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Objectives To explore and deepen understanding of factors influencing driving exposure for older drivers. Design Cross-sectional. Setting Baseline data on function and driving exposure from 1 week of driving were evaluated. Participants A convenience sample of 380 drivers aged 75 and older, residing in northwest Sydney, was recruited. Participants were required to be the primary drivers of their own vehicle. Measurements Driver function was evaluated using the DriveSafe and DriveAware clinic-based assessments to measure visual attention to the driving environment and awareness of driving ability. Demographic information was obtained through interview. An in-vehicle monitoring device with data logger and GPS receiver, was used to measure driving exposure in 362 of 380 participants' vehicles. Driving exposure outcomes were total distance driven, furthest distance traveled from home, and average trip length. Factors influencing these exposure outcomes were analyzed using generalized linear regression. Results Drivers typically drove 100 km in local and surrounding areas during the week. Function was predictive of all driving exposure outcomes. Drivers with lower levels of function drove fewer kilometers and took shorter trips closer to home. Age, health status, and personal circumstance (e.g., rural residence) also influenced exposure, but sex did not. Conclusion Using objective measures, this study provides evidence that function, age, health status, and personal circumstance influence driving exposure of older drivers. Understanding how older people use driving to preserve their independence is important for exploring safe driving strategies for older people.

Objectives. We sought to identify the program fidelity factors associated with successful implementation of the Buckle-Up Safely program, targeting correct use of age-appropriate child car restraints. Methods. In 2010, we conducted a cluster randomized controlled trial of 830 families with children attending preschools and long day care centers in South West Sydney, New South Wales, Australia. Families received the Buckle-Up Safely program in the intervention arm of the study (13 services). Independent observers assessed the type of restraint and whether it was used correctly. Results. This detailed process evaluation showed that the multifaceted program was implemented with high fidelity. Program protocols were adhered to and messaging was consistently delivered. Results from multilevel and logistic regression analyses show that age-appropriate restraint use was associated with attendance at a parent information session hosted at the center (adjusted odd ratio [AOR] = 3.66; 95% confidence interval [CI] = 1.61, 8.29) and adversely affected by the child being aged 2 to 3 years (AOR = 0.14; 95% CI = 0.07, 0.30) or being from a family with more than 2 children (AOR = 0.34; 95% CI = 0.17, 0.67). Conclusions. Findings highlight the importance of parents receiving hands-on education regarding the proper use of age-appropriate child restraints.

Objective: Crash and injury surveillance studies have identified a range of rider-related factors, including age, sex, licensure, training and experience, as being associated with motorcycle crash risk. The aim of this study was to establish whether these previously identified factors were associated with crash involvement in an Australian-based population. Methods: Data obtained from motorcyclists recruited from road authority licensing offices in a population-based survey design were analyzed. In addition to descriptive analysis, survey logistic regression was used to examine predictors of self-reported motorcycle crashes. A statewide population prevalence study of motorcyclists in New South Wales, Australia, was conducted using a multistage stratified random sampling plan. Participants (n = 503) represented 47% of eligible riders invited to participate. The distribution of responses was weighted to represent the population based on motorcycle registrations as a proxy for active motorcyclists, adjusted for age, sex, and variations in sample size and population density between survey sites. Results: This analysis investigated factors associated with having crashed in the past 12 months. The key predictors of increased crash risk included frequent near-crash experiences (6–10) in the past year (adjusted odds ratio [ORadj] = 5.3; 95% confidence interval [CI], 1.3–21.8), having 4 or more riding demerit points (ORadj = 4.1; 95% CI, 1.1–14.7), and motorcycle type and riding purpose. Sports (ORadj = 2.8; 95% CI, 1.1–7.3) and commuter motorcycles (ORadj = 4.0; 95% CI, 1.1–15.3) were associated with higher odds of crashes compared to cruiser/touring motorcycles. Those whose purpose for riding frequently involved commuting, high-speed roads, or motorcycle sports had higher odds of being involved in a crash compared to riders who rarely took part in such activities. Rider age, license type, and time holding a motorcycle license were not predictive of crash involvement when other factors were taken into account. Conclusions: These findings provide important population-level information and insights about risk exposure for motorcyclists. Taking a more tailored approach to data collection meant that factors associated with crash involvement were identified that are not commonly observed in studies relying on administrative data. In particular, the study highlights the importance of near-crash experiences as warnings to riders and the need to use such experiences as learning opportunities to improve their riding style and safety.

This chapter explores how the contrivance of asking people to imagine being cast away on a desert island has provided the basis for radio discussions of disc recordings that go beyond questions of taste and aesthetic value, opening up considerations of potential utility. Guests are simply asked which discs they would want to have with them if alone on a desert island, and why. Explanations for given choices often include the way in which music and other sound recordings might prove useful—for managing the castaway’s moods, their social isolation, their sense of loss and displacement, their ostensibly endless ‘free time’, and their likely desire to wish to keep memory of people and places alive. Castaways mostly choose music, but sometimes opt for recordings of other sorts, including of their children. These prove to be nostalgia ready and especially well-suited to managing the programme’s fictional scenario.

This chapter provides an overview of the long-standing and highly popular British radio programme Desert Island Discs (DID). It sets out the historical contexts in which the programme was established and developed, and interrogates both its changing format and the meanings and values that have been associated with DID over time. Developments in the production process are also assessed, including the impact of various presenters and the selection of castaways, as well as the programme’s place in broader media culture and its relationship to particular national identities. Finally, it considers the potential value of DID to the world of scholarship, particularly following the establishment in 2011 of the programme’s online archive, and the contribution of chapter authors to the realisation of that potential.

Background Glycaemic target recommendations vary widely between international professional organisations for women with gestational diabetes mellitus (GDM). Some studies have reported women’s experiences of having GDM, but little is known how this relates to their glycaemic targets. The aim of this study was to identify enablers and barriers for women with GDM to achieve optimal glycaemic control. Methods Women with GDM were recruited from two large, geographically different, hospitals in New Zealand to participate in a semi-structured interview to explore their views and experiences focusing on enablers and barriers to achieving optimal glycaemic control. Final thematic analysis was performed using the Theoretical Domains Framework. Results Sixty women participated in the study. Women reported a shift from their initial negative response to accepting their diagnosis but disliked the constant focus on numbers. Enablers and barriers were categorised into ten domains across the three study questions. Enablers included: the ability to attend group teaching sessions with family and hear from women who have had GDM; easy access to a diabetes dietitian with diet recommendations tailored to a woman’s context including ethnic food and financial considerations; free capillary blood glucose (CBG) monitoring equipment, health shuttles to take women to appointments; child care when attending clinic appointments; and being taught CBG testing by a community pharmacist. Barriers included: lack of health information, teaching sessions, consultations, and food diaries in a woman’s first language; long waiting times at clinic appointments; seeing a different health professional every clinic visit; inconsistent advice; no tailored physical activities assessments; not knowing where to access appropriate information on the internet; unsupportive partners, families, and workplaces; and unavailability of social media or support groups for women with GDM. Perceived judgement by others led some women only to share their GDM diagnosis with their partners. This created social isolation. Conclusion Women with GDM report multiple enablers and barriers to achieving optimal glycaemic control. The findings of this study may assist health professionals and diabetes in pregnancy services to improve their care for women with GDM and support them to achieve optimal glycaemic control.

We explored the factors influencing the use of age-appropriate car seats in a community with a high proportion of Aboriginal families in regional New South Wales. We conducted a survey and three focus groups with parents of children aged 3–5 years enrolled at three early learning centres on the Australian south-east coast. Survey data were triangulated with qualitative data from focus groups and analysed using the PRECEDE-PROCEED conceptual framework. Of the 133 eligible families, 97 (73%) parents completed the survey including 31% of parents who reported their children were Aboriginal. Use of age-appropriate car seats was reported by 80 (83%) of the participants, and awareness of the child car seat legislation was high (91/97, 94%). Children aged 2–3 years were less likely reported to be restrained in an age-appropriate car seat than were older children aged 4–5 years (60% versus 95%: χ2 = 19.14, p < 0.001). Focus group participants highlighted how important their child’s safety was to them, spoke of the influence grandparents had on their use of child car seats and voiced mixed views on the value of authorised child car seat fitters. Future programs should include access to affordable car seats and target community members as well as parents with clear, consistent messages highlighting the safety benefits of using age-appropriate car seats.

It has been consistently reported that women self-regulate their driving more than men. Volunteer drivers aged 75 years and older from the suburban outskirts of Sydney, Australia joined a longitudinal study in 2012-2014. GPS in-vehicle monitoring was used to objectively measure driving and surveys of driving patterns. The study included 343 drivers (203/343, 59% men) with an average age of 80 years. Our results revealed that men were 3.85 times more likely to report driving beyond their local shire during the past year (95% CI 2.03-5.72) and 1.81 times more likely to report that they do not avoid night driving (95% CI 1.21-3.22). In contrast sex was not predictive of any objective measure of driving during a one-week period of monitoring. These findings suggest that men and women report different self-regulation practices but that actual driving exposure is quite similar. These findings can inform strategies to promote safe mobility.

Introduction. Optimal glycaemic control in women with gestational diabetes mellitus (GDM) reduces maternal and infant morbidity.Method. A survey was administered to women diagnosed with GDM to explore their views and experiences in achieving optimal glycaemic control.Results. Sixty women participated. Enablers included being taught to test capillary blood glucose in group settings where the health professional demonstrated this on themselves first (60, 100%); health professionals listening (41, 68%); being reminded to perform blood glucose testing (33, 55%); and being provided healthy meals by friends and family (28, 47%). Barriers included not having information in a woman’s first language (33, 55%); being offered unhealthy food (19, 31%); not being believed by health professionals (13, 21%); receiving inconsistent information by health professionals (10, 16%); never being seen twice by the same health professional (8, 13%); and long waiting hours at clinics (7, 11%). Two-thirds of women (37, 62%) reported that food costs were not a barrier, but that they were always or frequently hungry.Conclusion. Optimising experiences for women with GDM for achieving glycaemic control and overcoming barriers, regardless of glycaemic targets, requires further focus on providing meaningful health literacy and support from health professionals, family, friends, and work colleagues.

Objective: Laboratory studies have demonstrated that impact protectors (IP) used in motorcycle clothing can reduce fracture severities. While crash studies have reported IP are associated with reduced likelihood of soft tissue injury, there is little evidence of their effectiveness in reducing fracture likelihood. This discrepancy might be related to IP quality. There are mandatory requirements for IP supplied with protective clothing in Europe, but not elsewhere. This study examines the energy attenuation performance of IP used by Australian riders. Methods: IP were harvested from clothing worn by crashed riders admitted to hospital. The IP were examined and energy attenuation properties were determined using EN 1621-1 test procedures. Impact injury was identified from medical records and defined as fractures, dislocations, and avulsions that occurred following impact to the rider's shoulders, elbows, hips, and/or knees. Fisher's exact test was used to examine the relationship between meeting the EN 1621-1 energy attenuation requirements and impact injury. The association between the average and maximum transmitted force, and impact injury was examined using generalized estimating equations. Motorcycle riders were recruited as part of an in-depth crash study through three hospitals in New South Wales, Australia, between 2012 and 2014. Riders were interviewed, and engineers conducted site, vehicle, and clothing inspections. Clothing was collected, or identical garments were purchased. Results: Clothing was inspected for 62 riders. Of these, 19 wore clothing incorporating 76 IP. Twenty-six of these were impacted in the crash event. Almost all impacted IP (96%) were CE marked, and most (83%) met Level 1 energy attenuation requirements of EN 1621-1 when tested. Of the 26 impacted IP, four were associated with impact injuries, including midshaft and distal clavicle fractures and a scapula and olecranon fracture. No associations between meeting EN 1621-1 requirements and impact injury were found (p = 0.5). There was no association between average force transmitted and impact injury (95% CI: 0.91–1.24); however, as maximum force transmitted increased, the odds of impact injury increased (95% CI: 1.01–1.2). These results indicate a high probability of impact injury at 50 kN, the limit of maximum transmitted force specified in EN 1621-1. Conclusion: The allowable transmitted force of EN 1621-1 may be too high to effectively reduce the probability of impact injury. This is not surprising, given human tolerance levels that are reported in literature. Reducing the force limit below the reported fracture tolerance limits might be difficult with current technology. However, there is scope to reduce the EN 1621-1 maximum limit of 50 kN transmitted force. A reduction in the maximum force limit would improve rider protection and appears feasible, as 77% of tested IP recorded a maximum force

