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Large territory middle cerebral artery (MCA) ischaemic strokes account for around 10% of all ischaemic strokes and have a particularly devastating prognosis when associated with malignant oedema. Progressive cerebral oedema starts developing in the first 24 to 48 hours of stroke ictus with an associated rise in intracranial pressure. The rise in intracranial pressure may eventually overwhelm compensatory mechanisms leading to a cascading secondary damage to surrounding unaffected parenchyma. This downward spiral can rapidly progress to death or severe neurological disability. Early decompressive craniectomy to relieve intracranial pressure and associated tissue shift can help ameliorate this secondary damage and improve outcomes. Evidence has been accumulating of the benefit of early surgical decompression in stroke patients. Earlier studies have excluded people above the age of 60 due to associated poor outcomes; however, newer trials have included this patient subgroup. This review follows a Cochrane Review published in 2012.To assess the effectiveness of surgical decompression in people with malignant oedema after ischaemic stroke with regard to reduction in mortality and improved functional outcome. We also aimed to examine the adverse effects of surgical decompression in this patient cohort.We searched the Cochrane Stroke Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2022, Issue 7 of 12), MEDLINE Ovid, Embase Ovid, Web of Science Core Collection, Scopus databases, ClinicalTrials.gov, and the WHO ICTRP to July 2022. We also reviewed the reference lists of relevant articles.We included randomised controlled trials (RCTs) comparing decompressive craniectomy with medical management to best medical management alone for people with malignant cerebral oedema after MCA ischaemic stroke.Two review authors independently screened the search results, assessed study eligibility, performed risk of bias assessment, and extracted the data. The primary outcomes were death and death or severe disability (modified Rankin Scale (mRS)gt; 4) at 6 to 12 months follow-up. Other outcomes included death or moderate disability (mRSgt; 3), severe disability (mRS = 5), and adverse events. We assessed the certainty of the evidence using the GRADE approach, categorising it as high, moderate, low, or very low.We included nine RCTs with a total of 513 participants included in the final analysis. Three studies included patients younger than 60 years of age; two trials accepted patients up to 80 years of age; and one trial only included patients 60 years or older. The majority of included trials (six) mandated a time from stroke ictus to treatment oflt; 48 hours, whilst in two of them this waslt; 96 hours. Surgical decompression was associated with a reduction in death (odds ratio (OR) 0.18, 95% confidence interval (CI) 0.12 to 0.27, 9 trials, 513 participants, Plt; 0.001; high-certainty evidence); death or severe disability (mRSgt; 4, OR 0.22, 95% CI 0.15 to 0.32, 9 trials, 513 participants, Plt; 0.001; high-certainty evidence); and death or moderate disability (mRSgt; 3, OR 0.34, 95% CI 0.22 to 0.52, 9 trials, 513 participants, Plt; 0.001; moderate-certainty evidence). Subgroup analysis did not reveal any significant effect on treatment outcomes when analysing age (lt; 60 years versus ≥ 60 years); time from stroke ictus to intervention (lt; 48 hours versus ≥ 48 hours); or dysphasia. There was a significant subgroup effect of time at follow-up (6 versus 12 months, P = 0.02) on death as well as death or severe disability (mRSgt; 4); however, the validity of this finding was affected by fewer participant numbers in the six-month follow-up subgroup. There was no consistent reporting of per-participant adverse event rates in any of the included studies, which prevented further analysis.Surgical decompression improves outcomes in the management of malignant oedema after acute ischaemic stroke, including a considerable reduction in death or severe disability (mRSgt; 4) and a reduction in death or moderate disability (mRSgt; 3). Whilst there is evidence that this positive treatment effect is present in patientsgt; 60 years old, it is important to take into account that these patients have a poorer prospect of functional survival independent of this treatment effect. In interpreting these results it must also be considered that the data demonstrating benefit are drawn from a unique patient subset with profound neurological deficit, reduced level of consciousness, and no pre-morbid disability or severe comorbidity.배경: 대뇌중뇌동맥(MCA) 허혈성 뇌졸중은 모든 허혈성 뇌졸중의 약 10%를 차지하며 악성 부종과 관련될 때 특히 파괴적인 예후를 보인다. 진행성 뇌부종은 두개내압의 상승과 함께 발작 발작의 첫 24~48시간 내에 발생하기 시작한다. 두개내압의 상승은 결국 보상 메커니즘을 압도하여 주변의 영향을 받지 않은 실질에 연속화 이차 손상을 일으킬 수 있다. 이 하향 나선은 사망 또는 심각한 신경학적 장애로 빠르게 진행될 수 있다. 두개내압 및 관련 조직 이동을 완화하기 위한 조기 감압 두개골 절제술은 이러한 이차 손상을 개선하고 결과를 개선하는 데 도움이 될 수 있다. 뇌졸중 환자에서 조기 외과적 감압의 이점에 대한 근거가 축적되었다. 이전 연구에서는 관련 불량 결과로 인해 60세 이상의 사람들을 제외했다. 그러나 새로운 시험에는 이 환자 하위 그룹이 포함되었다. 이 검토는 2012년에 게시된 Cochrane 검토를 따른다. 목적: 사망률 감소 및 기능적 결과 개선과 관련하여 허혈성 뇌졸중 후 악성 부종이 있는 사람들의 외과적 감압의 효과를 평가한다. 또한 이 환자 코호트에서 외과적 감압의 부작용을 조사하는 것을 목표로 했다. 검색 전략: Cochrane Stroke Group Trials Register, Cochrane Central Register of Controlled Trials(CENTRAL; 2022, Issue 7 of 12), MEDLINE Ovid, Embase Ovid, Web of Science Core Collection, Scopus 데이터베이스, ClinicalTrials.gov 및 WHO ICTRP를 2022년 7월까지 검색했다. 관련성이 있는 논문의 참고 문헌 목록도 검색했다. 선정 기준: MCA 허혈성 뇌졸중 후 악성 뇌부종이 있는 사람들을 대상으로 감압 두개골 절제술과 의료 관리를 최상의 의료 관리 단독으로 비교하는 무작위 대조 시험(RCT)을 포함했다. 자료 수집 및 분석: 2명의 검토자가 독립적으로 검색 결과를 검열하고 임상시험의 적합성을 평가하고 비뚤림위험을 평가하였으며 선택한 임상시험에서 데이터를 추출했다. 1차 결과는 6~12개월 추적 조사에서 사망 및 사망 또는 중증 장애(수정된 Rankin 척도(mRS)gt; 4)였다. 다른 결과에는 사망 또는 중등도 장애(mRSgt; 3), 중증 장애(mRS = 5) 및 부작용이 포함되었다. GRADE 접근 방식을 사용하여 근거의 확실성을 높음, 보통, 낮음 또는 매우 낮음으로 분류하여 평가했다. 주요 결과: 최종 분석에 포함된 총 513명의 참가자와 함께 9개의 RCT를 포함했다. 3건의 연구에는 60세 미만의 환자가 포함되었으며 2건의 임상시험은 80세까지의 환자, 1건의 임상시험에는 60세 이상의 환자만 포함되었다. 포함된 임상시험의 대부분(6개)은 발작 발작에서 치료까지 걸리는 시간이 48시간 미만인 반면, 그 중 2개는 96시간 미만이었다. 외과적 감압은 사망 감소와 관련이 있었다(교차비(OR) 0.18, 95% 신뢰 구간(CI) 0.12 ~ 0.27, 9건의 임상시험, 513명의 참가자, Plt; 0.001; 근거 확실성 높음); 사망 또는 중증 장애(mRSgt; 4, OR 0.22, 95% CI 0.15 ~ 0.32, 9건의 임상시험, 513명의 참가자, Plt; 0.001; 근거 확실성 높음); 사망 또는 중등도 장애(mRSgt; 3, OR 0.34, 95% CI 0.22 ~ 0.52, 9건의 임상시험, 513명의 참가자, Plt; 0.001; 근거 확실성 중간). 하위 그룹 분석은 연령을 분석할 때 치료 결과에 유의미한 영향을 나타내지 않았다(lt; 60세 대 ≥ 60세). 뇌졸중 발작에서 중재까지의 시간(lt; 48시간 대 ≥ 48시간); 또는 실어증. 사망 및 사망 또는 중증 장애(mRSgt; 4)에 대한 후속 조치 시간(6개월 대 12개월, P = 0.02)의 하위 그룹 효과가 유의미했다. 그러나 이 결과의 타당성은 6개월 추적 하위 그룹의 참가자 수가 적음에 따라 영향을 받았다. 포함된 모든 연구에서 참가자당 부작용 비율에 대한 일관된 보고가 없었기 때문에 추가 분석이 불가능했다. 연구진 결론: 외과적 감압술은 사망 또는 중증 장애(mRSgt; 4)의 상당한 감소와 사망 또는 중등도 장애(mRSgt; 3)의 감소를 포함하여 급성 허혈성 뇌졸중 후 악성 부종 관리의 결과를 개선한다. 이 긍정적인 치료 효과가 60세를 초과하는 환자에게 존재한다는 근거가 있지만, 이러한 환자는 이 치료 효과와 독립적으로 기능적 생존 가능성이 낮다는 점을 고려하는 것이 중요하다. 이러한 결과를 해석할 때 이점을 입증하는 데이터가 심오한 신경학적 결손, 감소된 의식 수준, 전병적 장애 또는 심각한 동반이환이 없는 고유한 환자 하위 집합에서 가져온 것임을 고려해야 한다.

