IEEE 802.11ah, marketed as Wi-Fi HaLow, extends Wi-Fi to the sub-1 GHz spectrum. Through a number of physical layer (PHY) and media access control (MAC) optimizations, it aims to bring greatly increased range, energy-efficiency, and scalability. This makes 802.11ah the perfect candidate for providing connectivity to Internet of Things (IoT) devices. One of these new features, referred to as the Restricted Access Window (RAW), focuses on improving scalability in highly dense deployments. RAW divides stations into groups and reduces contention and collisions by only allowing channel access to one group at a time. However, the standard does not dictate how to determine the optimal RAW grouping parameters. The optimal parameters depend on the current network conditions, and it has been shown that incorrect configuration severely impacts throughput, latency and energy efficiency. In this paper, we propose a traffic-adaptive RAW optimization algorithm (TAROA) to adapt the RAW parameters in real time based on the current traffic conditions, optimized for sensor networks in which each sensor transmits packets with a certain (predictable) frequency and may change the transmission frequency over time. The TAROA algorithm is executed at each target beacon transmission time (TBTT), and it first estimates the packet transmission interval of each station only based on packet transmission information obtained by access point (AP) during the last beacon interval. Then, TAROA determines the RAW parameters and assigns stations to RAW slots based on this estimated transmission frequency. The simulation results show that, compared to enhanced distributed channel access/distributed coordination function (EDCA/DCF), the TAROA algorithm can highly improve the performance of IEEE 802.11ah dense networks in terms of throughput, especially when hidden nodes exist, although it does not always achieve better latency performance. This paper contributes with a practical approach to optimizing RAW grouping under dynamic traffic in real time, which is a major leap towards applying RAW mechanism in real-life IoT networks. The Internet of Things (IoT) aims to provide connectivity among a huge number of “things” anytime and anywhere. This will highly impact every aspect of the world we live in, including economics, politics, and social life. Emerging IoT applications and services, such as smart meters, environmental/agricultural monitoring and automation of industrial processes, require myriads of battery-powered smart things  connected together in an energy efficient way. Currently, there are two categories of low-power IoT communication technologies: wireless personal area network (WPAN) and low-power wide area network (LPWAN) technologies. Within short transmission range , WPAN technologies  provide relatively high throughput , while long-range communications  can be supported by LPWAN technologies  at much lower throughput . As the transmission range of the WPAN technologies is too short and throughput of the LPWAN technologies is too low, both of them can only be applied in a limited set of IoT scenarios. Therefore, a gap still exists for a low-power IoT communication technology that offers sufficient throughput over longer ranges.The recently released IEEE 802.11ah Wi-Fi standard, marketed as Wi-Fi HaLow, fills this gap. It operates in the unlicensed sub-1 GHz frequency bands . Similar to previous Wi-Fi standards, it supports several modulation and coding schemes (MCS) in order to offer a trade-off between throughput, range and energy efficiency. This allows it to support transmission ranges from 100 m up to 1 km with data rates between 0.15 Mbps and 346.67 Mbps. Thus, IEEE 802.11ah has the potential to achieve much higher transmission ranges than existing WPAN and much higher throughput than both WPAN and LPWAN technologies. On the MAC (Media Access Control) layer, in order to increase efficiency in the face of a large number of densely deployed, energy constrained stations, several innovative mechanisms are introduced, including hierarchical organization, short MAC header, restricted access window (RAW), traffic indication map (TIM) segmentation and target wake time (TWT).The RAW feature aims to increase scalability in dense IoT networks, where a large number of stations connect to a single access point (AP). With RAW, stations are divided into groups, limiting simultaneous channel access to one group. Therefore, the collision probability for upstream traffic is highly reduced. However, the grouping strategy, which decides how to split stations among groups, is not mentioned in the standard. Concretely, a station grouping algorithm should be implemented at the AP side to determine the number of RAW groups, the duration of each group, and how to divide stations among them. Furthermore, these parameters should be dynamically adapted by the AP between consecutive beacon intervals. In previous work, we conducted an in-depth analysis of the influence of network and traffic conditions on the optimal station grouping parameters . We concIn this article, we present a novel real-time station grouping algorithm that adapts the RAW parameters based on the current (estimated) traffic conditions, optimized for sensor networks with mainly upstream traffic. It improves upon the state of the art in three ways. First, it is designed for dynamic and heterogeneous traffic conditions, where each station has a different packet transmission interval that may change over time. Second, it only uses information readily available on the AP side, estimating station-side variables based on available data. Third, it can be executed in real time, not relying on at-runtime evaluation of complex mathematical models. The combination of these three factors allows the algorithm to be deployed in realistic environments, executing it at the start of each beacon interval for instantaneous adaptation to changes in traffic conditions. To the best of our knowledge, this is the first real-time IEEE 802.11ah station grouping algorithm that can cope with dynamic and heterogeneous traffic. The algorithm is thoroughly evaluated using our previously presented 802.11ah ns-3 simulator [The remainder of this article is structured as follows. Even though the IEEE 802.11ah standard was only officially published recently, research on IEEE 802.11ah has been conducted for several years. Several articles ,5,6,7,8 Several recent works study physical layer aspects of 802.11ah and sub-1 GHz communications ,13,14. HMore relevant to the research presented in this article is work focusing on RAW analysis and optimization. Several studies have been conducted on the optimality of RAW configurations given specific network and traffic conditions ,16,17. PSeveral such station grouping algorithms have been proposed in literature, as shown in The algorithms presented in the table are broadly based on two approaches: (i) analytical modeling and (ii) set partitioning. The analytical models make use of different techniques, such as probability theory ,27,28, MThe set partitioning algorithms are much simpler. They assume the number of RAW slots and groups is given, and decide how to partition the associated stations among them, according to some metric. Their simplicity makes it computationally feasible to deploy them in real networks. Older work assumes simplified saturated and homogeneous network conditions. Moreover, it focuses on simple partitioning metrics, such as fully random  or basedAlthough the algorithms of Dong  and ChanIn this paper, we present a station grouping algorithm for the IEEE 802.11ah RAW mechanism that addresses these shortcomings. It supports both dynamic and heterogeneous traffic, real-time execution, estimation of station traffic intensity on the AP side , and optimization of all RAW parameters . Last but not least, it is evaluated using our IEEE 802.11ah ns-3 packet-based network simulator [IEEE 802.11ah operates over a set of unlicensed radio bands , supporting up to 1 km transmission range, and allowing up to 8192 stations to associate with a single AP. Due to these features, 802.11ah is a highly attractive wireless communication technology for long-distance IoT use cases, such as smart meters and environmental/agricultural monitoring. This section provides an overview of the RAW station grouping feature of the 802.11ah standard, which is the focus of this article. More detailed overview of the complete standard can be found in existing literature ,5,6,7.C represents slot duration count sub-field, which is either number of slots field is C is C is FCS field of the S1G beacon frame, and x is the index of the station. The goal of the RAW mechanism is to mitigate collisions and improve performance in dense IoT networks where a large number of stations are contending for channel access simultaneously. It splits stations into groups and only allows stations assigned to a certain group to access the channel at specific times.  follows :(2)islocross slot boundary (CSB) sub-field. Stations are allowed to continue their ongoing transmissions even after the end of the current RAW slot when CSB is set to true. Otherwise, stations should not start a transmission if the remaining time in the current RAW slot is not enough to complete it.The RPS also contains the Different from previous IEEE 802.11 standards, each station uses two back-off states of enhanced distributed channel access (EDCA) to manage transmission inside and outside their assigned RAW slot respectively cf. . The firThis section introduces the RAW optimization problem addressed in this article, and subsequently proposes the Traffic-Adaptive RAW Optimization Algorithm (TAROA). TAROA solves the RAW optimization problem in real-time, and is able to instantaneously adapt to changes in station association and traffic demand. We consider IoT sensor-based monitoring scenarios, where a large set of sensors b, maximizing the number of successful transmissions. As an input, it uses only information readily available at the access point. The first input is the last-in-first-out (LIFO) queue of times a packet was successfully received by the AP from station s or b, the set of RAW slots r, and the duration r. The goal can then be formally defined as:s during beacon interval b.The goal of RAW optimization is to assign stations to a set of RAW slots s on the AP side (as it is not known by the AP). This estimate b the set of RAW groups and slots TAROA aims to solve the aforementioned problem by estimating the transmission interval s places a packet in its transmit queue every s. Based on this estimate, the AP assigns RAW slots of varying duration s. At the top, s. For both cases, the figures graphically depict the parameter values for the last two transmissions results , the failure counter s may transmit multiple packets to the AP . In that case, the estimated transmission interval is reduced by 1 beacon interval (line 12). Finally, there are two more cases where the current estimated transmission interval is not larger than the beacon interval , then it is allowed to transmit part of its packets and its estimated transmission interval is updated accordingly (line 5). Otherwise, the station is expected to be able to transmit all of its packets and s is estimated to transmit in the beacon interval (line 8).In the first part (lines 2–8), the algorithm iterates over all stations At this point, it should be noted that