Background: Gestational diabetes (GDM) is glucose intolerance, first recognised in pregnancy and usually resolving after birth. GDM is associated with both short- and long-term adverse effects for the mother and her infant. Lifestyle interventions are the primary therapeutic strategy for many women with GDM. Objectives: To evaluate the effects of combined lifestyle interventions with or without pharmacotherapy in treating women with gestational diabetes.Search methods: We searched the Pregnancy and Childbirth Group's Trials Register (14 May 2016), ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP) (14th May 2016) and reference lists of retrieved studies. Selection criteria: We included only randomised controlled trials comparing a lifestyle intervention with usual care or another intervention for the treatment of pregnant women with GDM. Quasi-randomised trials were excluded. Cross-over trials were not eligible for inclusion. Women with pre-existing type 1 or type 2 diabetes were excluded.Data collection and analysis: We used standard methodological procedures expected by the Cochrane Collaboration. All selection of studies, data extraction was conducted independently by two review authors.Main results: Fifteen trials (in 45 reports) are included in this review (4501 women, 3768 infants). None of the trials were funded by a conditional grant from a pharmaceutical company. The lifestyle interventions included a wide variety of components such as education, diet, exercise and self-monitoring of blood glucose. The control group included usual antenatal care or diet alone. Using GRADE methodology, the quality of the evidence ranged from high to very low quality. The main reasons for downgrading evidence were inconsistency and risk of bias. We summarised the following data from the important outcomes of this review.Lifestyle intervention versus control groupFor the mother: There was no clear evidence of a difference between lifestyle intervention and control groups for the risk of hypertensive disorders of pregnancy (pre-eclampsia) (average risk ratio (RR) 0.70; 95% confidence interval (CI) 0.40 to 1.22; four trials, 2796 women; I2 = 79%, Tau2 = 0.23; low-quality evidence); caesarean section (average RR 0.90; 95% CI 0.78 to 1.05; 10 trials, 3545 women; I2 = 48%, Tau2 = 0.02; low-quality evidence); development of type 2 diabetes(up to a maximum of 10 years follow-up) (RR 0.98, 95% CI 0.54 to 1.76; two trials, 486 women; I2 = 16%; low-quality evidence); perineal trauma/tearing (RR 1.04, 95% CI 0.93 to 1.18; one trial, n = 1000 women; moderate-quality evidence) or induction of labour (average RR 1.20, 95% CI 0.99 to 1.46; four trials, n = 2699 women; I2 = 37%; high-quality evidence).More women in the lifestyle intervention group had met postpartum weight goals one year after birth than in the control group (RR 1.75, 95% CI 1.05 to 2.90; 156 women; one trial, low-quality evidence). Lifestyle interventions were associated with a decrease in the risk of postnatal depression compared with the control group (RR 0.49, 95% CI 0.31 to 0.78; one trial, n = 573 women; low-quality evidence).For the infant/child/adult: Lifestyle interventions were associated with a reduction in the risk of being born large-for-gestational age (LGA) (RR 0.60, 95% CI 0.50 to 0.71; six trials, 2994 infants; I2 = 4%; moderate-quality evidence). Birthweight and the incidence of macrosomia were lower in the lifestyle intervention group. Exposure to the lifestyle intervention was associated with decreased neonatal fat mass compared with the control group (mean difference (MD) -37.30 g, 95% CI -63.97 to -10.63; one trial, 958 infants; low-quality evidence). In childhood, there was no clear evidence of a difference between groups for body mass index (BMI) >= 85th percentile (RR 0.91, 95% CI 0.75 to 1.11; three trials, 767 children; I2 = 4%; moderate-quality evidence).There was no clear evidence of a difference between lifestyle intervention and control groups for the risk of perinatal death (RR 0.09, 95% CI 0.01 to 1.70; two trials, 1988 infants; low-quality evidence). Of 1988 infants, only five events were reported in total in the control group and there were no events in the lifestyle group. There was no clear evidence of a difference between lifestyle intervention and control groups for a composite of serious infant outcome/s (average RR 0.57, 95% CI 0.21 to 1.55; two trials, 1930 infants; I2 = 82%, Tau2 = 0.44; very low-quality evidence) or neonatal hypoglycaemia (average RR 0.99, 95% CI 0.65 to 1.52; six trials, 3000 infants; I2 = 48%, Tau2 = 0.12; moderate-quality evidence). Diabetes and adiposity in adulthood and neurosensory disability in later childhoodwere not prespecified or reported as outcomes for any of the trials included in this review.Authors' conclusions: Lifestyle interventions are the primary therapeutic strategy for women with GDM. Women receiving lifestyle interventions were less likely to have postnatal depression and were more likely to achieve postpartum weight goals. Exposure to lifestyle interventions was associated with a decreased risk of the baby being born LGA and decreased neonatal adiposity. Long-term maternal and childhood/adulthood outcomes were poorly reported.The value of lifestyle interventions in low-and middle-income countries or for different ethnicities remains unclear. The longer-term benefits or harms of lifestyle interventions remains unclear due to limited reporting.The contribution of individual components of lifestyle interventions could not be assessed. Ten per cent of participants also received some form of pharmacological therapy. Lifestyle interventions are useful as the primary therapeutic strategy and most commonly include healthy eating, physical activity and self-monitoring of blood glucose concentrations.Future research could focus on which specific interventions are most useful (as the sole intervention without pharmacological treatment), which health professionals should give them and the optimal format for providing the information. Evaluation of long-term outcomes for the mother and her child should be a priority when planning future trials. There has been no in-depth exploration of the costs 'saved' from reduction in risk of LGA/macrosomia and potential longer-term risks for the infants.

Coworking spaces (CWS) and the associated practice of coworking, have emerged in numerous forms and various urban contexts to critically challenge traditional concepts of the workplace and location of creative work, while simultaneously confronting the way in which creative workers interact with and relate to each other as well as with space and to place. Heralded as a solution to increasingly atomised work patterns, CWS are imagined and presented as spaces of serendipitous encounter, spontaneous exchange and collaboration. Nonetheless, little is known about how coworking positively supports workers and how coworking relates to wider urban transformation processes has been largely un-researched. This paper contributes to a critical discussion through empirical analysis of a project aimed at establishing new creative CWS in city-centre locations across SE England. The study adopts a novel approach using Q-methodology. Motivations for coworking and benefits (or dis-benefits) of co-location are assessed, as is the extent to which coworking facilitates interactional effects and wider neighbourhood interactions. In particular, the role of the CWS manager as “mediator” is explored. Coworker benefits relate primarily to peer-interaction and support rather than formal collaboration. While CWS managers play a key connecting role, also ensuring coworker complementarity and compatibility, the coworker profile (motivations, needs, experiences) ultimately influences outcomes. The study cautions against the use of CWS as “quick fix” urban renewal tools, with little indication that the benefits of coworking reach beyond immediate members or that linkages are easily established between coworkers and local (resident or business) communities.

Background Respiratory morbidity including respiratory distress syndrome (RDS) is a serious complication of preterm birth and the primary cause of early neonatal mortality and disability. While researching the effects of the steroid dexamethasone on premature parturition in fetal sheep in 1969, Liggins found that there was some inflation of the lungs of lambs born at gestations at which the lungs would be expected to be airless. Liggins and Howie published the first randomised controlled trial in humans in 1972 and many others followed. Objectives To assess the effects of administering a course of corticosteroids to the mother prior to anticipated preterm birth on fetal and neonatal morbidity and mortality, maternal mortality and morbidity, and on the child in later life. Search methods We searched Cochrane Pregnancy and Childbirth's Trials Register (17 February 2016) and reference lists of retrieved studies. Selection criteria We considered all randomised controlled comparisons of antenatal corticosteroid administration (betamethasone, dexamethasone, or hydrocortisone) with placebo, or with no treatment, given to women with a singleton or multiple pregnancy, prior to anticipated preterm delivery (elective, or following spontaneous labour), regardless of other co-morbidity, for inclusion in this review. Most women in this review received a single course of steroids; however, nine of the included trials allowed for women to have weekly repeats. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach. Main results This update includes 30 studies (7774 women and 8158 infants). Most studies are of low or unclear risk for most bias domains. An assessment of high risk usually meant a trial had potential for performance bias due to lack of blinding. Two trials had low risks of bias for all risk of bias domains. Treatment with antenatal corticosteroids (compared with placebo or no treatment) is associated with a reduction in the most serious adverse outcomes related to prematurity, including: perinatal death (average risk ratio (RR) 0.72, 95% confidence interval (CI) 0.58 to 0.89; participants = 6729; studies = 15; Tau² = 0.05, I² = 34%; moderate-quality); neonatal death (RR 0.69, 95% CI 0.59 to 0.81; participants = 7188; studies = 22), RDS (average RR 0.66, 95% CI 0.56 to 0.77; participants = 7764; studies = 28; Tau² = 0.06, I² = 48%; moderate-quality); moderate/severe RDS (average RR 0.59, 95% CI 0.38 to 0.91; participants = 1686; studies = 6; Tau² = 0.14, I² = 52%); intraventricular haemorrhage (IVH) (average RR 0.55, 95% CI 0.40 to 0.76; participants = 6093; studies = 16; Tau² = 0.10, I² = 33%; moderate-quality), necrotising enterocolitis (RR 0.50, 95% CI 0.32 to 0.78; participants = 4702; studies = 10); need for mechanical ventilation (RR 0.68, 95% CI 0.56 to 0.84; participants = 1368; studies = 9); and systemic infections in the first 48 hours of life (RR 0.60, 95% CI 0.41 to 0.88; participants = 1753; studies = 8). There was no obvious benefit for: chronic lung disease (average RR 0.86, 95% CI 0.42 to 1.79; participants = 818; studies = 6; Tau² = 0.38 I² = 65%); mean birthweight (g) (MD -18.47, 95% CI -40.83 to 3.90; participants = 6182; studies = 16; moderate-quality); death in childhood (RR 0.68, 95% CI 0.36 to 1.27; participants = 1010; studies = 4); neurodevelopment delay in childhood (RR 0.64, 95% CI 0.14 to 2.98; participants = 82; studies = 1); or death into adulthood (RR 1.00, 95% CI 0.56 to 1.81; participants = 988; studies = 1). Treatment with antenatal corticosteroids does not increase the risk of chorioamnionitis (RR 0.83, 95% CI 0.66 to 1.06; participants = 5546; studies = 15; moderate-quality evidence) or endometritis (RR 1.20, 95% CI 0.87 to 1.63; participants = 4030; studies = 10; Tau² = 0.11, I² = 28%; moderate-quality). No increased risk in maternal death was observed. However, the data on maternal death is based on data from a single trial with two deaths; four other trials reporting maternal death had zero events (participants = 3392; studies = 5; moderate-quality). There is no definitive evidence to suggest that antenatal corticosteroids work differently in any pre-specified subgroups (singleton versus multiple pregnancy; membrane status; presence of hypertension) or for different study protocols (type of corticosteroid; single course or weekly repeats). GRADE outcomes were downgraded to moderate-quality. Downgrading decisions (for perinatal death, RDS, IVH, and mean birthweight) were due to limitations in study design or concerns regarding precision (chorioamnionitis, endometritis). Maternal death was downgraded for imprecision due to few events. Authors' conclusions Evidence from this update supports the continued use of a single course of antenatal corticosteroids to accelerate fetal lung maturation in women at risk of preterm birth. A single course of antenatal corticosteroids could be considered routine for preterm delivery. It is important to note that most of the evidence comes from high income countries and hospital settings; therefore, the results may not be applicable to low-resource settings with high rates of infections. There is little need for further trials of a single course of antenatal corticosteroids versus placebo in singleton pregnancies in higher income countries and hospital settings. However, data are sparse in lower income settings. There are also few data regarding risks and benefits of antenatal corticosteroids in multiple pregnancies and other high-risk obstetric groups. Further information is also required concerning the optimal dose-to-delivery interval, and the optimal corticosteroid to use. We encourage authors of previous studies to provide further information, which may answer any remaining questions about the use of antenatal corticosteroids in such pregnancies without the need for further randomised controlled trials. Individual patient data meta-analysis from published trials is likely to answer some of the evidence gaps. Follow-up studies into childhood and adulthood, particularly in the late preterm gestation and repeat courses groups, are needed. We have not examined the possible harmful effects of antenatal corticosteroids in low-resource settings in this review. It would be particularly relevant to explore this finding in adequately powered prospective trials.