This protocol has been withdrawn as it will not be possible to complete the review within adequate deadlines. This review is considered low priority and therefore this review is currently not open for new authors.

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effectiveness of surgical decompression in patients with malignant oedema after ischaemic stroke with regards to reduction in mortality and improved functional survival. We also aim to examine the adverse effects of surgical decompression in this patient cohort.

Polycystic ovarian syndrome (PCOS) is a common reproductive disorder, which significantly impairs the fertility of 3-10% of women at reproductive age. It is getting very popular for women with PCOS to seek alternative therapies to treat PCOS, for example, acupuncture. This review examines the currently available evidence from the randomized controlled trial to guide future recommendation on using acupuncture to assist the treatment of PCOS.PCOS is manifested by oligo-amenorrhoea, infertility, and hirsutism. The standard treatment of PCOS includes oral pharmacological agents, lifestyle changes, and surgical modalities. Pharmacologically based therapies are only effective in 60% of the patients, which are also associated with different side-effects. As such, acupuncture offered an alternative option. Acupuncture can affect β-endorphin production, which may, in turn, affect gonadotropin-releasing hormone secretion and affecting ovulation and menstrual cycle. Therefore, it is postulated that acupuncture may induce ovulation and restore menstrual cycle via increasing β-endorphin production.Although modern medical science has discovered the action mechanisms underlying how acupuncture may manage the symptoms of PCOS, majority of the trials are small in sample size and lack of consistency in the choice of acupoints. Larger scale trials are needed to provide standardized protocols.

