Mantel-Haenszel Odds Ratio Research Articles

Clipping Versus Coiling in the Management of Posterior Communicating Artery Aneurysms with Third Nerve Palsy: A Systematic Review and Meta-Analysis

To compare surgical clipping with endovascular coiling in terms of recovery from oculomotor nerve palsy (ONP) in the management of posterior communicating artery (PCoA) aneurysms causing third nerve palsy. We conducted a systematic review of the literature and meta-analysis. The meta-analysis included 11 relevant studies involving 384 patients with third nerve palsy caused by PCoA aneurysms at baseline, of whom 257 (67.0%) were treated by clipping and 127 were treated by coiling (33.0%). Pooled odds ratios of the impact of clipping or coiling on complete ONP recovery, lack of ONP recovery, and procedure-related death were calculated. The overall complete ONP recovery rate was 42.5% in the coiling group compared with 83.6% in the clipping group. The increase in complete ONP recovery in the clipping group corresponds to an overall pooled Mantel-Haenszel odds ratio of 4.44 (95% confidence interval = 1.66-11.84). Subgroup analysis revealed a clear benefit of clipping over coiling in patients with ruptured aneurysms, but not in patients with unruptured aneurysms. No procedure-related deaths were reported by any of the 11 studies. Surgical clipping of PCoA aneurysms causing third nerve palsy achieves better ONP recovery than endovascular coiling; this could be particularly true in the case of ruptured aneurysms. In view of the purely observational data, statements about this effect should be made with great caution. A randomized trial would better address the therapeutic dilemma, but pending the results of such a trial, we recommend treating PCoA aneurysms causing ONP with surgery.

Ultrasound guidance for upper and lower limb blocks.

Ultrasound guidance for upper and lower limb blocks.

Dental health and alimentation among the Quintana Roo Mayas: coastal and inland sites of the classic-postclassic periods.

The goal of this study is to compare both dental and skeletal stress indicators of the Classic and Postclassic coastal and inland sites of the State of Quintana Roo, Mexico. The hypothesis is that coastal populations will show osteo and dental pathologies characteristic of a primarily marine food source combined with a diet of horticultural resources. This kind of alimentation provides people with less environmental stress and therefore a better health status. However, over time, in the Postclassic period, the health conditions deteriorated among both coastal and inland inhabitants, according to the hierarchization of the society, militarization, and commercial activities of all the coastal sites. The sample was drawn from 19 sites (196 individuals of both sexes) from the east coast of the Yucatan Peninsula, as well as from inland localities within the boundaries of Quintana Roo. Both dental and osteological stress indicators were analyzed, and crosstabs were applied for absolute and relative frequencies and their corresponding χ(2) and F Fisher analyses. The osteopathological index of the coastal and inland sites of the Classic period were compared over time between the Classic coastal inhabitants and the Postclassic coastal inhabitants so as to understand how life conditions changed over time. The Mantel-Haenszel odds ratio, with the crosstabs controlling for sex (males and females), was also carried out. There are low frequencies of dental pathologies and anemia present in both the coastal and inland populations of Quintana Roo in the Classic and Postclassic times. Only the presence of periostitis is highly common in both types of site, and this is the only indicator with significant differences. The dental pathologies, anemia and periostitis, in general, present a slight upward trend in both the coastal and inland populations over time. The coastal populations have fewer frequencies of the above than the inland sites whilst, in the Postclassic period, both the coastal and inland sites register increased frequencies of all the indicators. Linear enamel hypoplasia (LEH) is the only indicator that does not follow this tendency. The analyzed indicators are in accord with the general tendency reported in the literature. The results revealed a general trend whereby the Classic inland sites display poorer life conditions than the Classic coastal sites. In the Postclassic period, this pattern changed because the frequencies of all stress indicators increased. The explanations regarding this tendency are related to the differential access to food resources between regions; coastal people had a varied diet and better sources of protein, taking into account the culture of alimentation, the type, and the sources (in general, fish) that have an important impact on the absorption of micronutrients and therefore greater impact on local health conditions. Also, it is plausible that they were able to access imported food through commerce (such as meat and vegetables/corn). The decline in health of the coastal people in the Postclassic period was probably associated with social stratification, increasing militarism, changes in the economic corpus, new pathogens, and the decline of the power structures prevailing throughout the Classic period.

Hormonal and intrauterine methods for contraception for women aged 25 years and younger.

Women between the ages of 15 and 24 years have high rates of unintended pregnancy; over half of women in this age group want to avoid pregnancy. However, women under age 25 years have higher typical contraceptive failure rates within the first 12 months of use than older women. High discontinuation rates may also be a problem in this population. Concern that adolescents and young women will not find hormonal or intrauterine contraceptives acceptable or effective might deter healthcare providers from recommending these contraceptive methods. To compare the contraceptive failure (pregnancy) rates and to examine the continuation rates for hormonal and intrauterine contraception among young women aged 25 years and younger. We searched until 4 August 2015 for randomized controlled trials (RCTs) that compared hormonal or intrauterine methods of contraception in women aged 25 years and younger. Computerized databases included the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, CINAHL, and LILACS. We also searched for current trials via ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP). We considered RCTs in any language that reported the contraceptive failure rates for hormonal or intrauterine contraceptive methods, when compared with another contraceptive method, for women aged 25 years and younger. The other contraceptive method could have been another intrauterine contraceptive, another hormonal contraceptive or different dose of the same method, or a non-hormonal contraceptive. Treatment duration must have been at least three months. Eligible trials had to include the primary outcome of contraceptive failure rate (pregnancy). The secondary outcome was contraceptive continuation rate. One author conducted the primary data extraction and entered the information into Review Manager. Another author performed an independent data extraction and verified the initial entry. For dichotomous outcomes, we computed the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). Because of disparate interventions and outcome measures, we did not conduct meta-analysis. Five trials met the inclusion criteria. The studies included a total of 1503 women, with a mean of 301 participants. The trials compared the following contraceptives: combined oral contraceptive (COC) versus transdermal contraceptive patch, vaginal contraceptive ring, or levonorgestrel intrauterine system 20 µg/day (LNG-IUS 20); LNG-IUS 12 µg/day (LNG-IUS 12) versus LNG-IUS 16 µg/day (LNG-IUS 16); and LNG-IUS 20 versus the copper T380A intrauterine device (IUD). In the trials comparing two different types of methods, the study arms did not differ significantly for contraceptive efficacy or continuation. The sample sizes were small for two of those studies. The only significant outcome was that a COC group had a higher proportion of women who discontinued for 'other personal reasons' compared with the group assigned to the LNG-IUS 20 (OR 0.27, 95% CI 0.09 to 0.85), which may have little clinic relevance. The trial comparing LNG-IUS 12 versus LNG-IUS 16 showed similar efficacy over one and three years. In three trials that examined different LNG-IUS, continuation was at least 75% at 6 to 36 months. We considered the overall quality of evidence to be moderate to low. Limitations were due to trial design or limited reporting. Different doses in the LNG-IUS did not appear to influence efficacy over three years. In another study, continuation of the LNG-IUS appeared at least as high as that for the COC. The current evidence was insufficient to compare efficacy and continuation rates for hormonal and intrauterine contraceptive methods in women aged 25 years and younger.