Background Preterm infants are born with low skeletal stores of calcium and phosphorus. Preterm human milk provides insufficient calcium and phosphorus to meet the estimated needs of preterm infants for adequate growth. Supplementation of human milk with calcium and phosphorus may improve growth and development of preterm infants. Objectives To determine whether addition of calcium and phosphorus supplements to human milk leads to improved growth and bone metabolism of preterm infants without significant adverse effects. Search methods We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3), MEDLINE via PubMed (1966 to 14 April 2016), Embase (1980 to 14 April 2016) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 14 April 2016). We also searched clinical trials databases (11 May 2016) and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. Selection criteria Randomised and quasi-randomised trials comparing supplementation of human milk with calcium and/or phosphorus versus no supplementation in hospitalised preterm infants were eligible for inclusion in this review. Data collection and analysis Two review authors (JB, JW) independently extracted data and assessed trial quality using standard methods of the Cochrane Neonatal Review Group. We reported dichotomous data as risk ratios (RRs) and continuous data as mean differences (MDs) with 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the quality of evidence. Main results This is an update of a 2001 review that identified no eligible trials. One trial including 40 infants met the inclusion criteria for this review. Using GRADE criteria, we judged the quality of the evidence as low owing to risk of bias (inadequate reporting of methods of randomisation, allocation concealment and/or blinding) and imprecision (wide confidence intervals and data from a single small trial). We found no evidence of a difference between calcium and phosphorus supplementation versus no supplementation for neonatal growth outcomes (weight, length, head circumference) at any time point reported (two, four or six weeks postnatal age). At six weeks postnatal age, supplementation with calcium/phosphorus was associated with a decrease in serum alkaline phosphatase concentration (MD -56.85 IU/L, 95% CI -101.27 to -12.43; one randomised controlled trial (RCT); n = 40 infants). Investigators provided no data on growth at 12 to 18 months, neonatal fractures, feed intolerance, breastfeeding or any of the prespecified childhood outcomes for this review (fractures, growth, neurodevelopmental outcomes). Authors' conclusions We identified one small trial including only 40 infants that compared supplementation of human milk with calcium and phosphorus versus no supplementation in hospitalised preterm infants. We judged the evidence to be of low quality and found no evidence of differences between groups for clinically important outcomes including growth and fractures. Although serum alkaline phosphatase concentration was reduced in the group receiving supplementation at six weeks postnatal age, this difference is unlikely to be of clinical significance. We conclude that evidence is insufficient to determine whether benefit or harm ensues when human milk is supplemented with calcium and/or phosphorus for the hospitalised preterm infant. We see no advantage of conducting further trials of this intervention because with the advent of multi-component human milk fortifier, supplementation of human milk with calcium and/or phosphorus alone is no longer common practice. Future trials should consider assessing effects of multi-component fortifiers with different mineral compositions on clinically important outcomes during the neonatal period and in later childhood.

To conduct a process and impact evaluation of a multifaceted education-based pilot program targeting correct use of age-appropriate restraints in a regional setting with a high proportion of Aboriginal and Torres Strait Islander families.The program was delivered in 2010 in 3 early learning centers where 31 percent of the children were of Aboriginal and Torres Strait Islander descent. Each component of the program was assessed for message consistency and uptake. To measure program effectiveness, participating children were matched 1:1 by age, language spoken at home, and annual household income with 71 children from the control arm of a contemporaneous trial. The outcome measure in the control and program centers (a 4-category ordinal scale of restraint use) was compared using ordinal logistic regression accounting for age of the parent.Process evaluation found that though program components were delivered with a consistency of message, uptake was affected by turnover of all staff at one center and by parents experiencing difficulty in paying for subsidized restraints at each of the centers. Impact evaluation found that children from the centers receiving the program had nearly twice the odds of being in a better restraint category than children matched from the control group (adjusted odds ratio [ORadj] = 2.06, 95% confidence interval [CI], 1.09-3.90).This was a pragmatic study reflecting the real-life issues of implementing a program in preschools where 57 percent of families had a low income and turnover of staff was high. Despite these issues, impact evaluation showed that the integrated educational program showed promise in increasing correct use of age-appropriate restraints. The findings from this pilot study support the use of an integrated educational program that includes access to subsidized restraints to promote best practice child restraint use among communities that include a high proportion of Aboriginal and Torres Strait Islander families in New South Wales. Future trials in similar settings should consider offering more support in centers with high turnover of staff and offering alternative methods of payment when families experience financial difficulties in purchasing the subsidized restraints. If proven in larger trials, this approach could reduce death and injuries in child passengers in this vulnerable group.

In New Caledonia, blueschist and eclogite preserve, as inclusions in porphyroblastic minerals, a record of sulfide present during prograde subduction processes. Sulfide inclusions in prograde garnet and lawsonite became chemically isolated from the matrix whereas sulfide minerals in the matrix continued to equilibrate with matrix fluids, or grew later, during retrogression. Cu-Fe sulfide mineral inclusions have been found across metamorphic grade within silicate-defined metamorphic mineral zones spanning a crustal profile of 30 km. Bulk area scans of sulfide inclusions provide compositions that represent mixtures of the solid sulfide that were included as the host silicate minerals grew. In general, single sulfide inclusion compositions and aggregate sulfide assemblages are distinct from those of matrix phases. High Cu contents in sulfide inclusions are interpreted to be a consequence of Fe lost from sulfide to growing garnet, rather than the result of intrinsically high Cu in the bulk-rock.The distribution of sulfide inclusion compositions across metamorphic grade, considered together with the available thermodynamic data, suggests that covellite/nukundamite-bearing inclusions in lawsonite, high in both Cu and S, disappear at higher grades as these sulfide minerals are no longer stable. Similarly, clustering near the ratio Fe:Cu=1:1 may cease with increasing grade owing to the replacement of chalcopyrite/ intermediate solid solution (iss) by the denser assemblage pyrite+pyrrhotite+bornite/digenite.

Australians aged 17 to 25 years who travel in cars have a high risk of death and injury in crashes despite mandatory seat belt laws, graduated licensing programs for young drivers, and stringent enforcement. This analysis examined characteristics and injury outcomes of occupants aged 17 to 25 years injured in crashes in New South Wales, Australia. The study focused on restraint use. A linked hospital and police record data set for car occupants admitted to hospitals between 2005 and 2007 was used. Descriptive techniques were used to compare the characteristics of injured occupants of ages 17 to 25 years with those of older occupants and logistic regression was used to test the associations. Only 87% of injured young adults were wearing seat belts. Young adults were more likely than were their older counterparts to be in severe crashes, crashes that involved loss of control, crashes that involved single and older vehicles, and crashes when they were seated in the rear. Young adults also had more head, abdominal or lower torso, and neck injuries and fewer thoracic injuries than did older occupants. Young females were more likely to have been in newer vehicles and less likely to have been in more severe crashes than were young males. Young females also had fewer head injuries and more abdominal or lower torso injuries than young males had. Greater effort is required to increase the use of restraints and modern vehicles among young adults, to encourage industry to improve rear passenger protection, and to increase understanding of the factors that underpin the high involvement of young people in single-vehicle and loss-of-control crashes.

The color gray in E. M. Forster's Howards End lingers in the background like a mist. It both obscures and illuminates the landscape and the characters, and creates a sad refrain that parallels the ...

Objectives : To examine changes in child car restraint practices in low socioeconomic areas following the introduction of mandatory child car restraint legislation in New South Wales (NSW), Australia. Methods : Data from two cross-sectional studies of child car restraint use at pre-schools, early childhood centres and primary schools before and after the introduction of legislating mandatory age-appropriate car restraint use for children up to the age of seven years was used in this analysis. All included observations were from local government areas with socioeconomic status in the lowest 30% of urban Sydney. Children aged 2–5 years were observed in their vehicles as they arrived at observation sites (107 pre-legislation, 360 post-legislation). Multilevel logistic regression was used to examine changes in observed age-appropriate and correct use of car restraints. Results : Age-appropriate car restraint use was higher post-legislation than pre-legislation. After controlling for child's age, parental income, language spoken at home and adjusting for clustering, the odds of children being appropriately restrained post-legislation were 2.3 times higher than in the pre-legislation sample, and the odds of them being correctly restrained were 1.6 times greater. Conclusions : Results indicate an improvement in car restraint practices among children aged 2–5 in low socioeconomic areas after introduction of child restraint laws. Implications : Despite improvements observed with enhanced legislation, further efforts are required to increase optimal child car restraint use.

Equivocal findings exist regarding the ergogenic effects of caffeine in repeat sprint performance in team sports, and there is currently no meta-analysis of available data. Therefore, appropriate studies were obtained from electronic databases following identification using pre-determined search criteria. Extracted data on repeat sprint performance in team sport athletes were entered into a meta-analysis to determine a summary statistic for overall effect. Eight studies provided suitable data for analysis. Pooled data on sprint distances of 15m (Z=1.81, P=0.07), 18.3m (Z=0.26, P=0.79), 20m (Z=0.13, P=0.90), 30m (Z=1.26, P=0.21), and 36.6m (Z=0.78, P=0.44) indicated no ergogenic effect attributable to caffeine ingestion. Thus, the current available evidence does not support an ergogenic effect for caffeine in repeat sprint performance in team athletes.

Competence and skills in overcoming clinical inertia for diabetes treatment, and actually supporting and assisting the patient through adherence and compliance (as opposed to just reiterating what they “should” be doing and then assigning them the blame if they fail) is a key component to success in addressing diabetes, and to date it is a component that has received little formal attention. To improve and systematize diabetes care, it is critical to move beyond the “traditional” continuing medical education (CME) model of imparting knowledge as the entirety of the educational effort, and move toward a focus on Performance Improvement CME. This new approach does not just teach new information but also provides support for improvements where needed most within practice systems based on targeted data—based on self-assessments for the entire system of care. Joslin data conclude that this new approach will benefit support, clinical, and office teams as well as the specialist. In short, the Performance Improvement CME structure reflects the needed components of the successful practice today, particularly for chronic conditions such as diabetes, including the focus on interdisciplinary team care and on quality improvement, which is becoming more and more aligned with reimbursement schemes, public and private, in the U.S.

BACKGROUND: Endometriosis is a common gynaecological condition that affects women and can lead to painful symptoms and infertility. It greatly affects women's quality of life, impacting their careers, everyday activities, sexual and nonsexual relationships and fertility. Nonsteroidal anti-inflammatory drugs (NSAIDs) are most commonly used as first-line treatment for women with pain associated with endometriosis. OBJECTIVES: To assess effects of NSAIDs used for management of pain in women with endometriosis compared with placebo, other NSAIDs, other pain management drugs or no treatment. SEARCH METHODS: We searched the Cochrane Gynaecology and Fertility Group Specialised Register of Controlled Trials (October 2016), published in the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, as well as MEDLINE (January 2008 to October 2016), Embase (date limited from 1 January 2016 to 19 October 2016, as all earlier references are included in CENTRAL output as a result of the Embase project), registers of ongoing trials and the reference lists of relevant publications. We identified no new randomised controlled trials. Unless we identify new evidence in the future, we will not update this review. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) describing use of NSAIDs for management of pain associated with endometriosis in women of all ages. DATA COLLECTION AND ANALYSIS: In the 2009 update of this review, two review authors (CA and SH) independently read and extracted data from each of the included studies. We analysed cross-over trials using the inverse variance method of RevMan to calculate odds ratios for binary outcomes. MAIN RESULTS: We identified no new trials for the 2016 update. This review includes two trials, but we included only one trial, with 24 women, in the analysis.The overall risk of bias was unclear owing to lack of methodological detail. Using the GRADE method, we judged the quality of the evidence to be very low. We downgraded evidence for risk of bias and for imprecision (wide confidence intervals and evidence based on a single small trial).Comparison of NSAIDs (naproxen) versus placebo revealed no evidence of a positive effect on pain relief (odds ratio (OR) 3.27, 95% confidence interval (CI) 0.61 to 17.69; one trial, 24 women; very low-quality evidence) in women with endometriosis. Evidence indicating whether women taking NSAIDs (naproxen) were less likely to require additional analgesia (OR 0.12, 95% CI 0.01 to 1.29; one trial, 24 women; very low-quality evidence) or to experience side effects (OR 0.46, 95% CI 0.09 to 2.47; one trial, 24 women; very low-quality evidence) when compared with placebo was inconclusive.Studies provided no data on quality of life, effects on daily activities, absence from work or school, need for more invasive treatment or participant satisfaction with treatment. AUTHORS' CONCLUSIONS: Owing to lack of high-quality evidence and lack of reporting of outcomes of interest for this review, we can make no judgement as to whether NSAIDs (naproxen) are effective in managing pain caused by endometriosis. No evidence shows whether any individual NSAID is more effective than another. As shown in other Cochrane reviews, women taking NSAIDs must be aware that these drugs may cause unintended effects.

