The association between SARC-F status and quality of life in High Risk Foot Clinic patients

BackgroundHigh Risk Foot Clinic (HRFC) patients have foot ulceration commonly associated with poorer quality of life (QoL). A positive SARC-F test is predictive of sarcopenia. The objective of this study is to investigate whether SARC-F positive status is associated with lower QoL among attendees of HRFC, which is currently unknown. MethodsIn this cross-sectional study ambulatory HRFC patients were recruited at metropolitan tertiary referral hospital over one year. Demographics, comorbidities, SARC-F and EQ-5D-3L (EuroQol Group) outcomes were collected. Association between SARC-F status and EQ-5D visual analogue scale measurement, as well as individual EQ-5D-3L dimensions were investigated using, respectively, linear robust and ordinal logistic regression modelling.  ResultsThe clinic was attended by 122 new patients, 85 of whom (69%) completed the questionnaires with no selection bias identified. 43/85 (51%) patients were SARC-F positive as indicated by a score of 4 or greater. No significant differences between SARC-F positive and negative patients were identified in age or diabetes status. SARC-F positive patients had consistently lower EQ-5D-3L visual analogue scale measurement [mean 5.3 (SD 2.0); median 5 (IQR: 4, 6.5)] compared to SARC-F negative patients [6.6 (SD 1.9); 7 (5.5, 7.5)], adjusted mean difference -1.2 (95%CI: -2.1, -0.4; p=0.007). SARC-F positive patients demonstrated consistent and statistically significantly worse EQ-5D-3L scores on mobility, personal care and usual activities, but not on anxiety/depression and pain/discomfort components. ConclusionsApproximately half of HRFC patients are SARC-F positive and exhibit significantly lower QoL as measured by EQ-5D-3L compared to SARC-F negative patients.

Colonic microbiota can promote rapid local improvement of murine colitis by thioguanine independently of T lymphocytes and host metabolism

OBJECTIVE

Mercaptopurine (MP) and pro-drug azathioprine are 'first-line' oral therapies for maintaining remission in IBD. It is believed that their pharmacodynamic action is due to a slow cumulative decrease in activated lymphocytes homing to inflamed gut. We examined the role of host metabolism, lymphocytes and microbiome for the amelioration of colitis by the related thioguanine (TG).

DESIGN

C57Bl/6 mice with or without specific genes altered to elucidate mechanisms responsible for TG's actions were treated daily with oral or intrarectal TG, MP or water. Disease activity was scored daily. At sacrifice, colonic histology, cytokine message, caecal luminal and mucosal microbiomes were analysed.

RESULTS

Oral and intrarectal TG but not MP rapidly ameliorated spontaneous chronic colitis in Winnie mice (point mutation in Muc2 secretory mucin). TG ameliorated dextran sodium sulfate-induced chronic colitis in wild-type (WT) mice and in mice lacking T and B lymphocytes. Remarkably, colitis improved without immunosuppressive effects in the absence of host hypoxanthine (guanine) phosphoribosyltransferase (Hprt)-mediated conversion of TG to active drug, the thioguanine nucleotides (TGN). Colonic bacteria converted TG and less so MP to TGN, consistent with intestinal bacterial conversion of TG to so reduce inflammation in the mice lacking host Hprt. TG rapidly induced autophagic flux in epithelial, macrophage and WT but not Hprt^-/- fibroblast cell lines and augmented epithelial intracellular bacterial killing.

CONCLUSIONS

Treatment by TG is not necessarily dependent on the adaptive immune system. TG is a more efficacious treatment than MP in Winnie spontaneous colitis. Rapid local bacterial conversion of TG correlated with decreased intestinal inflammation and immune activation.

Nonsteroidal anti-inflammatory drugs for dysmenorrhoea

BACKGROUND

Dysmenorrhoea is a common gynaecological problem consisting of painful cramps accompanying menstruation, which in the absence of any underlying abnormality is known as primary dysmenorrhoea. Research has shown that women with dysmenorrhoea have high levels of prostaglandins, hormones known to cause cramping abdominal pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are drugs that act by blocking prostaglandin production. They inhibit the action of cyclooxygenase (COX), an enzyme responsible for the formation of prostaglandins. The COX enzyme exists in two forms, COX-1 and COX-2. Traditional NSAIDs are considered 'non-selective' because they inhibit both COX-1 and COX-2 enzymes. More selective NSAIDs that solely target COX-2 enzymes (COX-2-specific inhibitors) were launched in 1999 with the aim of reducing side effects commonly reported in association with NSAIDs, such as indigestion, headaches and drowsiness.

OBJECTIVES

To determine the effectiveness and safety of NSAIDs in the treatment of primary dysmenorrhoea.

SEARCH METHODS

We searched the following databases in January 2015: Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, November 2014 issue), MEDLINE, EMBASE and Web of Science. We also searched clinical trials registers (ClinicalTrials.gov and ICTRP). We checked the abstracts of major scientific meetings and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised controlled trial (RCT) comparisons of NSAIDs versus placebo, other NSAIDs or paracetamol, when used to treat primary dysmenorrhoea.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies, assessed their risk of bias and extracted data, calculating odds ratios (ORs) for dichotomous outcomes and mean differences for continuous outcomes, with 95% confidence intervals (CIs). We used inverse variance methods to combine data. We assessed the overall quality of the evidence using GRADE methods.

MAIN RESULTS

We included 80 randomised controlled trials (5820 women). They compared 20 different NSAIDs (18 non-selective and two COX-2-specific) versus placebo, paracetamol or each other. NSAIDs versus placeboAmong women with primary dysmenorrhoea, NSAIDs were more effective for pain relief than placebo (OR 4.37, 95% CI 3.76 to 5.09; 35 RCTs, I(2) = 53%, low quality evidence). This suggests that if 18% of women taking placebo achieve moderate or excellent pain relief, between 45% and 53% taking NSAIDs will do so.However, NSAIDs were associated with more adverse effects (overall adverse effects: OR 1.29, 95% CI 1.11 to 1.51, 25 RCTs, I(2) = 0%, low quality evidence; gastrointestinal adverse effects: OR 1.58, 95% CI 1.12 to 2.23, 14 RCTs, I(2) = 30%; neurological adverse effects: OR 2.74, 95% CI 1.66 to 4.53, seven RCTs, I(2) = 0%, low quality evidence). The evidence suggests that if 10% of women taking placebo experience side effects, between 11% and 14% of women taking NSAIDs will do so. NSAIDs versus other NSAIDsWhen NSAIDs were compared with each other there was little evidence of the superiority of any individual NSAID for either pain relief or safety. However, the available evidence had little power to detect such differences, as most individual comparisons were based on very few small trials. Non-selective NSAIDs versus COX-2-specific selectorsOnly two of the included studies utilised COX-2-specific inhibitors (etoricoxib and celecoxib). There was no evidence that COX-2-specific inhibitors were more effective or tolerable for the treatment of dysmenorrhoea than traditional NSAIDs; however data were very scanty. NSAIDs versus paracetamolNSAIDs appeared to be more effective for pain relief than paracetamol (OR 1.89, 95% CI 1.05 to 3.43, three RCTs, I(2) = 0%, low quality evidence). There was no evidence of a difference with regard to adverse effects, though data were very scanty.Most of the studies were commercially funded (59%); a further 31% failed to state their source of funding.

AUTHORS' CONCLUSIONS

NSAIDs appear to be a very effective treatment for dysmenorrhoea, though women using them need to be aware of the substantial risk of adverse effects. There is insufficient evidence to determine which (if any) individual NSAID is the safest and most effective for the treatment of dysmenorrhoea. We rated the quality of the evidence as low for most comparisons, mainly due to poor reporting of study methods.

Voltage transfer function as an optical method to characterize electrical properties of liquid crystal devices

The voltage transfer function is a rapid and visually effective method to determine the electrical response of liquid crystal (LC) systems using optical measurements. This method relies on crosspolarized intensity measurements as a function of the frequency and amplitude of the voltage applied to the device. Coupled with a mathematical model of the device it can be used to determine the device time constants and electrical properties. We validate the method using photorefractive LC cells and determine the main time constants and the voltage dropped across the layers using a simple nonlinear filter model.

Nonsteroidal anti-inflammatory drugs for dysmenorrhoea

BACKGROUND

Dysmenorrhoea is a common gynaecological problem consisting of painful cramps accompanying menstruation, which in the absence of any underlying abnormality is known as primary dysmenorrhoea. Research has shown that women with dysmenorrhoea have high levels of prostaglandins, hormones known to cause cramping abdominal pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are drugs which act by blocking prostaglandin production.

OBJECTIVES

The purpose of this review is to compare nonsteroidal anti-inflammatory drugs used in the treatment of primary dysmenorrhoea versus placebo, versus paracetamol and versus each other, to evaluate their effectiveness and safety.

SEARCH STRATEGY

We searched the following databases to May 2009: Cochrane Menstrual Disorders and Subfertility Group trials register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and Web of Science. The National Research Register and the Clinical Trials Register were also searched. Abstracts of major scientific meetings and the reference lists of relevant articles were checked.

