Depot medroxyprogesterone acetate and endometrial cancer: A multicenter case-control study.

OBJECTIVE: To assess the associations between depot medroxyprogesterone acetate (DMPA) and endometrial cancer. METHODS: This multicenter case-control study was conducted among tertiary hospitals in Thailand. Patients were women with endometrial cancer. Controls were women admitted for other conditions, matched for age within 5 years of the patients' age. The controls had to have no abnormal vaginal bleeding, history of hysterectomy, or cancers of the other organs. A standardized questionnaire was used to gather information. Conditional logistic regression was applied to calculate adjusted odds ratio (aORs) and 95% confidence intervals (CIs). RESULTS: During 2015 to 2021, 378 patients and 1134 controls were included. Ever use of DMPA was associated with a 70% decreased overall risk of endometrial cancer (aOR, 0.30 [95% CI, 0.21-0.42]). Endometrial cancer risk declined by 3% (aOR, 0.97 [95% CI, 0.96-0.98]) for every 3 months of DMPA use. The magnitude of the decline in endometrial cancer risk did not vary appreciably by cancer subtypes (aOR, 0.26 [95% CI, 0.17-0.41] and 0.38 [95% CI, 0.22-0.65] for low-grade and high-grade tumors, respectively). CONCLUSIONS: Depot medroxyprogesterone acetate use was inversely associated with endometrial cancer risk in a duration-dependent manner. This association was independent of cancer subtype.

Evaluation of mobile health applications for cervical cancer in the digital marketplace.

OBJECTIVE: To assess the quality of mobile health (mHealth) applications (apps) for cervical cancer using the mobile app rating scale (MARS), APPLICATIONS scoring system, and app rating using specific statements. METHODS: We searched for cervical cancer apps on two major mobile operating systems (Google Play Store and Apple iTunes Store) in March 2021. Eligible apps were downloaded and assessed for quality by two independent reviewers using multimodal assessment tools. RESULTS: The overall quality of the MARS score was 2.61±0.795. The highest scoring app was "The American Society for Colposcopy and Cervical Pathology (ASCCP) Management Guidelines" (3.98). Overall, apps scored highest in the functionality domain, followed by information, engagement, and aesthetics domains. The mean±standard deviation of the APPLICATIONS scoring system was 8.50±1.712. The highest-rated apps were "ASCCP Management Guidelines," "The British Society for Colposcopy and Cervical Pathology (BSCCP)," and "Cervical Cancer Guide." Apps scored the highest in the paid subscription and price domains. By contrast, apps scored poorly in the text search, literature, and subjective presentation domains. Concerning app content, many apps infrequently provided misconceptions regarding cervical cancer. The apps' rating using specific statements was 7.81±4.562. CONCLUSION: Overall, the apps analyzed using the MARS and APPLICATIONS scoring systems demonstrated above-average quality. However, there is a need to improve the essential information conveyed by these applications. Moreover, the assessment tools have influenced different app quality rating results, confirming the lack of standardized quality assessment tools for mHealth apps.

Postoperative adjuvant chemotherapy for resectable cholangiocarcinoma.