Background Ovarian hyperstimulation syndrome (OHSS) in assisted reproductive technology (ART) cycles is a treatment-induced disease that has an estimated prevalence of 20% to 33% in its mild form and 3% to 8% in its moderate or severe form. These numbers might even be higher for high-risk women such as those with polycystic ovaries or a high oocyte yield from ovum pickup. Objectives The objective of this overview is to identify and summarise all evidence from Cochrane systematic reviews on interventions for prevention or treatment of moderate, severe and overall OHSS in couples with subfertility who are undergoing ART cycles. Methods Published Cochrane systematic reviews reporting on moderate, severe or overall OHSS as an outcome in ART cycles were eligible for inclusion in this overview. We also identified Cochrane submitted protocols and title registrations for future inclusion in the overview. The evidence is current to 12 December 2016. We identified reviews, protocols and titles by searching the Cochrane Gynaecology and Fertility Group Database of Systematic Reviews and Archie (the Cochrane information management system) in July 2016 on the effectiveness of interventions for outcomes of moderate, severe and overall OHSS. We undertook in duplicate selection of systematic reviews, data extraction and quality assessment. We used the AMSTAR (Assessing the Methodological Quality of Systematic Reviews) tool to assess the quality of included reviews, and we used GRADE methods to assess the quality of the evidence for each outcome. We summarised the characteristics of included reviews in the text and in additional tables. Main results We included a total of 27 reviews in this overview. The reviews were generally of high quality according to AMSTAR ratings, and included studies provided evidence that ranged from very low to high in quality. Ten reviews had not been updated in the past three years. Seven reviews described interventions that provided a beneficial effect in reducing OHSS rates, and we categorised one additional review as 'promising'. Of the effective interventions, all except one had no detrimental effect on pregnancy outcomes. Evidence of at least moderate quality indicates that clinicians should consider the following interventions in ART cycles to reduce OHSS rates. • Metformin treatment before and during an ART cycle for women with PCOS (moderate-quality evidence). • Gonadotrophin-releasing hormone (GnRH) antagonist protocol in ART cycles (moderate-quality evidence). • GnRH agonist (GnRHa) trigger in donor oocyte or 'freeze-all' programmes (moderate-quality evidence). Evidence of low or very low quality suggests that clinicians should consider the following interventions in ART cycles to reduce OHSS rates. • Clomiphene citrate for controlled ovarian stimulation in ART cycles (low-quality evidence). • Cabergoline around the time of human chorionic gonadotrophin (hCG) administration or oocyte pickup in ART cycles (low-quality evidence). • Intravenous fluids (plasma expanders) around the time of hCG administration or oocyte pickup in ART cycles (very low-quality evidence). • Progesterone for luteal phase support in ART cycles (low-quality evidence). • Coasting (withholding gonadotrophins) - a promising intervention that needs to be researched further for reduction of OHSS. On the basis of this overview, we must conclude that evidence is currently insufficient to support the widespread practice of embryo cryopreservation. Authors' conclusions Currently, 27 reviews in the Cochrane Library were conducted to report on or to try to report on OHSS in ART cycles. We identified four review protocols but no new registered titles that can potentially be included in this overview in the future. This overview provides the most up-to-date evidence on prevention of OHSS in ART cycles from all currently published Cochrane reviews on ART. Clinicians can use the evidence summarised in this overview to choose the best treatment regimen for individual patients - a regimen that not only reduces the chance of developing OHSS but does not compromise other outcomes such as pregnancy or live birth rate. Review results, however, are limited by the lack of recent primary studies or updated reviews. Furthermore, this overview can be used by policymakers in developing local and regional protocols or guidelines and can reveal knowledge gaps for future research.

Background Pregnancies with pre-existing diabetes are high risk, with increased risk of poorer fetal, neonatal, and maternal outcomes. Identifying interventions to improving health outcomes for women with diabetes and their infants is a priority, as rates of diabetes continue to increase. Exercise has been shown to have benefits for non-pregnant individuals with pre-existing type 2 diabetes, such as improving glycaemic control, and reducing visceral adipose tissue and plasma triglycerides. For pregnant women with pre-existing diabetes, the effects of exercise interventions on the mother and her baby are unknown. An earlier Cochrane review on 'Exercise for pregnant women with diabetes' considered both pre-existing diabetes and gestational diabetes. That Cochrane review has now been split into two new reviews (following new protocols) - one on gestational diabetes and one on pre-existing diabetes (this review). Objectives To evaluate the effects of exercise interventions for improving maternal and fetal outcomes in women with pre-existing diabetes. Search methods We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) on 27 June 2017, and reference lists of retrieved studies. Selection criteria We had planned to include published or unpublished randomised controlled trials (RCT) or cluster-randomised trials, in full text or abstract format that compared any type of exercise programme, added to standard care, targeted at women with known pre-gestational diabetes (type 1 or type 2 diabetes), at any stage of pregnancy, compared with 1) standard care alone or 2) standard care plus another exercise intervention. Quasi-randomised and cross-over trials were excluded. Conference abstracts were handled in the same way as full-text publications. Women with gestational diabetes mellitus were excluded, as they were covered in a separate Cochrane review. Data collection and analysis We had planned that two review authors would independently assess all the potential studies we identified as a result of the search strategy. For eligible studies, two review authors would have independently extracted the data using an agreed form. We had planned to resolve discrepancies through discussion, or by consulting a third person. We also had planned to assess the evidence using the GRADE approach. Main results We did not identify any randomised controlled trials. Authors' conclusions There was no evidence from RCTs that evaluated the effects of exercise interventions for improving maternal and fetal outcomes in women with pre-existing diabetes. Good quality, large randomised controlled trials are urgently needed to identify exercise interventions that are safe, and improve health outcomes for women with pre-existing diabetes and their babies. Future studies in this area could utilise the standardised outcomes in this review, in order to improve consistency between trials in this area, and aid future meta-analysis.

Background Subfertility due to anovulation is a common problem in women. First-line oral treatment is with antioestrogens such as clomiphene citrate, but resistance may be apparent with clomiphene. Alternative and adjunctive treatments have been used including tamoxifen, dexamethasone, and bromocriptine. The effectiveness of these is to be determined. Objectives To determine the relative effectiveness of antioestrogen agents including clomiphene alone or in combination with other medical therapies in women with subfertility associated with anovulation, possibly caused by polycystic ovarian syndrome. Search methods We conducted a search of the Cochrane Gynaecology and Fertility Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, and CINAHL (all from inception to August 2016) to identify relevant randomised controlled trials (RCTs). We searched the United Kingdom National Institute for Clinical Excellence (NICE) guidelines and the references of relevant reviews and RCTs. We also searched the clinical trial registries for ongoing trials (inception until August 2016). Selection criteria We considered RCTs comparing oral antioestrogen agents for ovulation induction (alone or in conjunction with medical therapies) in anovulatory subfertility. We excluded insulin-sensitising agents, aromatase inhibitors, and hyperprolactinaemic infertility. Data collection and analysis Two review authors independently performed data extraction and quality assessment. The primary outcome was live birth; secondary outcomes were pregnancy, ovulation, miscarriage, multiple pregnancy, ovarian hyperstimulation syndrome, and adverse effects. Main results This is a substantive update of a previous review. We identified an additional 13 studies in the 2016 update. The review now includes 28 RCTs (3377 women) and five RCTs awaiting classification. Five of the 28 included trials reported live birth/ongoing pregnancy. Secondary outcomes were poorly reported. The quality of the evidence ranged from low to very low. The primary reasons for downgrading the evidence were imprecision and risk of bias associated with poor reporting. Antioestrogen versus placebo Live birth rate, miscarriage rate, multiple pregnancy rate, and ovarian hyperstimulation syndrome (OHSS) No data were reported for these outcomes. Clinical pregnancy rate Clomiphene citrate was associated with an increased chance of a clinical pregnancy compared with placebo, though the size of the benefit was very uncertain (odds ratio (OR) 5.91, 95% confidence interval (CI) 1.77 to 19.68; 3 studies; 133 women; low-quality evidence). If the chance of a clinical pregnancy was 5% in the placebo group, then between 8% and 50% of women would have a clinical pregnancy in the clomiphene group. Clomiphene citrate versus tamoxifen Live birth rate There was no clear evidence of a difference in the chance of a live birth between the clomiphene citrate and tamoxifen groups (OR 1.24, 95% CI 0.59 to 2.62; 2 studies; 195 women; low-quality evidence). If 20% of women in the tamoxifen group had a live birth, then between 13% and 40% of women in the clomiphene citrate group would have a live birth. Miscarriage rate There was no clear evidence of a difference in the chance of a miscarriage between the clomiphene citrate and tamoxifen groups (OR 1.81, 95% CI 0.80 to 4.12; 4 studies; 653 women; low-quality evidence). If 3% of women in the tamoxifen group had a miscarriage, then between 2% and 10% in the clomiphene citrate group would have a miscarriage. Clinical pregnancy rate There was no clear evidence of a difference in the chance of a clinical pregnancy between the clomiphene citrate and tamoxifen groups (OR 1.30, 95% CI 0.92 to 1.85; 5 studies; 757 women; I2 = 69%; low-quality evidence). If 22% of women in the tamoxifen group had a clinical pregnancy, then between 21% and 35% in the clomiphene citrate group would have a clinical pregnancy. Multiple pregnancy rate There was insufficient evidence of a difference in the chance of a multiple pregnancy between the clomiphene citrate group (OR 2.34, 95% CI 0.34 to 16.04; 3 studies; 567 women; very low-quality evidence). If 0% of women in the tamoxifen group had a multiple pregnancy, then between 0% and 0.5% of women in the clomiphene group would have a multiple pregnancy. OHSS There were no instances of OHSS in either the clomiphene citrate or the tamoxifen group reported from three studies. Clomiphene citrate with tamoxifen versus tamoxifen alone Clinical pregnancy rate There was insufficient evidence to determine whether there was a difference between groups (OR 3.32, 95% CI 0.12 to 91.60; 1 study; 20 women; very low-quality evidence). No data were reported for the other outcomes. Other comparisons of interest Limited evidence suggested that compared with a gonadotropin, clomiphene citrate was associated with a reduced chance of a pregnancy, ongoing pregnancy, or live birth, with no clear evidence of a difference in multiple pregnancy rates. The comparison of clomiphene citrate plus medical adjunct versus clomiphene alone was limited by the number of trials reporting the comparison and poor reporting of clinical outcomes relevant to this systematic review and by the number of adjuncts reported (ketoconazole, bromocriptine, dexamethasone, combined oral contraceptive, human chorionic gonadotropin, hormone supplementation). The addition of dexamethasone or combined oral contraceptive suggested a possible benefit in pregnancy outcomes, but findings were very uncertain and further research is required to confirm this. There was limited evidence suggesting that a 10-day regimen of clomiphene citrate improves pregnancy outcomes compared with a 5-day regimen. Data for early versus late regimens of clomiphene citrate were insufficient to be able to make a judgement on differences for pregnancy outcomes. Authors' conclusions We found evidence suggesting that clomiphene citrate improves the chance of a clinical pregnancy compared with placebo, but may reduce the chance of live birth or ongoing pregnancy when compared with a gonadotropin. Due to low event rates, we advise caution interpreting these data. The comparison of clomiphene citrate plus medical adjunctive versus clomiphene alone was limited by the number of trials reporting the comparison. The evidence was very low quality and no firm conclusions could be drawn, but very limited evidence suggested a benefit from adjunctive dexamethasone or combined oral contraceptives. Low-quality evidence suggested that a 10-day regimen of clomiphene citrate improves pregnancy rates compared with a 5-day regimen, but further research is required.

Background Embryo transfer (ET) was traditionally performed two days after oocyte retrieval; however, developments in culture media have allowed embryos to be maintained in culture for longer periods. Delaying transfer from Day two to Day three would allow for further development of the embryo and might have a positive effect on pregnancy outcomes. Objectives To determine if there are any differences in live birth and pregnancy rates when embryo transfer is performed on day three after oocyte retrieval, compared with day two, in infertile couples undergoing treatment with in vitro fertilisation (IVF), including intracytoplasmic sperm injection (ICSI). Search methods We searched the Cochrane Gynaecology and Fertility Group Specialised Register of Controlled Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) from the inception of the databases to 26th April 2016. We also searched ClinicalTrials.gov and the WHO portal for ongoing trials plus citation lists of relevant publications, review articles and included studies, as well as abstracts of appropriate scientific meetings. Selection criteria Randomised controlled trials that compared Day 3 versus Day 2 embryo transfer after oocyte retrieval during an IVF or ICSI treatment cycle in infertile couples. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. The primary outcome measures were live birth rate and ongoing pregnancy rate. Main results We included 15 studies. Fourteen studies reported data per woman (2894 women) and one study reported data per cycle (969 cycles). The quality of the evidence using the GRADE approach ranged from moderate quality to very low quality. The main reasons for downgrading evidence were poor methodological reporting, selective reporting, inconsistency and imprecision. Live birth per woman - Overall, there was no evidence of a difference in live birth rate between Day three and Day two embryo transfer (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.89 to 1.23; three studies, n = 1200 women; I2 = 63%; very low quality evidence). The data suggest that if 32% of women who underwent a Day two embryo transfer had a live birth, then between 28% to 39% of women undergoing a Day three embryo transfer would have a live birth. Ongoing pregnancy per woman - There was no evidence of a difference between Day three and Day two embryo transfer for ongoing pregnancy (RR 0.98, 95% CI 0.85 to 1.12; six studies, n = 1740 women; I2 = 52%; very low quality of evidence). The data suggest that if 33% of women undergoing a Day two embryo transfer had an ongoing pregnancy then between 28% to 37% of women undergoing a Day three embryo transfer would have an ongoing pregnancy. Clinical pregnancy per woman - There was no evidence of a difference between Day three and Day two embryo transfer for the chance of a clinical pregnancy (RR 1.08, 95% CI 0.98 to 1.19; 12 studies, n = 2461, I2 = 51%; very low quality evidence). The data suggest that if 39% of women undergoing Day two embryo transfer had a clinical pregnancy, then between 38% to 46% of women undergoing a Day three embryo transfer would have a clinical pregnancy. Multiple pregnancy per woman - There was no evidence of a difference between Day three and Day two embryo transfer for the risk of a multiple pregnancy (RR 1.12, 95% CI 0.86 to 1.44; eight studies, n = 1837; I2 = 0%; moderate quality evidence). The data suggest that if 11% of women undergoing Day two embryo transfer had a multiple pregnancy, then between 9% to 15% of women undergoing a Day three embryo transfer would have a multiple pregnancy. Miscarriage rate per woman - There was no evidence of a difference between Day three and Day two embryo transfer for the risk of miscarriage (RR 1.16, 95% CI 0.84 to 1.60; nine studies, n = 2153 women, I2 = 26%; moderate quality evidence). The data suggest that if 6% of women undergoing Day two embryo transfer had a miscarriage, then between 5% to 10% of women undergoing a Day three embryo transfer would have a miscarriage. Ectopic pregnancy rate per woman - There was no evidence of a difference between Day three and Day two embryo transfer for the risk of ectopic pregnancy (RR 0.99, 95% CI 0.29 to 3.40; six studies, n = 1531 women, I2 = 0%; low quality evidence). The data suggest that if 0.7% of women undergoing Day two embryo transfer have an ectopic pregnancy, then between 0.2% to 2% of women undergoing Day three embryo transfer would have an ectopic pregnancy. Subgroup analysis for pregnancy outcomes did not identify any differential effect between IVF and ICSI. None of the included studies prespecified complication rate (e.g. OHSS), fetal abnormality or women's evaluation of the procedure as outcomes in their studies. Authors' conclusions Twelve of 15 studies contributed data that could be included in meta-analyses. The quality of the evidence ranged from moderate to very low. Only three of the 15 studies reported data for live birth, although the data for ongoing pregnancy and clinical pregnancy are consistent with the live birth data, suggesting no difference between Day three and Day two embryo transfer for these outcomes. There was no evidence of a difference identified between Day three and Day two embryo transfer for multiple pregnancy, miscarriage or ectopic pregnancy per woman randomised. No data were reported for complication rate, fetal abnormality or woman's evaluation of the procedure. The current evidence has not identified any evidence of differences in pregnancy outcomes between Day two and Day three embryo transfers. Any further studies comparing these timings of embryo transfer are unlikely to alter the findings and we suggest that this review no longer be updated.