SELECTION CRITERIA

All randomised controlled comparisons of NSAIDs versus placebo, other NSAIDs or paracetamol, when used to treat primary dysmenorrhoea.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials for quality and extracted data, calculating odds ratios (ORs) for dichotomous outcomes and mean differences for continuous outcomes, with 95% confidence intervals (CIs). Inverse variance methods were used to combine data.

MAIN RESULTS

Seventy-three randomised controlled trials were included. Among women with primary dysmenorrhoea, NSAIDs were significantly more effective for pain relief than placebo (OR 4.50, 95% CI: 3.85, 5.27). There was substantial heterogeneity for this finding (I(2) statistic =53%): exclusion of two outlying studies with no or negligible placebo effect reduced heterogeneity, resulting in an odds ratio of 4.14 (95% CI: 3.52, 4.86, I(2)=40%). NSAIDs were also significantly more effective for pain relief than paracetamol (OR 1.90, 95% CI:1.05 to 3.44). However, NSAIDS were associated with significantly more overall adverse effects than placebo (OR 1.37, 95% CI: 1.12 to 1.66). When NSAIDs were compared with each other there was little evidence of the superiority of any individual NSAID for either pain-relief or safety. However the available evidence had little power to detect such differences, as most individual comparisons were based on very few small trials.

AUTHORS' CONCLUSIONS

NSAIDs are an effective treatment for dysmenorrhoea, though women using them need to be aware of the significant risk of adverse effects. There is insufficient evidence to determine which (if any) individual NSAID is the safest and most effective for the treatment of dysmenorrhoea.

Oral contraceptive pill for primary dysmenorrhoea

BACKGROUND

Dysmenorrhoea (painful menstrual cramps) is common. Combined OCPs are recommended in the management of primary dysmenorrhoea.

OBJECTIVES

To determine the effectiveness and safety of combined oral contraceptive pills for the management of primary dysmenorrhoea.

SEARCH STRATEGY

We conducted electronic searches for randomised controlled trials (RCTs) in the Cochrane Menstrual Disorders and Subfertility Group Register of controlled trials CENTRAL, CCTR, MEDLINE, EMBASE, and CINAHL (first conducted in 2001, updated on 5 November 2008).

SELECTION CRITERIA

RCTs comparing all combined OCPs with other combined OCPs, placebo, no management, or management with nonsteroidal anti-inflammatories (NSAIDs) were considered.

DATA COLLECTION AND ANALYSIS

Twenty three studies were identified and ten were included. Six compared the combined OCP with placebo and four compared different dosages of combined OCP.

MAIN RESULTS

One study of low dose oestrogen and four studies of medium dose oestrogen combined OCPs compared with placebo, for a combined total of 497 women, reported pain improvement. For the outcome of pain relief across the different OCPs the pooled OR suggested benefit with OCPs compared to placebo (7 RCTs: Peto OR 2.01 [95% CI 1.32, 3.08]).The Chi-squared test for heterogeneity showed there is significant heterogeneity with an I(2) statistic of 64% and a significant chi-square test (14.06, df=5, p=0.02). A sensitivity analysis removing the studies with inadequate allocation concealment suggested significant benefit of treatment with the pooled OR of 2.99 (95% CI 1.76, 5.07) and heterogeneity no longer statistically significant and I(2) statistic of 0%.Three studies reported adverse effects (Davis 2005; Hendrix 2002; GPRG 1968) The adverse effects were nausea, headaches and weight gain. Two studies reported if women experienced any side effect and no evidence of an effect was found (3 RCTs: OR = 1.45 (95% 0.71, 2.94). There was no evidence of statistical heterogeneity.There were no studies identified that compared combined OCP versus non steroidal anti-inflammatory drugsThere was no evidence of a difference for the pooled studies for 3rd generation pro gestagens (OR = 1.11 (95% CI 0.79 - 1.57)). For the 2nd generation versus 3rd generation the OR was 0.44 (95% CI 0.23-0.84) suggesting benefit of the 3rd generation OCP but this was for a single study (Winkler 2003).

AUTHORS' CONCLUSIONS

There is limited evidence for pain improvement with the use of the OCP (both low and medium dose oestrogen) in women with dysmenorrhoea. There is no evidence of a difference between different OCP preparations.

Oral contraceptive pill as treatment for primary dysmenorrhoea

BACKGROUND

Dysmenorrhoea (painful menstrual cramps) is common. Combined OCPs are recommended in the management of primary dysmenorrhoea.

OBJECTIVES

To determine the effectiveness and safety of combined oral contraceptive pills for the management of primary dysmenorrhoea.

SEARCH STRATEGY

We conducted electronic searches for randomised controlled trials (RCTs) in the Cochrane Menstrual Disorders and Subfertility Group Register of controlled trials CENTRAL, CCTR, MEDLINE, EMBASE, and CINAHL (first conducted in 2001, updated on 5 November 2008).

SELECTION CRITERIA

RCTs comparing all combined OCPs with other combined OCPs, placebo, no management, or management with nonsteroidal anti-inflammatories (NSAIDs) were considered.

DATA COLLECTION AND ANALYSIS

Twenty three studies were identified and ten were included. Six compared the combined OCP with placebo and four compared different dosages of combined OCP.

MAIN RESULTS

One study of low dose oestrogen and four studies of medium dose oestrogen combined OCPs compared with placebo, for a combined total of 497 women, reported pain improvement. For the outcome of pain relief across the different OCPs wthe pooled OR suggested benefit with OCPs compared to placebo (7 RCTs: Peto OR 2.01 [95% CI 1.32, 3.08]).The Chi-squared test for heterogeneity showed there is significant heterogeneity with an I(2) statistic of 64% and a significant chi-square test (14.06, df=5, p=0.02). A sensitivity analysis removing the studies with inadequate allocation concealment suggested significant benefit of treatment with the pooled OR of 2.99 (95% CI 1.76, 5.07) and hereterogeneity no longer statistically significant and I(2) statistic of 0%.Three studies reported adverse effects (Davis 2005; Hendrix 2002; GPRG 1968) The adverse effects were nausea, headaches and weight gain. Two studies reported if women experienced any side effect and no evidence of an effect was found (3 RCTs: OR = 1.45 (95% 0.71, 2.94). There was no evidence of statistical heterogeneity.There were no studies identified that compated combined OCP versus non steroidal anti-inflammatory drugs. There was no evidence of a difference for the pooled studies for 3rd generation progestagens (OR = 1.11 (95% CI 0.79 - 1.57)). For the 2nd generation versus 3rd generation the OR was 0.44 (95% CI 0.23-0.84) suggesting benefit of the 3rd generation OCP but this was for a single study (Winkler 2003).

AUTHORS' CONCLUSIONS

There is limited evidence for pain improvement with the use of the OCP (both low and medium dose oestrogen) in women with dysmenorrhoea. There is no evidence of a difference between different OCP preparations.

Chinese herbal medicine for primary dysmenorrhoea

BACKGROUND

Conventional treatment for primary dysmenorrhoea has a failure rate of 20% to 25% and may be contraindicated or not tolerated by some women. Chinese herbal medicine may be a suitable alternative.

OBJECTIVES

To determine the efficacy and safety of Chinese herbal medicine for primary dysmenorrhoea when compared with placebo, no treatment, and other treatment.

SEARCH STRATEGY

The Cochrane Menstrual Disorders and Subfertility Group Trials Register (to 2006), MEDLINE (1950 to January 2007), EMBASE (1980 to January 2007), CINAHL (1982 to January 2007), AMED (1985 to January 2007), CENTRAL (The Cochrane Library issue 4, 2006), China National Knowledge Infrastructure (CNKI, 1990 to January 2007), Traditional Chinese Medicine Database System (TCMDS, 1990 to December 2006), and the Chinese BioMedicine Database (CBM, 1990 to December 2006) were searched. Citation lists of included trials were also reviewed.

SELECTION CRITERIA

Any randomised controlled trials involving Chinese herbal medicine versus placebo, no treatment, conventional therapy, heat compression, another type of Chinese herbal medicine, acupuncture or massage. Exclusion criteria were identifiable pelvic pathology and dysmenorrhoea resulting from the use of an intra-uterine contraceptive device.

DATA COLLECTION AND ANALYSIS

Quality assessment, data extraction and data translation were performed independently by two review authors. Attempts were made to contact study authors for additional information and data. Data were combined for meta-analysis using either Peto odds ratios or relative risk (RR) for dichotomous data or weighted mean difference for continuous data. A fixed-effect statistical model was used, where suitable. If data were not suitable for meta-analysis, any available data from the trial were extracted and presented as descriptive data.

