for other factors, including changes in weight over time.

BACKGROUND: Worldwide, hormonal contraceptives are among the most popular reversible contraceptives. Despite high perfect‐use effectiveness rates, typical‐use effectiveness rates for shorter‐term methods such as oral and injectable contraceptives are much lower. In large part, this disparity reflects difficulties in ongoing adherence to the contraceptive regimen and low continuation rates. Correct use of contraceptives to ensure effectiveness is vital to reducing unintended pregnancy. OBJECTIVES: To determine the effectiveness of strategies aiming to improve adherence to, and continuation of, shorter‐term hormonal methods of contraception compared with usual family planning care. SEARCH METHODS: We searched to July 2018 in the following databases (without language restrictions): The Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 7), PubMed via MEDLINE, POPLINE, Web of Science, ClinicalTrials.gov, and the International Clinical Trials Registry Platform (ICTRP). SELECTION CRITERIA: We included randomized controlled trials (RCTs) comparing strategies aimed to facilitate adherence and continuation of shorter‐term hormonal methods of contraception (such as oral contraceptives (OCs), injectable depot medroxyprogesterone acetate (DMPA or Depo‐Provera), intravaginal ring, or transdermal patch) with usual family planning care in reproductive age women seeking to avoid pregnancy. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures recommended by Cochrane. Primary outcomes were continuation or discontinuation of contraceptive method, rates of discontinuation due to adverse events (menstrual disturbances and all other adverse events), and adherence to method use as indicated by missed pills and on‐time/late injections. Pregnancy was a secondary outcome. MAIN RESULTS: We included 10 RCTs involving 6242 women. Six trials provided direct in‐person counseling using either multiple counseling contacts or multiple components during one visit. Four trials provided intensive reminders of appointments or next dosing, of which two provided additional educational health information as well as reminders. All trials stated 'usual care' as the comparison. The certainty of the evidence ranged from very low to moderate. Main limitations were risk of bias (associated with poor reporting of methodological detail, lack of blinding, and incomplete outcome data), inconsistency, indirectness, and imprecision. Continuation of hormonal contraceptive methods It is uncertain whether intensive counseling improves continuation of hormonal contraceptive methods compared with usual care (OR 1.28, 95% CI 1.07 to 1.54; 2624 participants; 6 studies; I(2) = 79%; very low certainty evidence). The evidence suggested: if the chance of continuation with usual care is 39%, the chance of continuation with intensive counseling would be between 41% and 50%. The overall pooled OR suggested continuation of improvement, however, when stratified by contraceptive method type, the positive results were restricted to DMPA. It is uncertain whether reminders (+/‐ educational information) improve continuation of hormonal contraceptive methods compared with usual care (OR 1.33, 95% CI 1.03 to 1.73; 933 participants; 2 studies; I(2) = 69%; very low certainty evidence).The evidence suggested: if the chance of continuation with usual care is 52%, the chance of continuation with reminders would be between 52% and 65%. Discontinuation due to adverse events The evidence suggested that counseling may be associated with a decreased rate of discontinuation due to adverse events compared with usual care, with a lower rate of discontinuation due to menstrual disturbances (OR 0.20, 95% CI 0.11 to 0.37; 350 participants; 1 study; low certainty evidence), but may make little or no difference to all other adverse events (OR 0.73, 95% CI 0.36 to 1.47; 350 participants; 1 study; low certainty evidence). The evidence suggested: if the chance of discontinuation with usual care due to menstrual disturbances is 32%, the chance of discontinuation with intensive counseling would be between 5% and 15%; and that if the chance of discontinuation with usual care due to other adverse events is 55%, the chance of discontinuation with intensive counseling would be between 30% and 64%. Discontinuation was not reported among trials that investigated the use of reminders (+/‐ educational information). Adherence Adherence was not reported among trials that investigated the use of intensive counseling. Among trials that investigated reminders (+/‐ educational information), there was no conclusive evidence of a difference in adherence as indicated by missed pills (MD 0.80, 95% CI ‐1.22 to 2.82; 73 participants; 1 study; moderate certainty evidence) or by on‐time injections (OR 0.84, 95% CI 0.54 to 1.29; 350 participants; 2 studies; I(2) = 0%; low certainty evidence). The evidence suggested: if the chance of adherence to method use as indicated by on‐time injections with usual care is 50%, the chance of adherence with method use as indicated by on‐time injections with reminders would be between 35% and 56%. Pregnancy There was no conclusive evidence of a difference in rates of pregnancy between intensive counseling and usual care (OR 1.24, 95% CI 0.98 to 1.57; 1985 participants; 3 studies; I(2) = 0%, very low certainty evidence). The evidence suggested: if the chance of pregnancy with usual care is 18%, the chance of pregnancy with counseling would be between 18% and 25%. Pregnancy was not reported among trials that investigated the use of reminders (+/‐ educational information). AUTHORS' CONCLUSIONS: Despite the importance of this topic, studies have not been published since the last review in 2013 (nine studies) with only one study added in 2019 that neither changed the results nor improved the certainty of evidence. Overall, the certainty of evidence for strategies to improve adherence and continuation of contraceptives is low. Intensive counseling and reminders (with or without educational information) may be associated with improved continuation of shorter‐term hormonal contraceptive methods when compared with usual family planning care. However, this should be interpreted with caution due to the low certainty of the evidence. Included trials used a variety of shorter‐term hormonal contraceptive methods which may account for the high heterogeneity. It is possible that the effectiveness of strategies for improving adherence and continuation are contingent on the contraceptive method targeted. There was limited reporting of objectively measurable outcomes (e.g. electronic monitoring device) among included studies. Future trials would benefit from standardized definitions and measurements of adherence, and consistent terminology for describing interventions and comparisons. Further research requires larger studies, follow‐up of at least one year, and improved reporting of trial methodology.