BACKGROUND: Cholangiocarcinoma (cancer in the bile duct) is an aggressive tumour for which surgical resection is a mainstay of treatment. Despite complete resection, recurrences of the cancer are common and lead to poor prognosis in patients. Postoperative adjuvant chemotherapy given after surgical resection may reduce the risk of cancer recurrence by eradicating residual cancer and micrometastatic lesions. The benefits and harms of postoperative adjuvant chemotherapy versus placebo, no intervention, or other adjuvant chemotherapies are unclear. OBJECTIVES: To assess the benefits and harms of postoperative adjuvant chemotherapy versus placebo, no intervention, or other adjuvant chemotherapies for people with cholangiocarcinoma after curative-intent resection. SEARCH METHODS: We performed electronic searches in the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index - Science for trials that met the inclusion criteria up to 28 April 2021. SELECTION CRITERIA: Randomised clinical trials irrespective of blinding, publication status, or language comparing postoperative adjuvant chemotherapy versus placebo, no intervention, or a different postoperative adjuvant chemotherapy regimen for participants with curative-intent resection for cholangiocarcinoma. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods to develop and conduct the review. We conducted meta-analyses and presented results, where feasible, using a random-effects model and risk ratios (RR) with 95% confidence intervals (CI). We assessed risk of bias according to predefined domains suggested by Cochrane. We rated the certainty of evidence using the GRADE approach and presented outcome results in a summary of findings table. MAIN RESULTS: We included five published randomised clinical trials. The trials included 931 adults (18 to 83 years old) who underwent curative-intent resection for cholangiocarcinoma. Four trials compared postoperative adjuvant chemotherapy (mitomycin-C and 5-fluorouracil (5-FU); gemcitabine; gemcitabine plus oxaliplatin; or capecitabine) versus no postoperative adjuvant chemotherapy (surgery alone) in 867 participants with cholangiocarcinoma only. A fifth trial compared postoperative adjuvant S-1 (a novel oral fluoropyrimidine derivative) chemotherapy versus gemcitabine in 70 participants with intrahepatic cholangiocarcinoma, perihilar cholangiocarcinoma (64 participants), and gallbladder carcinoma (6 participants). We assessed all of the included trials at overall high risk of bias. One trial was conducted in France, three in Japan, and one in the United Kingdom. We could not perform all planned comparison analyses due to lack of data. Three trials used intention-to-treat analyses. Another trial used per-protocol analysis. In the remaining trial one participant in the intervention group and one in the control group were lost to follow-up. However, the outcomes of these two participants were not described. Postoperative adjuvant chemotherapy versus no postoperative adjuvant chemotherapy We are very uncertain as to whether postoperative adjuvant chemotherapy has little to no effect on all-cause mortality versus no postoperative adjuvant chemotherapy (RR 0.92, 95% CI 0.84 to 1.01; 4 trials, 867 participants, very low-certainty evidence). We are very uncertain of the effect of postoperative adjuvant chemotherapy on serious adverse events (RR 17.82, 95% CI 2.43 to 130.82; 1 trial, 219 participants, very low-certainty evidence). The trial indicated that postoperative adjuvant chemotherapy could increase serious adverse events, as 19/113 (20.5%) of participants developed an adverse event, compared to 1/106 (1.1%) of participants in the no-postoperative adjuvant chemotherapy group. None of the included trials reported data on health-related quality of life, cancer-related mortality, time to recurrence of the tumour, and non-serious adverse events in participants with only cholangiocarcinoma. Adjuvant S-1 chemotherapy (fluoropyrimidine derivative) versus adjuvant gemcitabine-based chemotherapy The only available trial analysed all participants with intrahepatic, perihilar cholangiocarcinoma and gallbladder carcinoma together, with data on participants with cholangiocarcinoma not provided separately. The authors reported that one-year overall mortality after adjuvant S-1 therapy was lower than with adjuvant gemcitabine-based therapy following major hepatectomy for biliary tract cancer. There were no differences in two-year overall mortality. FUNDING: two trials received support from drug companies; one trial received funding from the Japan Society of Clinical Oncology; one trial received support from "Programme Hospitalier de Recherche Clinique (PHRC2009) and Ligue Nationale Contre le Cancer"; and one trial did not provide information on support or sponsorship. We identified six ongoing randomised clinical trials. AUTHORS' CONCLUSIONS: Based on the very low-certainty evidence found in four trials in people with curative-intent resection for cholangiocarcinoma, we are very uncertain of the effects of postoperative adjuvant chemotherapy (mitomycin-C and 5-FU; gemcitabine; gemcitabine plus oxaliplatin; or capecitabine) versus no postoperative adjuvant chemotherapy on mortality. The effects of postoperative adjuvant chemotherapy compared with no postoperative adjuvant chemotherapy on serious adverse events are also very uncertain, but the result of the single trial showed 20% higher occurrences of haematologic adverse events. We assessed the certainty of the evidence as very low due to overall high risk of bias, and imprecision. Due to insufficient power of the only identified trial, the best postoperative adjuvant chemotherapy regimen in people with only cholangiocarcinoma could not be established. We also lack randomised clinical trials with outcome data on adjuvant S-1 chemotherapy versus adjuvant gemcitabine-based chemotherapy in people with cholangiocarcinoma alone. There is a need for further randomised clinical trials designed to be at low risk of bias and with adequate sample size exploring the best adjuvant chemotherapy treatment after surgery in people with cholangiocarcinoma.

Changing gloves during cesarean section for prevention of postoperative infections: a systematic review and meta-analysis.