Education for contraceptive use by women after childbirth.

Contraceptive education is generally a standard component of postpartum care, although the effectiveness is seldom examined. The assumptions that form the basis of such programs include postpartum women being motivated to use contraception and that they will not return to a health provider for family planning advice. Women may wish to discuss contraception both prenatally and after hospital discharge. Nonetheless, two-thirds of postpartum women have unmet needs for contraception. In the USA, many adolescents have repeat pregnancies within a year of giving birth. Assess the effectiveness of educational interventions for postpartum women on contraceptive use We searched for trials through June 2015 in PubMed, CENTRAL, CINAHL, POPLINE, and Web of Science. For current trials, we searched ClinicalTrials.gov and ICTRP. Previous searches also included EMBASE and PsycInfo. We also examined reference lists of relevant articles. For earlier versions, we contacted investigators to locate additional reports. We considered randomized controlled trials (RCTs) that examined postpartum education about contraceptive use, whether delivered to individuals or to groups of women. Studies that randomized clusters rather than individuals were eligible if the investigators accounted for the clustering in the analysis. The intervention must have started within one month after delivery. We assessed titles and abstracts identified during the literature searches. The data were abstracted and entered into Review Manager. Studies were examined for methodological quality. For dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI) was calculated. Where data were sFor continuous variables, we computed the mean difference (MD) with 95% CI. Due to varied interventions and outcome measures, we did not conduct meta-analysis. Twelve trials met our eligibility criteria, included the three added in this update. The studies included a total of 4145 women. Eight trials were conducted in the USA; the others were from Australia, Nepal, Pakistan, and Syria. Four studies provided one session before hospital discharge; three had structured counseling of varying intensity and one involved informal counseling. Of eight interventions with than one contact, five focused on adolescents. Three of the five involved home visiting, one provided multiple clinic services, and one had in-person contact and phone follow-up. Of the remaining three for women of varying ages, two involved home visits and one provided phone follow-up.Our sensitivity analysis included six trials with evidence of moderate or high quality. In a study with adolescents, the group with home-based mentoring had fewer second births within two years compared to the control group (OR 0.41, 95% CI 0.17 to 1.00). The other five interventions had no effect. Of trials with lower quality evidence, two showed some effectiveness. In Nepal, women with an educational session immediately postpartum were more likely to use contraception at six months than those with a later or no session (OR 1.62, 95% CI 1.06 to 2.50). In an Australian study, teenagers in a structured home-visiting program were more likely to have effective contraception use at six months than those with standard home visits (OR 3.24; 95% CI 1.35 to 7.79). We focused our results summary on trials with moderate or high quality evidence. Overall, the overall quality of evidence in this review was moderate to low and the evidence of effectiveness was mostly low quality. The interventions could be improved by strengthening the program design and implementation. Some studies did not report program training for providers, adherence to the intervention protocol, or measurement of participants' knowledge and skills. Many trials did not have an objective outcome measure, i.e., pregnancy test or structured questionnaire for contraceptive use. Valid and reliable outcome measures are needed to obtain meaningful results. Still, given the associated costs and logistics, some programs would not be feasible in many settings.

Interventions for pain with intrauterine device insertion.

