Complete Expulsion Research Articles

Effect of Whole Bowel Irrigation for Ingested Lead-Containing Foreign Bodies: A Pediatric Case Series

Background Foreign body (FB) ingestions cause lead toxicity in pediatric patients. These ingestions result in continued lead absorption until passage or removal from the gastrointestinal (GI) tract. Whole-bowel irrigation (WBI) is frequently recommended to aid in the removal of FBs, however effectiveness of this practice is not clear. Methods We performed a retrospective chart review of pediatric patients (<18 years old) admitted for treatment of lead toxicity at an academic pediatric medical center from 1 January 2017 through 31 October 2023. We abstracted patient age, identity of ingested FB, lead concentrations, duration of WBI, maximum flow rate of WBI, success or failure of FB passage, performance and results of endoscopy, and duration of hospital stay. Results Nine cases with radiopaque FB suspected to be lead were treated with WBI. Three cases resulted in the complete expulsion of the ingested FB. Four patients underwent endoscopic removal after WBI median duration of 47.5 h (range 27–80.5 h). One patient failed to clear despite 168.5 h of WBI. Conclusion WBI did not lead to the clearance of all FBs in this series. Practitioners should consider early endoscopic removal if WBI does not result in passage of the FB within the first 48 h.

The influence of baryons on low-mass haloes

ABSTRACT The Voids-within-Voids-within-Voids project used dark-matter-only (DMO) simulations to study the abundance and structure of dark matter (DM) haloes over the full mass range populated in the standard Lambda cold dark matter cosmology. Here, we explore how baryonic effects modify these results for $z=0$ halo masses in the range $10^4$–$10^7~\mathrm{M_\odot }$, below the threshold for galaxy formation. Our main study focuses on three simulations from identical initial conditions at $z=127$, one following DMO, one including non-radiative gas, and one additionally including the baryonic physics relevant in this halo mass range (cooling and photoheating). In the non-radiative simulation, above $10^{5.5}~\mathrm{M_\odot }$, halo abundance and internal structure are very similar to the DMO simulation, and the baryon to DM ratio is everywhere close to the cosmic value. At lower mass, this ratio drops and haloes are less concentrated and less massive in the non-radiative case. Test simulations at higher resolution show this to be mainly a resolution effect; the expected drop in baryon content due to residual pressure effects only becomes substantial for $z=0$ haloes below ${\sim}10^{2.7}~\mathrm{M_\odot }$. However, gas is heated by reionization at $z=6$ in our ‘full physics’ run, and this results in almost complete expulsion of gas from all haloes in our simulated mass range. This suppresses the halo mass function by ${\sim}30{{\ \rm per\ cent}}$, lowers halo concentration, and consequently weakens the DM annihilation signal by ${\sim}40{-}60{{\ \rm per\ cent}}$.

P-387 The use of cell-free DNA analysis to identify fetal aneuploidies in early pregnancy loss

