Effects of topical sesame (Sesamum indicum) oil on the pain severity of chemotherapy-induced phlebitis in patients with colorectal cancer: A randomized controlled trial

Background and purposeChemotherapy-induced phlebitis (CIP) is one of the most important and common complications in patients with cancer. Currently, the use of complementary methods to prevent or alleviate phlebitis symptoms has attracted great attention. In this study, we aimed to assess the effects of topical sesame oil in reducing the pain severity of CIP.Materials and methodsThis randomized clinical trial was conducted on 60 patients with colorectal cancer afflicted with CIP. Patients received, twice a day for seven consecutive days, a 5-min massage solely (as the control group) or with 10 drops of sesame oil (as the experimental group) within the 10 cm radius of the affected site. The pain severity was evaluated by the visual analog scale on the first, third, fifth, and seventh days of the intervention.ResultsMean changes of the pain severity compared to the baseline were significant on the third (P = 0.009), fifth (P < 0.001), and seventh (P < 0.001) days of the intervention in favor of the experimental group. Also, a significant reduction in the pain severity both in the experimental and control groups was observed during the seven days (F = 720.66, P_time < 0.001); however, the decrease was more significant in the experimental group (F = 21.46, P_group < 0.001).ConclusionApplication of massage with sesame oil as a complementary method is effective in reducing the pain severity of patients with CIP.     

Postpartum acute transverse myelitis complicated by epidural analgesia,a case report

ObjectivePostpartum acute transverse myelitis after epidural anesthesia is uncommon, but this complication is devastating. The relationship between anesthetic procedures and acute transverse myelitis is debatable.Case reportA 34-year-old woman experienced a cesarean section with lumbar epidural anesthesia at a local medical department. According to the patient herself, the process of lumbar puncture was uneven. After she woke up from intravenous anesthesia about 3 h later, she immediately found right lower extremity paralysis, dysesthesia and allodynia. A lumbar spine computed tomography and magnetic resonance imaging study the next day demonstrated subcutaneous emphysema from S1 to T10, an air bubble in the spinal canal between T12 and L1and intramedullary non-gadolinium-enhanced hyper intensity lesion within the cord at the level between T12 and L1 then diagnosed with acute transverse myelitis followed by the several examinations. High-dose IV methylprednisolone (solu-Medrol) pulsed therapy 500 mg Q12H for 4 days following with slowly tapering oral prednisolone was administered and symptoms got improved.ConclusionTransverse myelitis may emerge unpredictably following the process of lumbar puncture. If neurologic symptoms are raised after epidural analgesia, we should rule out the most well-known causes of infection, hematoma and use proper diagnostic approaches like CT and MRI as early as possible for diagnosis and management of acute myelitis. Early identification and treatment could minimize the neurologic sequelae.     

Effect of porcine placental extract on menopausal symptoms in postmenopausal women: A prospective,randomized, double-blind,placebo-controlled trial

ObjectivesTo determine the effect of oral administration of porcine placental extract (PPE) on the menopausal symptoms of Korean women.Materials and methodsThis study was a multicenter, randomized double-blind placebo-controlled trial. A hundred menopausal Korean women were randomly allocated either to the PPE 400 mg per day or the control group during 12 weeks of the study period. Menopausal symptoms were evaluated using the Kupperman Index (KMI).ResultsThe KMI decreased after 12 weeks in both groups; however, the difference in the changes was not statistically significant. Among overweight or obese women whose body mass index (BMI) was 23 kg/m² or higher, the KMI decreased more significantly in the PPE group than placebo group after 12 weeks (−18.52 ± 9.09 vs −11.40 ± 10.68, P < 0.05). Among 49 early menopausal women whose duration of menopause was less than 3 years, the KMI decreased more significantly in the PPE group after 12 weeks (−17.29 ± 9.07 vs −11.29 ± 10.68, P < 0.05). The baseline estradiol level was not statistically different between the two groups before trial, but the estradiol level of the PPE group was significantly increased at 12 weeks (11.13 ± 35.13 pg/m, P < 0.05).ConclusionsOral administration of 400 mg PPE per day decreases menopausal symptoms in women with BMI 23 kg/m² or higher or in early menopausal women. PPE may be considered as a short-term complementary treatment to reduce menopausal symptoms, especially in overweight or early menopausal women.     