BACKGROUND: Knowledge of contraceptive effectiveness is crucial to making an informed choice. The consumer has to comprehend the pros and cons of the contraceptive methods being considered. Choice may be influenced by understanding the likelihood of pregnancy with each method and factors that influence effectiveness. OBJECTIVES: To review all randomized controlled trials comparing strategies for communicating to consumers the effectiveness of contraceptives in preventing pregnancy. SEARCH METHODS: Through February 2013 we searched the computerized databases of MEDLINE POPLINE CENTRAL PsycINFO and CINAHL ClinicalTrials.gov and ICTRP. Previous searches also included EMBASE. We also examined references lists of relevant articles. For the initial review we wrote to known investigators for information about other published or unpublished trials. SELECTION CRITERIA: We included randomized controlled trials that compared methods for communicating contraceptive effectiveness to consumers. The comparison could be usual practice or an alternative to the experimental intervention.Outcome measures were knowledge of contraceptive effectiveness attitude about contraception or toward any particular contraceptive and choice or use of contraceptive method. DATA COLLECTION AND ANALYSIS: For the initial review two authors independently extracted the data. One author entered the data into RevMan and a second author verified accuracy. For the update an author and a research associate extracted entered and checked the data.For dichotomous variables we calculated the Mantel-Haenszel odds ratio with 95% confidence intervals (CI). For continuous variables we computed the mean difference (MD) with 95% CI. MAIN RESULTS: Seven trials met the inclusion criteria and had a total of 4526 women. Five were multi-site studies. Four trials were conducted in the USA while Nigeria and Zambia were represented by one study each and one trial was done in both Jamaica and India.Two trials provided multiple sessions for participants. In one study that examined contraceptive choice women in the expanded program were more likely to choose sterilization (OR 4.26; 95% CI 2.46 to 7.37) or use a modern contraceptive method (OR 2.35; 95% CI 1.82 to 3.03) i.e. sterilization pills injectable intrauterine device or barrier method. For the other study the groups received educational interventions with differing format and intensity. Both groups reportedly had increases in contraceptive use but they did not differ significantly by six months in consistent use of an effective contraceptive i.e. sterilization IUD injectable implant and consistent use of oral contraceptives diaphragm or male condoms.Five trials provided one session and focused on testing educational material or media. In one study knowledge gain favored a slide-and-sound presentation versus a physicians oral presentation (MD -19.00; 95% CI -27.52 to -10.48). In another trial a table with contraceptive effectiveness categories led to more correct answers than a table based on pregnancy numbers [ORs were 2.42 (95% CI 1.43 to 4.12) and 2.19 (95% CI 1.21 to 3.97)] or a table with effectiveness categories and pregnancy numbers [ORs were 2.58 (95% CI 1.5 to 4.42) and 2.03 (95% CI 1.13 to 3.64)]. Still another trial provided structured counseling with a flipchart on contraceptive methods. The intervention and usual-care groups did not differ significantly in choice of contraceptive method (by effectiveness category) or in continuation of the chosen method at three months. Lastly a study with couples used videos to communicate contraceptive information (control motivational contraceptive methods and both motivational and methods videos). The analyses showed no significant difference between the groups in the types of contraceptives chosen. AUTHORS CONCLUSIONS: These trials varied greatly in the types of participants and interventions to communicate contraceptive effectiveness. Therefore we cannot say overall what would help consumers choose an appropriate contraceptive method. For presenting pregnancy risk data one trial showed that effectiveness categories were better than pregnancy numbers. In another trial audiovisual aids worked better than the usual oral presentation. Strategies should be tested in clinical settings and measured for their effect on contraceptive choice. More detailed reporting of intervention content would help in interpreting results. Reports could also include whether the instruments used to assess knowledge or attitudes were tested for validity or reliability. Follow-up should be incorporated to assess retention of knowledge over time. The overall quality of evidence was considered to be low for this review given that five of the seven studies provided low or very low quality evidence.