MAIN RESULTS

Thirty-nine randomised controlled trials involving a total of 3475 women were included in the review. A number of the trials were of small sample size and poor methodological quality. Results for Chinese herbal medicine compared to placebo were unclear as data could not be combined (3 RCTs). Chinese herbal medicine resulted in significant improvements in pain relief (14 RCTs; RR 1.99, 95% CI 1.52 to 2.60), overall symptoms (6 RCTs; RR 2.17, 95% CI 1.73 to 2.73) and use of additional medication (2 RCTs; RR 1.58, 95% CI 1.30 to 1.93) when compared to use of pharmaceutical drugs. Self-designed Chinese herbal formulae resulted in significant improvements in pain relief (18 RCTs; RR 2.06, 95% CI 1.80 to 2.36), overall symptoms (14 RCTs; RR 1.99, 95% CI 1.65 to 2.40) and use of additional medication (5 RCTs; RR 1.58, 95% CI 1.34 to 1.87) after up to three months of follow-up when compared to commonly used Chinese herbal health products. Chinese herbal medicine also resulted in better pain relief than acupuncture (2 RCTs; RR 1.75, 95% CI 1.09 to 2.82) and heat compression (1 RCT; RR 2.08, 95% CI 2.06 to 499.18).

AUTHORS' CONCLUSIONS

The review found promising evidence supporting the use of Chinese herbal medicine for primary dysmenorrhoea; however, results are limited by the poor methodological quality of the included trials.

Chinese herbal medicine for primary dysmenorrhoea

BACKGROUND

Conventional treatment for primary dysmenorrhoea (PD) has a failure rate of 20% to 25% and may be contraindicated or not tolerated by some women. Chinese herbal medicine (CHM) may be a suitable alternative.

OBJECTIVES

To determine the efficacy and safety of CHM for PD when compared with placebo, no treatment, and other treatment.

SEARCH STRATEGY

The Cochrane Menstrual Disorders and Subfertility Group Trials Register (to 2006), MEDLINE (1950 to January 2007), EMBASE (1980 to January 2007), CINAHL (1982 to January 2007), AMED (1985 to January 2007), CENTRAL (The Cochrane Library issue 4, 2006), China National Knowledge Infrastructure (CNKI, 1990 to January 2007), Traditional Chinese Medicine Database System (TCMDS, 1990 to Dec 2006), and the Chinese BioMedicine Database (CBM, 1990 to Dec 2006) were searched. Citation lists of included trials were also reviewed.

SELECTION CRITERIA

Any randomised controlled trials (RCTs) involving CHM versus placebo, no treatment, conventional therapy, heat compression, another type of CHM, acupuncture or massage. Exclusion criteria were identifiable pelvic pathology and dysmenorrhoea resulting from the use of an intra-uterine contraceptive device (IUD).

DATA COLLECTION AND ANALYSIS

Quality assessment, data extraction and data translation were performed independently by two review authors. Attempts were made to contact study authors for additional information and data. Data were combined for meta-analysis using either Peto odds ratios or relative risk (RR) for dichotomous data or weighted mean difference for continuous data. A fixed-effect statistical model was used, where suitable. If data were not suitable for meta-analysis, any available data from the trial were extracted and presented as descriptive data.

MAIN RESULTS

Thirty-nine RCTs involving a total of 3475 women were included in the review. A number of the trials were of small sample size and poor methodological quality. Results for CHM compared to placebo were unclear as data could not be combined (3 RCTs). CHM resulted in significant improvements in pain relief (14 RCTs; RR 1.99, 95% CI 1.52 to 2.60), overall symptoms (6 RCTs; RR 2.17, 95% CI 1.73 to 2.73) and use of additional medication (2 RCTs; RR 1.58, 95% CI 1.30 to 1.93) when compared to use of pharmaceutical drugs. Self-designed CHM resulted in significant improvements in pain relief (18 RCTs; RR 2.06, 95% CI 1.80 to 2.36), overall symptoms (14 RCTs; RR 1.99, 95% CI 1.65 to 2.40) and use of additional medication (5 RCTs; RR 1.58, 95% CI 1.34 to 1.87) after up to three months follow up when compared to commonly used Chinese herbal health products. CHM also resulted in better pain relief than acupuncture (2 RCTs; RR 1.75, 95% CI 1.09 to 2.82) and heat compression (1 RCT; RR 2.08, 95% CI 2.06 to 499.18).

AUTHORS' CONCLUSIONS

The review found promising evidence supporting the use of CHM for primary dysmenorrhoea; however, results are limited by the poor methodological quality of the included trials.

Cleavage stage versus blastocyst stage embryo transfer in assisted conception

BACKGROUND

Recent advances in cell culture media have led to a shift in IVF practice from early cleavage embryo transfer to blastocyst stage transfer. The rationale for blastocyst culture is to improve both uterine and embryonic synchronicity and self selection of viable embryos thus resulting in higher implantation rates.

OBJECTIVES

To determine if blastocyst stage embryo transfers (ETs) affect live birth rate and associated outcomes compared with cleavage stage ETs and to investigate what factors may influence this.

SEARCH STRATEGY

Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials, Cochrane Controlled Trials Register (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and Bio extracts. The last search date was January 2007.

SELECTION CRITERIA

Trials were included if they were randomised and compared the effectiveness of early cleavage versus blastocyst stage transfers.

DATA COLLECTION AND ANALYSIS

Of the 50 trials that were identified, 18 randomised controlled trials (RCTs) met the inclusion criteria and were reviewed. The primary outcome was rate of live birth. Secondary outcomes were rates per couple of clinical pregnancy, multiple pregnancy, high order pregnancy, miscarriage, failure to transfer embryos and cryopreservation. Quality assessment, data extraction and meta-analysis were performed following Cochrane guidelines.

MAIN RESULTS

Evidence of a significant difference in live-birth rate per couple between the two treatment groups was detected in favour of blastocyst culture (9 RCTs; OR 1.35, 95% CI 1.05 to 1.74 (Day 2/3: 29.4% versus Day 5/6: 36.0%)). This was particularly for trials with good prognosis patients, equal number of embryos transferred (including single embryo transfer) and those in which the randomisation took place on Day 3. Rates of embryo freezing per couple was significantly higher in Day 2 to 3 transfers (9 RCTs; OR 0.45, 95% CI 0.36 to 0.56). Failure to transfer any embryos per couple was significantly higher in the Day 5 to 6 group (16 RCTs; OR 2.85, 95% CI 1.97 to 4.11 (Day 2/3: 2.8% versus Day 5/6: 8.9%)) but was not significantly different for good prognosis patients (9 RCTs; OR 1.50, 95% CI 0.79 to 2.84).

AUTHORS' CONCLUSIONS

This review provides evidence that there is a significant difference in pregnancy and live birth rates in favour of blastocyst transfer with good prognosis patients with high numbers of eight-cell embryos on Day three being the most favoured in subgroup for whom there is no difference in cycle cancellation. There is emerging evidence to suggest that in selected patients, blastocyst culture maybe applicable for single embryo transfer.

Gonadotrophins for idiopathic male factor subfertility

BACKGROUND

Male factor infertility accounts for 50% of all infertility. The treatment of idiopathic male infertility is empirical. Urinary, purified, and recombinant gonadotrophins have been used to improve sperm parameters in idiopathic male infertility with the goal of increasing pregnancy rates. Research addressing pregnancy rates in partners of men treated with gonadotrophins has had conflicting results and needs to be analysed.

OBJECTIVES

To determine the effectiveness of gonadotrophin administration in men with idiopathic subfertility in improving spontaneous pregnancy rate and in assisted reproductive technique cycles.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (31 May 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library, issue 2, 2007), MEDLINE (1966 to May 2007), EMBASE and Biological Abstracts (1980 to Week 21 2007). Searches were not limited by language. The bibliographies of included, excluded trials and abstracts of major meetings were searched for additional trials. Authors and pharmaceutical companies were contacted for missing and unpublished data.

SELECTION CRITERIA

Truly randomised controlled trials where gonadotrophins were administered for the treatment of idiopathic male subfertility with reporting of pregnancy rates were included in the review.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. Adverse effects information was collected from the trials. We analysed data regarding pregnancy occurring within three months after gonadotrophin therapy.

MAIN RESULTS

Four RCTs with 278 participants were included in the analysis. None of the studies had an adequate sample size and they had variable follow-up periods. None of the studies reported live birth or miscarriage rates. Compared to placebo or no treatment, gonadotrophins showed a significantly higher pregnancy rate per couple randomized within three months of completing therapy ( OR 4.17, 95% CI 1.30 to 7.09).

AUTHORS' CONCLUSIONS

The number of trials and participants is insufficient to draw final conclusions. A large multicenter study with adequate power is needed.

Selective serotonin reuptake inhibitors (SSRIs) for depressive disorders in children and adolescents

BACKGROUND

Depressive disorders are common in young people and are associated with significant negative impacts. Selective serotonin reuptake inhibitors (SSRIs) are often used, however, evidence of their effectiveness in children and adolescents is not clear. Furthermore, there have been warnings against their use in this population due to concerns about increased risk of suicidal ideation and behaviour.

OBJECTIVES

To determine the efficacy and adverse outcomes, including definitive suicidal behaviour and suicidal ideation, of SSRIs compared to placebo in the treatment of depressive disorders in children and adolescents.

SEARCH STRATEGY

We searched the CCDAN Trials Register, MEDLINE, PSYCHINFO and CENTRAL. Reference lists were checked, letters were sent to key researchers and internet databases searched.