Dance intervention for negative symptoms in individuals with autism spectrum disorder: A systematic review and meta-analysis

BackgroundAutism spectrum disorder (ASD) is a neurodevelopment disorder, marked by deficits in social communication and social interaction as well as by a restricted, repetitive patterns of behaviors, interests and activities. There is an increasing interest in the use of dance as part of rehabilitation for individuals with ASD. However, it is not clear how dance can influence on ASD symptoms. And few studies have measured and compared the outcomes of multiple studies. This study was aimed to provide a more comprehensive perspective of the efficacy of dance practice on ASD symptoms by conducting a systematic review with meta-analysis.MethodsThe electronic databases PubMed, EBSCO, MEDLINE, Cochrane and PsycINFO were searched for relevant studies reporting on the effects of dance on ASD symptoms. Only randomized controlled trials (RCTs) and non-randomized controlled studies were included in this review. Two review authors independently performed literature search, data extraction, and study quality assessment. Effect sizes for ASD symptoms were expressed as standardized mean differences (SMD) with 95% confidence intervals.ResultsSeven eligible studies were included for meta-analysis. Dance interventions varied in frequency (1–2 sessions/week), time (40 − 90 min), duration (7 − 17 weeks) and type. As compared to control groups, dance practice showed significant alleviation of overall symptoms of ASD (−1.48 points, CI −2.55 to − 0.42 points, p = 0.006, I² = 75%) and improvement in social interaction (0.88, CI 0.46 to 1.30, p < 0.0001, I² = 0%), but no significant effect on empathy (0.09, CI − 0.25 to 0.42, p = 0.61, I² = 2%).ConclusionsDance probably alleviate the negative symptoms and social deficits of individuals with ASD. However, little difference is found in empathy. Further research and studies are needed to determine the optimal dose and if dance results in greater benefits than other types of physical activity.     

Ovarian hyperstimulation syndrome: a review of recent practices

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic adverse event that occurs as a result of ovarian stimulation, particularly in susceptible women. It is caused by an unusually high ovarian response to stimulation and results in enlarged ovaries and fluid shift from intravascular compartment to the third space. Clinical features include abdominal distension, discomfort, ascites, and pleural effusion. There is a risk of thromboembolism and hepatic and renal dysfunction. Ovarian reserve tests can identify patients at high risk of OHSS, allowing targeted preventative measures. High-quality evidence supports the use of GnRH antagonist regimes in women with a high ovarian reserve. GnRH agonist trigger and elective cryopreservation of all embryos further reduce the risk of OHSS. All women at risk of OHSS should have adequate information and access to 24-hour care. Women presenting with possible OHSS should be assessed and investigated to confirm the diagnosis and classify severity. Mild and moderate OHSS can be managed on an out-patient basis, while severe OHSS often needs in-patient care. Principles of management are maintaining intravascular hydration by encouraging fluid intake guided by thirst, close monitoring of fluid balance, prevention of thromboembolic complications, drainage of ascites in selected cases and symptom relief. If conception occurs in the treatment, the course of OHSS is likely to be more severe and protracted.     

A Rare Association of Obstructed Hemivagina with Ipsilateral Renal Agenesis with Congenital Pouch Colon

BackgroundObstructed hemivagina and ipsilateral renal agenesis (OHVIRA), or Herlyn-Werner-Wunderlich syndrome, is a rare Mullerian duct anomaly. Several associations of OHVIRA with other anomalies are being reported.CaseA 13-year-old girl reported with acute onset abdominal pain. Patient was operated on in the past for type IV congenital pouch colon (all stages complete). She was diagnosed with hematometrocolpos and underwent tube vaginostomy. Further workup was suggestive of OHVIRA, which was subsequently managed with surgical repair.ConclusionDelineation of reproductive anomalies in female patients with anorectal malformations is of paramount importance. OHVIRA syndrome should be considered at a high index of suspicion in female patients with a solitary functioning kidney. Nonspecific symptoms in an adolescent female can lead to erroneous judgment, leading to unnecessary investigations, which, if not well managed in time, can be detrimental to fertility.     