Abstract Study question Can cell-free (cf) DNA-based analysis of a maternal blood sample be used to identify presence of fetal aneuploidies in early pregnancy loss (EPL) cases? Summary answer CfDNA analysis was able to detect fetal aneuploidies in EPL cases with 73.5% sensitivity and 100% specificity. What is known already Miscarriages occur in about 10%–20% of pregnancies, and the majority occur in the first trimester. About 50% of EPL cases result from the presence of fetal aneuploidy. Knowing the etiology of a miscarriage can be helpful for future reproductive planning along with providing a psychological benefit for patients. Although products of conception (POC) samples can be collected and assessed for presence of fetal aneuploidies, this is not always possible. Recent studies have shown that a noninvasive approach using cfDNA analysis of a blood sample can identify fetal aneuploidies in patients that experience EPL. Study design, size, duration In this prospective study, samples were collected from 78 patients across the United States from June 2021–December 2022. Blood specimens were collected for cfDNA analysis and maternal cell contamination analysis, and POC samples were collected following surgical evacuation for microarray analysis. Performance of the cfDNA assay was determined by comparing results from the cfDNA analysis against the gold standard of microarray results. Participants/materials, setting, methods Patients were recruited from six reproductive endocrinology/infertility practices. Eligible participants were between 5–20 weeks of gestation with miscarriage of a singleton pregnancy diagnosed by ultrasound and presence of pregnancy tissue in utero. Limited clinical information was collected, including demographics and expected clinical gestational age (GA) at sample collection. Blood samples underwent cfDNA analysis using an adapted version of a noninvasive prenatal test, which included establishment and use of pregnancy loss-specific log likelihood ratio thresholds. Main results and the role of chance Seventy-eight patients were recruited, of which two were excluded due to blood sample collection issues. Eleven of the 76 patients that underwent cfDNA analysis were excluded from performance calculations for several reasons including maternal cell contamination of POC samples and detection of triploidy by microarray. The final 65 samples included 49 affected and 16 unaffected samples based on POC microarray results; this included 42 with one fetal aneuploidy, six with two fetal aneuploidies, and one with three fetal aneuploidies. Average fetal fraction of these 65 samples was 4.9% (range: 0.6%–13.9%) and average expected clinical GA at time of sample collection was 8.7 weeks (range: 5.9–12.1 weeks). Performance of the cfDNA assay was determined by comparing cfDNA analysis results with POC microarray results using either a full concordance approach (correct classification of all affected chromosomes in an affected sample) or a partial concordance approach (correct classification of at least one affected chromosome in an affected sample). Based on the full concordance approach, sensitivity of the cfDNA assay was 69.4% and specificity was 100%. For the partial concordance approach, sensitivity of the cfDNA assay increased to 73.5% whilst specificity remained at 100%. The cfDNA assay failure rate was 0%. Limitations, reasons for caution Study limitations include a small study cohort, the inability of the cfDNA assay to detect triploidy or partial deletions/duplications &amp;lt;7 Mb and possibly mosaicism, and that this cfDNA analysis approach can only be used for EPL cases that are identified before complete expulsion of the products of conception. Wider implications of the findings This study provides further evidence of the ability of cfDNA analysis to detect fetal aneuploidies in EPL cases. A clinically available cost-effective noninvasive approach to determine the etiology of a miscarriage could help inform medical management of patients for future reproductive planning and could provide psychological benefits to patients. Trial registration number NCT04935138

Development and Validation of an Evidence‐Based Home Pursed Lip Breathing Protocol for Improving Health Outcomes in Patients With Chronic Obstructive Pulmonary Disease

ABSTRACTAimTo develop and validate an evidence‐based home pursed lip breathing (PLB) intervention protocol for improving related health outcomes (e.g., dyspnea and exercise capability) in patients with chronic obstructive pulmonary disease (COPD) and to present a detailed intervention development process.MethodsThis home PLB intervention protocol employed phase one of the Medical Research Council (MRC) Framework for Developing and Evaluating Complex Interventions to guide the development process of the PLB intervention. We searched for research evidence on 5 July 2023 from several databases, including PubMed, Embase (via Ovid), Cochrane Library, Google Scholar and China Biology Medicine Disk (CBM). Using the content validity index, a panel of experts assessed the appropriateness of the PLB protocol.ResultsWe developed the preliminary home PLB intervention protocol on the basis of several underlying rationales, which encompass the extension of expiration time, enhancement of respiratory muscle strength, augmentation of tidal volume and integration of the most reliable research evidence obtained from four systematic reviews, five RCTs, five clinical trials, and 10 recommendations. We structured the PLB intervention with a designated time ratio of inspiration to expiration, set at 1:2. Additionally, this study recommends that the training parameters of the PLB intervention were as follows: three sessions per day, each lasting for 10 min, over 8 weeks. Individualised PLB training intensity adjusted the inhalation component according to each participant's tolerance level while emphasising the exhalation phase to ensure the complete expulsion of air from the lungs. The home PLB intervention protocol established strong content validity through consensus, which was reached among all panel experts. The item‐level and scale‐level content validity indices (CVIs) reached a maximum score of 1.0, indicating a high level of agreement and credibility in the protocol's content as evaluated by the expert panel.ConclusionAn optimal evidence‐based home PLB protocol has been adapted and developed to manage health‐related outcomes of patients with COPD. The protocol is transparent and fully supported by relevant mechanisms, concrete evidence, recommendations and experts' consensus.Implications for PracticeIn this study, we consulted patients with COPD about the ‘Prepared Conditions Before PLB Practice’, to ensure appropriate measures to prevent patients with COPD from potential risks. In addition, patients with COPD also contributed to the PLB exercise frequency distribution.