Fear of pain during insertion of intrauterine contraception (IUC) is a barrier to use of this method. IUC includes copper-containing intrauterine devices and levonorgestrel-releasing intrauterine systems. Interventions for pain control during IUC insertion include non-steroidal anti-inflammatory drugs (NSAIDs), local cervical anesthetics, and cervical ripening agents such as misoprostol. To review randomized controlled trials (RCTs) of interventions for reducing IUC insertion-related pain We searched for trials in CENTRAL, MEDLINE, EMBASE, POPLINE, ClinicalTrials.gov, and ICTRP. The most recent search was 22 June 2015. We examined reference lists of pertinent articles. For the initial review, we wrote to investigators to find other published or unpublished trials. We included RCTs that evaluated an intervention for preventing IUC insertion-related pain. The comparison could have been a placebo, no intervention, or another active intervention. The primary outcomes were self-reported pain at tenaculum placement, during IUC insertion, and after IUC insertion (up to six hours). Two authors extracted data from eligible trials. For dichotomous variables, we calculated the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). For continuous variables, we computed the mean difference (MD) with 95% CI. In meta-analysis of trials with different measurement scales, we used the standardized mean difference (SMD). We included 33 trials with 5710 participants total; 29 were published from 2010 to 2015. Studies examined lidocaine, misoprostol, NSAIDs, and other interventions. Here we synthesize results from trials with sufficient outcome data and moderate- or high-quality evidence.For lidocaine, meta-analysis showed topical 2% gel had no effect on pain at tenaculum placement (two trials) or on pain during IUC insertion (three trials). Other formulations were effective compared with placebo in individual trials. Mean score for IUC-insertion pain was lower with lidocaine and prilocaine cream (MD -1.96, 95% CI -3.00 to -0.92). Among nulliparous women, topical 4% formulation showed lower scores for IUC-insertion pain assessed within 10 minutes (MD -15.90, 95% CI -22.77 to -9.03) and at 30 minutes later (MD -11.10, 95% CI -19.05 to -3.15). Among parous women, IUC-insertion pain was lower with 10% spray (median 1.00 versus 3.00). Compared with no intervention, pain at tenaculum placement was lower with 1% paracervical block (median 12 versus 28).For misoprostol, meta-analysis showed a higher mean score for IUC insertion compared with placebo (SMD 0.27, 95% CI 0.07 to 0.46; four studies). In meta-analysis, cramping was more likely with misoprostol (OR 2.64, 95% CI 1.46 to 4.76; four studies). A trial with nulliparous women found a higher score for IUC-insertion pain with misoprostol (median 46 versus 34). Pain before leaving the clinic was higher for misoprostol in two trials with nulliparous women (MD 7.60, 95% CI 6.48 to 8.72; medians 35.5 versus 20.5). In one trial with nulliparous women, moderate or severe pain at IUC insertion was less likely with misoprostol (OR 0.30, 95% CI 0.16 to 0.55). In the same trial, the misoprostol group was more likely to rate the experience favorably. Within two trials of misoprostol plus diclofenac, shivering, headache, or abdominal pain were more likely with misoprostol. Participants had no vaginal delivery. One trial showed the misoprostol group less likely to choose or recommend the treatment.Among multiparous women, mean score for IUC-insertion pain was lower for tramadol 50 mg versus naproxen 550 mg (MD -0.63, 95% CI -0.94 to -0.32) and for naproxen versus placebo (MD -1.94, 95% CI -2.35 to -1.53). The naproxen group was less likely than the placebo group to report the insertion experience as unpleasant and not want the medication in the future. An older trial showed repeated doses of naproxen 300 mg led to lower pain scores at one hour (MD -1.04, 95% CI -1.67 to -0.41) and two hours (MD -0.98, 95% CI -1.64 to -0.32) after insertion. Most women were nulliparous and also had lidocaine paracervical block. Nearly all trials used modern IUC. Most effectiveness evidence was of moderate quality, having come from single trials. Lidocaine 2% gel, misoprostol, and most NSAIDs did not help reduce pain. Some lidocaine formulations, tramadol, and naproxen had some effect on reducing IUC insertion-related pain in specific groups. The ineffective interventions do not need further research.

Immediate postpartum insertion of intrauterine device for contraception.

Women who want to start intrauterine contraception (IUC) during the postpartum period might benefit from IUC insertion immediately after delivery. Postplacental insertion greatly reduces the risk of subsequent pregnancy and eliminates the need for a return visit to start contraception. Without the option of immediate insertion, many women may never return for services or may adopt less effective contraception. Our aim was to examine the outcomes of IUC insertion immediately after placenta delivery (within 10 minutes), especially when compared with insertion at other postpartum times. We focused on successful IUC placement (insertion), subsequent expulsion, and method use. We searched for trials until 1 April 2015. Sources included PubMed (MEDLINE), the Cochrane Central Register of Controlled Trials (CENTRAL), POPLINE, Web of Science, EMBASE, LILACS, ClinicalTrials.gov, and ICTRP. For the original review, the authors contacted investigators to identify other trials. We sought randomized controlled trials (RCTs) with at least one treatment arm that involved immediate IUC placement (i.e., within 10 minutes of placenta delivery). Comparison arms could have included early postpartum insertion (from 10 minutes postplacental to hospital discharge) or standard insertion (during a postpartum visit). Trials could also have compared different IUC methods or insertion techniques. Delivery may have been vaginal or cesarean. Primary outcomes were placement (insertion), subsequent expulsion, and method use at study assessment. For dichotomous outcomes, we used the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). Earlier studies primarily reported results as life-table rates. We aggregated trials in a meta-analysis if they had similar interventions and outcome measures. A sensitivity analysis included studies with moderate or high quality evidence and sufficient outcome data. We included 15 trials. Seven studies reported from 2010 to 2014 were added to eight from the original 2001 review. Newer trials compared immediate postplacental insertion versus early (10 minutes to 48 hours) or standard insertion (during the postpartum visit). Of four with full reports, three were small trials. The other three studies had conference abstracts. The eight early trials examined immediate insertion of different devices or insertion techniques. Most studies were published in the 1980s, some with limited reporting.Our sensitivity analysis included trials with sufficient outcome data and moderate or high quality evidence. Four newer trials comparing insertion times met the inclusion criteria. Two studies used the levonorgestrel-releasing intrauterine system (LNG-IUS) after vaginal delivery. The other two trials placed IUC after cesarean section; one used the CuT 380A intrauterine device (IUD) and the other used the LNG-IUS.A pilot trial compared immediate insertion versus early or standard insertion. In groups comparing immediate versus early insertion (N = 30), all women had the LNG-IUS inserted. By six months, the groups had the same expulsion rate and did not differ significantly in IUC use.For immediate versus standard insertion, we conducted meta-analyses of four trials. Insertion rates did not differ significantly between study arms. However, the trial from Uganda showed insertion was more likely for the immediate group, although the estimate was imprecise. In the meta-analysis, expulsion by six months was more likely for the immediate group, but the confidence interval was wide (OR 4.89, 95% CI 1.47 to 16.32; participants = 210; studies = 4). IUC use at six months was more likely with immediate insertion than with standard insertion (OR 2.04, 95% CI 1.01 to 4.09; participants = 243; studies = 4). Study arms did not differ in use at 3 or 12 months in individual small trials. Recent trials compared different insertion times after vaginal or cesarean delivery. Evidence was limited because studies with full reports generally had small sample sizes. Overall, the quality of evidence was moderate; abstracts and older studies had limited reporting. Ongoing trials will add to the evidence, although some are small. Trials of adequate power are needed to estimate expulsion rates and side effects.The benefit of effective contraception immediately after delivery may outweigh the disadvantage of increased risk for expulsion. Frequent prenatal visits during the third trimester provide the opportunity to discuss effective contraceptive methods and desired timing for initiation. Clinical follow-up can help detect early expulsion, as can educating women about expulsion signs and symptoms.