Background Tubal sterilization by hysteroscopy involves inserting a foreign body in both fallopian tubes. Over a three-month period, the tubal lumen is occluded by tissue growth stimulated by the insert. Tubal sterilization by hysteroscopy has advantages over laparoscopy or mini-laparotomy, including the avoidance of abdominal incisions and the convenience of performing the procedure in an office-based setting. Pain, an important determinant of procedure acceptability, can be a concern when tubal sterilization is performed in the office. Objectives To review all randomized controlled trials that evaluated interventions to decrease pain during tubal sterilization by hysteroscopy. Search methods From January to March 2011, we searched the computerized databases of MEDLINE, POPLINE, CENTRAL, EMBASE, LILACS, and CINAHL for relevant trials. We searched for current trials via Clinicaltrials.gov. We also examined the reference lists of pertinent articles and wrote to known investigators for information about other published or unpublished trials. Selection criteria We included all randomized controlled trials that evaluated pain management at the time of sterilization by hysteroscopy. The intervention could be compared to another intervention or placebo. Data collection and analysis Initial data were extracted by one review author. A second review author verified all extracted data. Whenever possible, the analysis was conducted with all women randomized and in the original assigned groups. Data were analyzed using RevMan software. Pain was measured using either a 10-cm or 100-point visual analog scale (VAS). When pain was measured at multiple points during the procedure, the overall pain score was considered the primary treatment effect. If this was not measured, a summation of all pain scores for the procedure was considered to be the primary treatment effect. For continuous variables, the mean difference with 95% confidence interval was computed. Main results Two trials met the inclusion criteria. The total number of participants was 167. Using a 10-cm VAS to measure pain, no significant difference emerged in overall pain for the entire procedure between women who received a paracervical block with lidocaine versus normal saline (mean difference -0.77; 95% CI -2.67 to 1.13). No significant difference in pain score was noted at the time of injection of study solution to the anterior lip of the cervix (mean difference -0.6; 95% CI -1.3 to 0.1), placement of the device in the tubal ostia (mean difference -0.60; 95% CI -1.8 to 0.7), and postprocedure pain (mean difference 0.2; 95% CI -0.8 to 1.2). Procedure time (mean difference -0.2 minutes; 95% CI -2.2 to 1.8 minutes) and successful bilateral placement (OR 1.0; 95% CI 0.19 to 5.28) was not significantly different between groups. During certain portions of the procedure, such as placement of the tenaculum (mean difference -2.03; 95% CI -2.88 to -1.18), administration of the paracervical block (mean difference -1.92; 95% CI -2.84 to -1.00), and passage of the hysteroscope through the external (mean difference -2.31; 95% CI -3.30 to -1.32) and internal os (mean difference -2.31; 95% CI -3.39 to -1.23), use of paracervical block with lidocaine resulted in lower pain scores. Using a 600-point scale calculated by adding 100-point VAS scores from six different portions of the procedure, no significant difference emerged in overall pain between women who received intravenous conscious sedation versus oral analgesia (mean difference -23.00; CI -62.02 to 16.02). Using a 100-point VAS, no significant difference emerged at the time of speculum insertion (mean difference 4.0; 95% CI -4.0 to 12.0), cervical injection of lidocaine (mean difference -1.8; 95% CI -10.0 to 6.4), insertion of the hysteroscope (mean difference -8.7; 95% CI -19.7 to 2.3), placement of the first device (mean difference -4.4; 95% CI -15.8 to 7.0), and removal of the hysteroscope (mean difference 0.9; 95% CI -3.9 to 5.7). Procedure time (mean difference -0.2 minutes; 95% CI -2.0 to 1.6 minutes) and time in the recovery area (mean difference 3.6 minutes; 95% CI -11.3 to 18.5 minutes) was not different between groups. However, women who received intravenous conscious sedation had lower pain scores at the time of insertion of the second tubal device compared to women who received oral analgesia (mean difference -12.60; CI -23.98 to -1.22). Authors' conclusions The available literature is insufficient to determine the appropriate analgesia or anesthesia for sterilization by hysteroscopy. Compared to paracervical block with normal saline, paracervical block with lidocaine reduced pain during some portions of the procedure. Intravenous sedation resulted in lower pain scores during insertion of the second tubal device. However, neither paracervical block with lidocaine nor conscious sedation significantly reduced overall pain scores for sterilization by hysteroscopy.