The Success of Mifepristone and Misoprostol in the Management of Early Pregnancy Loss at a Community Hospital: A Prospective Study

ObjectivesThis prospective single-arm study was conducted to understand the expulsion rate of the gestational sac in the management of early pregnancy loss (EPL). MethodsWe recruited 441 participants; 188 met the eligibility criteria. Participants were 18 years of age and older who experienced a confirmed EPL (<12 weeks gestational age) defined by an intrauterine pregnancy with a non-viable embryonic or anembryonic gestational sac with no fetal heart activity. Participants were given 200 mg of mifepristone pre-treatment orally followed by 2 doses of misoprostol 800 μg vaginally after 24 and 48 hours. Participants were seen in follow-up on day 14 to confirm the absence of a gestational sac, classified as treatment success. For failed treatment (defined by retained gestational sac), we offered expectant management or a third dose of misoprostol and/or dilatation and curettage. We followed all participants for 30 days. We collected data on overtreatment for retained products of conception and hospital admissions for adverse events. ResultsOverall, 181 participants followed the protocol and 169 (93.3%) participants had a complete expulsion of the gestational sac by the second visit (day 14). Twelve (6.6%) failed the treatment and 1 had an adverse event of heavy vaginal bleeding requiring dilatation and curettage. Despite the expulsion of the gestational sac, 29 cases (17.1%) at subsequent follow-up were diagnosed as retained products of conception based on ultrasound assessment of thickened endometrium. ConclusionsPretreatment with mifepristone followed by 2 doses of misoprostol with a 14-day follow-up resulted in a high expulsion rate and is a safe management option for EPL.

MANAGEMENT OF KALLADAIPPU NOI (UROLITHIASIS) THROUGH SIDDHA MEDICINE: A CASE STUDY

In the Siddha System of medicine, Kalladdaipu (Renal stones) comes under Neerinai arukal noigal, which means diseases that reduce urinary output. Kalladdaipu presents with symptoms like burning micturition, renal and low back pain, urinary obstruction, and the presence of sand-like crystals in the urine, and it is compared with the urolithiasis, which refers to the formation of stones in the kidney, ureter, urinary bladder, or urethra. In Siddha medicine, kalladaippu is generally treated with lithotriptic and diuretic formulations. In this case study, a 69-year-old female patient with 6 mm renal calculus was treated with Neermulli kudineer and Nandukal parpam for four weeks, resulting in the renal calculi's complete expulsion. This case study underscores cost-effective Siddha treatment in expelling renal stones, showcasing synergistic actions leading to the disintegration and elimination of urinary stones providing valuable insights for clinicians in Siddha medicine.

Constitutive Innate Immunity and Systemic Responses to Infection of the American Alligator (Alligator mississippiensis).