Objectives To ascertain whether a safe-transportation program can change driving exposure while maintaining community participation of older drivers. Design Randomized controlled trial. Setting Northwest Sydney. Participants Drivers aged 75 and older (mean 80 ± 4) (n = 380). Intervention Intervention group participated in an individualized, one-on-one safe-transportation program adapted from the Knowledge Enhances Your Safety curriculum. A registered occupational therapist delivered the intervention in two sessions held approximately 1 month apart. Measurements An in-vehicle monitoring device hardwired into participants’ vehicles measured driving exposure. Community participation was measured using the Keele Assessment of Participation. A staging algorithm based on the Precaution Adoption Process Model measured behavior change toward increased and sustained driving self-regulation. Main outcomes were distance driven per week over 12 months and community participation. Secondary outcomes were behavior change, depressive symptoms, and alternate transportation use. Generalized estimating equations were used to model effect on driving exposure, adjusting for weekly measures, and ordinal regression was used to analyze differences in behavior change profiles between groups using an intention-to-treat approach. Results Participants were randomized after baseline assessment—190 each to the intervention and control groups. One hundred eighty-three of 190 completed the intervention and 366 of 380 completed the study. On average, participants drove 140 ± 167 km/wk. Although there was no significant difference between the groups in distance driven per week over 12 months (between-group difference −5.5 km, 95% confidence interval (CI) = −24.5–13.5 km, p = .57), intervention group participants showed greater readiness to engage in self-regulatory driving practices, such as reporting avoiding driving at night or at rush hours, than control group participants (odds ratio (OR) = 1.6, 95% CI = 1.1–2.3, P = .02). At 12 months, use of alternate transportation was similar (between-group difference 0.1, 95% CI = −1.4–1.6, P = .90). Although there was no difference in community participation (between-group difference −0.1, 95% CI = −0.6–0.3, P = .59), older drivers with low function in the intervention group were 3.1 times as likely to report depressive symptoms (95% CI = 1.04–9.2, P = .04) than those with low function in the control group. Conclusion An individualized safe-transportation program can promote behavior change but did not translate to significant differences in weekly mileage after 12 months. Longer follow-up may detect changes over time.

Within the literature there is an accumulating body of evidence to suggest that psychological stress may have a negative impact on wound healing. This article examines the psychoneuroimmulogy theory associated with stress and acute wound healing with reference to caring for patients with surgical wounds. The evidence reviewed in this article highlights the value of understanding individual patient need for reducing stress pre and post operatively to benefit the healing process.

Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with the prolapse.To determine the effects of the many different surgeries used in the management of pelvic organ prolapse.We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In Process and handsearching of journals and conference proceedings, healthcare-related bibliographic databases, handsearched conference proceedings (searched 20 August 2012), and reference lists of relevant articles. We also contacted researchers in the field.Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse.Trials were assessed and data extracted independently by two review authors. Six investigators were contacted for additional information with five responding.Fifty-six randomised controlled trials were identified evaluating 5954 women. For upper vaginal prolapse (uterine or vault) abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse on examination and painful intercourse than with vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. In single studies the sacral colpopexy had a higher success rate on examination and lower reoperation rate than high vaginal uterosacral suspension and transvaginal polypropylene mesh.Twenty-one trials compared a variety of surgical procedures for anterior compartment prolapse (cystocele). Ten compared native tissue repair with graft (absorbable and permanent mesh, biological grafts) repair for anterior compartment prolapse. Native tissue anterior repair was associated with more recurrent anterior compartment prolapse than when supplemented with a polyglactin (absorbable) mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.08, 95% CI 1.08 to 4.01), however there was no difference in post-operative awareness of prolapse after absorbable mesh (RR 0.96, 95% CI 0.33 to 2.81) or a biological graft (RR 1.21, 95% CI 0.64 to 2.30). Data on morbidity and other clinical outcomes were lacking. Standard anterior repair was associated with more anterior compartment prolapse on examination than for any polypropylene (permanent) mesh repair (RR 3.15, 95% CI 2.50 to 3.96). Awareness of prolapse was also higher after the anterior repair as compared to polypropylene mesh repair (28% versus 18%, RR 1.57, 95% CI 1.18 to 2.07). However, the reoperation rate for prolapse was similar at 14/459 (3%) after the native tissue repair compared to 6/470 (1.3%) (RR 2.18, 95% CI 0.93 to 5.10) after the anterior polypropylene mesh repair and no differences in quality of life data or de novo dyspareunia were identified. Blood loss (MD 64 ml, 95% CI 48 to 81), operating time (MD 19 min, 95% CI 16 to 21), recurrences in apical or posterior compartment (RR 1.9, 95% CI 1.0 to 3.4) and de novo stress urinary incontinence (RR 1.8, 95% CI 1.0 to 3.1) were significantly higher with transobturator meshes than for native tissue anterior repair. Mesh erosions were reported in 11.4% (64/563), with surgical interventions being performed in 6.8% (32/470).Data from three trials compared native tissue repairs with a variety of total, anterior, or posterior polypropylene kit meshes for vaginal prolapse in multiple compartments. While no difference in awareness of prolapse was able to be identified between the groups (RR 1.3, 95% CI 0.6 to 1.7) the recurrence rate on examination was higher in the native tissue repair group compared to the transvaginal polypropylene mesh group (RR 2.0, 95% CI 1.3 to 3.1). The mesh erosion rate was 35/194 (18%), and 18/194 (9%) underwent surgical correction for mesh erosion. The reoperation rate after transvaginal polypropylene mesh repair of 22/194 (11%) was higher than after the native tissue repair (7/189, 3.7%) (RR 3.1, 95% CI 1.3 to 7.3).Data from three trials compared posterior vaginal repair and transanal repair for the treatment of posterior compartment prolapse (rectocele). The posterior vaginal repair had fewer recurrent prolapse symptoms (RR 0.4, 95% CI 0.2 to 1.0) and lower recurrence on examination (RR 0.2, 95% CI 0.1 to 0.6) and on defecography (MD -1.2 cm, 95% CI -2.0 to -0.3).Sixteen trials included significant data on bladder outcomes following a variety of prolapse surgeries. Women undergoing prolapse surgery may have benefited from having continence surgery performed concomitantly, especially if they had stress urinary incontinence (RR 7.4, 95% CI 4.0 to 14) or if they were continent and had occult stress urinary incontinence demonstrated pre-operatively (RR 3.5, 95% CI 1.9 to 6.6). Following prolapse surgery, 12% of women developed de novo symptoms of bladder overactivity and 9% de novo voiding dysfunction.Sacral colpopexy has superior outcomes to a variety of vaginal procedures including sacrospinous colpopexy, uterosacral colpopexy and transvaginal mesh. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living, and increased cost of the abdominal approach.The use of mesh or graft inlays at the time of anterior vaginal wall repair reduces the risk of recurrent anterior wall prolapse on examination. Anterior vaginal polypropylene mesh also reduces awareness of prolapse, however these benefits must be weighted against increased operating time, blood loss, rate of apical or posterior compartment prolapse, de novo stress urinary incontinence, and reoperation rate for mesh exposures associated with the use of polypropylene mesh.Posterior vaginal wall repair may be better than transanal repair in the management of rectocele in terms of recurrence of prolapse. The evidence is not supportive of any grafts at the time of posterior vaginal repair. Adequately powered randomised, controlled clinical trials with blinding of assessors are urgently needed on a wide variety of issues, and they particularly need to include women's perceptions of prolapse symptoms. Following the withdrawal of some commercial transvaginal mesh kits from the market, the generalisability of the findings, especially relating to anterior compartment transvaginal mesh, should be interpreted with caution.

This is the protocol for a review and there is no abstract. The objectives are as follows: To summarise the evidence from Cochrane systematic Reviews regarding the effects of interventions for preventing gestational diabetes mellitus.

Background Apical vaginal prolapse is a descent of the uterus or vaginal vault (post-hysterectomy). Various surgical treatments are available and there are no guidelines to recommend which is the best. Objectives To evaluate the safety and efficacy of any surgical intervention compared to another intervention for the management of apical vaginal prolapse. Search methods We searched the Cochrane Incontinence Group's Specialised Register of controlled trials, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched July 2015) and ClinicalTrials.gov (searched January 2016). Selection criteria We included randomised controlled trials (RCTs). Data collection and analysis We used Cochrane methods. Our primary outcomes were awareness of prolapse, repeat surgery and recurrent prolapse (any site). Main results We included 30 RCTs (3414 women) comparing surgical procedures for apical vaginal prolapse. Evidence quality ranged from low to moderate. Limitations included imprecision, poor methodological reporting and inconsistency. Vaginal procedures versus sacral colpopexy (six RCTs, n = 583; one to four-year review). Awareness of prolapse was more common after vaginal procedures (risk ratio (RR) 2.11, 95% confidence interval (CI) 1.06 to 4.21, 3 RCTs, n = 277, I2 = 0%, moderate-quality evidence). If 7% of women are aware of prolapse after sacral colpopexy, 14% (7% to 27%) are likely to be aware after vaginal procedures. Repeat surgery for prolapse was more common after vaginal procedures (RR 2.28, 95% CI 1.20 to 4.32; 4 RCTs, n = 383, I2 = 0%, moderate-quality evidence). The confidence interval suggests that if 4% of women require repeat prolapse surgery after sacral colpopexy, between 5% and 18% would require it after vaginal procedures. We found no conclusive evidence that vaginal procedures increaserepeat surgery for stress urinary incontinence (SUI) (RR 1.87, 95% CI 0.72 to 4.86; 4 RCTs, n = 395; I2 = 0%, moderate-quality evidence). If 3% of women require repeat surgery for SUI after sacral colpopexy, between 2% and 16% are likely to do so after vaginal procedures. Recurrent prolapse is probably more common after vaginal procedures (RR 1.89, 95% CI 1.33 to 2.70; 4 RCTs, n = 390; I2 = 41%, moderate-quality evidence). If 23% of women have recurrent prolapse after sacral colpopexy, about 41% (31% to 63%) are likely to do so after vaginal procedures. The effect of vaginal procedures on bladder injury was uncertain (RR 0.57, 95% CI 0.14 to 2.36; 5 RCTs, n = 511; I2 = 0%, moderate-quality evidence). SUI was more common after vaginal procedures (RR 1.86, 95% CI 1.17 to 2.94; 3 RCTs, n = 263; I2 = 0%, moderate-quality evidence). Dyspareunia was also more common after vaginal procedures (RR 2.53, 95% CI 1.17 to 5.50; 3 RCTs, n = 106, I2 = 43%, low-quality evidence). Vaginal surgery with mesh versus without mesh (6 RCTs, n = 598, 1-3 year review). Awareness of prolapse - There may be little or no difference between the groups for this outcome (RR 1.08 95% CI 0.35 to 3.30 1 RCT n = 54, low quality evidence). The confidence interval was wide suggesting that if 18% of women are aware of prolapse after surgery without mesh, between 6% and 59% will be aware of prolapse after surgery with mesh. Repeat surgery for prolapse - There may be little or no difference between the groups for this outcome (RR 0.69, 95% CI 0.30 to 1.60; 5 RCTs, n = 497; I2 = 9%, low-quality evidence). If 4% of women require repeat surgery for prolapse after surgery without mesh, 1% to 7% are likely to do so after surgery with mesh. We found no conclusive evidence that surgery with mesh increases repeat surgery for SUI (RR 4.91, 95% CI 0.86 to 27.94; 2 RCTs, n = 220; I2 = 0%, low-quality evidence). The confidence interval was wide suggesting that if 2% of women require repeat surgery for SUI after vaginal colpopexy without mesh, 2% to 53% are likely to do so after surgery with mesh. We found no clear evidence that surgery with mesh decreases recurrent prolapse (RR 0.36, 95% CI 0.09 to 1.40; 3 RCTs n = 269; I2 = 91%, low-quality evidence). The confidence interval was very wide and there was serious inconsistency between the studies. Other outcomes There is probably little or no difference between the groups in rates of SUI (de novo) (RR 1.37, 95% CI 0.94 to 1.99; 4 RCTs, n = 295; I2 = 0%, moderate-quality evidence) or dyspareunia (RR 1.21, 95% CI 0.55 to 2.66; 5 RCTs, n = 501; I2 = 0% moderate-quality evidence). We are uncertain whether there is any difference for bladder injury (RR 3.00, 95% CI 0.91 to 9.89; 4 RCTs, n = 445; I2 = 0%; very low-quality evidence). Vaginal hysterectomy versus alternatives for uterine prolapse (six studies, n = 667) No clear conclusions could be reached from the available evidence, though one RCT found that awareness of prolapse was less likely after hysterectomy than after abdominal sacrohysteropexy (RR 0.38, 955 CI 0.15 to 0.98, n = 84, moderate-quality evidence). Other comparisons There was no evidence of a difference for any of our primary review outcomes between different types of vaginal native tissue repair (two RCTs), comparisons of graft materials for vaginal support (two RCTs), different routes for sacral colpopexy (four RCTs), or between sacral colpopexy with and without continence surgery (four RCTs). Authors' conclusions Sacral colpopexy is associated with lower risk of awareness of prolapse, recurrent prolapse on examination, repeat surgery for prolapse, postoperative SUI and dyspareunia than a variety of vaginal interventions. The limited evidence does not support use of transvaginal mesh compared to native tissue repair for apical vaginal prolapse. Most of the evaluated transvaginal meshes are no longer available and new lighter meshes currently lack evidence of safety The evidence was inconclusive when comparing access routes for sacral colpopexy. No clear conclusion can be reached from the available data comparing uterine preserving surgery versus vaginal hysterectomy for uterine prolapse.