Effects of pomegranate supplement on menopausal symptoms and quality of life in menopausal women: A double-blind randomized placebo-controlled trial

BackgroundMenopausal symptoms have negative effects on the aspects of quality of life and impose a high cost on the health system. In traditional Persian medicine, pomegranate is recommended to alleviate menopausal symptoms.Material and methodsA randomized double-blind placebo-controlled trial was performed among 78 healthy women. Participants were interviewed three times: Before receiving the supplement/placebo, after completing the treatment, and after 3 weeks with no intervention. They filled out the demographic information sheet, modified-Kupperman index, and Menopause-Specific Quality of Life (MENQOL) questionnaires.ResultsThe mean scores of the modified-Kupperman index and MENQOL characteristics before and after the treatment and after the follow-up period were significantly different between pomegranate and placebo groups in both modified-Kupperman and MENQOL scores (p < 0.001).ConclusionThis study demonstrated that 4 weeks' treatment with the pomegranate supplement significantly ameliorates the irritating symptoms of menopause and improves the quality of life in menopausal women even after 4 weeks' medicine deprivation.     

Prediction models for determining the success of labour induction: A systematic review and critical analysis

The purpose of this study was to systematically identify and critically appraise models developed in the past few years, using universally accessible clinical and demographic factors, that have been derived and validated to predict the success of labour induction. Our search identified 26 studies describing 24 prediction models derived between 1966 and 2021. Models varied with regard to methodology, scope and performance. Before any prediction model can be recommended for use in clinical practice, there is a need to determine thresholds of risk at which IoL should not be offered, subgroups that are most likely to benefit from the use of prediction models, and the clinical impact of prediction models on shared decision-making, parental satisfaction, caesarean rates, clinical outcomes and costs. A list of recommendations for improving model performance and utilization, as well as measures for encouraging appropriate use of prediction models and directions for future research, is provided.     

The influence of early virtual reality intervention on pain,anxiety, and function following primary total knee arthroplasty

BackgroundTotal knee arthroplasty (TKA) is one of the most popular surgeries in the orthopedic field. One of the reasons for a failed TKA is pain and difficulty to return to normal function. A pain control method that is becoming more and more popular is the use of virtual reality (VR). We aimed to examine VR intervention in the immediate post-operative physiotherapy following TKA.MethodsThis prospective randomized-controlled study recruited a total of 55 patients undergoing primary TKA in a single institute, operated by three surgeons. They were assigned either study group or control group. Both groups were treated with conventional physiotherapy and CPM equipment (Continuous passive motion device), the study group received additional VR modality. Both groups completed a series of questionnaires prior and after the intervention: State-Trait Anxiety Inventory (STAI) questionnaire (used to diagnose anxiety), Visual analog scale (VAS) for pain and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) (knee function score).ResultsThe average age was 70 years-old with equal distribution of male and female. Both groups showed a decrease in pain and anxiety following the intervention (p value < 0.05) but there was no difference between the groups (p value > 0.05 for all parameters). The was no difference in the WOMAC scores in the six-month post-operative examination between groups (p-value = 0.653).ConclusionsVirtual reality intervention in the immediate post-operative period following total knee arthroplasty decrease pain and anxiety but did not influence the pain, anxiety, and long-term function results more than conventional physiotherapy.     