Risk Factors for Non-Occupational Carbon Monoxide Poisoning: Anshan Prefecture, Liaoning Province, China, 2011-2012.

BackgroundCarbon monoxide (CO) poisoning can be fatal but is preventable. From October 2010 to February 2011, Anshan Prefecture reported 57 cases of non-occupational CO poisoning in District A, with two deaths. We conducted an investigation to identify risk factors and recommend preventive measures.MethodsWe defined a possible case of non-occupational CO poisoning as onset of at least two of the following symptoms: fatigue, headache, dizziness, nausea, vomiting, cyanosis, loss of consciousness, coma, and shock from October 1, 2010, to February 28, 2011, in a resident of Anshan Prefecture with non-occupational exposure to CO poisoning. We defined a probable case as onset of at least one of the following symptoms: cyanosis, loss of consciousness, coma and shock, plus at least one of the following symptoms: fatigue, headache, dizziness, nausea, vomiting, among possible cases. A confirmed CO poisoning case was a possible case or probable case plus hemoglobin (Hb) CO higher than 10%. We searched for cases by reviewing medical records and records of hyperbaric oxygen tank usage. In a case-control investigation, we compared home heating practices of 30 case-persons and 120 control-persons who were individually matched to each case by neighborhood.ResultsOverall, 56% (39/70) of case-patients’ households burned coal for home-heating. In the case-control investigation, 40% (12/30) of case-persons’ households compared with 5.8% (7/120) of control-persons’ households placed stoves in bedrooms (Mantel-Haenszel odds ratio [ORM-H] = 11, 95% confidence interval [CI] = 3.0–41); 53% (16/30) of case-patients’ households and 33% (40/120) of control-patients’ households did not extinguish the fire before sleeping (ORM-H = 3.6, 95% CI = 1.1–12); 13% (4/30) of case-patients’ households and 3% (4/120) of control-patients’ households had not installed the ventilation pipe vertically (ORM-H = 7.3, 95% CI = 1.0–56). Overall, 77% (23/30) of case-patients’ households and 39% (47/120) of control-patients’ households had at least one of those three risk factors (ORM-H = 10, 95% CI = 2.5–40; population attributable risk percentage: 78%).ConclusionsDangerous practices with coal-burning stoves inside the home accounted for the majority of CO poisoning incidents. Community health centers should provide instruction to and supervision of residents on proper installation and use of home heating stoves as well as inspection of installation.

Bisphosphonates and risk of cardiovascular events: a meta-analysis.

Background and ObjectivesSome evidence suggests that bisphosphonates may reduce atherosclerosis, while concerns have been raised about atrial fibrillation. We conducted a meta-analysis to determine the effects of bisphosphonates on total adverse cardiovascular (CV) events, atrial fibrillation, myocardial infarction (MI), stroke, and CV death in adults with or at risk for low bone mass.MethodsA systematic search of MEDLINE and EMBASE through July 2014 identified 58 randomized controlled trials with longer than 6 months in duration that reported CV events. Absolute risks and the Mantel-Haenszel fixed-effects odds ratios (ORs) and 95% confidence intervals (CIs) of total CV events, atrial fibrillation, MI, stroke, and CV death were estimated. Subgroup analyses by follow-up duration, population characteristics, bisphosphonate types, and route were performed.ResultsAbsolute risks over 25–36 months in bisphosphonate-treated versus control patients were 6.5% versus 6.2% for total CV events; 1.4% versus 1.5% for atrial fibrillation; 1.0% versus 1.2% for MI; 1.6% versus 1.9% for stroke; and 1.5% versus 1.4% for CV death. Bisphosphonate treatment up to 36 months did not have any significant effects on total CV events (14 trials; ORs [95% CI]: 0.98 [0.84–1.14]; I2 = 0.0%), atrial fibrillation (41 trials; 1.08 [0.92–1.25]; I2 = 0.0%), MI (10 trials; 0.96 [0.69–1.34]; I2 = 0.0%), stroke (10 trials; 0.99 [0.82–1.19]; I2 = 5.8%), and CV death (14 trials; 0.88 [0.72–1.07]; I2 = 0.0%) with little between-study heterogeneity. The risk of atrial fibrillation appears to be modestly elevated for zoledronic acid (6 trials; 1.24 [0.96–1.61]; I2 = 0.0%), not for oral bisphosphonates (26 trials; 1.02 [0.83–1.24]; I2 = 0.0%). The CV effects did not vary by subgroups or study quality.ConclusionsBisphosphonates do not have beneficial or harmful effects on atherosclerotic CV events, but zoledronic acid may modestly increase the risk of atrial fibrillation. Given the large reduction in fractures with bisphosphonates, changes in osteoporosis treatment decision due to CV risk are not justified.