BACKGROUND: Male hormonal contraception has been an elusive goal. Administration of sex steroids to men can shut off sperm production through effects on the pituitary and hypothalamus. However this approach also decreases production of testosterone so add-back therapy is needed. OBJECTIVES: To summarize all randomized controlled trials (RCTs) of male hormonal contraception. SEARCH METHODS: In January and February 2012 we searched the computerized databases CENTRAL MEDLINE POPLINE and LILACS. We also searched for recent trials in ClinicalTrials.gov and ICTRP. Previous searches included EMBASE. We wrote to authors of identified trials to seek additional unpublished or published trials. SELECTION CRITERIA: We included all RCTs that compared a steroid hormone with another contraceptive. We excluded non-steroidal male contraceptives such as gossypol. We included both placebo and active-regimen control groups. DATA COLLECTION AND ANALYSIS: The primary outcome measure was the absence of spermatozoa on semen examination often called azoospermia. Data were insufficient to examine pregnancy rates and side effects. MAIN RESULTS: We found 33 trials that met our inclusion criteria. The proportion of men who reportedly achieved azoospermia or had no detectable sperm varied widely. A few important differences emerged. 1) Levonorgestrel implants (160 mug daily) combined with injectable testosterone enanthate (TE) were more effective than levonorgestrel 125 microg daily combined with testosterone patches. 2) Levonorgestrel 500 mug daily improved the effectiveness of TE 100 mg injected weekly. 3) Levonorgestrel 250 mug daily improved the effectiveness of testosterone undecanoate (TU) 1000 mg injection plus TU 500 mg injected at 6 and 12 weeks. 4) Desogestrel 150 mug was less effective than desogestrel 300 mug (with testosterone pellets). 5) TU 500 mg was less likely to produce azoospermia than TU 1000 mg (with levonorgestrel implants). 6) Norethisterone enanthate 200 mg with TU 1000 mg led to more azoospermia when given every 8 weeks versus 12 weeks. 7) Four implants of 7-alpha-methyl-19-nortestosterone (MENT) were more effective than two MENT implants. We did not conduct any meta-analysis due to intervention differences.Several trials showed promising efficacy in percentages with azoospermia. Three examined desogestrel and testosterone preparations or etonogestrel and testosterone and two examined levonorgestrel and testosterone. AUTHORS CONCLUSIONS: No male hormonal contraceptive is ready for clinical use. Most trials were small exploratory studies. Their power to detect important differences was limited and their results imprecise. In addition assessment of azoospermia can vary by sensitivity of the method used. Future trials need more attention to the methodological requirements for RCTs. More trials with adequate power would also be helpful.

BACKGROUND: Quadriphasic oral contraceptives have been developed to reduce the adverse effects of oral contraceptives and are presented as more physiological since they mimic the natural cycle. However suggested disadvantages of quadriphasic oral contraceptives include a possible increased risk of pill-taking errors caused by the array of different color pills complicated directions for catching up when a pill is missed the higher price and potential inferiority in terms of side effects. OBJECTIVES: To compare the contraceptive effectiveness bleeding pattern minor side effects and acceptability of quadriphasic contraceptive pills versus monophasic contraceptive pills. SEARCH STRATEGY: We searched CENTRAL MEDLINE EMBASE POPLINE ClinicalTrials.gov and ICTRP for trials comparing quadriphasic pills with monophasic pills. We contacted researchers and manufacturers of quadriphasic oral contraceptives to identify additional studies. SELECTION CRITERIA: Randomized controlled trials (RCTs) comparing quadriphasic with monophasic oral contraceptives . Trials had to report on contraceptive effectiveness bleeding patterns minor side effects ease of use or trial discontinuation. We excluded studies where the intervention was primarily used as a treatment for disorders or was administered for fewer than three consecutive cycles. DATA COLLECTION AND ANALYSIS: T wo authors abstracted and entered data into RevMan. We critically appraised the methodological quality of the included trials. For continuous variables we computed the mean difference with 95% confidence interval (CI) using the random-effects model. For dichotomous variables we calculated the risk ratio with 95% CI using the random-effects model. MAIN RESULTS: We included one double-blind double-dummy RCT comparing a quadriphasic oral contraceptive composed of dienogest and estradiol valerate with a monophasic oral contraceptive composed of levonorgestrel and ethinylestradiol. Contraceptive effectiveness intracyclic bleeding and discontinuation due to side effects were similar for quadriphasic and monophasic pills. The number of women experiencing withdrawal bleeding was higher in the monophasic group compared to the quadriphasic group. Users of quadriphasic pills reported fewer bleeding/spotting days and fewer bleeding/spotting episodes than users of monophasic pills but the report did not specify whether the bleeding/spotting was scheduled or unscheduled. More women using quadriphasic oral contraceptives reported breast pain compared to women using monophasic oral contraceptives. AUTHORS CONCLUSIONS: The available evidence is insufficient to determine whether quadriphasic differ from monophasic oral contraceptives in contraceptive effectiveness bleeding pattern minor side effects and acceptability. Studies that compare quadriphasic and monophasic oral contraceptives with an identical progestogen and estrogen type are needed to determine whether the quadriphasic approach differs from the monophasic approach. Studies that compare quadriphasic pills with monophasic pills containing 30 mug ethinylestradiol are indicated to determine whether quadriphasic oral contraceptives have an advantage over the current first choice oral contraceptive . Until then we recommend monophasic pills containing 30 mug estrogen as the first choice for women starting oral contraceptive use.