Prospective feasibility study of a mindfulness-based program for breast cancer patients in the southeastern US

BackgroundMindfulness interventions can improve psychological distress and quality of life (QoL) in cancer survivors. Few mindfulness programs for cancer recovery exist in Southeastern U.S. The primary objective of this study was to assess the feasibility of a modified mindfulness-based stress reduction (MBSR) program for breast cancer patients in Birmingham, Alabama. The secondary objective was to explore potential program effects on mindfulness skills and QoL.MethodsThis study was a prospective, quasi-experimental feasibility study conducted over 10 months at a university hospital. Feasibility was achieved if 80% of eligible patients screened enrolled in the study and 70% of enrolled patients attended all 8 program sessions. Effectiveness was estimated by changes in mindfulness and QoL indicators measured with validated scales administered at 3 time points and assessed with a non-parametric Friedman test. Sessions included meditation, yoga, and an attention practice called body scan. There were 3 groups of 2–5 patients.ResultsThe sample totaled 12 patients. Forty-four percent (12/27) of eligible patients enrolled in the study, and two out of 12 enrolled patients completed 8 program sessions, resulting in 16.7% (2/12) retention. However, more than half (66.7%) of participants completed at least 7 sessions. Between baseline and 8-week follow-up, patients demonstrated statistically significant improvements in distress, general wellbeing, and fatigue-related QoL.ConclusionsFeasibility objectives were not achieved. However, a majority of participants (66.7%) completed 7 of 8 program sessions. Program effects were promising for distress, fatigue, and wellbeing. Results warrant further research on MBSR-like programs for breast cancer patients in Alabama.     

Efficacy of myofascial therapy and kinesitherapy in improving function in shoulder pathology with prolonged immobilization: A randomized,single-blind,controlled trial

BackgroundThe best physiotherapeutic approach in shoulder pathology that generates prolonged immobilization is still uncertain. Kinesitherapy remains the most widely used option. Myofascial therapy is a therapeutic approach in which the aim is to release fascial tension and regain mobility although its efficacy in shoulder pathology has not been sufficiently studied. This Prospective, single-blind randomized controlled trial in a university hospital setting aimed to compare the efficacy of myofascial therapy and kinesitherapy in improving function in shoulder pathology with prolonged immobilization.MethodsPatients were randomly assigned to a control group or to the intervention group.Both groups completed a therapeutic exercise program. Main Outcome Measures: The QuickDash questionnaire was the primary outcome, Pain Visual Analog Scale and the Range Of Motion of the shoulder were the secondary outcomes. The outcomes were evaluated at baseline (T0), at 4 (T2), 8 (T2), and 12 weeks (T3)Results44 participants were included. In the analysis of evolution over time, a significant improvement in functionality and range of motion measurements was observed in both groups (p < 0.05), although at 12 weeks only Myofasical Group achieved a clinically and statistically significant reduction in pain. Comparative analysis at 12 weeks revealed no statistically significant differences between the two therapies in the variables explored.ConclusionsBoth, myofascial therapy and kinesitherapy can improve function, mobility, and pain in patients with painful shoulder associated with prolonged immobilization, with no significant differences between therapies, although in the medium term only myofascial therapy achieves a clinically and statistically significant improvement in pain.Trial registrationTrial registration: ClinicalTrials.gov NCT04944446.     

Guideline No. 441: Antenatal Fetal Health Surveillance

ObjectiveTo summarize the current evidence and to make recommendations for antenatal fetal health surveillance (FHS) to detect perinatal risk factors and potential fetal decompensation in the antenatal period and to allow for timely intervention to prevent perinatal morbidity and/or mortality.Target populationPregnant individuals with or without maternal, fetal, or pregnancy-associated perinatal risk factors for antenatal fetal decompensation.OptionsTo use basic and/or advanced antenatal testing modalities, based on risk factors for potential fetal decompensation.OutcomesEarly identification of potential fetal decompensation allows for interventions that may support fetal adaptation to maintain well-being or expedite delivery.Benefits, harms, and costsAntenatal FHS in pregnant individuals with identified perinatal risk factors may reduce the chance of adverse outcomes. Given the high false-positive rate, FHS may increase unnecessary interventions, which may result in harm, including parental anxiety, premature or operative birth, and increased use of health care resources. Optimization of surveillance protocols based on evidence-informed practice may improve perinatal outcomes and reduce harm.EvidenceMedline, PubMed, Embase, and the Cochrane Library were searched from inception to January 2022, using medical subject headings (MeSH) and key words related to pregnancy, fetal monitoring, fetal movement, stillbirth, pregnancy complications, and fetal sonography. This document represents an abstraction of the evidence rather than a methodological review.Validation methodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).Intended audienceAll health care team members who provide care for or education to obstetrical patients, including maternal fetal medicine specialists, obstetricians, family physicians, midwives, nurses, nurse practitioners, and radiologists.SUMMARY STATEMENTS