all slots within a RAW group have the same duration and only stations with sequential AID can be assigned to the same group. Moreover, the optimal duration of a slot depends on the number of stations assigned to it, as well as their data rates, number of queued packets, and packet payload sizes. As such, for simplicity, we assume throughout the remainder of this paper that each RAW group has exactly one slot, allowing all slots to have a different size. Overcoming this problem is possible by selecting a worst-case slot duration  or performing dynamic AID reassignment. The latter is expected to increase optimality, but falls outside the scope of this paper.s is added to the expected number of packet transmissions in r (line 13). Finally, the optimal duration In the second part (lines 9–14), stations are assigned to RAW slots In addition to information about past transmissions, the TAROA algorithm takes two additional input parameters: (i) the optimal number of stations in one RAW slot As the idea of RAW is to limit the number of station contending for the channel, an appropriate number of stations Several researchers have proposed analytic models to calculate throughput of 802.11ah networks with a variable number of stations ,28,29,30As 802.11ah focuses on IoT and M2M scenarios, 1 and 2 MHz channel bandwidths are most commonly used, with the data rate ranging from 0.15 to 7.8 Mbps. As mentioned above, we derive the optimal number of stations ous work  and by tous work . In thisEven though the derived optimal value of L is the average packet payload size. When the channel is fully utilized   πmaxb anAll evaluations are performed using our previously developed 802.11ah ns-3 module , with a RAW performance is evaluated in terms of two metrics: throughput, latency and packet loss. Throughput is calculated as the average number of successfully received payload bytes by the AP per second. Latency is defined as the average time between a packet entering the transmit queue of the station and being received by the AP. Packet loss represents the ratio between the number of packets not received by AP, and the number of packets sent by all stations. Each simulation runs 600 s. This simulation time is long enough as each station transmits packets with a certain (predictable) frequency, the steady-state simulation result is achieved after less than 100 s in all experiments. All results are averaged over 10 iterations, with the variability of results over these iterations quantified using the standard deviation (SD).T = {0.75, 0.85, 1.2} Mbps for the HT scenario, and T = {0.095, 0.11, 0.15} Mbps for the LT scenario. Each station s randomly and uniformly chooses an integer value S isThis section evaluates the performance of TAROA for different traffic loads and numbers of stations in a static network, which means that stations stay active from the beginning to the end of the simulation and do not change their transmission interval. Three different total traffic loads are simulated for each scenario, i.e., s its traffic load is calculated as:For each station T = {T = {T = {Its actual packet transmission interval is subsequently calculated as:T = 1.2 Mbps, EDCA/DCF achieves throughput T = 0.85 Mbps, throughput of EDCA/DCF drops by T = 0.75 Mbps, there is no significant difference between TAROA and EDCA/DCF.T = 1.2 Mbps, packet loss of EDCA/DCF increases from T = 0.85 Mbps, packet loss of EDCA/DCF is T = 0.75 Mbps, there is no significant difference between TAROA and EDCA/DCF. When using TAROA, no packet loss due to collisions occurred.In terms of latency, Performance for the LT scenario is depicted in For the LT scenario, EDCA/DCF always results in better latency, due to the slotted nature of RAW and the large quantities of packet loss of EDCA/DCF in very dense networks.In this section, we study the impact of hidden nodes imposed on performance by extending the maximum distance between the AP and the stations to 100 m for the HT and 450 m for the LT scenario. The results are shown in T = {0.85, 0.75} Mbps  over time. The total traffic load, In addition to stations changing over time, we also evaluate the performance when the number of active stations does not change, but instead their transmission interval changes over time. For the HT scenario, the network consists of 1024 stations with a total traffic load of In this paper, we propose a novel traffic-adaptive RAW optimization algorithm (TAROA) to adjust the RAW parameters in real time based on the current traffic conditions, optimized for sensor networks with mainly upstream traffic in which each station is assumed to transmit packets with a certain (predictable) frequency. The TAROA algorithm improves upon the state of art in three ways, including supporting dynamic and heterogeneous traffic conditions, only using information available on the AP side and real-time execution. The combination of these three factors allows TAROA to be deployed in realistic environment. The TAROA algorithm is executed at each target beacon transmission time (TBTT), it first estimates the packet transmission interval of each station only based on packet transmission information obtained during the last beacon interval, and then determines the RAW parameters and assigns stations to RAW slots based on this estimated transmission frequency.The simulation results reveal three key points on TAROA. First, it scales much better than EDCA/DCF in dense networks in terms of throughput under static traffic conditions. Second, it is resilient to dynamic traffic conditions in which topology or transmission interval change over time. In the scenario under evaluation, TAROA only starts to experience throughput degradation when topology changes at Poisson rate 5. Third, TAROA gains additional advantages over EDCA/DCF when hidden nodes are present under both static and dynamic traffic conditions. Hidden nodes highly degrade the performance of EDCA/DCF, while TAROA is hardly affected. In summary, for dense IoT networks, TAROA can easily adapt to current traffic conditions in real time and significantly improves throughput.In future work, we will further improve the performance of the TAROA algorithm, and, in particular, the traffic estimation under high load. Moreover, TAROA will be extended to support adaptive MCS.


Mannheimia haemolytica is a Gram-negative, non-motile, and non-spore-forming rod-shaped coccobacillus bacterium. On blood agar plate, it shows complete hemolysis. This bacterium constitutes a part of normal flora of the upper respiratory system of ruminants. It is considered as the opportunistic pathogen and the main factor of pneumonic pasteurellosis, which has caused a severe economic loss in sheep and cattle industries. Considering the prevalence of the disease in sheep and goat population in the dry and hot regions of the country in general and in Fars province in particular in the form of pneumonia, the purpose of this study was to isolate and identify the bacterium M. haemolytica from the lung tissues of sheep slaughtered in Shiraz abattoir through culturing and polymerase chain reaction (PCR) methods.In this study, a total of 2500 sheep’s lungs were evaluated for finding pneumonic effects. Then, 161 infected pneumonic samples of lung tissues were investigated by culture and PCR methods.M. haemolytica by cultivation and then all the 38 isolates were confirmed by PCR and multiplex PCR (mPCR). Results of this study indicated that culture and PCR are both practical in identification and isolation of this bacterium though culture is more time-consuming. The utilized mPCR has been more successful in the identification of the bacteria since it requires less time and cost.After cultivation, purification, and DNA extraction, 38 samples were found positive for M. haemolytica in clinical samples of animals, was used.In this study, PCR as a superior method among other methods of bacteriology for fast examination of infectious diseases and mPCR, which is a valuable tool for identification of  Mannheimia haemolytica is a Gram-negative, non-motile, non-spore-forming, and rod-shaped coccobacillus bacterium. The G+C content of the DNA is about 39-44% [et al. [Pasteurella haemolytica into a new genus named M. haemolytica after the name of German biologist Walter Mannheimia. He improved the study and classification of Pasteurellaceae family through his investigations [t 39-44% . In 1999 [et al.  reclassiM. haemolytica is found as a natural flora on the mucous membrane of the upper respiratory tract of ruminants. Most of its known species were isolated from cattle, sheep, and goats. Virulence factors of M. haemolytica include adhesins, capsule, lipopolysaccharide, outer membrane proteins, iron-regulated proteins, and leukotoxin. The main pathogen of bovine pneumonic pasteurellosis (shipping fever) is M. haemolytica which can be the causative agent of pasteurellosis in sheep and goats. In addition, it causes two syndromes of pneumonia and septicemia in sheep and goats, respectively, and leads to gangrenous mastitis in ewes [ in ewes .M. haemolytica from slaughtered sheep’s lungs in Shiraz abattoirs through culture and polymerase chain reaction (PCR). Considering the significant role of this bacterium in sheep pneumonia, the effectiveness of these two methods in bacterial identification with improved sensitivity and rapidity was investigated.Therefore, the purpose of the current study was to identify and isolate Ethical approval was not necessary as samples were collected from dead animals.From October 2015 to June 2016, following the slaughter of the apparently healthy animals, all the lungs (≈2500) were inspected according to the standard postmortem meat inspection procedure; and then, 161 lungs that contain hepatization and consolidation in cranioventral lobes were selected for further examination. Each lung sample was separately placed in sterile zip-lock plastic bags and transferred to the laboratory of Bacteriology, Faculty of Veterinary Medicine, Shiraz University, in about 2 h, in cool condition. Samples were collected from cranioventral lungs’ lobes with hyperemia, rough surface, and consolidation symptoms.Upon inspection, the surface of each suspected lung was sterilized with a hot iron blade and incised using sterile scalpel blade and the inner surface of the incision was sampled with a sterile swab. Following that, the swabs were streaked on blood agar plates and incubated aerobically at 37°C for 24-48 h.Then, for isolation, a loopful of the identified colonies were streaked over a new blood agar plate and incubated aerobically at 37°C for 24 h. Next, from culture-positive plates, typical colonies were subjected to Gram’s staining to study staining reactions and cellular morphology under a light microscope. Mixed and Gram-negative bacteria were further subcultured with due care, on both blood and MacConkey agar plates for final identification.M. haemolytica [The growth of typical colonies on both blood agar and MacConkey agar plates was characterized using blood agar plate for the presence of hemolysis, the type of hemolysis, the general appearance of colonies  and MacConkey agar plates for the ability to ferment lactose. Pure cultures of single colony type were further analyzed by catalase and oxidase tests. Final identification of bacteria to species level was aided using the biochemical tests including Metabolism of sugars such as glucose, sorbitol, lactose, sucrose, maltose, and