SELECTION CRITERIA

We included published and unpublished randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Two or three review authors selected the trials, assessed the quality and extracted trial and outcome data. We used a fixed-effect meta-analysis. The relative risk was used to summarise dichotomous outcomes and the mean difference to summarise continuous measures.

MAIN RESULTS

Twelve trials were eligible for inclusion, with ten providing usable data. At 8-12 weeks, there was evidence that children and adolescents 'responded' to treatment with SSRIs (RR 1.28, 95% CI 1.17 to 1.41). There was also evidence of an increased risk of suicidal ideation and behaviour for those prescribed SSRIs (RR 1.80, 95% CI 1.19 to 2.72). Fluoxetine was the only SSRI where there was consistent evidence from three trials that it was effective in reducing depression symptoms in both children and adolescents (CDRS-R treatment effect -5.63, 95% CI -7.38 to -3.88), and 'response' to treatment (RR 1.86, 95% CI 1.49 to 2.32). Where rates of adverse events were reported, this was higher for those prescribed SSRIs.

AUTHORS' CONCLUSIONS

Caution is required to interpret the results. First, there were methodological issues, including high attrition, issues regarding measurement instruments and clinical usefulness of outcomes, often variously defined across trials. Second, patients seen in clinical practice are likely to be more unwell, and at greater risk of suicide, compared to those in the trials, and it is unclear how this group would respond to SSRIs. This needs to be considered, along with the evidence of an increased risk of suicide related outcomes in those treated with SSRIs. It is unclear what the effect of SSRIs is on suicide completion. While untreated depression is associated with the risk of completed suicide and impacts on functioning, it is unclear whether SSRIs would modify this risk in a clinically meaningful way.

Behavioural interventions for primary and secondary dysmenorrhoea

BACKGROUND

Dysmenorrhoea refers to the occurrence of painful menstrual cramps of uterine origin and is a common gynaecological condition with considerable morbidity. The behavioural approach assumes that psychological and environmental factors interact with, and influence, physiological processes. Behavioural interventions for dysmenorrhoea may include both physical and cognitive procedures and focus on both physical and psychological coping strategies for dysmenorrhoeic symptoms rather than modification of any underlying organic pathology.

OBJECTIVES

To determine the effectiveness of any behavioural interventions for the treatment of primary or secondary dysmenorrhoea when compared to each other, placebo, no treatment, or conventional medical treatments for example non-steroidal anti-inflammatory drugs (NSAIDs).

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched April 2005), Cochrane Central Register of Controlled Trials (CENTRAL on The Cochrane Library, Issue 2, 2005), MEDLINE (1966 to April 2005), EMBASE (1980 to April 2005), Social Sciences Index (1980 to April 2005), PsycINFO (1972 to April 2005) and CINAHL (1982 to April 2005) and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials comparing behavioural interventions with placebo or other interventions in women with dysmenorrhoea.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

Five trials involving 213 women were included. Behavioural intervention vs control: One trial of pain management training reported reduction in pain and symptoms compared to a control. Three trials of relaxation compared to control reported varied results, two trials showed no difference in symptom severity scores however one trial reported relaxation was effective for reducing symptoms in menstrual sufferers with spasmodic symptoms. Two trials reported less restriction in daily activities following treatment with either relaxation of pain management training compared to a control. One trial also reported less time absent from school following treatment wit pain management training compared to a control. Behavioural intervention vs other behavioural interventions: Three trials showed no difference between behavioural interventions for the outcome of improvement in symptoms. One trial showed that relaxation resulted in a decrease in the need for resting time compared to the relaxation and imagery.

AUTHORS' CONCLUSIONS

There is some evidence from five RCTs that behavioural interventions may be effective for dysmenorrhoea however results should be viewed with caution as they varied greatly between trials due to inconsistency in the reporting of data, small trial size, poor methodological quality and age of the trials.

Airway mechanoreceptor deactivation

Airway sensors play an important role in control of breathing. Recently, it was found that pulmonary slowly adapting stretch receptors (SARs) cease after a brief excitation following sodium pump blockade by ouabain. This deactivation can be explained by overexcitation. If this is true, mechanical stimulation of the SARs should also lead to a deactivation. In this study, we recorded unit activity of the SARs in anesthetized, open-chest, and mechanically ventilated rabbits and examined their responses to lung inflation at different constant pressures. Forty-seven of 137 units had a clear deactivation during the lung inflation. The deactivation threshold varied from unit to unit. For a given unit, the higher the inflation pressure, the sooner the deactivation occurs. For example, the SARs deactivated at 3.0 +/- 0.3 and 4.8 +/- 0.4 s when the lungs were inflated to constant pressures of 30 and 20 cmH(2)O, respectively (n = 25, P < 0.0001). The units usually ceased after a brief intense discharge. In some units, their activity shifted to a lower level, indicating a pacemaker switching. Our results support the notion that SARs deactivate due to overexcitation.

Genetic variation in the dopamine D4 receptor (DRD4) gene and smoking cessation: follow-up of a randomised clinical trial of transdermal nicotine patch

Smokers of European ancestry (n=720) who participated in a double-blind, randomised, placebo-controlled trial of transdermal nicotine replacement therapy, were genotyped for two functional polymorphisms (variable number of tandem repeats (VNTR) and a C to T transition at position -521 (C-521T)) in the dopamine D4 receptor gene (DRD4) gene. Logistic regression models of abstinence at 12- and 26-week follow-ups were carried out separately for each polymorphism. For the DRD4 VNTR models, the main effect of treatment was significant at both 12-week (P=0.001) and 26-week (P=0.006) follow-ups, indicating an increased likelihood of successful cessation on active nicotine replacement therapy transdermal patch relative to placebo. The main effect of DRD4 VNTR genotype was associated with abstinence at 12-week follow-up (P=0.034), with possession of one or more copies of the long allele associated with reduced likelihood of cessation (17 vs 23%), but this effect was not observed at 26-week follow-up. For the DRD4 C-521T models, no main effect or interaction terms involving genotype were retained in the models at either 12- or 26-week follow-up. These data are consistent with observations from studies of the DRD2 gene that genetic variants related to relatively decreased dopaminergic tone in the mesocorticolimbic system are associated with increased risk for relapse to smoking following a cessation attempt.

Moyamoya following cranial irradiation for primary brain tumors in children

OBJECTIVE

To study the risk factors for the development of moyamoya syndrome after cranial irradiation for primary brain tumors in children.

METHODS

We reviewed neuroimaging studies and dosimetry data for 456 children who were treated with radiation for a primary brain tumor and who were prospectively evaluated with serial neuroimaging studies and neurologic evaluations. A total of 345 patients had both adequate neuroimaging and radiation dosimetry data for further analysis. We used survival analysis techniques to examine the relationship of clinically important variables as risk factors for the development of moyamoya over time.

RESULTS

Overall, 12 patients (3.5%) developed evidence of moyamoya. The onset of moyamoya was more rapid for patients with neurofibromatosis type 1 (NF1) (median of 38 vs 55 months) and for patients who received >5,000 cGy of radiation (median of 42 vs 67 months). In a multiple Cox proportional hazards regression analysis controlling for age at start of radiation, each 100-cGy increase in radiation dose increased the rate of moyamoya by 7% (hazard ratio [HR] = 1.07, 95% CI: 1.02 to 1.13, p = 0.01) and the presence of NF1 increased the rate of moyamoya threefold (HR = 3.07, 95% CI: 0.90 to 10.46, p = 0.07).

CONCLUSIONS

Moyamoya syndrome is a potentially serious complication of cranial irradiation in children, particularly for those patients with tumors in close proximity to the circle of Willis, such as optic pathway glioma. Patients who received higher doses of radiation to the circle of Willis and with neurofibromatosis type 1 have increased risk of the development of moyamoya syndrome.

Spinal manipulation for primary and secondary dysmenorrhoea

BACKGROUND

Dysmenorrhoea refers to the occurrence of painful menstrual cramps of uterine origin and is a common gynaecological condition. One possible treatment is spinal manipulation therapy. One hypothesis is that mechanical dysfunction in certain vertebrae causes decreases spinal mobility. This could affect the sympathetic nerve supply to the blood vessels supplying the pelvic viscera, leading to dysmenorrhoea as a result of vasoconstriction. Manipulation of these vertebrae increases spinal mobility and may improve pelvic blood supply. Another hypothesis is that dysmenorrhoea is referred pain arising from musculoskeletal structures that share the same pelvic nerve pathways. The character of pain from musculoskeletal dysfunction can be very similar to gynaecological pain as it can present as cyclic pain altered by hormonal influences associated with menstruation.

OBJECTIVES

To determine the safety and efficacy of spinal manipulative interventions for the treatment of primary or secondary dysmenorrhoea when compared to each other, placebo, no treatment, or other medical treatment.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched April 2006), CENTRAL (The Cochrane Library 2006, Issue 1), MEDLINE (1966 to March 2006), EMBASE (1980 to April 2006), CINAHL (1982 to March 2006), AMED (1985 to April 2006), Biological Abstracts (1969 to March 2006), PsycINFO (1806 to April 2006), and SPORTDiscus (1830 to April 2006). Attempts were also made to identify trials from the metaRegister of Controlled Trials and the citation lists of review articles and included trials. In most cases the first or corresponding author of each included trial was contacted for additional information.