Combined hormonal versus nonhormonal versus progestin-only contraception in lactation

Postpartum contraception improves the health of mothers and children by lengthening birth intervals. For lactating women, contraception choices are limited by concerns about hormonal effects on milk quality and quantity and passage of hormones to the infant. Ideally, the contraceptive chosen should not interfere with lactation or infant growth. Timing of contraception initiation is also important. Immediately postpartum, most women have contact with a health professional, but many do not return for follow-up contraceptive counseling. However, immediate initiation of hormonal methods may disrupt the onset of milk production. To determine the effects of hormonal contraceptives on lactation and infant growth We searched for eligible trials until 2 March 2015. Sources included the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, POPLINE, Web of Science, LILACS, ClinicalTrials.gov, and ICTRP. We also examined review articles and contacted investigators. We sought randomized controlled trials in any language that compared hormonal contraception versus another form of hormonal contraception, nonhormonal contraception, or placebo during lactation. Hormonal contraception includes combined or progestin-only oral contraceptives, injectable contraceptives, implants, and intrauterine devices.Trials had to have one of our primary outcomes: breast milk quantity or biochemical composition; lactation initiation, maintenance, or duration; infant growth; or timing of contraception initiation and effect on lactation. Secondary outcomes included contraceptive efficacy while breastfeeding and birth interval. For continuous variables, we calculated the mean difference (MD) with 95% confidence interval (CI). For dichotomous outcomes, we computed the Mantel-Haenszel odds ratio (OR) with 95% CI. Due to differing interventions and outcome measures, we did not aggregate the data in a meta-analysis. In 2014, we added seven trials for a new total of 11. Five reports were published before 1985 and six from 2005 to 2014. They included 1482 women. Four trials examined combined oral contraceptives (COCs), and three studied a levonorgestrel-releasing intrauterine system (LNG-IUS). We found two trials of progestin-only pills (POPs) and two of the etonogestrel-releasing implant. Older studies often lacked quantified results. Most trials did not report significant differences between the study arms in breastfeeding duration, breast milk composition, or infant growth. Exceptions were seen mainly in older studies with limited information.For breastfeeding duration, two of eight trials indicated a negative effect on lactation. A COC study reported a negative effect on lactation duration compared to placebo but did not quantify results. Another trial showed a lower percentage of the LNG-IUS group breastfeeding at 75 days versus the nonhormonal IUD group (reported P < 0.05) but no significant difference at one year.For breast milk volume, two older studies indicated lower volume for the COC group versus the placebo group. One trial did not quantify results. The other showed lower means (mL) for the COC group, e.g. at 16 weeks (MD -24.00, 95% CI -34.53 to -13.47) and at 24 weeks (MD -24.90, 95% CI -36.01 to -13.79). Another four trials did not report any significant difference between the study groups in milk volume or composition with two POPs, a COC, or the etonogestrel implant.Seven trials studied infant growth; one showed greater weight gain (grams) for the etonogestrel implant versus no method for six weeks (MD 426.00, 95% CI 58.94 to 793.06) but less compared with depot medroxyprogesterone acetate (DMPA) from 6 to 12 weeks (MD -271.00, 95% CI -355.10 to -186.90). The others studied POPs, COCs versus POPs, or an LNG-IUS. Results were not consistent across the 11 trials. The evidence was limited for any particular hormonal method. The quality of evidence was moderate overall and low for three of four placebo-controlled trials of COCs or POPs. The sensitivity analysis included six trials with moderate quality evidence and sufficient outcome data. Five trials indicated no significant difference between groups in breastfeeding duration (etonogestrel implant insertion times, COC versus POP, and LNG-IUS). For breast milk volume or composition, a COC study showed a negative effect, while an implant trial showed no significant difference. Of four trials that assessed infant growth, three indicated no significant difference between groups. One showed greater weight gain in the etonogestrel implant group versus no method but less versus DMPA.

Systematic review and meta-analysis of histopathological predictive factors for lymph node metastasis in T1 colorectal cancer.

In this study we examined whether histopathological findings, specifically lymphatic vessel invasion identified by an anti-human podoplanin antibody, and several other factors are associated with lymph node metastasis in T1 colorectal cancer. We searched PubMed and Cochrane Library, and also handsearched relevant journals, for reports written in English and published between 1998 and 2012, utilizing combination headings, such as 'colorectal cancer,' 'lymph node metastasis,' and 'risk factors.' For the report to be included in our study, the following criteria had to be met: (1) data on the frequency of lymph node metastasis in T1 colorectal cancer in relation to histopathological factors were reported; (2) patients had undergone bowel resection and had histologically diagnosed T1 colorectal cancer; (3) lymphatic vessel invasion was identified by immunohistochemistry with an anti-human podoplanin antibody rather than by hematoxylin and eosin staining; (4) univariate and multivariate analyses were conducted. Studies investigating molecular markers were excluded. The independent predictive factors were confirmed in at least one study included in the meta-analysis in the present systematic review. Microsoft Excel 2013 for Windows was used for the statistical analysis. Initially, 369 publications were identified in the database searches and handsearches, of which five ultimately met all of the inclusion criteria and selected for this systematic review. The meta-analysis revealed that only two factors were significantly associated with T1 colorectal cancer lymph node metastasis: (1) lymphatic vessel invasion identified by an anti-human podoplanin antibody [Mantel-Haenszel odds ratio (OR) 5.19; (95% confidence interval (CI) 3.31-8.15; P = 0.01]; (2) tumor budding (OR 7.45; 95 % CI 4.27-13.02; P = 0.0077). Our meta-analysis revealed that lymphatic vessel invasion identified by an anti-human podoplanin antibody and tumor budding were significantly associated with T1 colorectal cancer lymph node metastasis.