mannose and tests for metabolic end products such as indole  following standard procedures. If the organism can produce a narrow zone of hemolysis on blood agar plate and grown on MacConkey agar plate, but unable to produce indole, it is interpreted as molytica .M. haemolytica from 24-48 h growth on blood agar plates were transferred into 1.5-ml Eppendorf tubes. The bacterial genomic DNA was extracted according to Gram-negative DNA extraction kit . The extracted DNA was determined to be of good quality according to A260/A280, and DNA concentration was measured using Nanodrop (10000 V 3.52). Finally, the extracted DNA was stored at −20°C until use.A few colonies from the phenotypically characterized pure cultures of 2, 1.5 μl (200 mM) dNTPs, 1.5 µl (100 nmol) each primer of M. haemolytica, 0.3 U of Taq DNA polymerase, 13.2 μl H2O, and 3 μl of DNA template to have a final volume of 25 μl. The master mix form mPCR is also shown in The oligonucleotide primers used in this study are listed in M. hemolytica from the bacterial collection of the Faculty of Veterinary Medicine, Shiraz University, were sent for sequencing of 16s DNA-PCR products, and then these bacterial strains were used as positive control in PCR.A negative control consisting of all components of reaction mixture except the DNA template was included in all PCR experiments. Positive controls were included in the PCR from colonies that were confirmed according to NCBI gene bank sequencing. After initial identification of isolates according to phenotypic characteristics and biochemical tests, some isolates and To evaluate the PCR results, electrophoresis in agarose gel was carried out. PCR amplicons were assessed by loading 8 µl of the PCR product plus 2 µl of loading buffer into separate wells of 2% (w/v) agarose gel  containing ethidium bromide (0.5 µg/ml). A molecular weight marker  was loaded into the first well to determine the size of the amplified fragments. The gel was immersed in TBE buffer and subjected to a voltage difference of 100 V that led to the separation of the fragments. Visualization was undertaken using an ultraviolet transilluminator , and the resulting image was captured by a computer software program .M. haemolytica, PCR products of some samples according to the Macrogene Company’s instructions were prepared at 50 μl volume and were transferred for sequencing. Sequence analysis was performed on an ABIPrism 3100 Genetic Analyzer .For the final confirmation of isolates of M. haemolytica with small gray circle colonies with β-hemolysis were observed that were rod-shaped in Gram staining  to identify Pasteurella. Among the 329 samples examined through PCR and culture, 14 samples (46.4%) were identified as M. haemolytica [M. haemolytica. It should be noted that in our study, in addition to culture and PCR, mPCR was also utilized for more accurate identification and determination.Abera molytica . Resultset al. in India. In their study, 12 isolates with culture and phenotypic characteristics of M. haemolytica were isolated, all of which according to PCR test were positive as M. haemolytica [Findings of the current study were in line with the findings of a study by Kumar molytica .Pasteurella species through culture and biochemical experiments and determining the prevalence of them in pneumonia risk factors in sheep and goats of 988 nasal swabs and blood samples, 322 samples were pneumonic, while 79.5% of isolates were M. haemolytica [In another study carried out in the northeast region of Ethiopia aimed at identifying and isolating Pasteurella and M. haemolytica were isolated from 64 samples . It is worth noting that all samples isolated from lung tissues were M. haemolytica, while 69% of nasal samples were M. haemolytica, which is strongly in line with our findings. Based on the findings of that study and the present study, it can be concluded that M. haemolytica is the main factor of pneumonic pasteurellosis in sheep [Still, in another study conducted in Ethiopia, sheep pneumonic pasteurellosis was examined. A total of 256 samples were collected. les (38 5.4% lung et al., using the same primers as in our study, an mPCR was run and 15 previously isolated bacteria and 44 new isolates studied in their study were found to be positive as M. haemolytica [Moreover, in a similar study by Alexander M. haemolytica, but culture is very time-consuming, and PCR is very useful for fast identification of infectious agents. In addition, findings of the present study agree with the findings of Sabiel et al. who indicated that PCR is very useful and time saving for the identification of P. multocida and M. haemolytica [Our findings showed that culture and PCR could be used for detection of molytica .M. haemolytica in clinical samples of animals.The present study indicated that culture and PCR are both practical in identification and isolation of this bacterium though culture is more time-consuming. The utilized mPCR has been more successful in the identification of the bacteria since it requires less time and cost. Furthermore, we propose the PCR as a superior method among other methods of bacteriology for fast examination of infectious diseases and mPCR, which is a valuable tool for identification of This study is the major component of the work toward the M.Sc. thesis of FA. MT as supervisor of this work provided guidance during the entire experiment. FA wrote the first draft of the manuscript. Then, the whole manuscript was critically revised by MT. All authors have read and approved the final version of the manuscript.


Supplemental Digital Content is available in the text As 2 major common types of chronic diarrhea, functional diarrhea (FD) and diarrhea-predominant irritable bowel syndrome (IBS-D) affect 1.54% to 1.72% of people in China. Acupuncture is commonly used in clinical practice for patients with chronic diarrhea. Here, we present a protocol of systematic review aimed at systematically review all the clinical evidence on the effectiveness of acupuncture for treating FD and IBS-D in adults.The review will be performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. We will search the following databases from their inception to January 2017: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, China Biology Medicine disc, Wan-Fang Data, China National Knowledge Infrastructure, Citation Information by National Institute of Informatics, Oriental Medicine Advanced Searching Integrated System by Korea Institute of Oriental Medicine, and Japan Science and Technology Information Aggregator (J-stage). Clinical trial registrations will also be searched. Primary outcome measures are the change of bowel movements. The secondary outcomes include stool consistency, quality of life scales, other standardized rating scales, patient satisfaction, and acupuncture-related adverse effects assessment.This review does not require ethical approval and will be disseminated electronically or in print.CRD42015017574. The 2 major types of chronic diarrhea are functional diarrhea (FD) and diarrhea-predominant irritable bowel syndrome (IBS-D). The predominant symptoms of these 2 illness are differentiable that IBS-D is distinguished by the recurrent abdominal pain/discomfort during diarrhea with a relief after the defecation, or a change of the bowel habits; and FD is characterized by the frequent presence of loose or watery stools (<75%) with or without abdominal pain.,5 Although these 2 illnesses are differentiable through Rome Criteria, IBS-D and FD still have considerable overlapped symptoms of chronic diarrhea such as loose or watery stools, increased stool frequency, and bloating. Based on a cross-sectional survey conducted in 16,078 respondents, the prevalence of FD and IBS-D is 1.72% and 1.54% in China, respectively. To date, the underlying pathophysiology is still unclear, and the development of FD and IBS-D may involve rapid intestinal transit, emotions, or specific nutrient intolerances.Chronic diarrhea is a common complaint in worldwide, which is termed chronic when it lasts for <4 weeks. Medications like anticholinergics, antimotility drugs, and antidiarrheal agents may be beneficial for FD and IBS-D symptoms.–12 However, the adverse effects including sleepiness, dizziness, nausea, vomiting, constipation, dependency, tolerance, and respiratory depression,,14 which might cause discontinuation of the medication.,16Recently, the treatments of chronic diarrhea are focused on symptom management, which can be classified as dietary and lifestyle modification, psychological therapies, pharmacologic therapies, and alternative modalities. Acupoints are located on meridians and the theory behind acupuncture was outlined in Inner Canon of Huangdi . Studies suggested that acupuncture may be effective for gastrointestinal diseases,–21 and a systematic review reported that the quality of life in patients with gastrointestinal diseases was improved significantly, independently through acupuncture method. Some animal trials manifested that acupuncture could increase or decrease the intestinal motility.,24 The mechanism of acupuncture on gastrointestinal motility seemed to be mediated via neural and humoral pathways, and some researchers found that acupuncture involved the central nervous system, autonomic nervous system, and enteric nervous system.,25–27 In this review, we aim to perform a systematic review to assess and appraise all the clinical evidence on the effectiveness and safety of acupuncture for treating FD and IBS-D in adults.Acupuncture is a nondrug technique among various interventions in complementary and alternative medicine. Most commonly, acupuncture is accomplished by manual manipulation or electrical stimulation via thin needles inserted in acupuncture points.2 This systematic review protocol has been registered on PROSPERO under the number CRD42015017574, and has been developed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocols (PRISMA-P) statement guidelines.2.12.1.1,30We will include all original studies published in English, Chinese, Korean, and Japanese that reported the effectiveness and/or safety on acupuncture for FD or IBS-D, only randomized controlled trials (RCTs) will be included in data syntheses. To RCTs, it should report adequate randomization methods, eligible diagnosis, eligible outcome measurement, and statistical methods description. We will also search the database to include nonrandomized study, which can be divided into nonrandomized intervention study and observational study . For all nonrandomized study, we will only extract the data from acupuncture group for effectiveness and safety assessment without data syntheses. The details will be described in the “Data syntheses” section and “Assessment and quality of included studies” section. Trials without established standard international diagnoses and/or outcome measures will be excluded.2.1.2Trials must include adult participants (more than 18 years old) with chronic diarrhea. In this review, we mainly focus on participants who were diagnosed as FD or IBS-D.For participants with FD: with loose (mushy) or watery stools, increased stool frequency without pain occurring in at least 75% of stools lasting more than 3 months. In addition to this, loose stool needed to be >25% and hard stool to be <25% of the time for this participants.For participants with IBS-D: recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months associated with improvement with defecation, onset associated with a change in frequency or appearance  of stool.2.1.3Any type of penetrating acupuncture will be included, such as acupuncture, electro-acupuncture, auricular acupuncture, abdominal acupuncture, and warm acupuncture. We will exclude nonpenetrating acupuncture such as laser acupuncture, acupressure, and transcutaneous or percutaneous electrical nerve stimulation. Control interventions will include no treatment, sham acupuncture/placebo acupuncture , and conventional drug therapies . Either sham acupuncture or placebo acupuncture will be seen as the sham controlled group instead of a sort of acupuncture, we will also exclude the trials that compare 2 different types of acupuncture (such as acupuncture vs. electro-acupuncture).2.1.4We will include trials that report at least one of the following outcomes.The primary outcome is the change from baseline in weekly bowel movements at the end of the treatment or follow-up.