SELECTION CRITERIA

Any randomised controlled trials (RCTs) including spinal manipulative interventions (for example chiropractic, osteopathy, or manipulative physiotherapy) versus each other, placebo, no treatment, or other medical treatment were considered. Exclusion criteria were: mild or infrequent dysmenorrhoea or dysmenorrhoea from an intrauterine device (IUD).

DATA COLLECTION AND ANALYSIS

Four trials of high velocity, low amplitude manipulation (HVLA), and one of the Toftness manipulation technique were included. Quality assessment and data extraction were performed independently by two review authors. Meta analysis was performed using odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes. Data unsuitable for meta-analysis were reported as descriptive data and were also included for discussion. The outcome measures were pain relief or pain intensity (dichotomous, visual analogue scales, descriptive) and adverse effects.

MAIN RESULTS

Results from the four trials of high velocity, low amplitude manipulation suggest that the technique was no more effective than sham manipulation for the treatment of dysmenorrhoea, although it was possibly more effective than no treatment. Three of the smaller trials indicated a difference in favour of HVLA, however the one trial with an adequate sample size found no difference between HVLA and sham treatment. There was no difference in adverse effects experienced by participants in the HVLA or sham treatment. The Toftness technique was shown to be more effective than sham treatment by one small trial, but no strong conclusions could be made due to the small size of the trial and other methodological considerations.

AUTHORS' CONCLUSIONS

Overall there is no evidence to suggest that spinal manipulation is effective in the treatment of primary and secondary dysmenorrhoea. There is no greater risk of adverse effects with spinal manipulation than there is with sham manipulation.

Cleavage stage versus blastocyst stage embryo transfer in assisted conception

BACKGROUND

In the past decade, advances in the understanding of nutrient requirements of embryos, has led to the evolution of culture media designed to support extended culture of embryos in vitro from the standard procedure of 2 to 3 days (for early cleavage embryo transfer) to 5 to 6 days (blastocyst culture). The rationale for blastocyst culture is to improve the synchronicity of uterine and embryonic development and provide a mechanism for self-selection of viable embryos. Since the initial widespread introduction of blastocyst culture in 1998, there has been conflicting reports about the clinical benefits of this technique.

OBJECTIVES

To determine if blastocyst stage embryo transfers (ETs) affects success rates compared with cleavage stage ETs and investigate what factors may influence this.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials. We also searched the Cochrane Controlled Trials Register (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and Bio extracts. Attempts were made to identify trials from the National Research Register, the Clinical Trials Register and the citation lists of review articles and included trials. The last search date was May 2005. The first or corresponding author of each included trial was contacted for additional information.

SELECTION CRITERIA

Trials were included if they were randomised and compared the effectiveness of early cleavage versus blastocyst stage transfers.

DATA COLLECTION AND ANALYSIS

Of the 45 trials that were identified, 16 trials met the inclusion criteria and were reviewed. Primary outcomes were rates of live birth, clinical pregnancy and multiple-pregnancy rates per couple. Secondary outcomes were rates of miscarriage, failure to transfer embryos, freezing, implantation and high order pregnancy and per cycle data. Quality assessment and data extraction were performed independently by two review authors. Meta-analysis was performed using odds ratios (OR) for dichotomous outcomes and weighted mean differences for binary outcomes with 95% confidence intervals (CI).

MAIN RESULTS

There was no evidence of a difference in live-birth rate per couple between the two treatment groups (7 RCTs; OR 1.16, 95% CI 0.74 to 1.44 [Day 2/3 34.3% vs. Day 5/6 35.4%]); in the clinical pregnancy rate per couple (15 RCTs; OR 1.05, 95% CI 0.88 to 1.26 [Day 2/3 38.8% vs. 40.3%]) even for good prognosis patients (6 RCTs: OR 96% 1.06 CI 0.83 to 1.34). There was also no difference in multiple-pregnancy rate per couple (12 RCTs; OR 0.85, 95% CI 0.63 to 1.13) particularly in trials where equal numbers of embryos were transferred in both groups (6 RCTs: OR 0.91, 95% CI 0.63 to 1.32). There was no evidence of a difference in high order multiple-pregnancy rates per couple (5 RCTs; OR 0.44, 95% CI 0.15 to 1.33) or miscarriage rate per couple between the two groups (9 RCTs; OR 1.33, 95% CI 0.89 to 2.01). Rates of embryo freezing per couple was significantly higher in Day 2 to 3 transfers (9 RCTs; OR 0.45, 95% CI 0.36 to 0.57). Failure to transfer any embryos per couple was significantly higher in the Day 5 to 6 group (10 RCTs: OR 3.21, 95% CI 2.15 to 4.81[Day 2/3 3.5% vs D 5/6 10.1%]), but was not significantly different for good prognosis patients (7RCTs, OR 1.58 95% CI 0.65 to 3.82).

AUTHORS' CONCLUSIONS

There is no evidence of a difference in live birth or pregnancy outcomes between Day 2 to 3 and Day 5 to 6 transfer of embryos. Blastocyst transfer was associated with an increase in failure to transfer any embryos in a cycle and a decrease in embryo freezing rates. In the absence of data on cumulative live birth rates resulting from fresh and thawed cycles, it is not possible to determine if this represents an advantage or disadvantage.

Recombinant versus urinary gonadotrophins for triggering ovulation in assisted conception

BACKGROUND

The objective of this systematic review was to assess the safety and efficacy of subcutaneous recombinant (r) HCG and high-dose rLH compared with intramuscular urinary (u) uHCG for inducing final oocyte maturation and triggering ovulation.

METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (August 27, 2003), the Cochrane Central Register of Controlled Trials (CENTRAL on The Cochrane Library, issue 4, 2003), MEDLINE (1966 to February 2004) and EMBASE (1980 to February 2004). Searches were not limited by language. The bibliographies of included and excluded trials and abstracts of major meetings were searched for additional trials. Authors and pharmaceutical companies were contacted for missing and unpublished data. Only truly randomized controlled trials (RCTs) were included. Assessment of inclusion/exclusion, quality assessment and data extraction were performed independently by at least two reviewers.

RESULTS

Seven RCTs were identified, four comparing rHCG and uHCG and three comparing rhLH and uHCG. There was no statistically significant difference between rHCG and uHCG regarding the ongoing pregnancy/live birth rate [odds ratio (OR) 0.98; 95% confidence interval (CI) 0.69-1.39], clinical pregnancy rate, miscarriage rate or incidence of ovarian hyperstimulation syndrome (OHSS). There was no statistically significant difference between rhLH and uHCG regarding the ongoing pregnancy/live birth rate (OR 0.94; 95% CI 0.50-1.76), pregnancy rate, miscarriage rate or incidence of OHSS. rHCG was associated with a reduction in the incidence of local site reactions (OR 0.47; 95% CI 0.32-0.70).

CONCLUSIONS

According to these data, there is no evidence of a difference in clinical outcomes between urinary and recombinant gonadotrophins used for induction of final follicular maturation. Additional factors should be considered when choosing gonadotrophin type, including safety, cost and drug availability.

Recombinant versus urinary human chorionic gonadotrophin for ovulation induction in assisted conception

BACKGROUND

For the last few decades urinary human chorionic gonadotrophin has been used to induce final follicular maturation and for triggering ovulation in assisted conception. Recombinant technology has allowed the production of two drugs that can be used for the same purpose: to mimic the endogenous luteinizing hormone (LH) surge. This would allow commercial production to be adjusted according to market requirements. In addition all urinary contaminants would also be removed. Hence, this would allow the safe subcutaneous administration of a compound with less batch-to-batch variation. However, prior to a change in practice, the effectiveness of the recombinant drugs should be known, compared to the currently used urinary human chorionic gonadotrophins.

OBJECTIVES

To assess the safety and efficacy of subcutaneous rhCG and high dose rLH compared with intramuscular uhCG for inducing final oocyte maturation and triggering ovulation.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (27 August 2003), the Cochrane Central Register of Controlled Trials (CENTRAL on The Cochrane Library, issue 4, 2003), MEDLINE (1966 to Feb 2004) and EMBASE (1980 to Feb 2004). Searches were not limited by language. The bibliographies of included, excluded trials and abstracts of major meetings were searched for additional trials. Authors and pharmaceutical companies were contacted for missing and unpublished data.

SELECTION CRITERIA

Two reviewers independently scanned titles and abstracts, and selected those that appeared relevant for collection of the full paper. Only truly randomised controlled trials comparing rhCG or high dose r-LH with urinary hCG for triggering ovulation in assisted conception for treatment of infertility in normogonadotrophic women were included.

DATA COLLECTION AND ANALYSIS

Assessment of inclusion/exclusion, quality assessment and data extraction were performed independently by at least two reviewers. Discrepancies were discussed in the presence of a third reviewer and a consensus reached. Quality assessment included method of randomisation, allocation concealment, blinding of participants and assessors, reporting of a power calculation, intention to treat analysis, and handling of dropouts. Data extraction included characteristics of participants, the intervention and control procedures, and outcomes.