BACKGROUND: Polycystic ovarian syndrome (PCOS) is characterised by the clinical signs of oligo‐amenorrhoea, infertility and hirsutism. Conventional treatment of PCOS includes a range of oral pharmacological agents, lifestyle changes and surgical modalities. Beta‐endorphin is present in the follicular fluid of both normal and polycystic ovaries. It was demonstrated that the beta‐endorphin levels in ovarian follicular fluid of otherwise healthy women who were undergoing ovulation were much higher than the levels measured in plasma. Given that acupuncture impacts on beta‐endorphin production, which may affect gonadotropin‐releasing hormone (GnRH) secretion, it is postulated that acupuncture may have a role in ovulation induction via increased beta‐endorphin production effecting GnRH secretion. This is an update of our previous review published in 2016. OBJECTIVES: To assess the effectiveness and safety of acupuncture treatment for oligo/anovulatory women with polycystic ovarian syndrome (PCOS) for both fertility and symptom control. SEARCH METHODS: We identified relevant studies from databases including the Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CNKI, CBM and VIP. We also searched trial registries and reference lists from relevant papers. CENTRAL, MEDLINE, Embase, PsycINFO, CNKI and VIP searches are current to May 2018. CBM database search is to November 2015. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that studied the efficacy of acupuncture treatment for oligo/anovulatory women with PCOS. We excluded quasi‐ or pseudo‐RCTs. DATA COLLECTION AND ANALYSIS: Two review authors independently selected the studies, extracted data and assessed risk of bias. We calculated risk ratios (RR), mean difference (MD), standardised mean difference (SMD) and 95% confidence intervals (CIs). Primary outcomes were live birth rate, multiple pregnancy rate and ovulation rate, and secondary outcomes were clinical pregnancy rate, restored regular menstruation period, miscarriage rate and adverse events. We assessed the quality of the evidence using GRADE methods. MAIN RESULTS: We included eight RCTs with 1546 women. Five RCTs were included in our previous review and three new RCTs were added in this update of the review. They compared true acupuncture versus sham acupuncture (three RCTs), true acupuncture versus relaxation (one RCT), true acupuncture versus clomiphene (one RCT), low‐frequency electroacupuncture versus physical exercise or no intervention (one RCT) and true acupuncture versus Diane‐35 (two RCTs). Studies that compared true acupuncture versus Diane‐35 did not measure fertility outcomes as they were focused on symptom control. Seven of the studies were at high risk of bias in at least one domain. For true acupuncture versus sham acupuncture, we could not exclude clinically relevant differences in live birth (RR 0.97, 95% CI 0.76 to 1.24; 1 RCT, 926 women; low‐quality evidence); multiple pregnancy rate (RR 0.89, 95% CI 0.33 to 2.45; 1 RCT, 926 women; low‐quality evidence); ovulation rate (SMD 0.02, 95% CI –0.15 to 0.19, I(2) = 0%; 2 RCTs, 1010 women; low‐quality evidence); clinical pregnancy rate (RR 1.03, 95% CI 0.82 to 1.29; I(2) = 0%; 3 RCTs, 1117 women; low‐quality evidence) and miscarriage rate (RR 1.10, 95% CI 0.77 to 1.56; 1 RCT, 926 women; low‐quality evidence). Number of intermenstrual days may have improved in participants receiving true acupuncture compared to sham acupuncture (MD –312.09 days, 95% CI –344.59 to –279.59; 1 RCT, 141 women; low‐quality evidence). True acupuncture probably worsens adverse events compared to sham acupuncture (RR 1.16, 95% CI 1.02 to 1.31; I(2) = 0%; 3 RCTs, 1230 women; moderate‐quality evidence). No studies reported data on live birth rate and multiple pregnancy rate for the other comparisons: physical exercise or no intervention, relaxation and clomiphene. Studies including Diane‐35 did not measure fertility outcomes. We were uncertain whether acupuncture improved ovulation rate (measured by ultrasound three months post treatment) compared to relaxation (MD 0.35, 95% CI 0.14 to 0.56; 1 RCT, 28 women; very low‐quality evidence) or Diane‐35 (RR 1.45, 95% CI 0.87 to 2.42; 1 RCT, 58 women; very low‐quality evidence). Overall evidence ranged from very low quality to moderate quality. The main limitations were failure to report important clinical outcomes and very serious imprecision. AUTHORS' CONCLUSIONS: For true acupuncture versus sham acupuncture we cannot exclude clinically relevant differences in live birth rate, multiple pregnancy rate, ovulation rate, clinical pregnancy rate or miscarriage. Number of intermenstrual days may improve in participants receiving true acupuncture compared to sham acupuncture. True acupuncture probably worsens adverse events compared to sham acupuncture. No studies reported data on live birth rate and multiple pregnancy rate for the other comparisons: physical exercise or no intervention, relaxation and clomiphene. Studies including Diane‐35 did not measure fertility outcomes as the women in these trials did not seek fertility. We are uncertain whether acupuncture improves ovulation rate (measured by ultrasound three months post treatment) compared to relaxation or Diane‐35. The other comparisons did not report on this outcome. Adverse events were recorded in the acupuncture group for the comparisons physical exercise or no intervention, clomiphene and Diane‐35. These included dizziness, nausea and subcutaneous haematoma. Evidence was very low quality with very wide CIs and very low event rates. There are only a limited number of RCTs in this area, limiting our ability to determine effectiveness of acupuncture for PCOS.