• 1.Accurate and ongoing early identification of risk factors for potential fetal decompensation allows care providers to develop an individualized care plan to optimize fetal well-being (moderate).
• 2.The nonstress test (NST) may be used in conjunction with a review of the total clinical picture to assess fetal well-being. An NST should be used only in the presence of a clear indication or finding associated with increased risk of fetal hypoxemia (moderate).
• 3.Sonography can evaluate amniotic fluid, estimated fetal weight, biophysical profile/modified biophysical profile, and Doppler blood flows to provide information regarding fetal well-being in pregnancies at risk of fetal morbidity (moderate).
• 4.Interprofessional team communication and documentation should be clear, using accepted and defined terminology (high).

RECOMMENDATIONS

• 1.Care providers should review and document perinatal risk factors (prior pregnancy, fetal, maternal, familial) at the initial visit and update factors throughout pregnancy (strong, moderate).
• 2.Pregnant individuals should be advised of local resources and/or the need for transfer of care based on pregnancy risk factors (strong, moderate).
• 3.Regular prenatal visits should include assessment and documentation of the presence of fetal heart tones, uterine size, pregnancy concerns or risk factors, the plan of care, and the discussion with the pregnant individual (strong, moderate).
• 4.All pregnant individuals should be advised to regularly monitor fetal movements starting at 26 weeks gestation (conditional, low).
• 5.If a reduction of fetal movements is identified, regardless of the technique used to assess fetal movements, pregnant individuals should be advised to present to their care provider or local obstetrical unit immediately for further evaluation (strong, low).
• 6.The nonstress test (NST) should be administered and interpreted by appropriately trained health professionals (strong, high).
• 7.A ≥2 cm × 1 cm pocket of fluid by transabdominal sonography should be used as the criterion for the amniotic fluid component of the biophysical profile (strong, moderate).
• 8.To ensure patient safety, care providers should develop clear protocols locally to communicate and document changes in fetal status identified during antenatal fetal surveillance and escalation of care (strong, moderate).
• 9.Care providers should use non-routine antenatal fetal health surveillance modalities, such as an NST, biophysical profile, or fetal Doppler sonography, only in the presence of a clear indication or finding associated with increased risk of fetal hypoxemia (strong, moderate).

     

Technical Update No. 433: eHealth Solutions for Urinary Incontinence Among Women

ObjectiveThe purpose of this technical update is to establish the state of the science regarding emerging and novel electronic health (eHealth) and mobile health (mHealth) solutions for urinary incontinence among women.Target populationWomen over 18 years with urinary incontinence.OptionsWebsites and mobile health applications are useful in the conservative care of urinary incontinence. Relevant care providers should be familiar with such tools, particularly those that use motivational principles for behaviour change, which can be used as adjunct tools for urinary incontinence care. Telemedicine is an effect mode to provide services for the conservative care of urinary incontinence.OutcomesUse of eHealth and mHealth solutions has potentially significant health outcomes for patients, providers, and global health systems. Broader use of telemedicine, in and of itself, could improve care access and reduce costs incurred by patients and the health care system.Benefits, Harms, and CostsEvidence for the efficacy of eHealth and mHealth technologies and applications for urinary incontinence ranges from weak to strong. However, the research landscape for many of these novel solutions is developing rapidly. Furthermore, these options have minimal or no harm and confer an established cost benefit and care access benefit.EvidenceThe Cochrane Library, Medline, EMBASE, CENTRAL databases (from January 2014 to April 2019) were searched to find articles related to conservative care of urinary incontinence in women (over 18 years) and studies on eHealth and mHealth interventions for urinary incontinence. Articles were appraised, and the collective evidence was graded.Validation methodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).Intended audienceRelevant primary care providers and medical specialists, including physicians, nurses, midwives, and pelvic health physiotherapists.SUMMARY STATEMENTS