MAIN RESULTS

Seven RCTs were identified, four comparing rhCG and uhCG and three comparing rhLH and uhCG. There was no statistically significant difference between rhCG vs uhCG regarding the ongoing pregnancy/ live birth rate (OR 0.98, 95% CI 0.69 to 1.39), pregnancy rate, miscarriage or incidence of OHSS. There was no statistically significant difference between rhLH vs uhCG regarding the ongoing pregnancy/ live birth rate (OR 0.94, 95% CI 0.50 to 1.76), pregnancy rate, miscarriage or incidence of OHSS. The manufacturer of rhLH has decided not to further develop this product. rhCG was associated with a reduction in the incidence of local site reactions and other minor adverse effects (OR 0.47, 95% CI 0.32 to 0.70).

AUTHORS' CONCLUSIONS

There is no evidence of difference in clinical outcomes between urinary and recombinant gonadotrophins for induction of final follicular maturation. Additional factors should be considered when choosing gonadotrophin type, including safety, cost and drug availability.

Oral anti-oestrogens and medical adjuncts for subfertility associated with anovulation

BACKGROUND

Infertility due to anovulation is a common problem in women. The first line oral treatment is with anti-oestrogens, such as clomiphene citrate. Unfortunately there may be resistance and alternative and adjunctive treatments have been developed. These include tamoxifen, dexamethasone, bromocriptine and aromatase inhibitors (AIs).

OBJECTIVES

To determine the relative effectiveness of anti-oestrogen agents, with or without medical adjuncts, in women with WHO group 2 anovulation.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group trial register (searched 5th July 2004), CENTRAL (The Cochrane Library Issue 2 2004), MEDLINE (1966 to June 2004) and EMBASE (1980 to June 2004) for identification of relevant randomised controlled trials (RCTs). Additionally the United Kingdom National Institute for Clinical Excellence (NICE) guidelines and the references of relevant reviews and RCTs were searched.

SELECTION CRITERIA

RCTs that compare oral anti-oestrogen agents for ovulation induction (alone or in conjunction with medical adjuncts) in anovulatory subfertility, were considered for inclusion in the review. Metformin and other insulin sensitizing agents were not included. Hyperprolactinaemic infertility was not included.

DATA COLLECTION AND ANALYSIS

Data extraction and quality assessment was done independently by two reviewers. The primary outcome was live birth, secondary outcomes were: pregnancy, ovulation, miscarriage, multiple pregnancy, overstimulation, ovarian hyperstimulation syndrome and patient reported adverse effects.

MAIN RESULTS

Twelve RCTs were found and included in this review. No trials reported live birth as an outcome. Miscarriage and multiple pregnancy rates were poorly reported. Clomiphene was shown to be effective in increasing pregnancy rate when compared to placebo (fixed OR 5.8, 95% CI 1.6 to 21.5; NNT 5.9, 95% CI 3.6 to 16.7). No evidence of a difference in effect was found between clomiphene and tamoxifen (fixed OR 1.0, 95% CI 0.5 to 2.1). The use of clomiphene in combination with tamoxifen did not find any evidence of effect on pregnancy rate when compared to clomiphene alone (fixed OR 3.3, 95% CI 0.1 to 91.6). The comparison between two AIs (letrozole and anastrozole) did not find any evidence of a difference in effect on pregnancy rate (fixed OR 1.9, 95% CI 0.4 to 8.9). For the intervention of clomiphene plus ketoconazole vs clomiphene no evidence of a difference in effect for pregnancy rate was found (fixed OR 2.4, 95% CI 0.9 to 6.4). For clomiphene plus bromocriptine vs clomiphene no evidence of a difference in effect on pregnancy rate was found (fixed OR 1.0, 95% CI 0.3 to 3.0) rates. However, clomiphene plus dexamethasone treatment resulted in a significant improvement in the pregnancy rate (fixed OR 11.3, 95% CI 5.3 to 24.0; NNT 2.7, 95% CI 2.1 to 3.6) when compared to clomiphene alone as did clomiphene plus pretreatment with combined oral contraceptives (fixed OR 27.2, 95% CI 3.1 to 235.0; NNT 2.0, 95% CI 1.4 to 3.4).

AUTHORS' CONCLUSIONS

This review shows evidence supporting the effectiveness of the current first line treatment, clomiphene citrate. No evidence of a difference in effect was found between clomiphene and tamoxifen. The use of dexamethasone as an adjunct to clomiphene therapy appears promising as do combined oral contraceptives. This review has highlighted a gap in the literature on effects of these drugs on outcomes such as miscarriage rate. Evidence in favour of these interventions is flawed. RCTs of adequate power and of high methodological quality are required for the older treatments such as clomiphene, alone and with medical adjuncts, and also for the newer drugs such as the AIs.

The merits of blastocyst versus cleavage stage embryo transfer: a Cochrane review

This paper is based on a Cochrane review published in The Cochrane Library, issue 2, 2002 (see www.CochraneLibrary.net for information) with permission from The Cochrane Collaboration and John Wiley and Sons. Cochrane reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and The Cochrane Library should be consulted for the most recent version of the review.

BACKGROUND

The aim of this study was to determine the relative merits of blastocyst versus cleavage stage embryo transfer, concerning the chance of pregnancy, live birth, multiple pregnancy and the factors contributing to these primary outcomes, from the best available evidence.

METHODS

A systematic review employing the principles of the Cochrane Menstrual Disorders and Subfertility Group was undertaken. Fourteen randomized controlled trials, all comparing day 2/3 with day 5/6 embryo transfer, were included in a meta-analysis.

RESULTS

For day 2/3 versus day 5/6 transfer, there was no significant difference in the odds of pregnancy [odds ratio (OR) = 0.91, 95% confidence interval (CI) 0.71-1.17] nor of live birth (OR = 0.83, 95% CI 0.48-1.42) per treated couple. These results were similar whether all trials, only trials with transfer of equal numbers of day 2/3 versus day 5/6, or only trials with transfer of fewer day 5/6 than day 2/3 embryos, were pooled. There was no significant difference in the odds of multiple pregnancy for day 2/3 versus day 5/6 transfer overall (OR 0.77, 95% CI 0.52-1.13) nor when fewer day 5/6 than day 2/3 embryos were transferred (day 2/3 versus day 5/6 OR 0.69, 95% CI 0.42-1.12).

CONCLUSION

The current evidence fails to support a widespread change of practice from cleavage stage to blastocyst stage embryo transfer in couples undergoing IVF.

Bradykinin causes hypotension by activating pulmonary sympathetic afferents in the rabbit

Bradykinin (BK) activates sympathetic afferents in the heart, intestine, and kidney, and it alters hemodynamics. However, we know little about the influence of pulmonary sympathetic afferents on circulation. Activation of pulmonary afferents by directly injecting stimulants into the lung parenchyma permits examination of reflexes that originate in the lung without confounding effects from the systemic circulation. In the present study, we tested the hypothesis that pulmonary sympathetic afferents exert a significant influence on hemodynamics. We examined reflex effects of injecting BK (1 microg/kg in 0.1 ml) into the lung parenchyma on circulation in anesthetized, open-chest, artificially ventilated rabbits. BK significantly decreased mean arterial blood pressure (BP) (27 +/- 3 mmHg) and heart rate (19 +/- 4 beats/min). Both effects remained after bilateral vagotomy. To rule out possible direct systemic vasodilation by BK, we examined renal sympathetic nerve activity (RSNA) in response to BK injection and examined BP responses to injection of ACh (0.1 ml of 10-4 M). BK suppressed the RSNA before and after vagotomy. ACh did not change BP when injected into the lung parenchyma, but it decreased BP (31 +/- 3 mmHg) when injected into the right atrium. Our data indicate that activating pulmonary sympathetic afferents reflexly suppresses hemodynamics.

Eight blue babies

Methemoglobinemia is a serious medical condition that affects hundreds of infants in the United States each year. The condition involves the oxidation of red cell hemoglobin to a state that is unable to transport oxygen. Affected infants appear cyanotic and may have altered mental status. The condition is readily reversible if recognized and treated appropriately. The Wisconsin Division of Public Health investigates all cases of infant methemoglobinemia in an attempt to determine their cause. Between January 1990 and September 1999, 8 infants were diagnosed with this condition. Review of their hospitalization records found that 3 of these cases involved infants whose formula was prepared with water from nitrate-contaminated wels. Risk factors identified in the remaining cases included use of folk remedies, misuse of over-the-counter analgesics, and an inherited enzyme deficiency. Causes were not identified for 2 of the cases. All of the affected infants recovered.

Gaps in the evidence for fertility treatment-an analysis of the Cochrane Menstrual Disorders and Subfertility Group database

BACKGROUND

The randomized controlled trial is considered the best approach to assess the effectiveness of treatments. The aim was to summarize the available evidence and determine gaps in the evidence for clinical decision making in subfertility.