BACKGROUND: Polycystic ovarian syndrome (PCOS) is characterised by both metabolic and reproductive disorders, and affects 5% to 15% of women of reproductive age. Different western medicines have been proposed for PCOS‐related subfertility, such as oral contraceptives, insulin sensitisers and laparoscopic ovarian drilling (LOD). Chinese herbal medicines (CHM) have also been used for subfertility caused by PCOS for decades, and are expected to become an alternative treatment for subfertile women with PCOS. OBJECTIVES: To assess the efficacy and safety of Chinese herbal medicine (CHM) for subfertile women with polycystic ovarian syndrome (PCOS). SEARCH METHODS: We searched the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase and six other databases, from inception to 2 June 2020. In addition, we searched three trials registries, the reference lists of included trials and contacted experts in the field to locate trials. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing CHM versus placebo, no treatment or conventional (western) therapies for the treatment of subfertile women with PCOS. DATA COLLECTION AND ANALYSIS: Two review authors independently screened trials for inclusion, assessed the risk of bias in included studies and extracted data. We contacted primary study authors for additional information. We conducted meta‐analyses. We used the odds ratios (ORs) to report dichotomous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods. MAIN RESULTS: We included eight RCTs with 609 participants. The comparisons in the included trials were as follows: CHM versus clomiphene, CHM plus clomiphene versus clomiphene (with or without ethinyloestradiol cyproterone acetate (EE/CPA)), CHM plus follicle aspiration plus ovulation induction versus follicle aspiration plus ovulation induction alone, and CHM plus laparoscopic ovarian drilling (LOD) versus LOD alone. The overall certainty of the evidence for most comparisons was very low. None of the included studies reported the primary outcome, live birth rate. Most studies reported the secondary outcomes, and only one study reported data on adverse events. In trials that compared CHM to clomiphene (with or without LOD in both study arms), we are uncertain of the effect of CHM on pregnancy rates (odds ratio (OR) 1.41, 95% confidence interval (CI) 0.63 to 3.19; I(2) = 28%; 3 studies, 140 participants; very low certainty evidence). Results suggest that if the chance of pregnancy following clomiphene is assumed to be 21.5%, the chance following CHM would vary between 14.7% and 46.7%. No study reported data on adverse events. When CHM plus clomiphene was compared to clomiphene (with or without EE/CPA), there was low certainty evidence of a higher pregnancy rate in the CHM plus clomiphene group (OR 3.06, 95% CI 2.05 to 4.55; I(2) = 10%; 6 studies, 470 participants; low certainty evidence). Results suggest that if the chance of pregnancy following clomiphene is assumed to be 31.5%, the chance following CHM plus clomiphene would vary between 48.5% and 67.7%. No data were reported on adverse events. In trials that compared CHM plus follicle aspiration and ovulation induction to follicle aspiration and ovulation induction alone, we are uncertain of the effect of CHM on pregnancy rates (OR 1.62, 95% CI 0.46 to 5.68; 1 study, 44 women; very low certainty evidence). Results suggest that if the chance of pregnancy following follicle aspiration and ovulation induction is assumed to be 29.2%, the chance following CHM with follicle aspiration and ovulation induction would vary between 15.9% and 70%. Reported adverse events included severe luteinised unruptured follicle syndrome (LUFS) (Peto OR 0.60, 95% CI 0.06 to 6.14; 1 study, 44 women; very low certainty evidence), ovarian hyperstimulation syndrome (OHSS) (Peto OR 0.16, 95% CI 0.00 to 8.19; 1 study, 44 women; very low certainty evidence) or multiple pregnancy (Peto OR 0.60, 95% CI 0.06 to 6.14; 1 study, 44 women; very low certainty evidence). These results suggest that if the chances of LUFS, OHSS, and multiple pregnancy following follicle aspiration and ovulation induction are assumed to be 8.3%, 4.2%, and 8.3% respectively, the chances following CHM with follicle aspiration and ovulation induction would be 0.5% to 35.8%, 0% to 26.3% and 0.5% to 35.8% respectively. In trials that compared CHM plus LOD to LOD alone, we are uncertain if CHM improves pregnancy rates (OR 3.50, 95% CI 0.72 to 17.09; 1 study, 30 women; very low certainty evidence). Results suggest that if the chance of pregnancy following LOD is assumed to be 40%, the chance following CHM with LOD would vary between 32.4% and 91.9%. No data were reported on adverse events. We are uncertain of the results in the comparison groups for all outcomes. The certainty of the evidence for all other comparisons and outcomes was very low. The main limitations in the evidence were failure to report live birth or adverse events, failure to describe study methods in adequate detail and imprecision due to very low event rates and wide CIs. AUTHORS' CONCLUSIONS: There is insufficient evidence to support the use of CHM for subfertile women with PCOS. No data are available on live birth. We are uncertain of the effect of CHM on pregnancy rates for there is no consistent evidence to indicate that CHM influences fertility outcomes. However, we find that the addition of CHM to clomiphene may improve pregnancy rates, but there is very limited, low certainty evidence for this outcome. Furthermore, there is insufficient evidence on adverse effects to indicate whether CHM is safe. In the future, well‐designed, carefully conducted RCTs are needed, with a particular focus on the live birth rate and other safety indexes.

The percentage of induced live birth has more than doubled from the 1990s to 2008. Induction of labour can either be based on medical indications, or performed as an elective procedure. A large range of pharmacological and non-pharmacological modalities are available for the induction of labour and the optimal method for labour induction is unknown. This article is aimed to examine literature on non-hormonal methods for labour induction, published from January 2012 to May 2013.Eleven studies were identified in our search and included into the review. Foley balloon catheter appears to be more cost-effective and commonly used non-hormonal technique for induction of labour, although further meta-analysis is required in this area. Currently, there is not enough evidence to support routine use in all women for labour induction among other methods including amniotomy, acupuncture, sexual intercourse, isosorbide mononitrate, hypnosis, castor oil and breast stimulation. The latest three studies suggest that amniotomy may increase need for oxytocin augmentation during labour induction.Many non-hormonal methods for labour induction still require further evidence to support their use within the clinical setting. Balloon catheter seems to be a more widely accepted non-hormonal method that has been supported by various literatures.

Background End-stage kidney disease (ESKD) is a chronic, debilitative and progressive illness that may need interventions such as dialysis, transplantation, dietary and fluid restrictions. Most patients with ESKD will require renal replacement therapy, such as kidney transplantation or maintenance dialysis. Advance care planning traditionally encompass instructions via living wills, and concern patient preferences about interventions such as cardiopulmonary resuscitation and feeding tubes, or circumstances around assigning surrogate decision makers. Most people undergoing haemodialysis are not aware of advance care planning and few patients formalise their wishes as advance directives and of those who do, many do not discuss their decisions with a physician. Advance care planning involves planning for future healthcare decisions and preferences of the patient in advance while comprehension is intact. It is an essential part of good palliative care that likely improves the lives and deaths of haemodialysis patients. Objectives The objective of this review was to determine whether advance care planning in haemodialysis patients, compared with no or less structured forms of advance care planning, can result in fewer hospital admissions or less use of treatments with life-prolonging or curative intent, and if patient's wishes were followed at end-of-life. Search methods We searched the Cochrane Kidney and Transplant Specialised Register to 27 June 2016 through contact with the Information Specialist using search terms relevant to this review. We also searched the Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Social Work Abstracts (OvidSP). Selection criteria All randomised controlled trials (RCTs) and quasi-RCTs (RCTs in which allocation to treatment was obtained by alternation, use of alternate medical records, date of birth or other predictable methods) looking at advance care planning versus no form of advance care planning in haemodialysis patients was considered for inclusion without language restriction. Data collection and analysis Data extraction was carried out independently by two authors using standard data extraction forms. Studies reported in non-English language journals were translated before assessment. Where more than one publication of one study exists, reports were grouped together and the publication with the most complete data was used in the analyses. Where relevant outcomes are only published in earlier versions these data were used. Any discrepancies between published versions were highlighted. Non-randomised controlled studies were excluded. Main results We included two studies (three reports) that involved 337 participants which investigated advance care planning for people with ESKD. Neither of the included studies reported outcomes relevant to this review. Study quality was assessed as suboptimal. Authors' conclusions We found sparse data that were assessed at suboptimal quality and therefore we were unable to formulate conclusions about whether advance care planning can influence numbers of hospital admissions and treatment required by people with ESKD, or if patients' advance care directives were followed at end-of-life. Further well designed and adequately powered RCTs are needed to better inform patient and clinical decision-making about advance care planning and advance directives among people with ESKD who are undergoing dialysis.