• 1.Electronic and mobile health interventions for urinary incontinence are growing, both in their availability in the health care market and in the science to support their use (moderate).
• 2.Electronic health interventions offered in conjunction with pelvic floor muscle training, either self-directed or directed by a health care provider (physiotherapist), may provide a marginal benefit in symptom improvement for stress urinary incontinence among women (low).
• 3.Application- and web-based programming for urinary incontinence should include traditional components of self-management programs, including motivational strategies to support behavioural interventions (high).
• 4.Bladder diaries are the most studied electronic health tool for overactive bladder and urge urinary incontinence. The acceptability and feasibility of these mobile health solutions has been established (low).
• 5.There is limited research on how electronic health interventions improve urge urinary incontinence and overactive bladder (low).
• 6.Telehealth can be an effective platform for patient education and counselling on conservative and surgical management of uncomplicated stress urinary incontinence (high).

RECOMMENDATIONS

• 1.Mobile health solutions, such as applications that incorporate evidence-based, motivational, behavioural intervention principles, should be recommended to women with stress urinary incontinence if tailored in-person care is not available or accessible (strong, high).
• 2.There is currently insufficient evidence to recommend the routine use of electronic health interventions that include a physical device to improve stress urinary incontinence symptoms (conditional, very low).
• 3.Electronic health interventions may be recommended to complement stress urinary incontinence treatment, but providers should familiarize themselves with the specific interventions recommended, since they vary significantly in terms of composition, cost, and benefit (conditional, very low).
• 4.Health care providers remain the key knowledge translators and advisors on overactive bladder and urge urinary incontinence; they should not assume that patients will get the information they need from a website (strong, moderate).
• 5.Health care providers may recommend web-based self-management programs that incorporate evidence-based motivational behavioural intervention principles if tailored in-person care is not available or accessible to patients (strong, low).
• 6.Application-based bladder diaries may be used as an alternative to traditional bladder diaries as a self-monitoring tool (conditional, low).
• 7.Follow-up visits for uncomplicated stress urinary incontinence may be considered in women who are comfortable with this platform (strong, low).
• 8.Although there is insufficient evidence to recommend virtual or telehealth consultation for routine pessary care instructions, these platforms can be considered on a case-by-case basis depending on the patient’s comfort with pessary self-care (conditional, very low).
• 9.Surgical counselling for stress urinary incontinence via telehealth or virtual platforms may be considered for women who are comfortable with shared decision-making on these platforms (strong, moderate).
• 10.Post-operative virtual visits may be offered as an alternative to in-person visits after uncomplicated surgery for stress urinary incontinence (strong, moderate).

     