This systematic review and meta-analysis was conducted to assess associations between changing gloves during cesarean section (CS) and postoperative infection. A literature search was conducted using the major electronic databases MEDLINE, Scopus, ISI Web of Science, PubMed, CINAHL, and CENTRAL from their inception to September 2020. Randomized controlled trials (RCTs) comparing glove change during CS to no glove change were included. Outcomes of interest were endometritis, febrile morbidity, and incisional surgical site infection (SSI). GRADE approach was applied to assess the quality of evidence. Ten reports of six studies involving 1707 participants were included in the analyses. Glove change was associated with a reduction in the risk of incisional SSI following CS (pooled RR 0.49, 95% CI 0.30, 0.78; moderate quality of evidence). Compared to no glove change, glove change during CS did not reduce the risks of endometritis (pooled RR 1.00, 95% CI 0.80, 1.24; low quality of evidence) or febrile morbidity (pooled RR 0.85, 95% CI 0.43, 1.71; very low quality of evidence). Changing gloves during CS was associated with a decreased risk of incisional SSI. The risks of postoperative endometritis and febrile morbidity were not altered by changing gloves.

Postoperative interventions for preventing bladder dysfunction after radical hysterectomy in women with early-stage cervical cancer.

BACKGROUND: Bladder dysfunction is a common complication following radical hysterectomy, caused by the damage to pelvic autonomic nerves that innervate the muscles of the bladder, urethral sphincter, and pelvic floor fasciae. Bladder dysfunction increases the rates of urinary tract infection, hospital visits or admission, and patient dissatisfaction. In addition, bladder dysfunction can also negatively impact patient quality of life (QoL). Several postoperative interventions have been proposed to prevent bladder dysfunction following radical hysterectomy. To our knowledge, there has been no systematic review evaluating the effectiveness and safety of these interventions for preventing bladder dysfunction following radical hysterectomy in women with cervical cancer. OBJECTIVES: To evaluate the effectiveness and safety of postoperative interventions for preventing bladder dysfunction following radical hysterectomy in women with early-stage cervical cancer (stage IA2 to IIA2). SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 4) in the Cochrane Library, MEDLINE via Ovid (1946 to April week 2, 2020), and Embase via Ovid (1980 to 2020, week 16). We also checked registers of clinical trials, grey literature, conference reports, and citation lists of included studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) evaluating the effectiveness and safety of any type of postoperative interventions for preventing bladder dysfunction following a radical hysterectomy in women with stage IA2 to IIA2 cervical cancer. DATA COLLECTION AND ANALYSIS: Two review authors independently selected potentially relevant RCTs, extracted data, assessed risk of bias, compared results, and made judgments on the quality and certainty of the evidence. We resolved any disagreements through discussion or consultation with a third review author. Outcomes of interest consisted of spontaneous voiding recovery one week after the operation, quality of life (QoL), adverse events, post-void residual urine volume one month after the operation, urinary tract infection over the one month following the operation, and subjective urinary symptoms. MAIN RESULTS: We identified 1464 records as a result of the search (excluding duplicates). Of the 20 records that potentially met the review criteria, we included five reports of four studies. Most of the studies had unclear risks of selection and reporting biases. Of the four studies, one compared bethanechol versus placebo and three studies compared suprapubic catheterisation with intermittent self-catheterisation. We identified two ongoing studies. Bethanechol versus placebo The study reported no information on the rate of spontaneous voiding recovery at one week following the operation, QoL, adverse events, urinary tract infection in the first month after surgery, and subjective urinary symptoms for this comparison. The volume of post-void residual urine, assessed at one month after surgery, among women receiving bethanechol was lower than those in the placebo group (mean difference (MD) -37.4 mL, 95% confidence interval (CI) -60.35 to -14.45; one study, 39 participants; very-low certainty evidence). Suprapubic catheterisation versus intermittent self-catheterisation The studies reported no information on the rate of spontaneous voiding recovery at one week and post-void residual urine volume at one month following the operation for this comparison. There was no difference in risks of acute complication (risk ratio (RR) 0.77, 95% CI 0.24 to 2.49; one study, 71 participants; very low certainty evidence) and urinary tract infections during the first month after surgery (RR 0.77, 95% CI 0.53 to 1.13; two studies, 95 participants; very- low certainty evidence) between participants who underwent suprapubic catheterisation and those who underwent intermittent self-catheterisation. Available data were insufficient to calculate the relative measures of the effect of interventions on QoL and subjective urinary symptoms. AUTHORS' CONCLUSIONS: None of the included studies reported rate of spontaneous voiding recovery one week after surgery, time to a post-void residual volume of urine of 50 mL or less, or post-void residual urine volume at 6 and 12 months after surgery, all of which are important outcomes for assessing postoperative bladder dysfunction. Limited evidence suggested that bethanechol may minimise the risk of bladder dysfunction after radical hysterectomy by lowering post-void residual urine volume. The certainty of this evidence, however, was very low. The effectiveness of different types of postoperative urinary catheterisation (suprapubic and intermittent self-catheterisation) remain unproven.