Objective The aim of this study was to investigate the association of Exonuclease1 (EXO1) genetic polymorphism and the development of cervical carcinoma. Methods This study was conducted with 126 patients diagnosed with cervical cancer and 278 people with no cancer history. The polymerase chain reaction–based restriction fragment length polymorphism was used to evaluate the K589E and C908G gene polymorphisms. Unconditional logistic regression analysis was used to estimate the association between the genotypes and the risk for cervical cancer. Results This is the first study on the role of EXO1 K589E (rs1047840) and EXO1 C908G (rs10802996) polymorphisms in cervical cancer in a Chinese population. Our results indicated that the EXO1 K589G polymorphism were significantly associated with the risk for cervical cancer. Compared with the G allele EXO1 K589E, the A allele increased the risk for cervical cancer (adjusted odds ratio, 1.67; 95% confidence interval, 1.13–2.45). By contrast, we have not found a significant association between the EXO1 C908G polymorphism and cervical cancer risk (P = 0.791). Conclusion These findings indicate that the SNPs of EXO1 K589E may contribute to cervical cancer carcinogenesis in Chinese populations. A larger population study will need to be carried out to further validate the potential association of EXO1 genetic polymorphism and cervical carcinoma.

Background Although several previous studies have assessed the association of fine particulate matter (PM2.5) exposure during pregnancy with preterm birth, the results have been inconsistent and remain controversial. This meta-analysis aims to quantitatively summarize the association between maternal PM2.5 exposure and preterm birth and to further explore the sources of heterogeneity in findings on this association. Methods We searched for all studies published before December 2014 on the association between PM2.5 exposure during pregnancy and preterm birth in the MEDLINE, PUBMED and Embase databases as well as the China Biological Medicine and Wanfang databases. A pooled OR for preterm birth in association with each 10 μg/m3 increase in PM2.5 exposure was calculated by a random-effects model (for studies with significant heterogeneity) or a fixed-effects model (for studies without significant heterogeneity). Results A total of 18 studies were included in this analysis. The pooled OR for PM2.5 exposure (per 10 μg/m3 increment) during the entire pregnancy on preterm birth was 1.13 (95 % CI = 1.03–1.24) in 13 studies with a significant heterogeneity (Q = 80.51, p

Inguinal endometriosis can present as a rare tumor when it occurs outside the abdomen and pelvis. We present a patient with a painful tumor in the right inguinal region, where its diagnosis was made before the operation. This enabled a conservative excisional surgery to be performed. The literature is reviewed and the diagnosis as well as management are discussed.

Objective. To investigate the regulatory effect of peptidoglycan on the expression of human Toll-like receptors 2 (TLR2) mRNA and proteins in the human extravillous trophoblast cell line (TEV-1). Methods. TEV-1 cells were incubated with different doses of peptidoglycan. The expression of TLR2 mRNA and protein was detected by reverse transcriptase-polymerase chain reaction (RT-PCR) and immunocytochemistry SP staining. Results. TLR2 was expressed in TEV-1 cells and localized to both the cytoplasm and plasma membrane. Compared with the untreated control, TEV-1 cells incubated with 30 g/ml peptidoglycan significantly upregulated the expression of TLR2 mRNA and protein after 12 hours of treatment (). However, the expression of TLR2 mRNA and protein was decreased but had no significant difference compared with the control () after 24 hours of treatment. On the other hand, 10 g/ml peptidoglycan did not seem to have regulatory effect on mRNA and protein expression of TLR2 (). Conclusion. Peptidoglycan has a role in regulating the expression of TLR2 mRNA and protein in TEV-1 cells. It suggests that the trophoblast cells may play important role in the immune response at the fetal-maternal interface and affect the result of pregnancy by expressing TLR2.

Objective To study the feasibility and result of LAVH performed in virgins and nulliparae. Study design Retrospective review of 297 consecutive cases of LAVH using the Biswas Uterine Vaginal Elevator (BUVE) in a private hospital in Hong Kong for benign gynaecological conditions between July 2006 and February 2009. Variables analysed included patient demographics, operative times, uterine weight, hospital stay, intraoperative blood loss, and operative complications. Patients who were virgins and nulliparae were compared to each other and to a control group of patients receiving LAVH during the same period of time. Results All 297 cases of LAVH were successfully performed without any conversion. Ninety-seven LAVHs were performed on 31 virgins and 66 nulliparae, while 200 LAVHs were performed on parous patients during the same study period. The uterine sizes in the virgin group were significantly larger than those in the other two groups. The operation times in the virgin and nullipara groups were significantly longer than those in the control group. The complication rates of LAVH in these three groups were 6.4%, 12.1% and 3% in the virgin, nulliparous and control groups respectively. The overall complication rate of this series was low at 5.3%. Conclusions LAVH is feasible with acceptable safety in virgins and nulliparae in spite of their narrow and tight vaginas.