Relationship between NADPH and Th1/Th2 ratio in patients with non-Hodgkin lymphoma who have been exposed to pesticides

The effect of pesticides on nicotinamide adenine dinucleotide phosphate hydrogen (NADPH), including its level and relationship with the T helper 1 (Th1)/Th2 ratio, in patients suffering from non-Hodgkin lymphoma (NHL) was investigated. One hundred newly diagnosed patients with aggressive NHL (53 men, 47 women) and 40 healthy age-, sex-, and body mass index-matched controls (23 men, 17 women), exposed or not to pesticides, were recruited for a cross-sectional study conducted at the Clinical Hematology Departments of Tlemcen and Sidi Bel-Abbès University Medical Centers in the northwest of Algeria. NADPH levels were significantly increased in patients compared with controls; and in exposed patients compared with those not exposed, and controls (one-way analysis of variance; P=0.000). Albumin, glutathione peroxidase, superoxide dismutase, catalase activity, and oxygen radical absorbance capacity levels were significantly decreased in patients compared with in the control group. Oxygen radical absorbance capacity levels were significantly decreased in exposed patients compared with in unexposed patients; however, malondialdehyde levels were significantly increased in exposed patients when compared with controls and unexposed patients. Protein carbonyl and xanthine oxidase levels were significantly increased in exposed patients compared with controls; meanwhile, there were no significant differences between the two patient groups or between unexposed patients and controls. The Th1/Th2 ratio was significantly decreased in patients when compared with controls; the neutrophil-to-lymphocyte ratio was significantly increased (for both comparisons, P<0.001). In addition, NADPH was strongly associated with NHL (Mantel–Haenszel common odds ratio estimate =5.55; 95% confidence interval, 2.22–13.88; P=0.000). Moreover, NADPH levels were significantly negatively related to the Th1/Th2 ratio, either in exposed patients or in unexposed patients (respectively, r=−0.498 [P=0.004] and r=−0.327 [P=0.006]). In conclusion, pesticide exposure was strongly associated with NADPH alteration in NHL. The relationship between NADPH and Th1/Th2 ratio should focus on new therapeutic strategies for the disease.

Compensatory sweating after restricting or lowering the level of sympathectomy: a systematic review and meta-analysis

OBJECTIVE:To compare compensatory sweating after lowering or restricting the level of sympathectomy.METHOD:A systematic review and meta-analysis were conducted of all randomized controlled trials published in English that compared compensatory sweating after lowering or restricting the level of sympathectomy. The Cochrane collaboration tool was used to assess the risk of bias, and the Mantel-Haenszel odds ratio method was used for the meta-analysis.RESULTS:A total of 11 randomized controlled trials were included, including a total of 1079 patients. Five of the randomized controlled trials studied restricting the level of sympathectomy, and the remaining six studied lowering the level of sympathectomy.CONCLUSIONS:The compiled randomized controlled trial results published so far in the literature do not support the claims that lowering or restricting the level of sympathetic ablation results in less compensatory sweating.

Beneficial effects of adjuvant intravitreal bevacizumab injection on outcomes of Ahmed glaucoma valve implantation in patients with neovascular glaucoma: systematic literature review.

We evaluated the effects of adjuvant intravitreal bevacizumab injection on the outcomes of Ahmed glaucoma valve (AGV) implantation in patients with neovascular glaucoma (NVG) through a systematic literature review. An extensive search of PubMed, EMBASE, and the Cochrane Library was performed in November 2014 for selection of relevant studies. The weighted mean difference of the percentage of intraocular pressure reduction (IOPR%) from baseline to endpoint was used as the primary efficacy estimate, and Mantel-Haenszel odds ratios and 95% confidence intervals (CIs) of the success rate were used as the secondary efficacy estimates. The incidence of adverse events was also documented through a review of the studies. Six studies involving 252 patients (256 eyes) were included in this systematic review. The differences in the means and 95% CIs of the IOPR% of 6 studies showed that adjuvant bevacizumab treatment tended to be more effective than AGV implantation alone. Comparison of the outcomes of AGV implantation only with those of AGV implantation+adjuvant bevacizumab showed a success rate in favor of AGV implantation+adjuvant bevacizumab. The incidence of bleeding-associated complications such as hyphema, vitreous hemorrhage, and suprachoroidal hemorrhage was lower in association with combination treatment than with AGV implantation only. Combination treatment seemed to be associated with a lower incidence of other adverse effects such as hypotony, flat chamber, choroidal detachment/effusion, tube-associated complications, and corneal decompensation. AGV implantation with adjuvant bevacizumab was more effective and had a higher success rate than surgery alone for lowering IOP in patients with NVG. The combined procedure tended to show a lower incidence of bleeding-associated complications, such as hyphema.

Cardiopulmonary reserve as determined by cardiopulmonary exercise testing correlates with length of stay and predicts complications after radical cystectomy.

To investigate whether poor preoperative cardiopulmonary reserve and comorbid state dictate high-risk status and can predict complications in patients undergoing radical cystectomy (RC). In all, 105 consecutive patients with transitional cell carcinoma (TCC; stage T1-T3) undergoing robot-assisted (38 patients) or open (67) RC in a single UK centre underwent preoperative cardiopulmonary exercise testing (CPET). Prospective primary outcome variables were all-cause complications and postoperative length of stay (LOS). Binary logistic regression analysis identified potential predictive factor(s) and the predictive accuracy of CPET for all-cause complications was examined using receiver operator characteristic (ROC) curve analysis. Correlations analysis employed Spearman's rank correlation and group comparison, the Mann-Whitney U-test and Fisher's exact test. Any relationships were confirmed using the Mantel-Haenszel common odds ratio estimate, Kaplan-Meier analysis and the chi-squared test. The anaerobic threshold (AT) was negatively (r = -206, P = 0.035), and the ventilatory equivalent for carbon dioxide (VE/VCO₂) positively (r = 0.324, P = 0.001) correlated with complications and LOS. Logistic regression analysis identified low AT (<11 mL/kg/min), high VE/VC0₂ (≥33) and hypertension as significant factors, such that, in their presence patients were 5.55-times more likely to have complications at 90 days postoperatively [P = 0.001, 95% confidence interval (CI) 2.2-13.9]. ROC analysis showed a high significance (area under the curve 0.78, 95% CI 0.69-0.87; P < 0.001). In addition, based on CPET criteria >50% of patients presenting for RC had significant heart failure, whereas preoperatively only very few (2%) had this diagnosis. Analysis using the Mann-Whitney test showed that a VE/VCO₂ ≥33 was the most significant determinant of LOS (P = 0.004). Kaplan-Meier analysis showed that patients in this group had an additional median LOS of 4 days (P = 0.008). Finally, patients with an American Society of Anesthesiologists grade of 3 (ASA 3) and those on long-term β-blocker therapy were found to be at particular risk of myocardial infarction (MI) and death after RC with odds ratios of 4.0 (95% CI 1.05-15.2; P = 0.042) and 6.3 (95% CI 1.60-24.8; P = 0.008). Patients with poor cardiopulmonary reserve and hypertension are at higher risk of postoperative complications and have increased LOS after RC. Heart failure is known to be a significant determinant of perioperative death and is significantly under diagnosed in this patient group.