Effects of Mefenamic Acid in Pain Control during Loop Electrical Excision Procedure:A Prospective Double-Blind Randomized Control Trial.

OBJECTIVE: To investigate the effectiveness of pre-procedural oral mefenamic acid compared with placebo in women undergoing Loop Electrosurgical Excision Procedure (LEEP) with intracervical lidocaine injection. STUDY DESIGNS: A prospective double-blinded randomized control trial. Materials, Setting, Methods: Women undergoing LEEP for any indications were asked to participate in the study. The participants were randomly allocated into two groups. In group 1 (oral mefenamic acid), the participants were offered oral mefenamic acid (500 mg) for 30 minutes before procedures. In group 2 (placebo), the patients were given oral placebo (identical tablet) for 30 minutes before operation. All participants received immediate 10 mL of 2% lidocaine with 1:100,000 of epinephrine intracervical injection before undergoing the LEEP. All participants were excised in one piece of LEEP. No top-hat excision in this study.  The patients graded their pain on a 10-cm visual analog scale (VAS) at different points during the procedure, including speculum insertion, at starting excision, and 30 minutes post excision. Primary outcomes revealed the difference of VAS during all steps of LEEP by generalized estimating equations procedure. RESULTS: Sixty participants (30 in mefenamic group and 30 in placebo group) participated in this study. The study did not find differences of VAS during all steps of LEEP and analgesic drug requirement at 30 minutes after LEEP procedure. All patients reported no immediate complications and no intervention-related adverse events were observed. CONCLUSION: Using pre-procedural oral mefenamic acid before LEEP procedure was not associated with pain reduction during all steps of excision.
.

Knowledge and Attitude Toward Human Papillomavirus Infection and Vaccination among Thai Women: A Nationwide Social Media Survey.

OBJECTIVES: This study was performed first to assess Thai women's knowledge and attitude toward Human papillomavirus (HPV) infection and vaccination and second to find out factors associated with knowledge in this regard. METHODS: The survey announcement was advertised via Facebook from 17 May 2019 to 14 June 2019 to recruit women aged 18-26 years living in Thailand. A score below 5 out of total score of 10 on the survey was considered as a poor level of knowledge. Multivariate analysis was applied to identify factors associated with HPV infection and vaccination knowledge. RESULTS: A total of 1,175 participants were recruited. The participants' median age was 22 years. Approximately, 46% of the participants had poor level of knowledge regarding HPV infection and vaccination. Factors associated with poor knowledge included low educational level (adjusted OR, 1.35; 95% CI 1.04-1.77), low family income (adjusted OR, 2.14; 95% CI 1.65-2.78), being Christian (adjusted OR, 4.04; 95% CI 1.22-13.40), being engaged in sexual intercourse (adjusted OR, 0.75; 95%CI 0.58-0.97), and being unvaccinated against HPV infection (adjusted OR, 5.74; 95% CI 3.07-10.74). CONCLUSION: Nearly half of the Thai women who participated in the survey had poor level of knowledge regarding HPV infection and vaccination, indicating a need for more effective health education intervention. Factors associated with knowledge included socioeconomic status and sexual behavior.
.