Uninfected alligators (Alligator mississippiensis) exhibited high constitutive levels of hepatic gene expression related to immune function, whereas the highest-expressed hepatic genes of uninfected mice were related to metabolism. Intraperitoneal challenge of mice with bacterial lipopolysaccharide results in dramatic inflammatory effects including peritoneal ascites, febrile response, dramatic alterations in electrophoretic serum profile, and mortality. In contrast, coelomic injection of alligators with 200× the murine LD50 of intraperitoneal bacterial lipopolysaccharide resulted in no changes in serum protein profiles, behavioral effects, mortality, and no coelomic ascites. However, injection of juvenile alligators with live bacteria resulted in a titer-dependent decrease in metabolic rate, as measured by oxygen consumption. These results are the opposite of those observed for mammalian and avian species. The decreased oxygen consumption was not accompanied by changes in heart or respiration rate, indicating that this phenomenon was not due to bradycardia or bradypnea. Interestingly, challenge of alligators with bacteria resulted in the complete expulsion of digestive tract contents within four hours. We interpret these activities as temporary minimization of other biological systemic activities to redirect and devote energy to immune function. The reallocation of resources within an organism to fight infection without increases in metabolic rate has not been described in other animals.

Menstrual cup use and intrauterine device expulsion in a copper intrauterine device randomized trial

ObjectiveTo evaluate menstrual cup use and intrauterine device (IUD) expulsion. Study designWe performed a secondary analysis of a 3-year contraceptive efficacy trial comparing two copper 380 mm2 IUDs. Investigators randomized participants approximately 1:4 to the TCu380A or NTCu380-Mini IUD. Approximately 12 months after enrollment began, we advised participants against menstrual cup use due to observed IUD expulsions in cup users. We evaluated IUD expulsion (including spontaneous partial and complete expulsion and accidental self-removal) at 12 and 36 months. We used multivariable logistic regression to evaluate IUD expulsion by age, baseline menstrual volume, body mass index, IUD type, menstrual cup use, parity, and uterine length. ResultsThis analysis included 1046 participants (203 TCu380A and 843 NTCu380-Mini), with 879 (84.0%) nulliparas. Through 12 and 36 months, expulsion occurred in 74 (7.1%, 95% CI 5.5–8.6%) and 133 (12.7%, 95% CI 10.7–14.7%) participants, respectively. Overall, 250 (23.9%) reported menstrual cup use. More menstrual cup users than non-users experienced expulsion through 12 months (32/203 [15.8%] vs. 42/843 [5.0%]) and 36 months (58/250 [23.2%] vs. 75/796 [9.4%]). Through 36 months, NTCu380-Mini menstrual cup users had higher expulsion odds, while TCu380A cup users did not. Menstrual cup users more frequently experienced accidental self-removal than non-users in participants using the TCu380A (3/53 [5.7%] vs. 0/150 [0.0%]) and the NTCu380-Mini (20/197 [10.2%] vs. 7/646 [1.1%]). In multivariable regression, we found increased odds of expulsion through 36 months in participants using menstrual cups with the NTCu380-Mini (aOR 3.13, 95% CI 1.16–8.46) and <25 years (aOR 1.59, 95% CI 1.07–2.34). ConclusionsWe found higher odds of IUD expulsion with menstrual cup and concurrent NTCu380-Mini IUD use over 36 months of use, but not with concurrent TCu380A IUD use. Menstrual cup users experienced higher likelihood of accidental self-removal regardless of IUD type. ImplicationsMenstrual cup and NTCu380-Mini use may increase IUD expulsion risk and may increase accidental self-removal risk with TCu380A and NTCu380-Mini use. Clinicians should advise patients of these risks and consider warning patients using an IUD shaped like the NTCu380-Mini (Nova-T frames) of expulsion risk with menstrual cup use.