Striped bass Morone saxatilis were collected from Lake Anna, a thermally enriched Virginia reservoir, and Smith Mountain Lake, an ambient-temperature Virginia reservoir, and their ovaries were compared for differences in vitellolipid and vitelloprotein. Habitat analyses indicated summer temperatures and dissolved oxygen concentrations were stressful to striped bass in Lake Anna and nonstressful to striped bass in Smith Mountain Lake. Summer ovary weights, condition factors, and body lengths and weights were significantly lower for Lake Anna striped bass than for Smith Mountain Lake fish. Total vitellolipid and total vitelloprotein concentrations did not differ significantly between the two samples, but concentrations of vitellotriglyceride and other esters and of certain component vitelloproteins were significantly greater in ovaries of Smith Mountain Lake striped bass. These data indicate bioenergetic stresses in Lake Anna did not significantly affect the quantity of vitellolipids and vitellopro...

This book was written as an authoritative update to the previous textbook produced in 1999 by the National Abortion Federation (NAF). The previous text, A Clinician’s Guide to Medical and Surgical Abortion, addressed rapidly changing issues of the time in the provision of excellent abortion care. This new text further updates the ongoing evolution of the field, in an area of medical care with a fairly scanty literature. The important context of such work is the immense political and religious turmoil in the United States, and the world, on the subject of abortion, despite the fact that it is one of the most common procedures performed in medicine. Abortion has been a common, if often hidden, fact of life in all cultures, in all periods of history. Unsafe abortion leads, all too often, to death or permanent injury; safe abortion is much medically safer than continuing a pregnancy. The intent of this book is to improve the provision of safe abortion. The book addresses a broad range of abortion-related issues, from the sociopolitical and global health challenges, to technical aspects of specialized areas of abortion care such as late pregnancy terminations and selective reduction of multiple gestations, as well as practical aspects of counseling, contraception, and requirements for establishing safe services. There is a comprehensive appendix of resources for abortion providers. The book is consistently readable. The organization is sound, and the progression of chapters and topics flows quite smoothly. What I particularly appreciated was the flexibility of recommendations. Many clinicians will have strong preferences for the “right” way to do things. This text strives to offer appropriate options for individual practice, without insisting on a specific method. The panel of editors includes some of the most highly regarded experts in the field and draws on a distinguished group of authors, including some from England, Sweden, and the World Health Organization in Switzerland. I was disappointed by the absence of family physicians in the authorial collection. Family physicians are an increasingly active group within the abortion community, and increasing access to abortion training in family medicine residencies is an area of ongoing activism within our field. Physicians from several disciplines other than OB-GYN, particularly family medicine and pediatrics, have produced significant research in the abortion field and have contributed considerably to the provision of abortion services, particularly in communities where there would otherwise be little to no access to such care. This book will be most useful for clinicians providing abortion care, at every level of training and experience, from medical students to senior practitioners. It will, however, also prove useful for those interested in the social, psychological, and public health aspects of abortion. Many readers will learn from a single reading; abortion clinicians will want this book on their reference shelf.

Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health

Side effects caused by oral contraceptives discourage compliance with and continuation of oral contraceptives. A suggested disadvantage of biphasic compared to triphasic oral contraceptive pills is an increase in breakthrough bleeding. We conducted this systematic review to examine this potential disadvantage.To compare biphasic with triphasic oral contraceptives in terms of efficacy, cycle control, and discontinuation due to side effects.We searched computerized databases MEDLINE, EMBASE, POPLINE and the Cochrane Controlled Trials Register (CCTR). In addition, we searched the reference lists of potentially relevant articles and book chapters. We also contacted the authors of relevant studies and pharmaceutical companies in Europe and the USA.We included randomized controlled trials comparing any biphasic with any triphasic oral contraceptive when used to prevent pregnancy.We examined the studies found during the various literature searches for possible inclusion and assessed their methodological quality using Cochrane guidelines. We contacted the authors of all included studies and of possibly randomized studies for supplemental information about the study methods and outcomes. We entered the data in RevMan 3.1 and later imported it into RevMan 4.1. We calculated Peto odds ratios for incidence of incidence of discontinuation due to medical reasons, intermenstrual bleeding, absence of withdrawal bleeding, and discontinuation due to intermenstrual bleeding.Only two trials of limited quality met our inclusion criteria. Larranaga (1978) compared two biphasic and one triphasic pills, each containing levonorgestrel and ethinyl estradiol. No important differences emerged, and the frequency of discontinuation due to medical problems was similar with all three pills. Percival Smith (1990) compared a biphasic pill containing norethindrone (Ortho 10/11) with a triphasic pill containing levonorgestrel (Triphasil) and another triphasic pill containing norethindrone (Ortho 7/7/7). The biphasic pill had inferior cycle control compared with the levonorgestrel triphasic pill. The odds ratio of cycles with intermenstrual bleeding was 1.7 (95%CI 1.3-2.2) for the biphasic pill compared with the triphasic levonorgestrel pill. The odds ratio of cycles without withdrawal bleeding was 6.5 (95%CI 3.1-13). In contrast, cycle control with the biphasic pill was comparable to that with the triphasic pill containing the same progestin (norethindrone).The available evidence is limited and of poor quality; the internal validity of these trials is questionable. Given the high losses to follow-up after randomization, these reports may be better considered observational in nature. Given that caveat, the biphasic pill containing norethindrone was associated with inferior cycle control compared with the triphasic pill containing levonorgestrel. This suggests that the choice of progestin may be more important than the phasic regimen in determining bleeding patterns.