Cervical endometriosis is uncommon and usually an incidental or retrospective finding on histopathology reports. It can be asymptomatic or present with a diverse range of persistent symptoms and even life-threatening hemorrhage. The condition can be managed expectantly in asymptomatic patients, however persistent symptoms may warrant surgery. We encountered four cases of histologically proven cervical endometriosis at our tertiary hospital in New South Wales, Australia. All our patients had different symptoms, presentations and indications for their surgery leading to their diagnosis. This review is to report these cases followed by discussion with a review of the literature.

The aim of this article is to introduce an electrical bioimpedance device that uses an old and little-known impedance measuring technique to study the impedance of the meridian and nonmeridian tissue segments.Three (3) pilot experimental studies involving both a tissue phantom (a cucumber) and 3 human subjects were performed using this BIRD-I (Bioimpedance Research Device) device. This device consists of a Fluke RCL meter, a multiplexer box, a laptop computer, and a medical-grade isolation transformer. Segment and surface sheath (or local) impedances were estimated using formulae first published in the 1930s, in an approach that differs from that of the standard four-electrode technique used in most meridian studies to date.Our study found that, when using a quasilinear four-electrode arrangement, the reference electrodes should be positioned at least 10 cm from the test electrodes to ensure that the segment (or core) impedance estimation is not affected by the proximity of the reference electrodes. A tissue phantom was used to determine the repeatability of segment (core) impedance measurement by the device. An applied frequency of 100 kHz was found to produce the best repeatability among the various frequencies tested. In another preliminary study, with a segment of the triple energizer meridian on the lower arm selected as reference segment, core resistance-based profiles around the lower arm showed three of the other five meridians to exist as local resistance minima relative to neighboring nonmeridian segments. The profiles of the 2 subjects tested were very similar, suggesting that the results are unlikely to be spurious.In electrical bioimpedance studies, it is recommended that the measuring technique and device be clearly defined and standardized to provide optimal working conditions. In our study using the BIRD I device, we defined our standard experimental conditions as a test frequency of 100 kHz and the position of the reference electrodes of at least 10 cm from the test electrodes. Our device has demonstrated potential for use in quantifying the degree of electrical interconnection between any two surface-defined test meridian or nonmeridian segments. Issues arising from use of this device and the measurement Horton and van Ravenswaay technique were also presented.

Study Objective To assess the appearance of the endometrial cavity after microwave endometrial ablation. Design Prospective observational study. Setting GuangDong Women's and Children's Hospital, GuangDong, China. Patients A total of 349 patients who underwent microwave endometrial ablation from January 2000 through August 2008 were followed up for 1 month to 8 years. At follow-up in 2007 and 2008, patients were advised of this clinical study and were randomly selected for participation if they agreed to undergo outpatient hysteroscopy to assess the uterine cavity during follow-up visits. Fifty three patients (median [range] age, 43.1 [33–53] years) were recruited into the study at the time of endometrial ablation. Intervention Outpatient hysteroscopy. Main Results Within the first 3 months after ablation, outpatient hysteroscopy revealed varying amounts of necrotic tissue from the endometrium and superficial myometrium of the uterus. Six months postablation, a granulomatous reaction and fibrosis were present. A fibrotic cavity was also evident, and menstrual flow was reduced or had ceased. One year after ablation, hysteroscopy demonstrated a fibrotic cavity with myofibrous scars. Most patients developed amenorrhea at this time. Two years or more postablation, a second hysteroscopy demonstrated various types of intrauterine adhesions in 28 of the 53 women (52.8%). A cervical adhesion was observed in 1 patient (1.9%), focal adhesions in the fundal area in 12 (22.6%), a narrowed and scarred uterine cavity with bilateral stenotic tubal ostia in 11 (20.7%), and complete obliteration of the cavity in 4 (7.5%). Of these 28 women, 22 had amenorrhea, 3 had vaginal spotting during menstruation, and 2 had hypomenorrhea. Of those without intrauterine adhesions, only 5 had amenorrhea, 10 had vaginal spotting, and 8 had hypomenorrhea. Conclusion The hysteroscopic appearance of the uterine cavity after microwave endometrial ablation varies considerably. In this study, the menstrual outcome was correlated with postablation uterine cavity appearance.

This was a review of 512 consecutive cases of laparoscopic-assisted vaginal hysterectomy (LAVH) for benign gynecologic conditions with the Biswas uterovaginal elevator (BUVE) from February 2003 through June 2008. A single operator, using the BUVE and a standard surgical protocol, performed all hysterectomies. Variables analysis included patient demographics, operative times, uterine weight, hospital stay, intraoperative blood loss, and intraoperative and postoperative complications. LAVH was successfully performed for all patients. The median operative time was 62 [corrected] minutes, range 35 to 250 minutes. The median uterine weight was 231 [corrected] g (range 43-1690 g). The median estimated blood loss was 100 [corrected] mL (range 5-1600 mL). The median length of hospital stay was 1 [corrected] days (range 1-6 days). [corrected] No case sustained injury to the ureter or major vessels or required conversion. LAVH with the BUVE eliminates the need for laparotomy in performing hysterectomies for benign gynecologic disorders. The BUVE can achieve a full range of uterine manipulation. It allows safe and easy dissection of the bladder and precise colpotomy through simultaneous uterine elevation and delineation of vaginal fornices. Prevention of ureteric injury is made possible by moving the surgical field away from the ureter. The technique described can be used to handle a wide variety of diseases and situations and has been shown to be safe, fast, easy to learn, and reproducible and carries few complications.