(1) According to BSFS, stool consistency is classified into 7 types, in which, type 5 to 7 denote the stool type of diarrhea, and type 4 denotes a normal stool consistency.The score change from baseline in stool consistency assessed through Bristol Stool Form Scale .(2)Score change from baseline in quality of life measurement.(3)Other standardized rating scales .(4)Patient satisfaction at the end of treatment.(5)Acupuncture-related adverse effects assessment such as broken or left needle; hypodermal bleeding, hematoncus, or infection around the site of needling; unbearable pricking, faint, nausea, or dizziness during the needling; injury to organs during or after acupuncture; other discomfort such as fatigue, or sleeplessness after the acupuncture.The secondary outcomes includeFor the studies from China used “Criteria of diagnosis and therapeutic effect of diseases and syndromes in traditional Chinese medicine” to report outcomes based on a fuzzy assessment such as “cured,” “improved,” and “failed” will be excluded.2.22.2.1http://www.clinicaltrials.gov) and International Clinical Trials Registry Platform . Besides, before this review will be finished, we will search each database and registration plat once again to ensure the latest study could be included .The search strategy of Chinese, English, and Japanese will be developed by ZQ, JT, and SX, the search strategy of Korean will be developed by T-HK. The following databases will be searched from their inception to January 2017: the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Chinese Biology Medicine disc, Wan-Fang Data, China National Knowledge Infrastructure, Citation Information by National Institute of Informatics, Oriental Medicine Advanced Searching Integrated System by Korea Institute of Oriental Medicine, and Japanese database Science and Technology Information Aggregator (J-stage). In addition, we will also search other electronic sources of trial registries, including Clinicaltrials.gov  will screen the title and abstracts of the articles independently to confirm that the trials included are eligible. If necessary, the full text will be scanned. We will use Endnote X7  software to manage the trials that have been searched and remove duplicates. Any disagreement with the selection will be discussed and judged by an arbiter (ZL). The details of the selection process are shown in Fig. 2.3.2http://links.lww.com/MD/B535), including general information , study characteristics, eligibility criteria, interventions, outcome measurements, duration, adverse events, results, and type of needle used. Any disagreements will be discussed and judged by an arbiter (ZL or T-HK).For different language database, 2 review authors (same as “Selection of studies” section) will independently extract the data. Before beginning extraction, a consistency assessment between these 2 authors will be performed through a pilot test, in which each of them will evaluate 2 trials, respectively. After a common consensus is reached, we will use a predefined extraction form to collect data from included trials  will independently evaluate the quality. The result of the consistency assessment will be presented with Kappa statistics. Kappa value <0.75 will be considered that the 2 authors are consistent. The evaluation of the trials’ quality will cover 7 aspects: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other bias. Additionally, we will use the GRADEpro software of Cochrane Systematic Reviews to create a Summary of Findings Tables, and the Summary of Findings Tables will be integrated in the RevMan. For nonrandomized study, we will use Newcastle–Ottawa Quality Assessment Scale (NOS) for assessing the observational study (including cohort studies), or methodological index for nonrandomized studies (MINORS) for assessing the nonrandomized interventional study.,35 Any disagreements will be discussed and judged by an arbiter (ZL or T-HK).The Cochrane Collaboration tool for assessing the risk of bias will be used to facilitate the assessment of risk of bias for the included RCTs.2.3.4If there are cross-over trials, we will only analyze the data from the first period. When there are more than 2 arms in 1 trial, we will choose data of the arm that meet our inclusion criteria for data synthesis. If there are multiple observations, we will extract the short-term effect (at the end of treatment) and long-term effect (at the end of follow-up) for analyzing.2.3.5 When studies reported standard errors, t-statistics, or P values without standard deviations (SDs), we will transform them into SDs. For the trials meet our inclusion criteria without available date, we will only provide the characteristics in the supplementary without data extraction and synthesis.Review authors who are responsible for different language databases will make every effort to obtain the missing information from the trials including sending emails or calling the authors to ask for the missing data. For trials that provide data of baseline and end-point without change value, we will estimate the approximate value of changes using the methods recommended in the Cochrane Handbook.2.3.62 statistic to test clinical heterogeneity. Variability factors included in the trials will be taken into consideration . I2 ≥ 50% will be considered indicative of substantial heterogeneity among the trials, and we will explore the source of the heterogeneity from the design of trials and characteristics in the included trials through conducting sensitive analysis or subgroup analysis.We will use Higgins I2.3.7We will use Funnel plot to assess the reporting bias if a sufficient count of the included RCTs is available .2.3.82 value. The dichotomous data will be determined by using relative risk with 95% confidence interval (CI), and continuous outcomes will be analyzed using standard mean difference with 95% CI. For each outcome, we will initially assume that each meta-analysis comparing acupuncture group and control group has its own heterogeneity variance parameter τ2 using fixed-effects model. When the heterogeneity is significant, we will use a random-effects model. When we meet the situation that quantitative synthesis is not appropriate such as insufficient RCTs or significant heterogeneity that cannot be identified, we will provide systematic narrative synthesis to describe the characteristics and findings of the included trials. For nonrandomized study, the data will not be combined, as it may result in inestimable heterogeneity due to clinical and methodological differences. However, we will generate visual results of forest plots to present the data from different studies to show the direction and magnitude of effects.We will use the RevMan V.5.3.4 to perform meta-analysis for RCTs included if studies are sufficiently homogeneous in terms of design and comparator, we will explore the homogeneous from following aspects: The clinical homogeneous, which will be judged by professional and experienced assessor and described in the characteristic summary table; the second respect is methodological homogeneous, which will be assessed by the Cochrane Q-test and quantified with I2.3.9Sensitivity analysis will be performed to assess whether there is significant heterogeneity, we will exclude trials rated as low or unclear risk of bias in the allocation concealment domain and then reassess the before and after outcome from the data synthesis to observe the heterogeneity in the synthesis of remained trials. Furthermore, we will use subgroup analysis to explore the sources of heterogeneity in following fields: the data from the participants with FD and those with IBS-D will be analyzed separately after data combination; duration of intervention will be considered, we will classify the trials into 2 subgroups based on the treatment duration. Additionally, if the number of included trials is available , meta-regression analysis will be conducted using Stata software version 12.0  to explore sources of heterogeneity.3 In addition to pharmacological treatment, there are some complementary and alternative approaches that may be effective to gastrointestinal disease.,38 Studies have indicated that acupuncture has effects on some digestive system diseases.,39The cause of FD and IBS-D is still unclear and there are few specific treatment aside from symptomatic management to prevent electrolyte and water loss. Numerous pharmacologic treatments can be used in these patients; however, comparative studies establishing a hierarchy of cost–benefit and a sequence of use of such agents are still lacking. However, the measurement of effective rate used in this study is assessment of global improvement instead of subjective outcomes such as stool frequency. Another systematic review of IBS reported that acupuncture is not superior to sham acupuncture on IBS symptom severity or IBS-related QoL. But this review did not separate IBS-D from constipation predominant IBS, and did not provide a subgroup analysis of IBS-D as well, which might not reveal the effectiveness of acupuncture for IBS-D adequately. It is hard to distinguish FD and IBS-D absolutely in the clinical practice for the considerable overlapped symptoms between them. Acupuncture might manage the symptoms of diarrhea through regulating the bowel motility, and the mechanism of acupuncture treatment for FD and IBS-D might be similar. Owing to the study focus on both FD and IBS-D is rare, the conclusion that if acupuncture could be an optional treatment for FD and IBS-D is still unclear.One systematic review reported that acupuncture might be more effective than drugs on treating FD from total effective rate, antidiarrheal time, and symptom total scores aspects.Therefore, we aim to conduct this systematic review to assess the effectiveness and safety of acupuncture in the treatment of FD and IBS-D. Besides, considering the insufficient amount of potential RCTs, we will also include nonrandomized study that meet our criteria set in advance, in order to provide a visual representation of results to show the direction and magnitude of effects; thus, the results could be more enriched. We will generate an assessment table using NOS and MINORS to evaluate the quality of included nonrandomized study. We hope that this systematic review can provide a convincing conclusion and summarize the evidence on the effectiveness and safety of acupuncture on this disorders for clinicians, patients, and health policy conductors.