Strategies for improving postpartum contraceptive use: evidence from non-randomized studies.

Nearly two-thirds of women in their first postpartum year have an unmet need for family planning. Adolescents often have repeat pregnancies within a year of giving birth. Women may receive counseling on family planning both antepartum and postpartum. Decisions about contraceptive use made right after counseling may differ considerably from actual postpartum use. In earlier work, we found limited evidence of effectiveness from randomized trials on postpartum contraceptive counseling. For educational interventions, non-randomized studies may be conducted more often than randomized trials. We reviewed non-randomized studies of educational strategies to improve postpartum contraceptive use. Our intent was to examine associations between specific interventions and postpartum contraceptive use or subsequent pregnancy. We searched for eligible non-randomized studies until 3 November 2014. Sources included CENTRAL, PubMed, POPLINE, and Web of Science. We also sought current trials via ClinicalTrials.gov and ICTRP. For additional citations, we examined reference lists of relevant reports and reviews. The studies had to be comparative, i.e., have intervention and comparison groups. The educational component could be counseling or another behavioral strategy to improve contraceptive use among postpartum women. The intervention had to include contact within six weeks postpartum. The comparison condition could be another behavioral strategy to improve contraceptive use, usual care, other health education, or no intervention. Our primary outcomes were postpartum contraceptive use and subsequent pregnancy. Two authors evaluated abstracts for eligibility and extracted data from included studies. We computed the Mantel-Haenszel odds ratio (OR) for dichotomous outcomes and the mean difference (MD) for continuous measures, both with 95% Confidence Intervals (CI). Where studies used adjusted analyses for continuous outcomes, we presented the results as reported by the investigators. Due to differences in interventions and outcome measures, we did not conduct meta-analysis. To assess the evidence quality, we used the Newcastle-Ottawa Quality Assessment Scale. Six studies met our inclusion criteria and included a total of 5143 women. Of three studies with self-reported pregnancy data, two showed pregnancy to be less likely in the experimental group than in the comparison group (OR 0.48, 95% CI 0.27 to 0.87) (OR 0.60, 95% CI 0.41 to 0.87). The interventions included a clinic-based counseling program and a community-based communication project.All studies showed some association of the intervention with contraceptive use. Two showed that treatment-group women were more likely to use a modern method than the control group: ORs were 1.77 (95% CI 1.08 to 2.89) and 3.08 (95% CI 2.36 to 4.02). In another study, treatment-group women were more likely than control-group women to use pills (OR 1.78, 95% CI 1.26 to 2.50) or an intrauterine device (IUD) (OR 3.72, 95% CI 1.27 to 10.86) but less likely to use and injectable method (OR 0.23, 95% CI 0.05 to 1.00). One study used a score for method effectiveness. The methods of the special-intervention group scored higher than those of the comparison group at three months (MD 13.26, 95% CI 3.16 to 23.36). A study emphasizing IUDs showed women in the intervention group were more likely to use an IUD (OR 1.79, 95% CI 1.20 to 2.69) and less likely to use no method (OR 0.48, 95% CI 0.31 to 0.75). In another study, contraceptive use was more likely among women in a health service intervention compared to women in a community awareness program at four months (OR 1.79, 95% CI 1.40 to 2.30) or women receiving standard care at 10 to 12 months (OR 2.08, 95% CI 1.58 to 2.74). That study was the only one with a specific component on the lactational amenorrhea method (LAM) that had sufficient data on LAM use. Women in the health service group were more likely than those in the community awareness group to use LAM (OR 41.36, 95% CI 10.11 to 169.20). We considered the quality of evidence to be very low. The studies had limitations in design, analysis, or reporting. Three did not adjust for potential confounding and only two had sufficient information on intervention fidelity. Outcomes were self reported and definitions varied for contraceptive use. All studies had adequate follow-up periods but most had high losses, as often occurs in contraception studies.