Pulmonary Recruitment Maneuver for Reducing Shoulder Pain after Laparoscopic Gynecologic Surgery: A Network Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Shoulder pain is a common symptom following laparoscopic surgery. This systematic review was undertaken to assess updated evidence regarding the effectiveness and complications of the pulmonary recruitment maneuver (PRM) for reducing shoulder pain after laparoscopic gynecologic surgery. METHODS: A number of databases for randomized controlled trials (RCTs) investigating PRM for reducing shoulder pain were searched up to June 2019. Two authors independently selected potentially relevant RCTs, extracted data, assessed risk of bias, and compared results. Network meta-analyses were employed to simultaneously compare multiple interventions. Effect measures were presented as pooled mean difference (MD) or risk ratio (RR) with corresponding 95% confidence intervals (CI). RESULTS: Of the 44 records that we identified as a result of the search (excluding duplicates), eleven RCTs involving 1111 participants were included. Three studies had an unclear risk of selection bias. PRM with a maximum pressure of 40 cm H2O was most likely to result in the lowest shoulder pain intensity at 24 hours (MD -1.91; 95% CI -2.06 to -1.76) while PRM with a maximum pressure of 40 cm H2O plus intraperitoneal saline (IPS) appeared to be the most efficient at 48 hours (MD -2.09; 95% CI -2.97 to -1.21). The estimated RRs for analgesia requirement, nausea/vomiting, and cardiopulmonary events were similar across the competing interventions. CONCLUSION: PRM with 40 cm H2O performed either alone or accompanied by IPS is a promising intervention for alleviating shoulder pain within 48 hours following gynecologic laparoscopy.

Endometriosis-Associated Massive Ascites in an Asian Woman: A Case Report of a Rare Clinical Entity.

Massive ascites as a presentation of endometriosis is a rare clinical entity that is most commonly seen in black nulliparous females. Herein, we describe a case of a 32-year-old multiparous Thai woman who presented with a two-year history of abdominal distension. Computerized tomography of the abdominopelvic region showed an infiltrative enhancing lesion involving the cul-de-sac and perirectal region with massive loculated ascites, suggesting carcinomatosis peritonei. Abdominal paracentesis was performed to yield fluid samples for evaluation, which revealed no malignant cells, and polymerase chain reaction (PCR) was negative for tuberculosis. The patient underwent exploratory laparotomy which revealed a large amount of serosanguinous ascites, thickened matted bowel loops, and necrotic debris covering the entire surface of the peritoneum and visceral organs. The surgical procedures included drainage of 6.5 liters of ascites, lysis adhesion, biopsy of the peritoneum, and right salpingo-oophorectomy. Histologic examination revealed benign endometrial glands with stroma at the peritoneum tissue and broad ligament. Other causes of ascites were excluded. The ascites responded to drainage and hormonal suppression. A final diagnosis of endometriosis was made based on these findings. Endometriosis should therefore be considered in differential diagnosis in women of childbearing age who present with ascites.

Outcomes associated with anaesthetic techniques for caesarean section in low- and middle-income countries: a secondary analysis of WHO surveys.

Associations between anaesthetic techniques and pregnancy outcomes were assessed among 129,742 pregnancies delivered by caesarean section (CS) in low- and middle-income countries (LMICs) using two WHO databases. Anaesthesia was categorized as general anaesthesia (GA) and neuraxial anaesthesia (NA). Outcomes included maternal death (MD), maternal near miss (MNM), severe maternal outcome (SMO), intensive care unit (ICU) admission, early neonatal death (END), neonatal near miss (NNM), severe neonatal outcome (SNO), Apgar score <7 at 5 minutes, and neonatal ICU (NICU) admission. A two-stage approach of individual participant data meta-analysis was used to combine the results. Adjusted odds ratio (OR) with 95% confidence intervals (CIs) were presented. Compared to GA, NA were associated with decreased odds of MD (pooled OR 0.28; 95% CI 0.10, 0.78), MNM (pooled OR 0.25; 95% CI 0.21, 0.31), SMO (pooled OR 0.24; 95% CI 0.20,0.28), ICU admission (pooled OR 0.17; 95% CI 0.13, 0.22), NNM (pooled OR 0.63; 95% CI 0.55, 0.73), SNO (pooled OR 0.55; 95% CI 0.48, 0.63), Apgar score <7 at 5 minutes (pooled OR 0.35; 95% CI 0.29, 0.43), and NICU admission (pooled OR 0.53; 95% CI 0.45, 0.62). NA therefore was associated with decreased odds of adverse pregnancy outcomes in LMICs.

Risk of Severe Adverse Maternal and Neonatal Outcomes in Deliveries with Repeated and Primary Cesarean Deliveries versus Vaginal Deliveries: A Cross-Sectional Study.