Background Historically, oestrogen and progesterone were each commonly used to save threatened pregnancies. In the 1940s it was postulated that their combined use would be synergistic and thereby led to the rationale of combined therapy for women who risked miscarriage. Objectives To determine the efficacy and safety of combined oestrogen and progesterone therapy to prevent miscarriage. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 June 2013) CENTRAL (OVID) (The Cochrane Library 2013, Issue 6 of 12), MEDLINE (OVID) (1946 to June Week 2 2013), OLDMEDLINE (1946 to 1965), Embase (1974 to Week 25 2013), Embase Classic (1947 to 1973), CINAHL (1994 to 23 June 2013) and reference lists of retrieved studies. Selection criteria We included randomised controlled trials that assessed the effectiveness of combined oestrogen and progesterone for preventing miscarriage. We included one stratified randomised trial and one quasi-randomised trials. Cluster-randomised trials were eligible for inclusion but none were identified. We excluded studies published only as abstracts. We included studies that compared oestrogen and progesterone versus placebo or no intervention. Data collection and analysis Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors extracted data. Data were checked for accuracy. Main results Two trials (281 pregnancies and 282 fetuses) met our inclusion criteria. However, the two trials had significant clinical and methodological heterogeneity such that a meta-analysis combining trial data was considered inappropriate. One trial (involving 161 pregnancies) was based on women with a history of diabetes. It showed no statistically significant difference between using combined oestrogen and progestogen and using placebo for all our proposed primary outcomes, namely, miscarriage (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.32 to 2.80), perinatal death (RR 0.94, 95% CI 0.53 to 1.69) and preterm birth (less than 34 weeks of gestation) (RR 0.91, 95% CI 0.80 to 1.04). In terms of this review's secondary outcomes, use of combined oestrogen and progestogen was associated with an increased risk of maternal cancer in the reproductive system (RR 6.65, 95% CI 1.56 to 28.29). However, for the outcome of cancer other than that of the reproductive system in mothers, there was no difference between groups. Similarly, there were no differences between the combined oestrogen and progestogen group versus placebo for other secondary outcomes reported: low birthweight of less than 2500 g, genital abnormalities in the offspring, abnormalities other than genital tract in the offspring, cancer in the reproductive system in the offspring, or cancer other than of the reproductive system in the offspring. The second study was based on pregnant women who had undergone in-vitro fertilisation (IVF). This study showed no difference in the rate of miscarriage between the combined oestrogen and progesterone group and the no treatment group (RR 0.66, 95% CI 0.23 to 1.85). The study did not report on this review's other primary outcomes (perinatal death or rates of preterm birth), nor on any of our proposed secondary outcomes. Authors' conclusions There is an insufficient evidence from randomised controlled trials to assess the use of combined oestrogen and progesterone for preventing miscarriages. We strongly recommend further research in this area.

Background: Chinese herbs are thought to be effective for type A H1N1 influenza. Series of Chinese herbs have been authorized recommended by the Chinese government, and until now a number of clinical trials of Chinese herbs for H1N1 influenza have been conducted. However, there is no critically appraised evidence such as systematic reviews or meta-analyses on potential benefits and harms of medicinal herbs for H1N1 influenza to justify their clinical use and their recommendation. Methods and Findings: CENTRAL, MEDLINE, EMBASE, CBM, CNKI, VIP, China Important Conference Papers Database, China Dissertation Database, and online clinical trial registry websites were searched for published and unpublished randomized controlled trials (RCTs) of Chinese herbs for H1N1 influenza till 31 August, 2011. A total of 26 RCTs were identified and reviewed. Most of the RCTs were of high risk of bias with flawed study design and poor methodological quality. The combination of several Chinese herbal medicines with or without oseltamivir demonstrated positive effect on fever resolution, relief of symptoms, and global effectiveness rate compared to oseltamivir alone. However, only one herbal medicine showed positive effect on viral shedding. Most of the trials did not report adverse events, and the safety of herbal medicines is still uncertain. Conclusions: Some Chinese herbal medicines demonstrated potential positive effect for 2009 type A H1N1 influenza; however, due to the lack of placebo controlled trial and lack of repeated test of the intervention, we could not draw confirmative conclusions on the beneficial effect of Chinese herbs for H1N1 influenza. More rigorous trials are warranted to support their clinical use. © 2011 Chen et al.

The antenatal shared care model has become increasingly popular among Australian women as the preferred mode of pregnancy care. General practitioners are often asked by their pregnant women patients about the nutrients needed during pregnancy.This article discusses the role of various micronutrients and trace elements needed in pregnancy, and provides daily intake recommendations of these nutrients as a reference point.Much attention has been given to micronutrients such as folate and iron, but less regard to other trace elements that are also important in pregnancy. Encouraging a balanced diet and ensuring the adequacy of these micronutrients is essential for minimising pregnancy complications. However, GPs should also be aware of the maximum level of recommended intakes and any possible adverse effects.

This paper aims to provide a literature review on evaluating the efficacy of acupuncture therapy in the treatment of polycystic ovarian syndrome (PCOS) by reviewing clinical trials; randomised and non-randomised and observational studies on PCOS. The paper will also determine the possible mechanism of acupuncture treatment in PCOS, limitations of recruited studies and suggest further improvements in future studies.A comprehensive literature search was conducted through the databases Medline, PubMed, EMBASE, Cochrane, AMED (Allied and Complementary Medicine), NCCAM (The National Centre for Complementary and Alternative Medicine) to identify relevant monographs.Four studies were recruited. Several studies showed that acupuncture significantly increases beta-endorphin levels for periods up to 24 h and may have regulatory effect on FSH, LH and androgen. beta-endorphin increased levels secondary to acupuncture affects the hyperthalamic-pituitary-adrenal (HPA) axis through promoting the release of ACTH through stimulation of its precursor pro-opiomelanocortin synthesis.All available acupuncture studies on human subjects with PCOS from June 1970 to June 2009.Studies not meeting the inclusion criteria, published in languages other than English or animal studies.Acupuncture is a safe and effective treatment to PCOS as the adverse effects of pharmacologic interventions are not expected by women with PCOS. Acupuncture therapy may have a role in PCOS by: increasing of blood flow to the ovaries, reducing of ovarian volume and the number of ovarian cysts, controlling hyperglycaemia through increasing insulin sensitivity and decreasing blood glucose and insulin levels, reducing cortisol levels and assisting in weight loss and anorexia. However, well-designed, randomised controlled trials are needed to elucidate the true effect of acupuncture on PCOS.