METHODS

A search of the Cochrane Library for Menstrual Disorders and Subfertility Group reviews was undertaken and, where the reviews were related to subfertility, the authors' conclusions were appraised and correlated with the results and meta-analysis sections of the reviews. Each review was then categorized as to what extent it had answered the clinical question posed by the reviewers.

RESULTS

Of 38 subfertility reviews currently or previously published on the Cochrane Library from the Menstrual Disorders and Subfertility Group, 12 reviews concluded that there was evidence of effectiveness of the interventions studied. There was insufficient evidence of effectiveness in 26 reviews, from which the authors of 23 reviews called for further research. A tabulated summary of the review conclusions is presented.

CONCLUSION

Cochrane subfertility reviews have eliminated some gaps in the evidence and highlighted others. Future clinical trial design should focus on adequate power and reporting the major outcome of live-births per couple as well as adverse events.

Growth hormone for in vitro fertilization

BACKGROUND

In an effort to improve outcomes of in vitro fertilisation (IVF) cycles the use of growth hormone (GH) has been considered. Most studies investigate the role of GH in normally ovulating infertile women but there is also an interest in the effect of GH on women who respond poorly to ovulation induction and IVF.

OBJECTIVES

To assess the effectiveness of GH or growth hormone releasing (GRF) adjuvant therapy, primarily in terms of improving livebirth rate, for women undergoing ovulation induction prior to IVF in (a) patients with no previous history of poor response and (b) patients with a history of poor response.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group's trials register (24 March 2003), the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 1, 2003), MEDLINE (1966 to Feb 2003), EMBASE (1988 to Feb 2003) and Biological Abstracts (1969 to Feb 2003). Reference lists of articles were also searched.

SELECTION CRITERIA

All randomised controlled trials were included if they addressed the research question and provided outcome data for intervention and control subjects.

DATA COLLECTION AND ANALYSIS

Assessment of trial quality and extraction of relevant data was performed independently by two reviewers. Validity was assessed in terms of method of randomisation, completeness of follow-up and co-intervention.

MAIN RESULTS

Nine studies (401 couples) were included. Three trials concerned patients with no history of poor response to IVF (91 women) and six investigated previous poor responders (302 women). There was no evidence that routine use of GH affected the outcome of livebirth (3 RCTs; OR 1.17, 95% CI 0.38 to 3.59). In women who had previously responded poorly to IVF there was no significant differences in livebirth when combining trials of GH and GRF (4 RCTs; OR 2.42, 95% CI 0.94 to 6.23). However when trials using GH were analysed separately there was an increase in livebirths (3 RCTs; OR 4.37, 95% CI 1.06 to 18.01). There was no significant differences in any adverse events, but these were poorly and inconsistently reported.

REVIEWER'S CONCLUSIONS

Although the use of GH in previous poor responders has been found to show a significant improvement in livebirth rate, this result was only just significant. Also, this data is from just three small trials. Therefore, before recommending GH in IVF further research is necessary to fully define its role. Meanwhile GH should only be considered in the context of a clinical trial.

Cleavage stage versus blastocyst stage embryo transfer in assisted conception

BACKGROUND

Despite numerous advances in the field of in vitro fertilisation (IVF), many of the widely applied embryo culture techniques and resulting implantation rates have remained relatively unchanged since the first treatment was performed in the mid 1970's. Recent advances in the understanding of nutrient requirements of embryos, have led to a renaissance of extending their culture from the standard procedure of 2-3 days (early cleavage embryo transfer) to 5-6 days (blastocyst culture). The rationale for blastocyst culture is to improve the synchronicity of uterine and embryonic development and provide a mechanism for self-selection of viable embryos. Numerous reports on the clinical benefits of blastocyst culture have led to the worldwide introduction of this technique, despite a deficiency of conclusive evidence to do so.

OBJECTIVES

Primary: To determine if blastocyst stage embryo transfers (ET's) result in higher success rates, than cleavage stage embryo transfers. Secondary: To assess the overall embryo utilisation rate of both techniques.

SEARCH STRATEGY

Electronic searches of the Cochrane Menstrual Disorders and Subfertility Group specialised register of controlled trials, CCTR, MEDLINE, EMBASE, and Bio extracts were performed to identify relevant randomised controlled trials (RCTs). Attempts were also made to identify trials from the National Research Register, the Clinical Trial Register and the citation lists of review articles and included trials. The first or corresponding author of each included trial was also contacted for additional information.

SELECTION CRITERIA

Trials were included if they were randomised and compared the effectiveness of early cleavage versus blastocyst stage transfers.

DATA COLLECTION AND ANALYSIS

Of the 29 trials that were identified, ten trials met the inclusion criteria and were reviewed. Primary outcomes were rates of; live birth, clinical pregnancy and implantation per woman. Secondary outcomes were rates of; miscarriage, monozygotic twinning, embryo freezing, embryo utilisation, cancellation, multiple pregnancy and high order pregnancy and per cycle data. Quality assessment and data extraction were performed independently by two reviewers. Meta analysis was performed using odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes.

MAIN RESULTS

There was no significant difference between the two treatment groups in live birth rate, although this was reported by only one quasi-random trial (Peto OR 1.59, 95% CI 0.80, 3.15). There was also no evidence of a difference in pregnancy rate (both overall and subgroups) between the two groups for pregnancy rate per couple randomised (4 RCTs: Peto OR 0.86, 95% CI 0.57, 1.29). There was also no suggestion of an overall difference in implantation rates per embryo's transferred although it was impossible to calculate valid confidence intervals from published data (Day 2/3 17.1% vs Day 5/6 18.9%). The subgroup of sequential media trials suggested higher implantation rate for blastocyst transfer (Day 2/3 22.6% vs Day 5/6 32%). The miscarriage rate was no different between the two groups (1 RCT, Peto OR 1.66, 95% CI 0.41, 6.81). The RCTs reporting embryo freezing showed no difference (Peto OR 1.71, 95% CI 1.00, 2.94), however the two quasi-random trials showed a significant difference in favour of the Day 2/3 group (Peto OR 2.99, 95% CI 1.88, 4.75). Embryo transfer cancellation rates were significantly higher in the Day 5/6 group (5 RCTs: Peto OR 0.57, 95% CI 0.40, 0.83). There was no significant difference in the rate of multiple pregnancies or the rate of high order pregnancies (3 RCTs, Peto OR 0.58, 95% CI 0.30, 1.12)(2 RCTs, Peto OR 7.88, 95% CI 0.49, 126.30 respectively).

REVIEWER'S CONCLUSIONS

Overall this review of the best available evidence based on data from randomised controlled trials, suggests that to date little difference in the major outcome parameters has been demonstrated between early embryo transfer and blastocyst culture. Collectively, the increase in cancellation and the possible decrease in cryopreservation rates suggest that the routine practice of blastocyst culture should be offered to patients with caution. The subgroup of trials employing sequential media, did however demonstrate a substantial improvement in implantation rates and similar pregnancy rates, despite the transfer of less embryos. Whether this trend will culminate in convincing higher live birth rates per woman, has yet to be validated.

Oral versus injectable ovulation induction agents for unexplained subfertility

BACKGROUND

Oral (anti-oestrogens) and injectable (gonadotrophins) ovulation induction agents have been used to increase the number of eggs produced by a woman per cycle in treatment for unexplained subfertility. It is unclear whether there are significant advantages of one type of treatment over the other in this context or in terms of fertility.

OBJECTIVES

To assess the efficacy of oral versus injectable ovulation induction agents for unexplained subfertility.

SEARCH STRATEGY

The search strategy of the Menstrual Disorders and Subfertility Group was used for the identification of relevant randomised controlled trials.

SELECTION CRITERIA

All trials where oral ovulation induction agents were compared with injectable ovulation induction agents in treatment groups generated by randomisation, from couples with unexplained subfertility, were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Five randomised controlled trials, including a total of 231 identified couples with unexplained subfertility, were found and included in this review. All trials were assessed for quality criteria. The studied outcomes were pregnancy, live birth, miscarriage, multiple birth, occurrence of ovarian hyperstimulation syndrome and cycle cancellation.

MAIN RESULTS

Where trials with important co-interventions were excluded, there was no significant difference in the odds of beneficial outcomes for oral versus injectable ovulation induction agents - live birth per couple (OR 0.06, 95%CI 0.00-1.15), pregnancy per woman (OR 0.33, 95%CI 0.09-1.20); nor of detrimental outcomes for injectable versus oral agents - miscarriage (OR 0.11, 95%CI 0.00-2.84); there were no reported cases of multiple births, cases of ovarian hyperstimulation or discontinued cycles consequent upon overstimulation. Where trials with the co-intervention of a human chorionic gonadotrophin trigger injection (given only in the injectable ovulation induction agent treatment arm) were not excluded there was no significant difference in the odds of live birth per couple (OR 0.40, 95%CI 0.15-1.08). However oral ovulation induction agents had significantly reduced odds of pregnancy per woman compared to injectable ovulation induction agents (OR 0.41, 95%CI 0.17-0.80). For detrimental outcomes, there were no significant differences in the odds of miscarriage (OR 0.61, 95%CI 0.09-4.01) and multiple birth (OR 1.08, 95%CI 0.16-7.03) for injectable versus oral agents. No data were available concerning the occurrence of ovarian hyperstimulation syndrome nor cycle cancellation.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to suggest that oral agents are inferior or superior to injectable agents in the treatment of unexplained subfertility. Information on harms is sketchy, and remains compatible with large differences in either direction. Much larger trials than have previously been undertaken are required to provide information on relative harms as well as benefits.