OBJECTIVE: To determine risks of severe adverse maternal and neonatal outcomes in women with repeated cesarean delivery (CD) and primary CD compared with those with vaginal delivery (VD). METHODS: Data of this cross-sectional study were extracted from 2,262 pregnant women who gave birth between August 2014 and December 2016, at Srinagarind Hospital, Khon Kaen University. Severe maternal outcomes were categorized based on the World Health Organization criteria. Adjusted odds ratio (aOR) and 95% confidence intervals (CI) were calculated to indicate the risk of severe adverse maternal and neonatal outcomes among women underwent CD compared with those who underwent VD. RESULTS: There were no cases of maternal death in this study. CD significantly increased risk of severe adverse maternal outcomes (SMO) (aOR 10.59; 95% CI, 1.19-94.54 for primary CD and aOR 17.21; 95% CI, 1.97-150.51 for repeated CD) compared with women who delivered vaginally. When compared with vaginal delivery, the risks of neonatal near miss (NNM) and severe adverse neonatal outcomes (SNO) were significantly higher in primary CD group (aOR 1.71; 95% CI 1.17-2.51 and aOR 1.66; 95% CI 1.14-2.43), respectively. For repeated CD, the risks were borderline significant (aOR, 1.58; 95% CI, 0.98-2.56 for NNM and aOR, 1.61; 95% CI, 0.99-2.60 for SNO). CONCLUSION: Primary and repeated CD significantly increased the risk of SMO compared with VD. Risks of NNM and SNO were also significantly increased in women with primary CD. The risks of NNM and SNO for repeated CD trended toward a significant increase.

Health education interventions to promote early presentation and referral for women with symptoms of endometrial cancer.

BACKGROUND: Diagnosis of endometrial (womb) cancer is normally made at an early stage, as most women with the disease experience abnormal vaginal bleeding, which prompts them to seek medical advice. However, delays in presentation and referral can result in delay in diagnosis and management, which can lead to unfavourable treatment outcomes. This is particularly a problem for pre- and peri-menopausal women. Providing educational information to women and healthcare providers regarding symptoms relating to endometrial cancer may raise awareness of the disease and reduce delayed treatment. OBJECTIVES: To assess the effectiveness of health education interventions targeting healthcare providers, or individuals, or both, to promote early presentation and referral for women with endometrial cancer symptoms. SEARCH METHODS: We searched CENTRAL, MEDLINE and Embase. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of review articles. SELECTION CRITERIA: We planned to include randomised controlled trials (RCTs), both individually randomised and cluster-RCTs. In the absence of RCTs we planned to include well-designed non-randomised studies (NRS) with a parallel comparison assessing the benefits of any type of health education interventions. DATA COLLECTION AND ANALYSIS: Two review authors independently evaluated whether potentially relevant studies met the inclusion criteria for the review, but none were found. MAIN RESULTS: A comprehensive search of the literature yielded the following results: CENTRAL (1022 references), MEDLINE (2874 references), and Embase (2820 references). After de-duplication, we screened titles and abstracts of 4880 references and excluded 4864 that did not meet the review inclusion criteria. Of the 16 references that potentially met the review inclusion, we excluded all 16 reports after reviewing the full texts. We did not identify any ongoing trials. AUTHORS' CONCLUSIONS: There is currently an absence of evidence to indicate the effectiveness of health education interventions involving healthcare providers or individuals or both to promote early presentation and referral for women with endometrial cancer symptoms. High-quality RCTs are needed to assess whether health education interventions enhance early presentation and referral. If health education interventions can be shown to reduce treatment delays in endometrial cancer, further studies would be required to determine which interventions are most effective.

Management of drainage for malignant ascites in gynaecological cancer.