Internet-accessed sexually transmitted infection testing (e-STI testing) is increasingly available as an alternative to testing in clinics. Typically this testing modality enables users to order a test kit from a virtual service (via a website or app), collect their own samples, return test samples to a laboratory, and be notified of their results by short message service (SMS) or telephone. e-STI testing is assumed to increase access to testing in comparison with face-to-face services, but the evidence is unclear. We conducted a randomised controlled trial to assess the effectiveness of an e-STI testing and results service  on STI testing uptake and STI cases diagnosed.P < 0.001). The proportion of participants diagnosed was 2.8% in the intervention group versus 1.4% in the control group . No evidence of heterogeneity was observed for any of the pre-specified subgroup analyses. The proportion of participants treated was 1.1% in the intervention group versus 0.7% in the control group . Time to test, was shorter in the intervention group compared to the control group , but no differences were observed for time to treatment . We were unable to recruit the planned 3,000 participants and therefore lacked power for the analyses of STI diagnoses and STI cases treated.The study took place in the London boroughs of Lambeth and Southwark. Between 24 November 2014 and 31 August 2015, we recruited 2,072 participants, aged 16–30 years, who were resident in these boroughs, had at least 1 sexual partner in the last 12 months, stated willingness to take an STI test, and had access to the internet. Those unable to provide consent and unable to read English were excluded. Participants were randomly allocated to receive 1 text message with the web link of an e-STI testing and results service (intervention group) or to receive 1 text message with the web link of a bespoke website listing the locations, contact details, and websites of 7 local sexual health clinics (control group). Participants were free to use any other services or interventions during the study period. The primary outcomes were self-reported STI testing at 6 weeks, verified by patient record checks, and self-reported STI diagnosis at 6 weeks, verified by patient record checks. Secondary outcomes were the proportion of participants prescribed treatment for an STI, time from randomisation to completion of an STI test, and time from randomisation to treatment of an STI. Participants were sent a £10 cash incentive on submission of self-reported data. We completed all follow-up, including patient record checks, by 17 June 2016. Uptake of STI testing was increased in the intervention group at 6 weeks  is increasingly available. Yet the effectiveness of e-STI testing compared to face-to-face services is unclear.We conducted a large randomised controlled trial in London, United Kingdom, to assess the effects of an e-STI testing and results service (SH:24) on uptake of STI testing and STI cases diagnosed and treated, when delivered alongside usual care.The intervention offered postal self-sampling test kits for chlamydia, gonorrhoea, HIV, and syphilis, results delivered via text message or telephone, and web-based safer sex health information.We found that e-STI testing almost doubled uptake of testing among all groups, including groups at high risk for STIs.A larger study is required to understand the effects of e-STI testing on STI diagnosis and STI cases treated.Further research is required to evaluate the proportion of those diagnosed who are treated. Our findings suggest that additional inputs may be required to strengthen linkages to treatment .e-STI testing should be considered as a complement to existing services and as an effective measure to increase uptake of STI testing.The effect of e-STI testing on cases diagnosed and treated requires further evaluation. Sexually transmitted infections (STIs) continue to be a global public health concern, with an estimated 357 million new infections of curable STIs  each year . In EnglLeft undiagnosed and untreated, curable STIs such as chlamydia, trichomoniasis, gonorrhoea, and syphilis can facilitate the transmission of HIV and can cause sub-fertility, ectopic pregnancy, chronic pelvic pain, neurological and cardiovascular disease, neonatal mortality, and infant morbidities . Undiagn3) [Increasing testing, diagnosis, and treatment of STIs and reducing time to treatment is a global priority to reduce the prevalence of STIs and their associated sequelae ,8. In thDigital technologies are increasingly utilised to deliver sexual health interventions  ,12. These-STI testing may bypass the inconvenience and stigma associated with face-to-face services ,16, and Public sector providers in the UK, Canada, the United States, Australia, and some European countries offer e-STI testing to high-risk groups –26. Yet We carried out a single-blind randomised controlled trial of an e-STI testing and results service. The trial was conducted in London, UK, and participants were recruited between 24 November 2014 and 31 August 2015. Ethical approval was obtained from the National Research Ethics Service (NRES) Committee London–Camberwell St Giles (Ref 14/LO/1477). The trial protocol was accepted for publication in April 2015 and was published in January 2016 ,28.Young people aged 16 to 30 years of age, resident in the London boroughs of Lambeth and Southwark, sexually active , with stated willingness to take an STI test, and with access to the internet were eligible for inclusion. People who were unable to read English (the websites were only in English) or unable to provide consent were excluded.We recruited in community settings to reach individuals who may not use conventional STI testing services. We utilised both face-to-face and online recruitment strategies. We promoted the trial in universities, further education colleges, market stalls, barber shops, bars, and nightclubs in South East London and via Facebook, Twitter, and Grindr . Advocacy and health promotion groups advertised the trial among their networks. The study was promoted in conjunction with a health promotion message, to motivate participants to join the trial and consider taking an STI test.Research assistants assessed eligibility, provided study information, obtained written consent, and collected baseline data. Alternatively, participants read the information, entered their eligibility data, provided online consent, and entered their baseline data on the trial website. An independent computer-based randomisation programme allocated participants to the intervention or control group. Participants were sent 1 automated SMS text message with the uniform resource locator (URL) of the intervention or control STI services according to their allocation.The randomisation system utilised a minimisation algorithm balancing for gender , age , number of sexual partners in last 12 months , and sexual orientation . All factors had equal weight in determining marginal imbalance. To minimise imbalances on these selected factors, allocation was weighted towards the underrepresented group using a probability of 0.8. In the case of equal representation, participants were allocated by simple randomisation in a 1:1 ratio. Laboratory staff and researchers assessing outcomes were blinded to the treatment allocation.All participants were sent 1 text message inviting them to get an STI test see .Control text message:You have been invited to use a clinic-based sexual health service.https://text4health.lshtm.ac.uk/trials/UI/public_htm/info/clinic.aspx to obtain your free STI test at a walk-in sexual health clinic.Please visit If you have problems accessing this link, please text ‘HELP’Intervention text message:You have been invited to use an internet-based sexual health service.https://sh24.org.uk/betatester to order your free STI test online.Please visit Please do not share this link with anyone.If you have problems accessing this link, please text ‘HELP’If participants contacted the research team to say they had difficulty accessing the URL, they were resent the text message.https://www.sh24.org.uk). SH:24 offers free postal self-sampling test kits for chlamydia, gonorrhoea, HIV, and syphilis. Participants who ordered a test kit from SH:24, were required to complete a short order form. Those reporting STI symptoms were advised via a pop-up message to visit their local clinic for immediate treatment. Those reporting complex needs such as depression, drug and alcohol dependency, or exploitative sexual partnerships were telephoned by a clinician and referred to relevant clinical services. All participants could continue to use the online service if they wished.Participants in the intervention group were sent a text message with the URL of SH:24  of sexual health clinics in Lambeth and Southwark. These clinics provided usual care via walk-in services. Some clinics also offered an appointment service for those with symptoms or complex needs. Those diagnosed with an STI were asked to attend clinic for treatment. All participants were free to use any other sexual health services or interventions during the trial period. We used evidence-based methods to maximise response rates .Our co-primary outcomes were self-reported diagnosis of an STI at 6 weeks, confirmed by patient health records, and self-reported completion of an STI test at 6 weeks, confirmed by patient health records. We defined completion of an STI test as samples processed by the laboratory and results delivered to SH:24 or to clinic.Nucleic acid amplification tests (NAATs) were used to detect chlamydia and gonorrhoea in all services. In the online service, positive gonorrhoea results were confirmed using a second NAAT . Syphilis IgG/IgM was assessed , and HIV I and II/p24Ag were assessed . Reactive results for HIV or syphilis were counted as positive test results only when confirmed by assays in clinic. We defined STI diagnoses as those arising from laboratory testing.Our secondary outcomes were the proportion of participants prescribed treatment for an STI, time from randomisation to completion of an STI test, and time from randomisation to treatment of an STI.Our process outcomes were the proportion of STI tests that were positive in each group, median time from diagnosis to treatment in each group, the proportion of participants who completed an STI test in each group by service type, the proportion of participants diagnosed in each group by service type, and, in the intervention group only, the proportion who agreed that the intervention was acceptable and the proportion who adhered to an appropriate e-STI testing pathway. All pathways were considered appropriate unless participants completed a test via SH:24, received a negative result, and then retested for the same STI in a face-to-face setting within 6 weeks. In addition to our pre-specified process outcomes, we report the proportion of participants who tested positive for an STI among those who completed a test at 6 weeks, with 95% confidence intervals. All outcomes and their definitions are summarised in Participants provided self-reported data by post or directly entered data on a website. Participants were sent £5 with a request to complete a follow-up questionnaire and an additional £5 on receipt of the completed questionnaire.To obtain objective measures for our endpoints, we searched the SH:24 database, and data managers at the hospital trusts searched patient record databases, for all randomised participants using either (1) mobile phone and gender or (2) name and date of birth as identifiers. If participants reported using another service , we contacted the service to collect STI testing, diagnosis, and treatment data.The trial steering committee approved the pre-specified statistical analysis plan prior to unblinding. Our study was powered for our co-primary outcome of the proportion of participants diagnosed with an STI in each group ,28. Two We anticipated that not all of the intervention group would order a test kit. We estimated that 30% would not complete this first step. Among the 70% who ordered a kit, we assumed that 50% would return the kit for analysis (based on return rates of an e-STI testing service in the London borough of Greenwich).There were no available data that would give us an estimate of the likely number of individuals who would complete an STI test in the control group. We assumed that fewer people (10%) would seek a test in clinic-based settings.We based our STI prevalence estimates on the proportion of positive chlamydia tests among 15–24-year-olds in general practice settings in Lambeth and Southwark, which was 6% in 2012 . We baseA sample size of 3,000 participants would lead to 90% power  to detect a relative risk (RR) of 3.5 (2.1% risk of diagnosis in the intervention group versus 0.6% risk of diagnosis in the control group), allowing for 10% loss to follow-up. This equates to 10% of the control group being tested, with a 6% probability of infection as in general practice settings, and 35% of the intervention group being tested, with a 6% probability of infection as in general practice settings.With regard to our other co-primary outcome measure, 3,000 participants would lead to 99% power  to detect an absolute difference of 25% in the proportion of participants who completed a test in the intervention group versus the proportion who completed a test in the control group (35% versus 10%).All analyses were undertaken on an intention to treat basis with Stata version 14.2. Effect measures were RRs with 95% confidence intervals and time to outcomes. We assessed overall heterogeneity for subgroups by summing the individual chi-squared statistics and their degrees of freedom to 1 overall chi-squared test on the sum of the degrees of freedom at a 5% level of significance.For the primary analysis we used multivariate imputation by chained equations (MICE) to correct for any potential bias caused by missing data, assuming data are missing at random (MAR). Under this assumption, the distribution of the outcome for both missing and non-missing groups is the same for individuals with the same observed data. All baseline