Guideline No. 437: Diagnosis and Management of Adenomyosis

ObjectiveTo describe the current evidence-based diagnosis and management of adenomyosis.Target PopulationAll patients with a uterus of reproductive age.OptionsDiagnostic options include transvaginal sonography and magnetic resonance imaging. Treatment options should be tailored to symptoms (heavy menstrual bleeding, pain, and/or infertility) and include medical options (non-steroidal anti-inflammatory drugs, tranexamic acid, combined oral contraceptives, levonorgestrel intrauterine system, dienogest, other progestins, gonadotropin-releasing analogues), interventional options (uterine artery embolization), and surgical options (endometrial ablation, excision of adenomyosis, hysterectomy).OutcomesOutcomes of interest include reduction in heavy menstrual bleeding, reduction in pelvic pain (dysmenorrhea, dyspareunia, chronic pelvic pain), and improvement in reproductive outcomes (fertility, miscarriage, adverse pregnancy outcomes).Benefits, Harms, and CostsThis guideline will benefit patients with gynaecological complaints that may be caused by adenomyosis, especially those patients who wish to preserve their fertility, by presenting diagnostic methods and management options. It will also benefit practitioners by improving their knowledge of various options.EvidenceDatabases searched were MEDLINE Reviews, MEDLINE ALL, Cochrane, PubMed, EMBASE. The initial search was completed in 2021 and updated with relevant articles in 2022. Search terms included adenomyosis, adenomyoses, endometritis (used/indexed as adenomyosis before 2012), (endometrium AND myometrium) uterine adenomyosis/es, symptom/s/matic adenomyosis] AND [diagnosis, symptoms, treatment, guideline, outcome, management, imaging, sonography, pathogenesis, fertility, infertility, therapy, histology, ultrasound, review, meta-analysis, evaluation]. Articles included randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Articles in all languages were searched and reviewed.Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Table A1 for definitions and Table A2 for interpretations of strong and conditional [weak] recommendations).Intended AudienceObstetrician-gynaecologists, radiologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, residents, and fellows.Tweetable AbstractAdenomyosis is common in reproductive-aged women. There are diagnostic and management options that preserve fertility available.SUMMARY STATEMENTS

• 1.Providers should be aware that adenomyosis has been associated with heavy menstrual bleeding, pelvic pain, infertility, miscarriage, and adverse pregnancy outcomes (moderate).

RECOMMENDATIONS

• 1.Transvaginal sonography should be the first-line modality for imaging of suspected adenomyosis in patients presenting with heavy menstrual bleeding, pelvic pain, infertility, miscarriage, and adverse pregnancy outcomes (strong, high).
• 2.Transvaginal sonography in patients presenting with symptoms suggestive of adenomyosis should be assessed by radiologists for the following: presence of features typical of adenomyosis, location, focal or diffuse disease, cystic or non-cystic disease, uterine layer involvement, extent of disease, and the size of the largest lesion or affected area (strong, high).
• 3.Magnetic resonance imaging should be considered by clinicians if there is inconclusive sonographic evaluation of adenomyosis or suspicion of significant concomitant pelvic pathology (conditional, moderate).
• 4.Oral contraceptives, levonorgestrel-releasing intrauterine system, and dienogest should be used as first-line medical options for pain and heavy menstrual bleeding from adenomyosis (strong, moderate).
• 5.Gonadotropin-releasing hormone (GnRH) agonists can be considered as a second-line agent for management of pain and heavy menstrual bleeding from adenomyosis; add-back hormones should be initiated if GnRH agonists are used longer than 6 months (strong, low).
• 6.Uterine artery embolization is an effective treatment option for heavy bleeding and pain associated with adenomyosis; it can be offered to patients who have completed child-bearing and would like to preserve their uterus (strong, moderate).
• 7.Minimally invasive thermal ablation procedures, such as high-intensity focused ultrasound, radiofrequency ablation, and percutaneous microwave ablation, might be used for the treatment of symptomatic adenomyosis in the future, but more data are needed before they are used outside of a research context (conditional, low).
• 8.Adenomyomectomy is an effective treatment option for symptomatic adenomyosis (strong, moderate).
• 9.Adenomyomectomy can be a challenging surgical procedure, with the potential for significant perioperative morbidity, and should be performed by an experienced surgeon (strong, low).
• 10.Focal adenomyosis may be amenable to surgical excision using minimally invasive routes (laparoscopy, robotic); however, diffuse adenomyosis is best approached using an open technique (conditional, low).
• 11.Given the substantial risk of intraoperative hemorrhage, anemia (hemoglobin <120 g/L) should be corrected before adenomyomectomy (strong, low).
• 12.Patients undergoing adenomyomectomy should be counselled about the uncertain impact of these procedures on fertility and pregnancy. They should be specifically informed about the increased risk of uterine rupture during pregnancy, and the need for pre-labour cesarean delivery (strong, low).
• 13.Total hysterectomy is an effective treatment option for symptomatic adenomyosis and can be offered to women who have completed child-bearing after appropriate counselling regarding risks, benefits, and alternative treatments (strong, low).
• 14.Patients with dysmenorrhea undergoing surgical management of adenomyosis should be counselled to have concurrent excision of any coexisting endometriosis during surgery, for more complete relief of their symptoms (strong, low).
• 15.The impact of adenomyosis on pregnancy outcomes in patients undergoing fertility treatments is uncertain (conditional, low).
• 16.For patients with adenomyosis undergoing in vitro fertilization, gonadotropin-releasing hormone agonist downregulation for a period of 2 to 4 months may be considered before transferring fresh or frozen embryos (weak, low).