The male condom which consists of a thin sheath placed over the glans and shaft of the penis is designed to prevent pregnancy by providing a physical barrier against the deposition of semen into the vagina during intercourse. Beginning in the 1990s nonlatex male condoms made of polyurethane film or synthetic elastomers were developed as alternative male barrier methods for individuals with allergies sensitivities or preferences that prevented the consistent use of condoms made of latex. The review sought to evaluate nonlatex male condoms in comparison with latex condoms in terms of contraceptive efficacy breakage slippage safety and user preferences. We searched the the Cochrane Central Register of Controlled Trials (CENTRAL) MEDLINE using PubMed EMBASE Popline and LILACS for randomized controlled trials of nonlatex condoms. The references of eligible publications were assessed for inclusion. We also wrote to the manufacturers of nonlatex condoms and known investigators in an attempt to locate any other published or unpublished trials not identified in our search. The review included all randomized controlled trials identified in the literature search that evaluated a male nonlatex condom made of polyurethane film or synthetic elastomers in comparison with a latex condom. We evaluated all titles and abstracts located in the literature searches for inclusion in the review. Two reviewers independently extracted data from the identified studies. We entered and analyzed data with RevMan 4.1. Peto odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for the outcomes contraceptive efficacy condom breakage and slippage discontinuation of use safety and user preference. The number of condoms men or women was used as the denominator for the ORs. Contraceptive efficacy early discontinuation and safety outcomes were also measured with survival analysis techniques and entered into "Additional tables." While the eZ·on condom did not protect against pregnancy as well as its latex comparison condom no differences were found in the typical-use efficacy in the comparisons between the Avanti and the Standard Tactylon and their latex counterparts. The nonlatex condoms were associated with higher rates of clinical breakage than their latex comparison condoms. The statistically significant odds ratios for clinical breakage for the nonlatex condoms versus their latex comparisons ranged from 2.6 (95% CI: 1.6 to 4.3) to 5.0 (95% CI: 3.6 to 6.8). Few adverse events were reported. In almost all of the comparisons substantial proportions of participants preferred the nonlatex condom or reported that they would recommend its use to others. Although the nonlatex condoms were associated with higher rates of clinical breakage than their latex comparison condoms the new condoms still provide an acceptable alternative for those with allergies sensitivities or preferences that might prevent the consistent use of latex condoms. The contraceptive efficacy of the nonlatex condoms requires more research. (authors)

Background 'Fertility awareness-based methods' of family planning "involve identification of the fertile days of the menstrual cycle, whether by observing fertility signs such as cervical secretions and basal body temperature, or by monitoring cycle days. Fertility awareness-based methods can be used in combination with abstinence or barrier methods during the fertile time" (WHO 2000). Several names have been used to describe this approach to contraception, including 'rhythm,' 'natural family planning' and 'periodic abstinence.' Fertility awareness-based methods can be used with abstinence from sexual intercourse. Alternatively, they can be used with barrier contraceptives or withdrawal during presumed fertile times. Objectives We retrieved and analyzed all randomized controlled trials (RCTs) that examined any fertility awareness-based methods used for contraception. Search methods In February 2012, we searched the computerized databases CENTRAL, MEDLINE, POPLINE, and LILACS for randomized controlled trials of fertility awareness-based methods. We also searched for trials in ClinicalTrials.gov and ICTRP. Previous searches also included EMBASE. For the initial review, we examined the reference lists of trial reports as well as that of review articles. Selection criteria We included all RCTs in any language that compared any fertility awareness-based methods for contraception with a placebo; another method, including an alternative fertility awareness-based method; or fertility awareness-based methods used in conjunction with another contraceptive. Data collection and analysis We assessed all titles and abstracts found for inclusion. We evaluated the methodological quality of the trials for potential biases by qualitatively assessing the study design, randomization method, allocation concealment, blinding, premature discontinuation rates, and loss to follow-up rates. Because of methodological weaknesses, we could not enter the trial results in RevMan, calculate measures of association, or aggregate data. Main results Because of poor methods and reporting, pregnancy rates could not be determined. A trial in Colombia found similar numbers of pregnancies among women randomized to the ovulation and symptothermal methods. In contrast, a companion trial in Los Angeles observed more pregnancies in the group assigned to the ovulation method. In the two USA trials, recruitment of participants was unexpectedly difficult; this aspect was not mentioned in the report from Colombia. Continuation rates were poor. In the two larger trials, most participants discontinued their assigned method before entering the observation phase of the trial. Authors' conclusions The comparative efficacy of fertility awareness-based methods of contraception remains unknown. Despite intensive training and ongoing support, most participants in these trials discontinued prematurely. Contraceptive methods should be properly evaluated, preferably in randomized controlled trials, before adoption and dissemination.