This is the protocol for a review and there is no abstract. The objectives are as follows: To evaluate the effectiveness and safety of oral supplementation with inositol on reproductive outcomes for subfertile women with polycystic ovary syndrome (PCOS).

In this paper, a review of evidence provided to the World Health Organization (WHO) guideline development, who prepare global guidance on the management of ovarian stimulation for women undergoing IVF, is presented. The purpose of ovarian stimulation is to facilitate retrieval of multiple oocytes during a single IVF cycle. Availability of multiple oocytes compensates for inefficiencies in subsequent stages of the cycle, which include oocyte maturation, IVF, embryo culture, embryo transfer, and implantation. Multiple embryos can be transferred in most women, and spare embryos can be frozen to allow for future chances of pregnancy without the need for repeated ovarian stimulation and oocyte retrieval. Our evidence synthesis team addressed 10 clinical questions on management of ovarian stimulation for IVF, prepared a narrative review of the evidence and drafted recommendations to be considered through WHO guideline development processes. Our main outcome measures were live birth, clinical pregnancy, and ovarian hyperstimulation syndrome.

Background Gestational diabetes mellitus (GDM) is any degree of glucose intolerance that first presents and is recognised during pregnancy and usually resolves after the birth of the baby. GDM is associated with increased short- and long-term morbidity for the mother and her baby. Treatment usually includes lifestyle modification and/or pharmacological therapy (oral antidiabetic agents or insulin) with the aim to maintain treatment targets for blood glucose concentrations. Finding novel treatment agents which are effective, acceptable and safe for the mother and her baby are important. One such emerging potential intervention is myo-inositol which is an isomer of inositol and occurs endogenously and is found in natural dietary sources such as fruits, vegetables, nuts and cereals. Objectives To assess if dietary supplementation with myo-inositol during pregnancy is safe and effective, for the mother and fetus, in treating gestational diabetes. Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (30 April 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (7 April 2016), and reference lists of retrieved studies. Selection criteria All published and unpublished randomised controlled trials or cluster-randomised controlled trials reporting on the use of myo-inositol compared with placebo, no treatment or another intervention for the treatment of women with gestational diabetes. Quasi-randomised and cross-over studies are not eligible for inclusion. Women with pre-existing diabetes were excluded. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. For key outcomes (where data were available), we assessed the quality of the evidence using the GRADE approach. Main results We included two studies (142 women and infants), both were conducted in women in Italy and compared myo-inositol with a placebo control. None of the maternal primary outcomes pre-specified for this review were reported in the included studies: hypertensive disorders of pregnancy; caesarean section; development of subsequent type 2 diabetes mellitus. No data were reported for the majority of this review's maternal secondary outcomes. We could only perform meta-analysis for two secondary outcomes: fasting oral glucose tolerance test and additional pharmacological treatment. All other results are based on data from single studies. Overall, the risk of bias of the included studies was judged to be unclear due to lack of key methodological information. There was no evidence of a difference between treatment groups in need for additional pharmacotherapy or weight gain during pregnancy, although myo-inositol was associated with a lower body mass index (BMI) change (mean difference (MD) -1.50 kg/m2; 95% confidence interval (CI) -2.35 to -0.65; one trial, n = 73). Myo-inositol was associated with a reduction in the fasting blood glucose concentration at the end of treatment (MD -0.47 mmol/L; 95% CI -0.59 to -0.35; two trials, n = 142 women) compared with the control group. One small trial reported that myo-inositol was associated with a reduction in one-hour post-prandial blood glucose concentration at the end of treatment (MD -0.90 mmol/L; 95% CI -1.73 to -0.07; one trial, n = 73 women) compared with the control group. There was no difference between groups for the two-hour post-prandial blood glucose concentrations between groups (MD -0.70 mmol/L; 95% CI -1.46 to 0.06; one trial, n = 73 women). The one-hour and two-hour blood glucose concentrations show evidence of imprecision associated with wide CIs and small sample size. For the infant, there was no evidence of a difference in the risk for being born large-for-gestational age between the myo-inositol and the control group (risk ratio (RR) 0.36; 95% CI 0.02 to 8.58; one trial, n = 73 infants; low-quality evidence). The evidence was downgraded due to imprecision. This review's other primary outcomes were not reported in the included trials: perinatal mortality (stillbirth and neonatal mortality); mortality of morbidity composite (as defined by the trials); neurosensory disability. Infants in the myo-inositol group were less likely to have neonatal hypoglycaemia compared with the placebo group (RR 0.05; 95% CI 0.00 to 0.85; one study, n = 73 infants; low-quality evidence). There is evidence of imprecision for this outcome with low event rates and small sample size. There was no evidence of a difference between treatment and placebo groups for preterm birth or birthweight. Myo-inositol was associated with a later gestational age at birth compared with the placebo group (MD 2.10 weeks; 95% CI 1.27 to 2.93; one trial, n = 73 infants). No data were reported for any of the other neonatal outcomes for this review. No long-term outcomes were reported for the mother, infant as a child, infant as an adult, or health service outcomes. Authors' conclusions There are insufficient data to evaluate the effect of myo-inositol for the treatment of gestational diabetes, with no data to examine the majority of outcomes in this review. There do not appear to be any benefits for the infant associated with exposure to myo-inositol such as reduced risk of being born large-for-gestational age. Although the risk of neonatal hypoglycaemia is reduced for the myo-inositol group, there is evidence of imprecision. Evidence from two studies suggested that myo-inositol was associated with a reduced change in maternal BMI and fasting blood sugar concentration compared with placebo. There is a lack of reporting of the clinically meaningful outcomes pre-specified for this review. Uncertainty of the effectiveness of myo-inositol as a treatment for GDM for key maternal and infant outcomes remains and further high- quality trials with appropriate sample sizes are required to further investigate the role of myo-inositol as a treatment or co-treatment for women with gestational diabetes. Future trials should report on the core outcomes for GDM identified in the methods section of this review. Participants of varying ethnicities and with varying risk factors for GDM should be included in future trials. In addition, further trials of myo-inositol for the treatment of GDM should explore the optimal dose, frequency and timing of supplementation, report on adverse effects and assess the long- term effects of this intervention. Economic analysis or health service use and costs should also be included.

Background Active participation of consumers in health care decision making, policy and clinical research is increasingly encouraged by governments, influential bodies and funders. Identifying the best way to achieve this is difficult due to the paucity of evidence. Consumers have mixed feelings towards clinical practice guidelines (CPG) demonstrating scepticism towards their purpose and applicability to their needs. There is no information pertaining to consumers’ views and attitudes on the receipt of antenatal corticosteroids (ACS). The aim of this study was to examine the barriers and enablers to receiving ACS and use of CPG amongst consumers. Methods Consumers were recruited from neonatal units across three district health boards (DHBs) in Auckland, New Zealand. Participants completed a semi-structured interview or questionnaire. The questions posed and analyses were informed by the Theoretical Domains Framework (TDF). Barriers and enablers were identified by the presence of conflicting beliefs within a domain; the frequency of beliefs; and the likely strength of the impact of a belief on use of CPG and receipt of ACS. Results Twenty four consumers participated in the study. Six domains were identified as barriers to receipt of ACS and use of CPG. Key barriers to receipt of ACS included: difficulty retaining information conveyed, requiring further information in a variety of formats, and time constraints faced by consumers and health professionals in the provision and understanding of information to facilitate decision making. Barriers to use of CPG included: uncertainty about applicability of guideline use among consumers and scepticism about health professionals adhering too rigidly to guidelines. Enablers to receipt of ACS included: optimism toward ACS use, a strong knowledge of why ACS were administered, improved resilience in their pregnancy and confidence in their decision making following receipt of information about ACS. Enablers to use of CPG included: validation and standardisation of decision making among health professionals providing care and facilitating the best care for women and their babies. Conclusions Key barriers and enablers exist among consumers regarding receipt of ACS and use of CPG. These need to be addressed or modified in any intervention strategy to facilitate implementation of the ACS CPG. Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-1043-4) contains supplementary material, which is available to authorized users.