     

High Prevalence of Congenital Factor VII (FVII) Deficiency in Adolescent Females with Heavy Menstrual Bleeding and Iron Deficiency Anemia

Study ObjectiveTo examine the clinical characteristics and prevalence of congenital bleeding disorders (CBDs), with emphasis on congenital factor VII (FVII) deficiency and other rare bleeding disorders, in adolescent and young adult females referred to a hemophilia treatment center (HTC) for evaluation and management of heavy menstrual bleeding (HMB) and iron deficiency anemia (IDA)DesignIn this single-center retrospective study, we reviewed the clinical characteristics and prevalence of CBDs in postmenarchal females, younger than 22 years of age, referred to an HTC from 2015 to 2021 for evaluation of HMB with or without IDA.ResultsOne hundred females, with a mean age of 15 years (range 9-20 years), met initial study criteria, and 95 were included in the final analysis. Forty-five (47%) females were ultimately diagnosed with a CBD. The most prevalent diagnoses were FVII deficiency and type 1 von Willebrand disease (VWD) (42.3%, n = 19 each). Forty-two percent of patients with FVII deficiency had a low-for-age FVII activity level, 21.1% were only positive for the FVII R353Q variant associated with borderline FVII levels, whereas 36.8% had both a low-for-age FVII activity level and a positive R353Q variant. Eighty percent of patients with a CBD were found to have relatives with abnormal bleeding symptoms.ConclusionCongenital FVII deficiency is prevalent among female adolescents experiencing HMB with or without IDA. In addition to VWD, evaluation for this specific factor deficiency should be considered as part of the initial CBD workup. Presence of abnormal bleeding history in the family could also help to predict presence of a CBD.     

Efficacy and safety of Buyang-Huanwu-Tang (Boyang-Hwano-Tang) in patients with vascular dementia: A systematic review and meta-analysis

BackgroundBuyang-Huanwu-Tang (Boyang-Hwano-Tang, BHT) is a widely used traditional Chinese herbal medicine for treating ischemic stroke in South Korea and China. Its efficacy in vascular dementia has been reported. There has been no comprehensive systematic review of BHT for vascular dementia.MethodsWe searched 15 electronic databases from inception to November 25, 2021. We included only randomised controlled clinical trials. Studies that used BHT alone or with Western medicine were included. Two independent reviewers conducted the screening, data extraction, and the Cochrane risk of bias and quality of evidence assessment. A meta-analysis was performed.ResultsA total of 18 eligible trials with 1254 participants were included. Of these, 15 were included in the meta-analysis. The pooled results suggested that BHT alone (mean difference [MD] 1.31; 95% confidence interval [CI] −2.94 to 5.56; P = 0.55) was similar to Western medicine alone in terms of the Mini-Mental State Examination(MMSE). Additive BHT therapy showed a significant improvement in the MMSE (MD 1.42; 95% CI 0.28 to 2.56; P = 0.01), Hasegawa Dementia Scale score (MD 3.91; 95% CI 2.87 to 4.94; P < 0.001) and total effective rate (risk ratio 1.35; 95% CI 1.20 to 1.52; P < 0.001). The overall risk of bias was unclear or high. The quality of evidence was very low to moderate. Only four studies reported minor or no adverse events.ConclusionsThe results support the clinical use of BHT for the improvement of cognitive function in patients with vascular dementia. The methodological quality of the included studies was relatively poor. Therefore, further rigorously designed trials are required.