The UBX domain: a widespread ubiquitin-like module

The UBX domain is an 80 amino acid residue module that is present typically at the carboxyl terminus of a variety of eukaryotic proteins. In an effort to elucidate the function of UBX domains, we solved the three-dimensional structure of the UBX domain of human Fas-associated factor-1 (FAF1) by NMR spectroscopy. The structure has a beta-Grasp fold characterised by a beta-beta-alpha-beta-beta-alpha-beta secondary-structure organisation. The five beta strands are arranged into a mixed sheet in the order 21534. The longer first helix packs across the first three strands of the sheet, and a second shorter 3(10) helix is located in an extended loop connecting strands 4 and 5. In the absence of significant sequence similarity, the UBX domain can be superimposed with ubiquitin with an r.m.s.d. of 1.9 A, suggesting that the two structures share the same superfold, and an evolutionary relationship. However, the absence of a carboxyl-terminal extension containing a double glycine motif and of suitably positioned lysine side-chains makes it highly unlikely that UBX domains are either conjugated to other proteins or part of mixed UBX-ubiquitin chains. Database searches revealed that most UBX domain-containing proteins belong to one of four evolutionarily conserved families represented by the human FAF1, p47, Y33K, and Rep8 proteins. A role of the UBX domain in ubiquitin-related processes is suggested.

Nurses' knowledge of palliative care in the Australian Capital Territory

Australia has a growing number of specialist palliative care services. As they expanded in the Australian Capital Territory, a working party was established to discuss issues associated with palliative care. One activity authorized by this committee was a survey of nurses' knowledge of palliative care. The Palliative Care Quiz for Nurses (Ross et al, 1996) was adapted with permission for this survey: 455 registered and enrolled nurses were surveyed; 247 (54%) participants returned completed questionnaires. The overall mean score for the Palliative Care Quiz was 12.4 of a possible 20; the mean scores were 13.2 for registered nurses and 10.6 for enrolled nurses. Nurses with some oncology or palliative care experience scored significantly higher than others. Nurses with more work experience as measured by working years also attained significantly higher scores. Analysis and examination of correct items suggest that nurses have acquired basic knowledge through experience. However, as other studies have suggested, there is also a lack of knowledge of complex symptoms found in palliative care patients.

Biophysical characterization of elongin C from Saccharomyces cerevisiae

Elongin C (ELC) is an essential component of the mammalian CBC(VHL) E3 ubiquitin ligase complex. As a step toward understanding the role of ELC in assembly and function of CBC-type ubiquitin ligases, we analyzed the quaternary structure and backbone dynamics of the highly homologous Elc1 protein from Saccharomyces cerevisiae. Analytical ultracentrifugation experiments in conjunction with size exclusion chromatography showed that Elc1 is a nonglobular monomer over a wide range of concentrations. Pronounced line broadening in (1)H,(15)N-HSQC NMR spectra and failure to assign peaks corresponding to the carboxy-terminal helix 4 of Elc1 indicated that helix 4 is conformationally labile. Measurement of (15)N NMR relaxation parameters including T(1), T(2), and the (1)H-(15)N nuclear Overhauser effect revealed (i) surprisingly high flexibility of residues 69-77 in loop 5, and (ii) chemical exchange contributions for a large number of residues throughout the protein. Addition of 2,2,2-trifluoroethanol (TFE) stabilized helix 4 and reduced chemical exchange contributions, suggesting that stabilization of helix 4 suppresses the tendency of Elc1 to undergo conformational exchange on a micro- to millisecond time scale. Binding of a peptide representing the major ELC binding site of the von Hippel-Lindau (VHL) tumor suppressor protein almost completely eliminated chemical exchange processes, but induced substantial conformational changes in Elc1 leading to pronounced rotational anisotropy. These results suggest that elongin C interacts with various target proteins including the VHL protein by an induced fit mechanism involving the conformationally flexible carboxy-terminal helix 4.

Antibiotic susceptibility of invasive Streptococcus pneumoniae in Wisconsin, 1999

BACKGROUND

Streptococcus pneumoniae is a major cause of community acquired infections in the United States, and rates of antibiotic resistance have increased dramatically in the past decade. Statewide rates of pneumococcal resistance to penicillin and other antibiotics have not been previously reported in Wisconsin. To determine these rates, we assessed invasive pneumococcal isolates for reduced susceptibility to nine different antibiotics.

METHODS

Pneumococcal isolates from blood, cerebrospinal fluid or other normally sterile body sites were submitted by 91% of laboratories that perform invasive bacterial cultures. Isolates were tested for susceptibility to penicillin, cefotaxime, ceftriaxone, levofloxacin, meropenem, erythromycin, vancomycin, sulfamethoxazole-trimethoprim and chloramphenicol.

RESULTS

There were 409 invasive pneumococcal isolates identified in 1999 among Wisconsin residents, including 385 (94%) isolates from blood. The mean patient age was 42.5 years (range, < 1 year to 96 years), and 213 (52%) were male. Of the pneumococcal isolates, 24% were not susceptible to penicillin, including 10% with high level resistance. Isolates with reduced penicillin susceptibility were also likely to have reduced susceptibility to other antibiotics. Patients with penicillin nonsusceptible (intermediate and fully resistant) pneumococcal isolates were significantly younger (mean, 37.0 years) than those with susceptible isolates (mean, 44.3 years) (p = .04). The proportion of patients with a penicillin nonsusceptible isolate varied by region, ranging from 12.8% in northeastern Wisconsin to 35.5% in northern Wisconsin.

CONCLUSIONS

The proportion of invasive pneumococcal isolates with penicillin resistance in Wisconsin is similar to other regions of the United States. Inappropriate antibiotic use contributes to the emergence of resistant pneumococcal infections, and educational efforts are underway to promote judicious antibiotic use in Wisconsin.

Pulmonary edema develops after recurrent obstructive apneas

There are anecdotal reports of pulmonary edema after a night of recurrent obstructive apneas (OAs) in humans, but no data on lung water, gas exchange, filling pressure, or cardiac output (Q) exist in these patients. By clamping the endotracheal tube of eight intubated, anesthesized dogs, we created repetitive OAs of 45-s duration at 30-s intervals, for 8 h. Five additional dogs without apneas, but identically instrumented, were studied simultaneously, serving as nonapneic controls. Sa (O(2)) was measured by intraarterial catheter, pulmonary capillary wedge pressure (Pcw), continuous cardiac output (Q), and mixed venous oxygen saturation (Sv(O(2))) were measured by flotation catheter. Basal and hourly hemodynamics and blood gases (arterial and venous) under steady state respiration were measured. Venous admixture (Q S/Q T) was calculated by standard equations. Pa(O(2)) from the beginning to the end of the experiment fell from 89.6 to 82.8 mm Hg in apneic animals and from 92.2 to 85.5 mm Hg in controls. The Q S/Q T increased in both groups but more so in the apnea group (3.3 to 19.4%) than in nonapneic controls (3.1 to 7.9%). Neither Q nor Pcw changed significantly in either group. Lung wet/dry weight was 5.40 +/- 0.93 in apneic animals and 5.00 +/- 0.67 in controls. Light microscopy showed gross alveolar fluid in three apneic dogs, and electron microscopy showed interstitial fluid in two additional apneic dogs. One of the lung edema dogs expired of acute heart failure in the seventh hour of the experiment. Worsening of gas exchange and histology suggest that lung edema can result from recurrent OAs.

Structural changes in the transition state of protein folding: alternative interpretations of curved chevron plots

The interpretation of folding rates is often rationalized within the context of transition state theory. This means that the reaction rate is linked to an activation barrier, the height of which is determined by the free energy difference between a ground state (the starting point) and an apparent transition state. Changes in the folding kinetics are thus caused by effects on either the ground state, the transition state, or both. However, structural changes of the transition state are rarely discussed in connection with experimental data, and kinetic anomalies are commonly ascribed to ground state effects alone, e.g., depletion or accumulation of structural intermediates upon addition of denaturant. In this study, we present kinetic data which are best described by transition state changes. We also show that ground state effects and transition state effects are in general difficult to distinguish kinetically. The analysis is based on the structurally homologous proteins U1A and S6. Both proteins display two-state behavior, but there is a marked difference in their kinetics. S6 exhibits a classical V-shaped chevron plot (log observed rate constant vs denaturant concentration), whereas U1A's chevron plot is symmetrically curved, like an inverted bell curve. However, S6 is readily mutated to display U1A-like kinetics. The seemingly drastic effects of these mutations are readily ascribed to transition state movements where large kinetic differences result from relatively small alterations of a common free energy profile and broad activation barriers.