Abstract 19514: Race and Willingness to Participate in Cardiovascular Clinical Research

African Americans (AA) are underrepresented in clinical trials in the United States for a variety of reasons. The majority of studies examining this issue were conducted &gt;10 years ago and since then, efforts have been implemented to improve AA enrollment in research. We took advantage of the cardiovascular research data of a large community academic center in New Orleans, Louisiana to examine whether race was associated with participation in cardiovascular research. We used a nested case control design with 80% power to detect a doubling in odds of non-participation. Individuals could be included if they were offered participation in any of the 4 largest studies conducted in 2012, were White or AA and were American citizens (n=974). Median income household income was inferred using postal codes. Cases were defined as individuals who declined to participate and did not sign a consent form. Controls were defined as individuals who agreed to participate and signed a consent form. We identified 100 cases and selected 200 controls matched on age (within 1 year) and sex using a random selection algorithm. Of the 974 eligible for analysis, mean (SD) age was 65 (14) years, median household income in thousands was 51.92 (19.9), and 65.3% were men. Of those who agreed to participate, 32.2% were AA while of those who refused, 31.0% were AA. The unadjusted Mantel-Haenszel odds ratio for non-participation by race was 1.06 (95% CI: 0.60 to 1.94) for AA individuals compared to their White age and sex matched counterparts. Using multivariable conditional logistic regression, the odds ratio for participation in a study was 1.04 (95% CI: 0.56 to 1.92) for AA as compared to their White age and sex matched counterparts, after adjustment for median household income, employment, and marital status. Our findings suggest that, at a large community academic center, race does not significantly affect willingness to participate in cardiovascular research independent of age, gender, socioeconomic and marital status.

Use of Antiasthmatic Drugs during Pregnancy after the First Trimester and Maternal and Neonatal Outcomes

Background. Women with asthma using antiasthmatics during the later part of the pregnancy have an increased risk for obstetric complications and their infants of neonatal complications. Material and Methods. The study is based on a linkage between the Swedish Medical Birth Register and a register of prescribed drugs in Sweden for the years 2009–2011, identifying women who had filled prescriptions for antiasthmatics after the first trimester. Their characteristics, their obstetric history, and the neonatal conditions of their infants were compared with all other women who gave birth. Adjusted Mantel-Haenszel odds ratios were determined. Results. We found an increased risk for a number of maternal conditions but no risk increase for gestational diabetes (after adjustment for body mass index) or for premature rupture of membranes. There was an increase in preterm births for some drugs used at severe asthma and of low birth weight and small for gestational age for most drug combinations. An increased risk was seen for neonatal hypoglycemia, respiratory problems, and low Apgar score. Conclusions. There are many hazards associated with maternal asthma and use of antiasthmatic drugs. Most evidence suggests a disease effect. A careful control of the asthma during pregnancy is important.

A Comparison Between Nasobiliary Drainage and Biliary Stenting in Acute Suppurative Cholangitis

Introduction: Acute severe cholangitis is a life-threatening condition that requires immediate medical intervention. Although surgical drainage is the traditional treatment, it is associated with significant morbidity and mortality. Endoscopic biliary drainage (EBD) has become the standard alternative treatment because of effective drainage and lower associated risk. Endoscopic nasobiliary drain (ENBD) and indwelling biliary stent are the 2 modalities used to obtain adequate biliary drainage. There is uncertainty about the best EBD method. We aimed to do a meta-analysis and compare the safety and efficacy of ENBD and biliary stenting. Methods: We searched PubMed, Embase, and Cochrane databases for prospective controlled trials comparing ENBD to biliary stenting in acute severe cholangitis. We excluded studies that did not evaluate endoscopic treatment, retrospective studies, mild cholangitis, and studies without a control group. Quality for each included study was assessed by CONSORT system. Heterogeneity was analyzed by Cochran’s Q statistics. Mantel Haenszel odds ratios (ORs) were calculated with a fixed effect model to combine studies. We used RevMan 5.2 for the analysis where a 2-tailed p<0.05 was considered significant. Results: We included 4 controlled prospective studies with 398 participants (203 ENBD, 195 stent). Better pain relief was observed in the first 12 hours with ENBD, 74% compared to 62%, in the indwelling stent group (OR 2.02; 95% CI 1.00-4.12). There was no significant difference in fever resolution between ENBD 65% and biliary stenting 53% (OR 1.87; 95% CI 0.83-4.18). Jaundice resolution was also similar in the two groups (OR: 1.53, CI: 0.46 - 5.09). Post-procedure pancreatitis occurred in 1.4% in the ENBD group compared to 4.6% in the stent group with no statistically significant difference (OR 0.38; 95% CI 0.12-1.20). There was no difference in 30-day mortality between the 2 groups, 2% ENBD versus 3% stent, (OR 0.63; 95% CI 0.19-2.12). No significant heterogeneity was noted between the studies. Conclusion: We conclude that the use of ENBD or indwelling biliary stent is equally effective in treating acute suppurative cholangitis in terms of the outcomes and complications.

A Meta-Analysis of Socio-Demographic Factors Predicting Birth in Health Facility

The low proportion of health facility delivery in developing countries is one of the main challenges in achieving the Millennium Development Goal of a global reduction of maternal deaths by 75% by 2015. There are several primary studies which identified socio-demographic and other predictors of birth in health facility. However, there are no efforts to synthesis the findings of these studies. The objective of this meta-analysis was to determine the strength of the association of birth in the health facility with selected sociodemographic factors. A meta-analysis of Mantel-Haenszel odds ratios was conducted by including 24 articles which were reported between 2000 and 2013 from developing countries. A computer-based search was done from MEDLINE, African Journals Online, Google Scholar and HINARI databases. Included studies did compare the women's' health facility delivery in relation to their selected socio-demographic characteristics. The pooled analysis demonstrated association of health facility delivery with living in urban areas (OR = 9.8), secondary and above educational level of the parents (OR = 5.0), middle to high wealth status (OR = 2.3) and first time pregnancy (OR = 2.8). The risk of delivering outside the health facility was not significantly associated with maternal age (teenage vs 20 years and above) and marital status. The distance of pregnant women's residence from the health facility was found to have an inverse relation to the proportion of health facility delivery. Although the present meta-analysis identified several variables which were associated with an increase in health facility delivery, the most important predictor of birth in the health facility amenable to intervention is educational status of the parents to be. Therefore, formal and informal education to women and family members on the importance of health facility delivery needs to be strengthened. Improving the wealth status of the population across the world may not be achieved soon, but should be in the long-term strategy to increase the birth rate in the health facility.