The objective of this study is to review the existing scientific evidence on the potential role of acupuncture on induction of labor during pregnancy.The Medline, EMBASE, Cochrane Central Register of Controlled Trials, AMED (Allied and Complementary Medicine), and NCCAM (The National Center for Complementary and Alternative Medicine) databases were searched to identify relevant monographs from 1970 to 2008.These criteria included all available human acupuncture studies on pregnant women carrying a viable fetus due for third trimester induction of labor.These criteria included studies not meeting the inclusion criteria, in languages other than English, or animal studies.Ten (10) studies on labor induction were identified. The duration of labor as a result of acupuncture treatment ranged from 10 hours 20 minutes to 29.1 hours. All of the studies demonstrated labor induction by acupuncture treatment. However, because two randomized controlled trials reported that there was no statistically significant effect of acupuncture, these results are more suggestive than definitive. Furthermore, although the relationship between cervical ripening and interleukin-8 (IL-8), prostaglandin F(2alpha) (PGF(2alpha)), and beta-endorphin is well documented in the literature, there is no evidence to suggest that acupuncture alters these mediators. Serum levels of IL8, beta-endorphin, and PGF(2alpha) were not found to be significantly influenced by acupuncture.Although the definitive role of acupuncture in inducing labor is still yet to be established, the existing studies suggest that acupuncture may be beneficial in labor induction. Further randomized clinical trials are needed to investigate this further.

At laparoscopic-assisted vaginal hysterectomy with a novel “paper roll” vaginal morcellation technique, large uteri (≥500 g) can be removed via the vagina with safety, speed, and ease. The technique provides protection for the bladder and rectum, and large uteri can be removed in 1 piece, allowing the pathologist to reconstruct the entire uterus.

Polycystic ovarian syndrome (PCOS), which is a common endocrinopathy seen not only in adult women but also in female adolescents nowadays, is associated with reproductive, metabolic and cardiovascular problems.This article aims to review the current evidence on managing PCOS in adolescence. In addition, the pathophysiology, risk factors, clinical presentations and existing diagnostic criteria of PCOS will also be discussed.Certain risk factors are available to assist the clinicians to identify adolescents at risk of PCOS as the signs can be masked by the normal physiological changes during puberty. It is important to screen and diagnose adolescent PCOS in order to prevent the development of future infertility, type II diabetes mellitus, cardiovascular disease, and even endometrial cancer. Lifestyle modification is of the greatest benefit for adolescents in terms of management, with the condition that full support is available from both the clinicians and their families. The psychological impact of PCOS also constitutes a major concern in adolescent PCOS.

To determine the efficacy and safety of common complementary and alternative medicine (CAM) therapies used to relieve the menopausal symptoms.Comprehensive literature search was conducted through the databases Medline, EMBASE, Cochrane, AMED (Allied and Complementary Medicine), NCCAM (The National Centre for Complementary and Alternative Medicine) to identify relevant monographs in English language.Studies have shown that some therapies such as clonidine, selective serotonin receptor inhibitors (SSRIs) and gabapentin are effective in decreasing the degree and frequency of somatic symptoms in menopause, while phytooestrogens and black cohosh have shown mixed results. Use of Ginseng, evening primrose, Dong Quai or vitamin E appears not to be efficacious for the relieving hot flushes. Other effects of these therapies including possible improvements in mood are yet to be substantiated.All available human complementary medicine studies on menopausal women with regard to the relief of menopausal symptoms.Studies not meeting the inclusion criteria, published in languages other than English or animal studies.There is a general lacking of longer-term follow-up beyond the trial lengths of 6-12 weeks in the use of CAM, although women may be taking these medications for many years. Well-designed, randomised control trials are needed to elucidate the true effect of these therapies above the placebo effect.

To evaluate the incidence, predisposing factors, early diagnosis and treatment options of heterotopic pregnancy (HP) following in vitro fertilization and embryo transfer (IVF-ET) procedure. A retrospective review study was performed to identify the HP cases after IVF-ET at the Reproductive Centre in Guangdong Women and Children’s Hospital in China between the years of 2002–2007. Twelve out of 1,476 pregnancies (0.81%) were diagnosed for HP, of which nine patients elected for exploratory salpingectomy, two patients received selective fetal reduction by embryo aspiration under ultrasound guidance, and one patient opted for expectant treatment. Postoperatively, four intrauterine pregnancies were continued to develop until term while two were delivered at 35 weeks of gestation. The achievement ratio of continuous pregnancy was 66.7% (6/9). The incidence of HP is increasing due to the widespread use of assisted reproductive technology. An early transvaginal sonography performed by experienced radiologist/radiographer is considered to be essential and beneficial in establishing early diagnosis of HP. Both salpingectomy and selective fetal reduction by embryo aspiration can be administered as one of the effective therapies for HP with the optimal outcome of intrauterine pregnancy.

Bioelectric impedance measurements have been reported to show significant variation between individuals. Different physiological conditions like thickened skin, obesity, and fluid retention can affect the impedance measurement. Therefore, it is important to learn what other factors can affect the measurements of impedance even in healthy individuals. Such information is a prerequisite for understanding the changes in impedance associated with acupuncture treatment. This study investigated the bio-impedance properties of tissue segments in the arms of a number of healthy subjects, so as to define the factors that might influence the variation of the bio-impedance data in acupuncture meridians studies. 51 healthy subjects were recruited through Liverpool Hospital, Sydney. Demographic data was collected from each subject including the age, sex, BMI, and time since most recent meal. Electrodes were applied to the forearms of each test subject. Measurements were done by a purpose-built Bio-Impedance Research Device (BIRD-I) which allowed the determination of core resistance (Rc) and core reactance (Xc) of each of the three meridian tissue segments on the anterior surface of the forearm. No significant difference was found in the core resistance attributable to age group, gender, BMI or meal intake. However, a statistically significant trend in increasing resistance from the radial to ulnar aspect of the forearm (p