Background Successful treatments for gestational diabetes mellitus (GDM) have the potential to improve health outcomes for women with GDM and their babies. Objectives To provide a comprehensive synthesis of evidence from Cochrane systematic reviews of the benefits and harms associated with interventions for treating GDM on women and their babies. Methods We searched the Cochrane Database of Systematic Reviews (5 January 2018) for reviews of treatment/management for women with GDM. Reviews of pregnant women with pre-existing diabetes were excluded. Two overview authors independently assessed reviews for inclusion, quality (AMSTAR; ROBIS), quality of evidence (GRADE), and extracted data. Main results We included 14 reviews. Of these, 10 provided relevant high-quality and low-risk of bias data (AMSTAR and ROBIS) from 128 randomised controlled trials (RCTs), 27 comparisons, 17,984 women, 16,305 babies, and 1441 children. Evidence ranged from high to very low-quality (GRADE). Only one effective intervention was found for treating women with GDM. Effective Lifestyle versus usual care Lifestyle intervention versus usual care probably reduces large-for-gestational age (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.50 to 0.71; 6 RCTs, N = 2994; GRADE moderate-quality). Promising No evidence for any outcome for any comparison could be classified to this category. Ineffective or possibly harmful Lifestyle versus usual care Lifestyle intervention versus usual care probably increases the risk of induction of labour (IOL) suggesting possible harm (average RR 1.20, 95% CI 0.99 to 1.46; 4 RCTs, N = 2699; GRADE moderate-quality). Exercise versus control Exercise intervention versus control for return to pre-pregnancy weight suggested ineffectiveness (body mass index, BMI) MD 0.11 kg/m², 95% CI -1.04 to 1.26; 3 RCTs, N = 254; GRADE moderate-quality). Insulin versus oral therapy Insulin intervention versus oral therapy probably increases the risk of IOL suggesting possible harm (RR 1.3, 95% CI 0.96 to 1.75; 3 RCTs, N = 348; GRADE moderate-quality). Probably ineffective or harmful interventions Insulin versus oral therapy For insulin compared to oral therapy there is probably an increased risk of the hypertensive disorders of pregnancy (RR 1.89, 95% CI 1.14 to 3.12; 4 RCTs, N = 1214; GRADE moderate-quality). Inconclusive Lifestyle versus usual care The evidence for childhood adiposity kg/m² (RR 0.91, 95% CI 0.75 to 1.11; 3 RCTs, N = 767; GRADE moderate-quality) and hypoglycaemia was inconclusive (average RR 0.99, 95% CI 0.65 to 1.52; 6 RCTs, N = 3000; GRADE moderate-quality). Exercise versus control The evidence for caesarean section (RR 0.86, 95% CI 0.63 to 1.16; 5 RCTs, N = 316; GRADE moderate quality) and perinatal death or serious morbidity composite was inconclusive (RR 0.56, 95% CI 0.12 to 2.61; 2 RCTs, N = 169; GRADE moderate-quality). Insulin versus oral therapy The evidence for the following outcomes was inconclusive: pre-eclampsia (RR 1.14, 95% CI 0.86 to 1.52; 10 RCTs, N = 2060), caesarean section (RR 1.03, 95% CI 0.93 to 1.14; 17 RCTs, N = 1988), large-for-gestational age (average RR 1.01, 95% CI 0.76 to 1.35; 13 RCTs, N = 2352), and perinatal death or serious morbidity composite (RR 1.03; 95% CI 0.84 to 1.26; 2 RCTs, N = 760). GRADE assessment was moderate-quality for these outcomes. Insulin versus diet The evidence for perinatal mortality was inconclusive (RR 0.74, 95% CI 0.41 to 1.33; 4 RCTs, N = 1137; GRADE moderate-quality). Insulin versus insulin The evidence for insulin aspart versus lispro for risk of caesarean section was inconclusive (RR 1.00, 95% CI 0.91 to 1.09; 3 RCTs, N = 410; GRADE moderate quality). No conclusions possible No conclusions were possible for: lifestyle versus usual care (perineal trauma, postnatal depression, neonatal adiposity, number of antenatal visits/admissions); diet versus control (pre-eclampsia, caesarean section); myo-inositol versus placebo (hypoglycaemia); metformin versus glibenclamide (hypertensive disorders of pregnancy, pregnancy-induced hypertension, death or serious morbidity composite, insulin versus oral therapy (development of type 2 diabetes); intensive management versus routine care (IOL, large-for-gestational age); post- versus pre-prandial glucose monitoring (large-for-gestational age). The evidence ranged from moderate-, low- and very low quality. Authors’ conclusions Currently there is insufficient high-quality evidence about the effects on health outcomes of relevance for women with GDM and their babies for many of the comparisons in this overview comparing treatment interventions for women with GDM. Lifestyle changes (including as a minimum healthy eating, physical activity and self-monitoring of blood sugar levels) was the only intervention that showed possible health improvements for women and their babies. Lifestyle interventions may result in fewer babies being large. Conversely, in terms of harms, lifestyle interventions may also increase the number of inductions. Taking insulin was also associated with an increase in hypertensive disorders, when compared to oral therapy. There was very limited information on long-term health and health services costs. Further high-quality research is needed.

Since the 1980's, paediatric surgeons have increasingly managed blunt splenic injury (BSI) in children non-operatively. However, studies in North America have shown higher operation rates in non-paediatric centres and by adult surgeons. This association has not been examined elsewhere.To investigate the management of BSI in New South Wales (NSW) children, to determine the patient and hospital factors related to the odds of operation. Secondarily, to investigate whether the likelihood of operation varied by year.Children age 0-16 admitted to a NSW hospital between July 2000 and December 2011 with a diagnosis of BSI were identified in the NSW Admitted Patient Data Collection, and linked to deaths data from Registry of Births Deaths and Marriages, and Bureau of Statistics. The operation rate was calculated and compared between different hospital types. Univariable analysis was used to determine patient and hospital factors associated with operative management. The difference in the odds of operation between the oldest data (July 2000-December 2005) and most recent (January 2006-December 2011) was also examined. Multivariable logistic regression with stepwise elimination was then performed to determine likelihood of operative management according to hospital category and era, adjusting for potential confounders.955 cases were identified, with 101(10.6%) managed operatively. On multivariable analysis, factors associated with operation included age (OR 1.11, 95% CI 1.01-1.18, p0.05), massive splenic disruption (OR 3.10, 95% CI 1.61-6.19, p0.001), hollow viscus injury (OR 11.03, 95% CI 3.46-34.28, p0.001) and transfusion (OR 7.70, 95% CI 4.54-13.16, p0.001). Management outside a paediatric trauma centre remained significantly associated with operation, whether it be metropolitan adult trauma centre (OR 4.22 95% CI 1.70-10.52, p0.01), rural trauma centre (OR 3.72 95% CI 1.83-7.83, p0.001) or metropolitan local hospital (OR 5.23, 95% CI 1.22-18.93 p0.05). Comparing the 2 eras, the overall operation rate fell, although not significantly, from 12.9% to 8.7% (OR 1.3, 95% CI 0.89-243 p=0.13) CONCLUSION: While Paediatric Surgeons have wholeheartedly adopted non-operative management, away from paediatric centres, children in NSW are still being operated on for BSI unnecessarily. While the factors at play may be complex, further evaluation of the management and movement of injured children within the broad NSW trauma system is required.

Rapid deceleration occurs when substantial force slows the speed of a vehicle. Rapid deceleration events (RDEs) have been proposed as a surrogate safety measure. As there is concern about crash involvement of older drivers and the effect of age-related declining visual and cognitive function on driving performance, we examined the relationship between RDEs and older driver’s vision, cognitive function and driving confidence, using naturalistic driving measures. Participants aged 75 to 94 years had their vehicle instrumented for 12 months. To minimise the chance of identifying false positives, accelerometer data was processed to identify RDEs with a substantial deceleration of >750 milli-g (7.35 m/s 2 ). We examined the incidence of RDEs amongst older drivers, and how this behaviour is affected by differences in age; sex; visual function, cognitive function; driving confidence; and declines over the 12 months. Almost two-thirds (64%) of participants were involved in at least one RDE, and 22% of these participants experienced a meaningful decline in contrast sensitivity during the 12 months. We conducted regression modelling to examine associations between RDEs and predictive measures adjusted for (i) duration of monitoring and (ii) distance driven. We found the rate of RDEs per distance increased with age; although, this did not remain in the multivariate model. In the multivariate model, we found older drivers who experienced a decline in contrast sensitivity over the 12 months and those with lower baseline driving confidence were at increased risk of involvement in RDEs adjusted for distance driven. In other studies, contrast sensitivity has been associated with increased crash involvement for older drivers. These findings lend support for the use of RDEs as a surrogate safety measure, and demonstrate an association between a surrogate safety measure and a decline in contrast sensitivity of older drivers.

Background Gestational diabetes mellitus (GDM) is associated with both short- and long-term complications for the mother and her baby. Exercise interventions may be useful in helping with glycaemic control and improve maternal and infant outcomes. The original review on Exercise for diabetic pregnant women has been split into two new review titles reflecting the role of exercise for pregnant women with gestational diabetes and for pregnant women with pre-existing diabetes. Exercise for pregnant women with gestational diabetes for improving maternal and fetal outcomes (this review) Exercise for pregnant women with pre-existing diabetes for improving maternal and fetal outcomes Objectives To evaluate the effects of exercise interventions for improving maternal and fetal outcomes in women with GDM. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (27 August 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (18th August 2016), and reference lists of retrieved studies. Selection criteria We included randomised controlled trials (RCTs) comparing an exercise intervention with standard care or another intervention in pregnant women diagnosed with gestational diabetes. Quasi-randomised and cross-over studies, and studies including women with pre-existing type 1 or type 2 diabetes were not eligible for inclusion. Data collection and analysis All selection of studies, assessment of trial quality and data extraction was conducted independently by two review authors. Data were checked for accuracy. Main results We included 11 randomised trials, involving 638 women. The overall risk of bias was judged to be unclear due to lack of methodological detail in the included studies. For the mother, there was no clear evidence of a difference between women in the exercise group and those in the control group for the risk of pre-eclampsia as the measure of hypertensive disorders of pregnancy (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.01 to 7.09; two RCTs, 48 women; low-quality evidence), birth by caesarean section (RR 0.86, 95% CI 0.63 to 1.16; five RCTs, 316 women; I2 = 0%; moderate-quality evidence), the risk of induction of labour (RR 1.38, 95% CI 0.71 to 2.68; one RCT, 40 women; low-quality evidence) or maternal body mass index at follow-up (postnatal weight retention or return to pre-pregnancy weight) (mean difference (MD) 0.11 kg/m2, 95% CI -1.04 to 1.26; three RCTs, 254 women; I2 = 0%; high-quality evidence). Development of type 2 diabetes, perineal trauma/tearing and postnatal depression were not reported as outcomes in the included studies. For the infant/child/adult, a single small (n = 19) trial reported no perinatal mortality (stillbirth and neonatal mortality) events in either the exercise intervention or control group (low-quality evidence). There was no clear evidence of a difference between groups for a mortality and morbidity composite (variously defined by trials, e.g. perinatal or infant death, shoulder dystocia, bone fracture or nerve palsy) (RR 0.56, 95% CI 0.12 to 2.61; two RCTs, 169 infants; I2 = 0%; moderate-quality evidence) or neonatal hypoglycaemia (RR 2.00, 95% CI 0.20 to 20.04; one RCT, 34 infants; low-quality evidence). None of the included trials pre-specified large-for-gestational age, adiposity (neonatal/infant, childhood or adulthood), diabetes (childhood or adulthood) or neurosensory disability (neonatal/infant) as trial outcomes. Other maternal outcomes of interest: exercise interventions were associated with both reduced fasting blood glucose concentrations (average standardised mean difference (SMD) -0.59, 95% CI -1.07 to -0.11; four RCTs, 363 women; I2 = 73%; T2 = 0.19) and a reduced postprandial blood glucose concentration compared with control interventions (average SMD -0.85, 95% CI -1.15 to -0.55; three RCTs, 344 women; I2 = 34%; T2 = 0.03). Authors' conclusions Short- and long-term outcomes of interest for this review were poorly reported. Current evidence is confounded by the large variety of exercise interventions. There was insufficient high-quality evidence to be able to determine any differences between exercise and control groups for our outcomes of interest. For the woman, both fasting and postprandial blood glucose concentrations were reduced compared with the control groups. There are currently insufficient data for us to determine if there are also benefits for the infant. The quality of the evidence in this review ranged from high to low quality and the main reason for downgrading was for risk of bias and imprecision (wide CIs, low event rates and small sample size). Development of type 2 diabetes, perineal trauma/tearing, postnatal depression, large-for-gestational age, adiposity (neonate/infant, childhood or adulthood), diabetes (childhood or adulthood) or neurosensory disability (neonate/infant) were not reported as outcomes in the included studies. Further research is required comparing different types of exercise interventions with control groups or with another exercise intervention that reports on both the short- and long-term outcomes (for both the mother and infant/child) as listed in this review.

Motorcycle riders are over-represented in road fatalities in Australia. While riders represent 18% of the road users killed each year, motorcycle registrations constitute only 4.5% of the registered vehicle fleet. The Motorcycle Rider Behaviour Questionnaire (MRBQ) was developed with a view toward understanding behaviours likely to be associated with crash risk. These include behaviours that are either intentional (such as violations of road and speed regulations and stunts) or unintentional (such as errors relating to traffic or control of the motorcycle), as well as protective behaviours related to use of safety equipment. The dual aims of the current study were, first, to determine the appropriate structure of a modified version of the MRBQ for use in a representative sample of riders in Australia and, second, to understand which MRBQ factors are associated with crash involvement. A stratified sampling procedure was undertaken to ensure the socio-economic status of local government area, age and gender of the sample was representative of the broader population of riders in New South Wales, Australia. The sample consisted of 470 riders (males=89%). Exploratory factor analysis revealed a 29-item, five factor structure was suitable on the Australian data encompassing traffic errors, speed violations, protective gear, control errors and stunts. Overall, riders reported relatively safe behaviours, with frequent use of protective gear and infrequent aberrant behaviours. However, even though infrequent, violations of speed and errors related to control of the motorcycle increased the odds of near-crash involvement, whilst stunt behaviours were associated with increased odds of crash involvement. Interventions and countermeasures need to target these specific behaviours.