BACKGROUND: Ascites is the accumulation of fluid within the abdominal cavity. Most women with advanced ovarian cancer and some women with advanced endometrial cancer need repeated drainage for ascites. Guidelines to advise those involved in the drainage of ascites are usually produced locally and are generally not evidence-based. Managing drains that improve the efficacy and quality of the procedure is key in making recommendations that could improve the quality of life (QoL) for women at this critical period of their lives. OBJECTIVES: To evaluate the effectiveness and adverse events of different interventions for the management of malignant ascites drainage in the palliative care of women with gynaecological cancer. SEARCH METHODS: We searched CENTRAL, MEDLINE, and Embase to 4 November 2019. We checked clinical trial registries, grey literature, reports of conferences, citation lists of included studies, and key textbooks for potentially relevant studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of women with malignant ascites with gynaecological cancer. If studies also included women with non-gynaecological cancer, we planned to extract data specifically for women with gynaecological cancers or request the data from trial authors. If this was not possible, we planned to include the study only if at least 50% of participants were diagnosed with gynaecological cancer. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, extracted data, evaluated the quality of the included studies, compared results, and assessed the certainty of the evidence using Cochrane methodology. MAIN RESULTS: In the original 2010 review, we identified no relevant studies. This updated review included one RCT involving 245 participants that compared abdominal paracentesis and intraperitoneal infusion of catumaxomab versus abdominal paracentesis alone. The study was at high risk of bias in almost all domains. The data were not suitable for analysis. The median time to the first deterioration of QoL ranged from 19 to 26 days in participants receiving paracentesis alone compared to 47 to 49 days among participants receiving paracentesis with catumaxomab infusion (very low-certainty evidence). Adverse events were only reported among participants receiving catumaxomab infusion. The most common severe adverse events were abdominal pain and lymphopenia (157 participants; very low-certainty evidence). There were no data on the improvement of symptoms, satisfaction of participants and caregivers, and cost-effectiveness. AUTHORS' CONCLUSIONS: Currently, there is insufficient evidence to recommend the most appropriate management of drainage for malignant ascites among women with gynaecological cancer, as there was only very low-certainty evidence from one small RCT at overall high risk of bias.

Sexual behavior and infection with cervical human papillomavirus types 16 and 18.

OBJECTIVE: This study assessed whether sexual behavior, including engaging in early sexual intercourse and having had multiple sexual partners, can predict the risk of infection with cervical human papillomavirus (HPV) types 16 and 18. METHODS: Records were reviewed of women who underwent cervical cancer screening and were found to be infected with high-risk HPV. The genotypes of high-risk HPV were categorized as HPV 16, HPV 18, and other than 16 or 18. Early sexual intercourse was defined as first sexual intercourse at the age of 19 years or younger. Multiple sexual partners was defined as having more than three lifetime sexual partners. Associations between sexual behavior and HPV 16/18 infection were presented as odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Of the 349 women included in the study, 72 (20.6%) and 30 (8.6%) were infected by HPV 16 and 18, respectively. Eighty-two women (26.0%) reported having engaged in early sexual intercourse, and 33 (10.4%) reported having had multiple sexual partners. After adjustment for age, parity, and smoking habits, we found that women who had engaged in early sexual intercourse tended to have a higher risk of HPV 16 (OR 1.74; 95% CI 0.93-3.29), and those who had had multiple sexual partners were found to be at a significantly higher risk for HPV 18 (OR 4.58; 95% CI 1.44-14.58). CONCLUSION: Sexual behavior was associated with an increased risk of HPV 16/18 infection. Engaging in early sexual intercourse increased the risk of HPV 16 infection, and having had multiple sexual partners increased that of HPV 18.

Quality Assessment of Websites Providing Information on Human Papillomavirus Vaccines in Thailand.

OBJECTIVES: To assess the quality of websites that provide information about human papillomavirus (HPV) vaccination using the criteria laid out by the World Health Organization Global Advisory Committee on Vaccine Safety. METHODS: This study assessed the quality of 154 Thai-language websites accessible in November 2018 via the three most popular search engines. Differences in scores were reported as mean difference (MD) and 95% confidence interval (CI). RESULTS: With regard to credibility, all of the websites examined indicated their mission but, in most cases (91.6%), lacked transparency with regard to sponsorship. In terms of content, almost all of the websites (97.4%) met our writing/editing and content accuracy standards but did not provide complete information regarding the benefits of vaccination or adverse events associated with it. None of the websites contained information regarding their editorial/review process. All of the websites were accessible and were designed to be adaptable to mobile device screens. News and personal websites had lower credit scores than those of academic institutions (MD -0.63, 95% CI -1.05 to -0.20; MD -0.71, 95% CI -1.16 to -0.25, respectively). CONCLUSION: Most of the websites met standards in terms of writing/editing and content accuracy. However, fundamental information regarding the benefits and adverse events associated with HPV vaccination were infrequently reported, the editorial process and transparency issues were rarely addressed.

Effects of Cassia alata Linn on bowel function recovery following surgery for gynecological cancer: A randomized controlled trial.