data were complete, except for sexual orientation, for which a missing category was used.To obtain more precise estimates and confidence intervals with the correct coverage, we accounted for baseline factors by estimating the propensity score for randomised allocation for all participants . We usedWe imputed our 2 co-primary outcomes (STI testing and STI diagnosis) and the secondary outcome proportion of participants prescribed treatment using 3 conditional models. Each imputation model included randomised group as a covariate and was weighted by the inverse of the estimated propensity score . In addition, the 2 models to impute STI testing and STI diagnosis conditioned on self-reported testing, self-reported diagnosis, and self-reported treatment. The model to impute treatment conditioned on self-reported testing and self-reported treatment only, due to collinearity with other variables, which led to non-convergence. Each imputed data set was produced with 10 cycles. We generated 100 imputed data sets for each missing outcome. Multiple imputation inference proceeded via Rubin’s rules .To explore departures from MAR assumptions for our co-primary outcomes, we performed a sensitivity analysis to explore the impact of possible differences between participants with complete outcome data and participants with missing outcome data. We multiply imputed missing outcome data, using inverse probability weighting on the estimated propensity score and with allocated group and self-reported testing, diagnosis, and treatment as covariates. The odds of STI diagnosis and the odds of a completed STI test for missing participants were varied to be 1/4, 1/2, 1, 2, and then 4 times as large as the MAR analyses; this was done factorially for the 2 randomised groups, giving a total of 25 analyses .We explored heterogeneity of the intervention effect on our primary outcomes. We tested for interaction at a 5% level of significance to assess whether effectiveness varied by gender , ethnicity , sexual orientation , age group , number of sexual partners , SH:24 availability , and Index of Multiple Deprivation rank (linear). The Index of Multiple Deprivation is a relative measure of deprivation that ranks every small area in England from 1 (most deprived area) to 32,844 (least deprived area) .These analyses were conducted in the complete cases under a MAR assumption. They were not weighted by the inverse of the estimated propensity score, as specified in the analysis plan, due to non-convergence of the models.t* = 6 weeks (42 days) for time to test and t* = 3 months (84 days) for time to treatment using a ‘3df/1df’ Royston–Parmar model [We used survival analysis to estimate time from randomisation to test completion and time from randomisation to treatment. We estimated the restricted mean survival time (RMST), which is a meaningful measure even when the proportional hazards assumption is in doubt. As with other analyses, the RMST accounted for covariates by weighting on the inverse of the estimated propensity score. We set the restricted mean time ar model .In all, 2,072 participants were randomly assigned to the SH:24 online testing and results service or to the control group . We exclPrimary outcome data, prior to multiple imputation, were available for 921 (89%) participants in the intervention group and 818 (79%) in the control group .The proportions of participants in each group who reported completing a test at 6 weeks, and who were confirmed to have tested via patient record checks, are provided in P < 0.001; P = 0.079; Our primary analyses were based on multiply imputed data sets. In all, 1,031 in the intervention group and 1,032 in the control group were included in the analyses. At 6 weeks, 50.0% of the intervention group had completed an STI test compared to 26.6% in the control group  tested positive for an STI in the intervention group and 4.6%  tested positive for an STI in the control group. The median time from diagnosis to treatment among those with complete treatment data was 2 days in the intervention group and 4 days in the control group . Four ofThree participants in the intervention group tested via SH:24, received a negative result, and retested in clinic for the same STI within 6 weeks .Regarding intervention acceptability, 76% (294/388) of participants in the intervention group who tested via SH:24 provided acceptability data. Of these, 71% (209/294) found the intervention to be acceptable .In all, 88% (388/439) of participants in the intervention group who completed an STI test at 6 weeks tested via SH:24 . NineteeIn the intervention group, 2.8% (12/432) of chlamydia tests were positive, 1.4% (6/433) of gonorrhoea tests were positive, and 0.8% (3/363) of syphilis tests were positive. In the control group, 2.4% (4/169) of chlamydia tests were positive, 3% (5/169) of gonorrhoea tests were positive, and none of the 137 (0/137) syphilis tests were positive.In all, 365 participants tested for HIV in the intervention group, and 140 in the control group. There were no confirmed HIV diagnoses. One participant tested for hepatitis B in the intervention group, and 11 in the control group. There were no hepatitis B diagnoses in either group.Among participants who were diagnosed with an STI, most (24/27) were diagnosed with a single STI, and 3 with more than 1 STI.When STI testing is promoted, offering e-STI testing alongside usual care significantly increases uptake of STI testing. The intervention increased STI testing in all groups including those at high risk for STIs. We lacked power for the analyses of STI diagnoses and STI cases treated, but our estimates are in the expected direction. The intervention reduced time to test but not time to treatment.This study has several strengths. We used an independent, remote computer-based randomisation system to ensure study staff had no prior knowledge of the treatment allocation. We collected objective outcomes even for those participants who tested outside of Lambeth and Southwark or via a different pathway . Laboratory staff and researchers carrying out the analyses were blinded to the allocation. Baseline prognostic factors were well balanced between groups, and our co-primary outcomes were known for 84% of participants. In trials where it is not possible to blind participants, allocation to the control group could reduce motivation to carry out the desired behaviour. To mitigate potential performance bias, participants were informed at the time of recruitment that they would be invited via text message to use one type of sexual health service without stating the options. All analyses were intention to treat.We successfully recruited high-risk groups including MSM , 16–24-year-olds , and individuals reporting 2 or more sexual partners in the last year . We enrolled individuals who reported limited prior contact with conventional STI testing services. A quarter of our study population had never tested for STIs prior to the trial  . In all,Our trial has a number of limitations. We fell short of our recruitment target of 3,000 participants, and we were unable to extend the recruitment period due to a pre-existing plan to promote SH:24 widely across the study area. As a result, the study lacked power to detect differences in STI diagnoses and STI cases treated. As with other online enrolment systems , a high It is likely that those who enrolled in the study had a greater interest in STI testing than those who declined. Testing uptake in the control and intervention groups in all trials may be higher than in the general population. This could result in a smaller risk difference if the intervention were to be implemented in the general population. In all, 26% of our study population identified as BME at baseline. This is lower than the proportion of individuals in Lambeth and Southwark identifying as BME , whiWhile there is some reporting bias in the self-reported data , the potAt enrolment, participants were informed that the £10 incentive was for completing follow-up, but some participants later reported that they thought it was for completing an STI test. Given that all participants were told about the £10 incentive, and sent money at follow-up, the impact of this incentivisation should be non-differential and would not explain our statistically significant results.Although the laboratory tests used by services are highly sensitive and specific, some misclassification is possible. This misclassification could have biased our STI diagnosis results towards the null. We randomised 8 people twice and excluded them from the analyses. It is possible that we randomised other people twice but only if they provided an incorrect name and date of birth. All service providers were motivated to record STI testing data in line with national surveillance requirements. If some providers were more accurate than others, this might result in differential misclassification and bias.Although we achieved high response rates for our co-primary outcomes, these rates were differential as we achieved higher follow-up in the intervention group than in the control group. This can result in biased estimates under a complete case approach . To dealTo our knowledge, this is the first trial of an e-STI testing service that offers testing for 4 STIs . Descriptive studies from the US suggest that services that offer internet-based testing for chlamydia, gonorrhoea, and trichomoniasis can attract at-risk populations (young and BME groups) and yield high STI positivity ,44. One Our finding of increased STI testing uptake with e-STI testing is similar to increases in testing reported in trials of self-sampling and self-testing interventions that are not accessed via the internet ,47.The theory of change underpinning SH:24 proposes that online diagnostic pathways will increase testing uptake as they are convenient, private, and non-judgemental and offer more choice than traditional clinic pathways .The similar effect of e-STI testing on STI testing uptake across different population groups is of public health importance as it suggests a potential to increase testing among those most in need. Moreover, higher proportions of participants in the intervention group tested for all infections, including HIV and syphilis, compared to the control group.Seven of the 19 participants diagnosed in the intervention group were diagnosed in a sexual health clinic. This highlights the continued importance of face-to-face services and is consistent with the theory of change, which proposes that e-STI testing offers patients more choice.While our findings are in line with the proposed theory of change, they provide little evidence regarding the mechanism of action. Qualitative research is underway to explore participants’ experiences of using the intervention and their views on how it may have worked. These findings will be reported separately.National guidelines in the UK recommend increasing testing among key population groups, and in areas of high HIV prevalence, in order to detect asymptomatic infection and normalise testing practices ,19. Our e-STI testing is currently being implemented in the UK as one measure to meet increasing demand for STI testing against a backdrop of severe budget cuts ,49. PublThe effect size for STI cases treated was lower than for STI diagnoses, as we were unable to confirm if all those diagnosed were treated. At the time of the trial, SH:24 required those diagnosed with an infection to attend clinics in person for treatment. Attendance at clinic for treatment was confirmed for 11 of 19 participants diagnosed with an STI in the intervention group and 7 of 8 participants diagnosed in the control group. Some participants may have obtained treatment outside the study area, but as they did not state where they were treated, we were unable to verify this. The intervention did not reduce time to treatment.It is plausible that whilst the intervention removed the barrier of having to attend a clinical service for testing, the subsequent requirement to attend clinic for treatment may have deterred some participants. Additional inputs are required so that increases in STI testing and STI diagnoses translate into similar increases in cases treated. This is likely to ensure that the potential public health benefits of e-STI testing can be fully realised.We trialled SH:24 in a community setting, in 2 boroughs well served by face-to-face clinical services. Providing e-STI testing in contexts where supply is more limited, or targeting particular high-risk groups, might strengthen the contribution of e-STI testing to the control and management of STIs.e-STI testing models could be adapted for countries with sufficient laboratory facilities. Established distribution channels for health products may be suitable for sending and receiving test kits, where postal services are limited. Future iterations of e-STI testing could include a wider range of services such as self-testing for HIV. Self-testing differs from the self-sampling modality evaluated by this study. Self-testing enables individuals to take a sample, perform a test, and interpret the results by themselves, without the need of a laboratory .Delivering e-STI testing and results services to scale is technically feasible as demonstrated by SH:24, which currently delivers 42,000 tests per year in 6 regions in the UK. The long-term public health benefits of e-STI services will depend on testing, diagnosis, and treatment rates when implemented. These outcomes should be subject to ongoing monitoring and evaluation.S1 Data(XLS)Click here for additional data file.S1 Fig(PPTX)Click here for additional data file.S2 Fig(PDF)Click here for additional data file.S3 Fig(PDF)Click here for additional data file.S4 Fig(PDF)Click here for additional data file.S5 Fig(PDF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 TableComparison of analyses based on multiple imputation (MI) and analyses in the complete cases.(PPTX)Click here for additional data file.S3 Table(PPTX)Click here for additional data file.S1 Text(PDF)Click here for additional data file.S2 Text(PDF)Click here for additional data file.S3 Text(DOC)Click here for additional data file.