BACKGROUND: Neonatal hypoglycaemia, a common condition, can be associated with brain injury. It is frequently managed by providing infants with an alternative source of glucose, often given enterally with milk‐feeding or intravenously with dextrose solution, which may decrease breastfeeding success. Intravenous dextrose also often requires that mother and baby are cared for in separate environments. Oral dextrose gel is simple and inexpensive, and can be administered directly to the buccal mucosa for rapid correction of hypoglycaemia, in association with continued breastfeeding and maternal care. This is an update of a previous review published in 2016. OBJECTIVES: To assess the effectiveness of oral dextrose gel in correcting hypoglycaemia in newborn infants from birth to discharge home and reducing long‐term neurodevelopmental impairment. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase from database inception to October 2021. We also searched international clinical trials networks, the reference lists of included trials, and relevant systematic reviews identified in the search. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi‐RCTs comparing oral dextrose gel versus placebo, no treatment, or other therapies for the treatment of neonatal hypoglycaemia in newborn infants from birth to discharge home. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed study quality and extracted data; they did not assess publications for which they were study authors. We contacted investigators to obtain additional information. We used fixed‐effect models and the GRADE approach to assess the certainty of evidence. MAIN RESULTS: We included two studies conducted in high‐income countries, involving 312 late preterm and at‐risk term infants and comparing oral dextrose gel (40% concentration) to placebo gel. One study was at low risk of bias, and the other (an abstract) was at unclear to high risk of bias. Oral dextrose gel compared with placebo gel probably increases correction of hypoglycaemic events (rate ratio 1.08, 95% confidence interval (CI) 0.98 to 1.20; rate difference 66 more per 1000, 95% CI 17 fewer to 166 more; 1 study; 237 infants; moderate‐certainty evidence), and may result in a slight reduction in the risk of major neurological disability at age two years or older, but the evidence is uncertain (risk ratio (RR) 0.46, 95% CI 0.09 to 2.47; risk difference (RD) 24 fewer per 1000, 95% CI 41 fewer to 66 more; 1 study, 185 children; low‐certainty evidence). The evidence is very uncertain about the effect of oral dextrose gel compared with placebo gel or no gel on the need for intravenous treatment for hypoglycaemia (RR 0.78, 95% CI 0.46 to 1.32; RD 37 fewer per 1000, 95% CI 91 fewer to 54 more; 2 studies, 312 infants; very low‐certainty evidence). Investigators in one study of 237 infants reported no adverse events (e.g. choking or vomiting at the time of administration) in the oral dextrose gel or placebo gel group (low‐certainty evidence). Oral dextrose gel compared with placebo gel probably reduces the incidence of separation from the mother for treatment of hypoglycaemia (RR 0.54, 95% CI 0.31 to 0.93; RD 116 fewer per 1000, 95% CI 174 fewer to 18 fewer; 1 study, 237 infants; moderate‐certainty evidence), and increases the likelihood of exclusive breastfeeding after discharge (RR 1.10, 95% CI 1.01 to 1.18; RD 87 more per 1000, 95% CI 9 more to 157 more; 1 study, 237 infants; moderate‐certainty evidence). AUTHORS' CONCLUSIONS: Oral dextrose gel (specifically 40% dextrose concentration) used to treat hypoglycaemia in newborn infants (specifically at‐risk late preterm and term infants) probably increases correction of hypoglycaemic events, and may result in a slight reduction in the risk of major neurological disability at age two years or older. Oral dextrose gel treatment probably reduces the incidence of separation from the mother for treatment and increases the likelihood of exclusive breastfeeding after discharge. No adverse events have been reported. Oral dextrose gel is probably an effective and safe first‐line treatment for infants with neonatal hypoglycaemia in high‐income settings. More evidence is needed about the effects of oral dextrose gel treatment on later neurological disability and the need for other treatments for hypoglycaemia. Future studies should be conducted in low‐and middle‐income settings, in extremely and moderately preterm infants, and compare oral dextrose gel with other therapies such as intravenous dextrose. There are two ongoing studies that may alter the conclusions of this review when published.

Background Policies and protocols vary widely for fetal surveillance in a pregnancy where the fetus is suspected to be large-for-gestational-age (LGA). All ultimately culminate in decisions about the mode and timing of birth. LGA is known to be associated with increased risks to both the mother and baby. Interventions based on surveillance regimen findings may be associated with risks to the mother and baby. Objectives To assess the effectiveness or efficacy of different antenatal surveillance methods for the suspected LGA fetus on important health outcomes for the mother and baby. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 August 2015), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (21 August 2015). Selection criteria Published and unpublished randomised, quasi-randomised and cluster-randomised trials comparing the effects of described antenatal fetal surveillance regimens for women with suspected LGA infants. Data collection and analysis We identified no studies that met the inclusion criteria for this review. Main results There are no included trials. Authors' conclusions We found no randomised controlled trials that assessed the effect of antenatal fetal surveillance regimens of a suspected LGA fetus on important health outcomes for the mother and baby. There has been a rise in the prevalence of LGA babies over the past few decades in many countries. Research is therefore required on regimens of antenatal surveillance of suspected LGA infants, in order to guide practice and improve the health outcomes for the mother and infant. In particular, randomised control trials to investigate whether serial antenatal clinic and ultrasound assessments of suspected LGA infants (including liquor volume and markers of fetal adiposity) would be useful, to assess whether surveillance methods improve health outcomes. In addition, as there are concerns that identifying suspected LGA fetuses may lead to unnecessary maternal anxiety, investigations and interventions, any such trial would need to assess the risks as well as benefits of regimens of fetal surveillance for suspected LGA fetuses.

Background Dysmenorrhoea refers to painful menstrual cramps and is a common gynaecological complaint. Conventional treatments include non-steroidal anti-inflammatory drugs (NSAIDs) and oral contraceptive pills (OCPs), which both reduce myometrial activity (contractions of the uterus). A suggested alternative approach is dietary supplements. We used the term 'dietary supplement' to include herbs or other botanical, vitamins, minerals, enzymes, and amino acids. We excluded traditional Chinese medicines. Objectives To determine the efficacy and safety of dietary supplements for treating dysmenorrhoea. Search methods We searched sources including the Cochrane Gynaecology and Fertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, PsycINFO (all from inception to 23 March 2015), trial registries, and the reference lists of relevant articles. Selection criteria We included randomised controlled trials (RCTs) of dietary supplements for moderate or severe primary or secondary dysmenorrhoea. We excluded studies of women with an intrauterine device. Eligible comparators were other dietary supplements, placebo, no treatment, or conventional analgesia. Data collection and analysis Two review authors independently performed study selection, performed data extraction and assessed the risk of bias in the included trials. The primary outcomes were pain intensity and adverse effects. We used a fixed-effect model to calculate odds ratios (ORs) for dichotomous data, and mean differences (MDs) or standardised mean differences (SMDs) for continuous data, with 95% confidence intervals (CIs). We presented data that were unsuitable for analysis either descriptively or in additional tables. We assessed the quality of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods. Main results We included 27 RCTs (3101 women). Most included studies were conducted amongst cohorts of students with primary dysmenorrhoea in their late teens or early twenties. Twenty-two studies were conducted in Iran and the rest were performed in other middle-income countries. Only one study addressed secondary dysmenorrhoea. Interventions included 12 different herbal medicines (German chamomile (Matricaria chamomilla, M recutita, Chamomilla recutita), cinnamon (Cinnamomum zeylanicum, C. verum), Damask rose (Rosa damascena), dill (Anethum graveolens), fennel (Foeniculum vulgare), fenugreek (Trigonella foenum-graecum), ginger (Zingiber officinale), guava (Psidium guajava), rhubarb (Rheum emodi), uzara (Xysmalobium undulatum), valerian (Valeriana officinalis), and zataria (Zataria multiflora)) and five non-herbal supplements (fish oil, melatonin, vitamins B1 and E, and zinc sulphate) in a variety of formulations and doses. Comparators included other supplements, placebo, no treatment, and NSAIDs. We judged all the evidence to be of low or very low quality. The main limitations were imprecision due to very small sample sizes, failure to report study methods, and inconsistency. For most comparisons there was only one included study, and very few studies reported adverse effects. Effectiveness of supplements for primary dysmenorrhoea We have presented pain scores (all on a visual analogue scale (VAS) 0 to 10 point scale) or rates of pain relief, or both, at the first post-treatment follow-up. Supplements versus placebo or no treatment There was no evidence of effectiveness for vitamin E (MD 0.00 points, 95% CI −0.34 to 0.34; two RCTs, 135 women). There was no consistent evidence of effectiveness for dill (MD -1.15 points, 95% CI −2.22 to −0.08, one RCT, 46 women), guava (MD 0.59, 95% CI −0.13 to 1.31; one RCT, 151 women); one RCT, 73 women), or fennel (MD −0.34 points, 95% CI −0.74 to 0.06; one RCT, 43 women). There was very limited evidence of effectiveness for fenugreek (MD −1.71 points, 95% CI −2.35 to −1.07; one RCT, 101 women), fish oil (MD 1.11 points, 95% CI 0.45 to 1.77; one RCT, 120 women), fish oil plus vitamin B1 (MD −1.21 points, 95% CI −1.79 to −0.63; one RCT, 120 women), ginger (MD −1.55 points, 95% CI −2.43 to −0.68; three RCTs, 266 women; OR 5.44, 95% CI 1.80 to 16.46; one RCT, 69 women), valerian (MD −0.76 points, 95% CI −1.44 to −0.08; one RCT, 100 women), vitamin B1 alone (MD −2.70 points, 95% CI −3.32 to −2.08; one RCT, 120 women), zataria (OR 6.66, 95% CI 2.66 to 16.72; one RCT, 99 women), and zinc sulphate (MD −0.95 points, 95% CI −1.54 to −0.36; one RCT, 99 women). Data on chamomile and cinnamon versus placebo were unsuitable for analysis. Supplements versus NSAIDS There was no evidence of any difference between NSAIDs and dill (MD 0.13 points, 95% CI −1.01 to 1.27; one RCT, 47 women), fennel (MD −0.70 points, 95% CI −1.81 to 0.41; one RCT, 59 women), guava (MD 1.19, 95% CI 0.42 to 1.96; one RCT, 155 women), rhubarb (MD −0.20 points, 95% CI −0.44 to 0.04; one RCT, 45 women), or valerian (MD points 0.62 , 95% CI 0.03 to 1.21; one RCT, 99 women), There was no consistent evidence of a difference between Damask rose and NSAIDs (MD −0.15 points, 95% CI −0.55 to 0.25; one RCT, 92 women). There was very limited evidence that chamomile was more effective than NSAIDs (MD −1.42 points, 95% CI −1.69 to −1.15; one RCT, 160 women). Supplements versus other supplements There was no evidence of a difference in effectiveness between ginger and zinc sulphate (MD 0.02 points, 95% CI −0.58 to 0.62; one RCT, 101 women). Vitamin B1 may be more effective than fish oil (MD −1.59 points, 95% CI −2.25 to −0.93; one RCT, 120 women). Effectiveness of supplements for secondary dysmenorrhoea There was no strong evidence of benefit for melatonin compared to placebo for dysmenorrhoea secondary to endometriosis (data were unsuitable for analysis). Safety of supplements Only four of the 27 included studies reported adverse effects in both treatment groups. There was no evidence of a difference between the groups but data were too scanty to reach any conclusions about safety. Authors' conclusions There is no high quality evidence to support the effectiveness of any dietary supplement for dysmenorrhoea, and evidence of safety is lacking. However for several supplements there was some low quality evidence of effectiveness and more research is justified.

Falls in infants are a common cause of injury. Compared to older children, infants under age one are likely to have distinctive causation and injury patterns, as they are pre-mobile or have limited independent mobility and falls are more directly the responsibility of the care giver. There is little known about the mechanistic factors, predictors of injury and injury patterns in this age group.We conducted a retrospective review of infants under age one who presented after a fall to a paediatric trauma centre in Sydney, Australia. Circumstances and mechanisms of the fall, injury patterns, burden of investigations and outcomes were analysed.Over a 3-year period (2011-2013), 916 infants presented following a fall. One hundred and six (11.6%) were admitted and there was one death. Head injury was the most common reason for admission (85%). While there were severe and critical head injuries (Abbreviated Injury Scale 4-5) these were infrequent (2% of presentations). All admitted cases involved a short distance fall. Patients dropped by others were three times more likely to be admitted than infants presenting following other fall types (95% CI 1.9-4.8). Compared to other mechanisms, patients who fell from furniture had significantly longer hospital stays.Fall mechanisms involving infants being dropped by adults, and falls from beds or couches carry the highest clinical burden. These mechanisms should be targets for injury prevention and inform the design of safe equipment and environments for babies.

‘Mixed use’ is a solution often used to address (urban) sustainability concerns. The claim is that more compact, high-density urban developments that serve a multitude of uses and users can be socially beneficial while being environmentally sound and economically viable. In the case of the Luneside East regeneration project in Lancaster, UK, ‘mixed use’ has been specified towards the goal of achieving a ‘vibrant, sustainable quarter of the city’ and a ‘sustainable and balanced community’. In this paper, a specific dimension of mixed use critical to community sustainability – provision of social infrastructure – is assessed using a futures analysis. Providing services and facilities that meet the needs of residents, promoting social interaction and enhancing overall quality of life are vital for building sustainable communities. However, to deliver these social benefits, one of the conditions is that there is equitable access for residents, both in the new development and for the existing community. The results of the study indicate that this condition is vulnerable in several of the futures analysed. It is important for planners to take account of these findings in order to ensure the Luneside East development will meet its social sustainability objectives both now and in the future.