BACKGROUND: Postoperative ileus is a common complication following abdominal surgery. This study was undertaken to determine the effectiveness and safety of Cassia alata Linn in stimulating gastrointestinal function recovery among women with gynecologic cancer who had undergone laparotomy for surgical staging or cytoreductive surgery. METHODS: A total of 90 participants were randomly allocated to postoperative consumption of either Cassia alata Linn tea (n = 45) or warm water (N = 45). Outcomes of interest included time to first passage of flatus, time to first defecation, time to toleration of solid food, and ileus symptoms. Differences between the groups were measured as mean difference (MD) or odds ratio (OR) with 95% confidence interval (CI). RESULTS: Women allocated to the Cassia alata Linn group had shorter times to first passage of flatus (MD -8.53; 95% CI -3.69, -13.38 h) and first defecation (MD -19.83; 95% CI -11.18, -28.48 h) compared with controls. There were no differences in terms of time to toleration of solid food (MD 0.26; 95% CI -2.13, 1.61 h) or ileus symptoms (OR 0.10; 95% CI 0.01, 1.94) between the two groups. CONCLUSION: Postoperative consumption of Cassia alata Linn hastens gastrointestinal function recovery after laparotomy in women with gynecologic cancer.

Pregnancy outcomes of women with previous caesarean sections: Secondary analysis of World Health Organization Multicountry Survey on Maternal and Newborn Health.

Secondary analysis of World Health Organization Multicountry Survey on Maternal and Newborn Health (WHOMCS) was undertaken among 173,124 multiparous women to assess the association between previous caesarean sections (CS) and pregnancy outcomes. Maternal outcomes included maternal near miss (MNM), maternal death (MD), severe maternal outcomes (SMO), abnormal placentation, and uterine rupture. Neonatal outcomes were stillbirth, early neonatal death, perinatal death, neonatal near miss (NNM), neonatal intensive care unit (NICU) admission, and preterm birth. Previous CS was associated with increased risks of uterine rupture (adjusted Odds Ratio (aOR); 7.74; 95% confidence interval (CI) 5.48, 10.92); morbidly adherent placenta (aOR 2.60; 95% CI 1.98, 3.40), MNM (aOR 1.91; 95% CI 1.59, 2.28), SMO (aOR 1.80; 95% CI 1.52, 2.13), placenta previa (aOR 1.76; 95% CI 1.49, 2.07). For neonatal outcomes, previous CS was associated with increased risks of NICU admission (aOR 1.31; 95% CI 1.23, 1.39), neonatal near miss (aOR 1.19; 95% CI 1.12, 1.26), preterm birth (aOR 1.07; 95% CI 1.01, 1.14), and decreased risk of macerated stillbirth (aOR 0.80; 95% CI 0.67, 0.95). Previous CS was associated with serious morbidity in future pregnancies. However, these findings should be cautiously interpreted due to lacking data on indications of previous CS.

Programmed Death Ligand 1 (PD-L1) Expression in Epithelial Ovarian Cancer: A Comparison of Type I and Type II Tumors

Objective: To examine the expression of programmed death ligand 1 (PD-L1) in type I and type II epithelial ovarian cancers (EOC) and its associations with outcomes. Methods: Records of 132 women with EOC were reviewed. Immunostaining of PD-L1 was performed with formalin-fixed, paraffin-embedded specimens. Expression of PD-L1 was classified into four categories (0; 1+; 2+; 3+) according to intensity of expression. Expression of PD-L1 ≥2+ was deemed to be high. Results: Of the 132 women, 75 (56.8%) and 57 (43.2%) women had type I and type II tumors, respectively. Approximately 70% of cases exhibited high PD-L1 expression. There was no significant difference in the rate of high PD-L1 expression between the two EOC types (65.3% versus 59.6%). In type I tumors, high PD-L1 expression was associated with more advanced stages (51.0% versus 34.6%), greater recurrence (46.9% versus 26.9%), and shorter median progression-free survival (27 months versus 62 months) than low expression. In type II tumors, there were no apparent differences between high and low expression of PD-L1 in terms of the percentage of advanced-stage tumors (82.6% versus 79.4%), recurrence (56.5% versus 58.8%), and median progression-free survival (21 months versus 24 months). Conclusion: high PD-L1 expression is associated with worse oncological outcomes in type I EOC. This finding emphasizes the merit of further studies to confirm this promising result and to determine the potential role of PD-L1 blockade therapy in type I EOC.