Gastric cancer (GC) has a poor prognosis with wide variation in survival rates across the world. Several studies have shown premalignant lesions gastric atrophy (GA) and intestinal metaplasia (IM) influence gastric cancer risk. This systematic review examines all available evidence of the risk of GC in patients with GA or IM and explores the geographical variation between countries.EMBASE, MEDLINE, Web of Science and the Cochrane Library were searched for relevant articles published to June 2016 investigating the risk of GC in individuals with GA or IM. Analysis was performed to determine variation based on geographical location. Study quality was assessed using the Newcastle-Ottawa Scale and heterogeneity between studies was also evaluated.Fifteen relevant articles were identified, in which there were eight studies of GC incidence in GA and nine in IM cohorts (two articles investigated both GA and IM). The incidence rate of GC in patients with GA ranged from 0.53 to 15.24 per 1000 person years, whereas there was more variation in GC incidence in patients with IM (0.38 to 17.08 per 1000 person years). The greatest GC incidence rates were in Asian countries, for patients with GA, and the USA for those with IM . The largest studies  had an incidence rate range of 1.0–2.5 per 1000 person years, however, in general, study quality was poor and there was marked heterogeneity.Overall there is a wide variation in annual incidence rate of GC from premalignant lesions. With the recent introduction of surveillance guidelines for gastric atrophy and intestinal metaplasia in the Western world, future assessment of this risk should be performed. Furthermore, substantial heterogeneity supports the need for more robust studies in order to pool results and determine the overall incidence rate of gastric cancer for patients with these premalignant lesions.The online version of this article (10.1186/s12876-017-0708-4) contains supplementary material, which is available to authorized users. H. pylori), the most common contributing factor to GC, [H. pylori, chronic inflammation of the stomach mucosa results in atrophic changes, including loss of structured glandular cells, which are replaced by intestinal-type epithelium, pyloric-type glands and fibrous tissue [Gastric cancer (GC) is the fifth most common malignancy and third leading cause of death from cancer worldwide . There ir to GC,  in theses tissue . The ress tissue , 7.Studies have shown a significantly increased risk of GC in patients with either GA (5.8 times the risk of GC compared to patients without GA) . SeveralTo date, one systematic review has been published on the risk of GC in patients with GA, which used a serological method for diagnosis of these lesions . The aimThis systematic review was conducted in line with PRISMA guidelines  and the Independent screening of the titles and abstracts was conducted by the corresponding/first author (ADS) and one co-author  to determine eligibility for inclusion. A further search was conducted by hand searching reference lists of included studies. At each stage of the review process, discrepancies were resolved by discussion with a third author.Studies were eligible for inclusion if they were observational cohort or interventional study designs. The study patients must have been adults who had a histological diagnosis  of GA or IM at endoscopy. Studies were required to have a minimum of 100 cases of GA or IM, and to report the incidence rate of GC and 95% confidence intervals (CI), or provide enough information to allow these to be calculated. In the original protocol, studies which included GC cases within 6 months of GA/IM were to be excluded from the review , however this was used as a criteria in the study quality assessment rather than exclusion criteria. In the instance where two studies may be included but used the same sample population we will select the study with the longest follow-up/the one which allows us to calculate the incidence rate of GC.A data extraction form was developed following piloting on five included publications. Data were extracted from all included studies and statistical risk estimates were verified. Where available, data were extracted from included studies on characteristics of study participants , follow-up period , number of GC and GA or IM cases, proportion of participants who were H. pylori positive, identification and verification methods to determine GC and GA/IM cases.Quality of individual studies was assessed using a modified version of the Newcastle-Ottawa Scale . Two secThe primary summary measure to describe risk of GC was incidence rate per year in GA or IM populations. Where the risk of progression of GA or IM to GC was not reported, person-years were calculated using the number of participants multiplied by mean follow-up in years. In five studies the mean was not reported and therefore the median follow-up was used instead , [Review Manager 5.3  was used to present, graphically, the incidence rates in each study. It was planned overall meta-analysis for pooled incidence rate would be performed, and sensitivity analyses conducted, as per our protocol. This included subgroup analyses by geographical study location, age and sex of participants. Additional subgroup analyses, including GA/IM location, tumour site and histological subtype were also planned but too few studies reported on these to facilitate analyses. However, due to high clinical heterogeneity between studies ,  the resuAs shown in Fig. I2 statistic of 94%), which precluded calculation of a pooled estimate.The total number of patients in the GA cohorts was 19,749, in who 261 progressed to GC over a total of 171,170 person-years of follow-up . The range of GC incidence in patients with GA was from 0.53 to 15.24 per 1000 person-years, as shown in Fig. I2 statistic of 93%) between studies of IM patients, therefore a pooled estimate was not calculated.There were a total of 18,800 patients in the IM cohorts, in who 193 developed GC over a total of 118,237 person-years of follow-up . The range of GC incidence in patients with IM was from 0.38 to 17.08 per 1000 person-years . There was a lack of detail regarding methods used to recruit patients for endoscopy, with only three studies reporting their techniques. Furthermore, there was a substantial variation in the amount of person-years follow up, ranging from 232 (which detected no gastric cancer cases) to 115,583. Of note, the studies producing the more extreme results had significantly less follow up than other studies , which may have contributed to the wide range in incidence rates results. Takata et al. showed a much higher incidence rate than other studies (15.2 per 1000 person-years), a cause for which may include the outcome source . This arSimilar to the studies of GA, two of the nine studies in the IM cohorts had extreme incidence rates (0.38 and 17.08 per 1000 person-years), , 27 wherDespite the significant increase in 5-year survival from GC in Japan, attributed to introduction of GC surveillance methods, a 2009 report indicated that introduction of such a programme was not feasible in the UK, . This isConsistent with published literature, we found study location impacted the rate of transformation to GC . PatientH. pylori is the most common risk factor for GC development, often resulting in atrophy of the gastric mucosa, commencing a cascade toward carcinoma [H. pylori infection as those that included this risk factor in analysis described its prevalence but not adjustment in GC incidence calculation. Therefore, due to the prominent role H. pylori bacteria has in carcinogenesis, [H. pylori infection when determining GC incidence in patients with GA or IM.arcinoma . We weregenesis,  further A recognised limitation of systematic reviews includes the impact of demographic and within/between study methodology variation . FurtherIn conclusion, this systematic review has shown the incidence rate of progression from GA and IM to GC varies by study geographical location. We also highlight the substantial heterogeneity between studies and that more robust studies are required so that reliable pooled estimates can be calculated. As this disease has a poor prognosis and is a common cause of death from cancer, influenced by its advanced stage at diagnosis, further research in this area is of importance.Additional file 1: Table S1.Terms and database search strategy used in MEDLINE for systematic review. (DOCX 41 kb)Additional file 2: Figure S1.Funnel plots to show potential publication bias for GA (left) and IM (right). (PNG 100 kb)


Objective. Mechanism of action of cosmetic products is not often studied. The aim of this study is to determine the histological, immunohistochemical, and clinical changes of a new cosmetic formulation. Methods. Prospective, single-blind, patient-controlled, randomized study in 10 volunteers with mild to moderate skin photoaging on the back of their hands. The product was applied on one hand and a standard cream on the other hand, twice a day for three months. Standardized photographs were taken on basal (T0) and final visit (T1) and skin biopsies were performed. Changes on histological and immunohistochemical markers were studied. Subjective clinical changes were determined. Results. After treatment, a 26.3% improvement on epidermal thickness was detected and a significant increase on collagens I and III, elastin, and fibronectin fibers was achieved (p < 0.05). As the expression of MMPs remained stable, this improvement of dermal matrix was attributed to the stimulation of their synthesis. A significant clinical improvement on the treated hand was obtained, compared to control hand. Conclusion. This new cosmetic product with combination of three registered technologies , focused on regenerating dermal matrix and activating proliferation of skin cells, has shown to be efficient in the reversion of skin photoaging. There are two basic types of skin aging, namely, intrinsic and extrinsic aging. The former, also called chronological aging, is related to telomere shortening and to the accumulation of reactive oxygen species (ROS), mainly generated by mitochondrial metabolism, which the cells are unable to neutralize . Slight Aged skin is