Background This review has been updated by a new team. The new review title is: Chawanpaiboon S, Laopaiboon M, Lumbiganon P, Sangkomkamhang US, Dowswell T. Terbutaline pump maintenance therapy after threatened preterm labour for reducing adverse neonatal outcomes. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD010800. DOI: 10.1002/14651858.CD010800.pub2. Women with preterm labor that is arrested with tocolytic therapy are at increased risk of recurrent preterm labor. Terbutaline pump maintenance therapy has been given to such women to decrease the risk of recurrent preterm labor, preterm birth, and its consequences. Objectives To determine the effectiveness and safety of terbutaline pump maintenance therapy after threatened preterm labor in preventing preterm birth and its complications. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2007). We updated the search in January 2010 and added the results to the awaiting classification section. Selection criteria Randomized trials comparing terbutaline pump maintenance therapy with alternative therapy, placebo, or no therapy after threatened preterm labor. Data collection and analysis Two review authors independently assessed the studies for inclusion and then extracted data from eligible studies. Main results We included two studies. Terbutaline pump maintenance therapy did not appear to offer any advantages over the saline placebo pump or oral terbutaline maintenance therapy in preventing preterm births by prolonging pregnancy or its complications among women with arrested preterm labor. The weighted mean difference (WMD) for gestational age at birth was -0.14 weeks (95% confidence interval (CI) -1.66 to 1.38) for terbutaline pump therapy compared with saline placebo pump for both trials combined and 1.40 weeks (95% CI -1.13 to 3.93) for terbutaline pump versus oral terbutaline therapy for the first trial. The second trial reported a relative risk (RR) of 1.17 (95% CI 0.79 to 1.73) of preterm birth (less than 37 completed weeks) and a RR of 0.97 (95% CI 0.51 to 1.84) of very preterm birth (less than 34 completed weeks) for terbutaline pump compared with saline placebo pump. Terbutaline pump therapy also did not result in a higher rate of therapy continuation or a lower rate of infant complications. No data were reported on long-term infant outcomes, costs, or maternal assessment of therapy. Authors' conclusions Terbutaline pump maintenance therapy has not been shown to decrease the risk of preterm birth by prolonging pregnancy. Furthermore, the lack of information on the safety of the therapy, as well as its substantial expense, argues against its role in the management of arrested preterm labor. Future use should only be in the context of well-conducted, adequately powered randomized controlled trials. [Note: The two citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]