microscopically characterized by cellular senescence, which determines a decrease in the proliferation and physiology of keratinocytes and fibroblasts. This results in decreased epidermal renewal and reduced synthesis of dermal extracellular matrix (ECM) components, such as collagen and elastin. Additionally, degeneration of the ECM is accelerated due, in part, to the increased expression of metalloproteinases (MMPs), mainly MMP-1 and MMP-3 , 5.A new product has recently been designed based on a combination of three technologies, each of which tackles a clinical sign of photoaging, thus trying to provide a global approach to this skin condition: IFC-CAF (Cellular Activating Factor), WGC (Wharton Gel Complex), and RetinSphere.Mechanism of Action of the Different Technologies of the Study ProductRetinSphere TechnologyNormalization of epidermal proliferation and follicular keratinizationAnti-inflammatory propertiesEnhancing penetration of productsIFC-CAFAntioxidant effectsProliferation and migration of cutaneous stem cells, keratinocyte cells, and fibroblasts.Stability of DNAWGCAntioxidant effectsProliferation and migration of fibroblastsSynthesis collagens I, III, and VII and elastin.RetinSphere encompasses the association of two topical retinoids: retinol glycospheres and hydroxypinacolone retinoate. It has anti-inflammatory properties and normalizes epidermal proliferation. In addition, it enhances the penetration of the other components of the cosmetic formulation . This inIFC-Cellular Activating Factor (IFC-CAF) is a cosmetic ingredient obtained from a lysate of the eggs of gastropods from the Helicidae family, with powerful regenerative properties, which has demonstrated to slow down stem cell proliferation [β-galactosidase, p53, and p16INK4 in senescent fibroblasts and improves cell survival after UVB irradiation and nuclear repair in HaCaT cells [feration  and to iaT cells . AdditioaT cells .Wharton Gel Complex (WGC) is constituted by a natural mixture of glycosaminoglycans (GAGs) obtained from Wharton's jelly from the umbilical cord of swine. WGC stimulates proliferation of fibroblasts and exhibits a high chemotactic activity, stimulating their migration to the site of injection, as shown through a transwell migration assay.The analysis of ECM components proved the ability of WGC to increase the levels of collagen I and fibronectin fibers, as well as the synthesis of collagens III and VII and hyaluronic synthases 1 and 3 (HAS1 and HAS3) . Thus WGThe main objective of the study was to evaluate the efficacy in improving facial photodamage of a cosmetic product containing, among others, the combination of these three active ingredients, which will be assessed by analyzing the improvement of the expression of several immunohistochemical markers.The evaluation of clinical changes, such as pigmentation and hydration, after using the product, as well as the degree of improvement perceived by investigator and patient, were deemed as secondary variables. Adverse events were monitored throughout the study.This is a prospective, single-blind, randomized study where the volunteers acted as their own comparators self-administering the product only in one hand, while applying their standard hydration regime on the other hand. The patients also acted as their own internal control before and after treatment. Ten volunteers were recruited.Women aged between 45 and 64 years.Absence of treatment on their hands in the last 3 months.No desire to get pregnant in the forthcoming months and use of contraceptives.No concomitant diseases.No administration of another topical or systemic product that may interfere with or affect the results.No allergy to the product ingredients.The treatment included the application of the new formulation (Endocare Cellage®/CellPro®—IFC SA) twice a day for three months on the dorsal area of the assigned hand for each volunteer. On the other hand, a standard cream was applied.Clinical assessment of both hands and skin biopsy of the hand that received the study product were performed at basal visit (T0) and following three months of treatment (T1). No biopsies were performed in the untreated hand for ethical reasons.At both time points, classical clinical photography was carried out with Reveal® System with RBX technology and biopsies were performed. To camouflage postbiopsy wounds at the base of the fifth metatarsal, a bandage was placed covering them, and the same was done in the same place in the contralateral hand so the evaluation remained blinded. Two different dermatologists, who were different from the one who performed the biopsies, performed clinical assessments independently.Age.Phototype.Clinical Evaluation Graduation Assessed by Patient and Investigators”). Photoaging signs that the patient should evaluate included rhytides, roughness, lack of brightness, lack of elasticity, lentigines, and desquamative lesions.Degree of hands photoaging as perceived by the patient (0 to 3) .Degree of pigmentation and hydration as perceived by the investigator (0 to 3) .Degree of improvement of photoaging as perceived by the patient (−2 to 3) .Degree of improvement of photoaging perceived by the investigator (−2 to 3) : desquamation, itching, burning, erythema, dryness, or others .The following parameters were recorded:Clinical Evaluation Graduation Assessed by Patient and InvestigatorsPigmentation and hydration by investigator were as follows: 0: none, 1: light, 2: moderate, and 3: intense.Photoaging changes described by investigator were as follows: 0: none, 1: slight improvement, 2: moderate improvement, 3: intense improvement, −1: slight worsening, and −2: intense worsening.Patient and Investigator Global Assessment were as follows: 0: none, 1: slight improvement, 2: moderate improvement, 3: intense improvement, −1: slight worsening, and −2: intense worsening.Adverse Events: Desquamation, Itching, Burning, Erythema, Dryness, and Others were as follows: 0: none, 1: moderate, and 2: intense.μM slices were cut for histological and immunohistochemical staining.The pathologist who evaluated the biopsies was not informed whether the samples were before or after treatment. Positive and negative controls were included. After paraffin fixation, 4 Biopsies were stained with hematoxylin-eosin to assess epidermal and dermal thickness and morphology.Orcein staining was performed to evaluate the expression of elastic fibers before and after treatment. Semiquantitative analysis of elastosis (0–3) and elastic fibers density in reticular dermis were assessed.Mucopolysaccharides of reticular dermis were semiquantitatively assessed (0–3) by colloidal iron staining.Immunohistochemical analysis was also performed to address the expression of several markers: CD31 , Ki67 , collagen I , collagen III , fibronectin , metalloproteinase 1 , and metalloproteinase 3 .Cells positive for these markers were quantified and expressed as positive cells/mm2 (40x), and the expression of collagen fibers and fibronectin was semiquantitatively evaluated, scoring the microscopy images from 0 (none) to 3 (high levels).p value less than 5% (p < 0.05) was considered as significant . All the calculations and tests were made by using the software SPSS, V21.0.The comparisons between the effects of the cosmetic product and the pre- and posttreatment effects were evaluated with semiquantitative or quantitative variables, depending on the immunohistochemical biomarker. For each variable in the study, a nonparametric Wilcoxon test (paired samples) was used to contrast the possible significant differences between the period after and that before treatment and between treated and nontreated side. Results are expressed as the mean ± standard deviation of each clinical and histological variable. A A total of 10 women aged between 45 and 64 years were included. All of them completed the study.The clinical and photographic analysis with RBX technology is shown in p = 0.083), was observed in the pigmentation of the treated hand compared to the untreated hand at the end of the treatment  and compared to baseline (p = 0.008), while both hands showed exactly the same hydration at baseline   .p = 0.046) , objectifying a significant improvement in the treated hand compared to untreated hand after treatment  .p = 0.004). The degree of improvement after treatment perceived by both the investigator and the patient resulted in a very significant amelioration of photoaging perception in the treated compared to the untreated hand. This improvement of the treated hand was classified as severe or moderate in 6 patients and mild in 4 of them. By contrast, in the untreated hand, neither the investigator nor the patient observed any improvement.Both patient and investigator assessment showed significant improvement of the treated hand after completing the treatment with the new product   (p = 0.093).The hematoxylin-eosin staining of the biopsies performed in the treated hand showed obvious differences in many of the samples regarding the epidermal and dermal thickness of the treated hand after treatment compared to baseline, although only epidermal thickness increased significantly. At baseline the average epidermal thickness was 94.4 = 0.008) . Howeverp = 0.007)  after treatment was 73.2% higher compared to baseline (= 0.007) .p = 0.014)  and III    was detected  (vessels/×40) to address capillarity in the biopsies, a 102.3% increase in the expression of this endothelial marker after treatment (detected .p = 0.025) compared to baseline  has demonstrated the improvement of hyperpigmentation in previous studies and therefore it may be indicated for the treatment . Even thTolerance was excellent, which is considered essential for any antiaging product to ensure a proper compliance.In conclusion, this new cosmetic combination has demonstrated that it is effective for the treatment of skin photoaging, as treatment with it achieved a significant improvement of both histological and clinical parameters. A significant proliferation and epidermal renewal were achieved, as well as replenishment of the components of the dermal extracellular matrix, including collagen, elastin, and fibronectin fibers, which altogether were manifested as a clinical improvement of several signs of photoaging.