BACKGROUND The cervical cap and the diaphragm are vaginal barrier contraceptive methods that prevent pregnancy by covering the cervix. The two devices also act as a reservoir for spermicide. The cervical cap is smaller and can remain in place longer than the diaphragm. Two types of cervical caps, the Prentif cap and the FemCap, have been compared to the diaphragm in randomized controlled trials. OBJECTIVES The review seeks to evaluate the contraceptive efficacy, safety, discontinuation, and acceptability of the cervical cap with that of the diaphragm. SEARCH STRATEGY We searched MEDLINE, Popline, Cochrane Controlled Trials Register, EMBASE, and LILACS for randomized controlled trials of cervical caps, and we reviewed the references of the included publications. Also, we wrote to the manufacturers and known investigators to request information about any other published or unpublished trials not found in our search. SELECTION CRITERIA All randomized controlled trials in any language comparing a cervical cap with a diaphragm were eligible for inclusion. DATA COLLECTION AND ANALYSIS All titles and abstracts located in the literature searches were assessed, and articles identified for inclusion were independently abstracted by two reviewers. Data were entered and analyzed with RevMan 4.1, and a second reviewer verified the data entered. Outcome measures include contraceptive efficacy, safety, discontinuation, and acceptability. Outcomes were calculated as Peto odds ratios with 95 percent confidence intervals using women as the denominators. Life-table and Kaplan-Meier cumulative rate ratios for selected measures were also presented in "Additional Tables." MAIN RESULTS The Prentif cap was comparable to the diaphragm in preventing pregnancy, but the FemCap was not as effective in preventing pregnancy as its comparison diaphragm. The curves for the life-table cumulative pregnancy rates through 24 months for the Prentif cap and the diaphragm were not statistically significantly different (p-value of 0.39). However, the six-month Kaplan-Meier cumulative pregnancy rates for the FemCap and the diaphragm did not meet the a priori definition of clinical equivalence. The Prentif cap had a higher proportion of Class I to Class III cervical cytologic conversions at the three-month visit than the diaphragm; the odds ratio was 2.3 (95% CI, 1.0-5.1). The FemCap trial did not find differences in Papanicolaou smear results between the cap and diaphragm groups. Prentif cap users had a lower odds ratio of vaginal ulcerations or lacerations (0.3; 95% CI, 0.1-0.7) than diaphragm users. FemCap users had a higher odds ratio of blood in the device on removal (2.3; 95% CI, 1.3-4.1), but a lower odds ratio of urinary tract infections (0.6; 95% CI, 0.4-1.0) than those in the diaphragm group. In the FemCap trial, similar proportions of women reported liking their assigned device "somewhat" or "a lot" at the two-week interview. However, FemCap users were less likely than the diaphragm users to state that they were "probably" or "definitely" likely to use the device alone after completing the trial (odds ratio of 0.5; 95% CI, 0.3-0.7) or that they would recommend it to a friend (odds ratio of 0.5; 95% CI, 0.3-0.8). REVIEWER'S CONCLUSIONS The Prentif cap was as effective as its comparison diaphragm in preventing pregnancy, but the FemCap was not. Both cervical caps appear to be medically safe.

Bilateral ovarian neoplasms are believed more likely to be malignant than are unilateral neoplasms. To our knowledge, this clinical tenet has not been evaluated or quantified. To test this hypothesis, we conducted a 10-year review of ovarian neoplasms found at the time of celiotomy at the Women's Hospital, Los Angeles County-University of Southern California Medical Center. Overall, women with bilateral neoplasms had a 2.6-fold increased risk of malignancy when compared with women who had unilateral neoplasms (95% confidence interval, 2.0 to 3.4; p less than 0.001). The age-standardized relative risk was 1.8 (95% confidence interval 1.4 to 2.3). When standardized for the effect of menopausal status, the relative risk was 2.0 (95% confidence interval, 1.6 to 2.5). Bilaterality is associated with a doubling in the risk of cancer, a highly significant difference.

Scientific skepticism, known more formally as the discipline of epidemiology, can help overcome five obstacles that impede perinatal care: seduction by authority, the false idol of technology, letting sleeping dogmas lie, the pursuit of pedantry, and numerators in search of denominators. When the seduction by authority is strong, epidemiology shows us how to judge data on their own merit and not on the stature of their proponent. Epidemiology teaches us that we need not blindly worship technology; that technology can be our servant, not our master. Epidemiology compels us to rouse those slumbering dogmas and make them prove their merit. Despite the powerful lure of medical pedantry, epidemiology shows us the way out of this multiple-choice mentality. When we are still stinging from our last unpleasant case, epidemiology guides and sustains us through science, reason, and logic—rather than through clinical impression.

2-Ethyl-2-hexenal was hydrogenated over Raney Nickel and nickel boride in a batch slurry reactor. Using Raney Nickel, the reaction went to completion, and the formation of both 2-ethylhexanal and 2-ethylhexanol followed zero order kinetics. Using nickel boride, the reaction ceased at the saturated aldehyde, with saturation of the double bond a zero order reaction. Unsaturated alcohol was not detected in any of the reaction mixtures. On a hydrogene, dans un reacteur discontinu avec suspension de catalyseur, le 2-ethyl-2-hexenal sur du nickel de Raney et du borure de nickel. En presence du nickel de Raney, la reaction est complete et les formations du 2-ethyl-hexenal et du 2-ethylhexanol suivent une cinetique d'ordre zero. En presence de borure de nickel, la reaction s'arrěte a l'aldehyde sature et la saturation de la double liaison est une reaction d'ordre zero. On n'a pas decele d'alcool non sature dans les produits.

A 15-year-old primigravida with severe preeclampsia at term developed blindness. Following delivery by cesarean section, her visual acuity returned promptly. Computerized tomography demonstrated bilateral cerebral lesions in the occipital cortex, which resolved partially by five days and completely by seven months after delivery. Persistent electroencephalogram abnormalities and transient episodes of blindness suggest the presence of residual cerebral damage.