Risk factors for and outcomes of ring expulsions with a 1-year contraceptive vaginal system

The US Food and Drug Administration-approved segesterone acetate and ethinyl estradiol ring-shaped contraceptive vaginal system, known as Annovera (Sever Pharma Solutions/QPharma, Malmö, Sweden), was inserted and removed under a woman's control for a 21 day in and 7 day out regimen for up to 13 cycles of use. We aimed to describe the patterns of ring expulsion over time, to identify potential predictors of expulsion, and to evaluate the impact of expulsions on method discontinuation and pregnancy risk. Using data from 2064 participants who were enrolled in 2 multinational phase 3 clinical trials on the use of this contraceptive vaginal system, we examined data from participants' daily diaries for documentation of complete ring expulsion. We modeled the odds of reported expulsions over time with adjustment for background and demographic characteristics using mixed-effects logistic regression models with random intercepts. We compared the probability of continuation between those who did and those who did not report expulsions in the first cycle of use using survival analysis and hazards modeling. To determine if expulsions during the first cycle of use affected the risk for pregnancy, we calculated Pearl Indices. Most participants (75%) never experienced any expulsions during any cycle of use, and 91% to 97% did not experience an expulsion during any 1 cycle. The incidence of expulsion was highest in cycle 1 (9%). The odds of experiencing expulsions decreased by half in cycles 2 to 8 when compared with cycle 1 (0.48; 95% confidence interval, 0.40-0.58), and in cycles 9 to 13, expulsions were about a third of that in cycle 1 (0.32; 95% confidence interval, 0.26-0.41). Of those who did experience expulsions, most (62%-84%) experienced ≤2 expulsions per cycle. Participants from study sites in Latin America vs those in the United States had higher odds of not experiencing an expulsion (odds ratio, 1.95; 95% confidence interval, 1.45-2.63). Women with a higher education level had higher odds of experiencing an expulsion. Notably, parity, age, and body mass index were not associated with expulsion. Participants who experienced any expulsions in cycle 1 were more likely to discontinue use early (hazard ratio, 1.28; 95% confidence interval, 1.14-1.43) than participants who did not have an expulsion. The Pearl Index for participants who had expulsions during cycle 1 was 3.99 (95% confidence interval, 1.29-9.31), which was higher than that among participants who reported no expulsions (Pearl Index, 2.39; 95% confidence interval, 1.61-3.41), but the overlapping confidence intervals indicate that there is not sufficient evidence to demonstrate an association between expulsions and pregnancy risk. Expulsions were infrequent overall, decreased with subsequent cycles of use, and were not associated with body mass index or parity. Early discontinuation of product use was higher among participants who experienced an expulsion during cycle 1. Although it is unclear whether pregnancy risk was associated with expulsions, early recognition of expulsions among users may identify those at higher risk for discontinuation and may highlight when enhanced anticipatory counselling and guidance may be advantageous.

The MISOPRED score: Development and validation of a clinical scoring system to predict the effectiveness of Misoprostol treatment for early pregnancy loss.

Misoprostol treatment for early pregnancy loss has varied success demonstrated in previous studies. Incorporating predictors in a single clinical scoring system would be highly beneficial in clinical practice. To develop and evaluate the accuracy of a scoring system to predict misoprostol treatment outcomes for managing early pregnancy loss. Retrospective cohort and validation study. Patients discharged from the gynecologic emergency department from 2013 to 2016, diagnosed with early pregnancy loss, who were treated with 800 mcg misoprostol, administrated vaginally were included. All were sonographically reevaluated within 48-72 hours. Patients in whom the gestational sac was not expelled or with endometrial lining >30 mm were offered a repeat dose and returned for reevaluation after seven days. A successful response was defined as complete expulsion. Clinical data were reviewed to identify predictors for successful responses. The scoring system was then retrospectively evaluated on a second cohort to evaluate its accuracy. Multivariate logistic regression was performed to identify factors most predictive of treatment response. The development cohort included 126 patients. Six factors were found to be most predictive of misoprostol treatment effectiveness: nulliparity, prior complete spontaneous abortion, gestational age, vaginal bleeding, abdominal pain, and mean sac diameter, yielding a score of 0-8 (the MISOPRED score), where 8 represents the highest-likelihood of success. The score was validated retrospectively with 119 participants. Successful response in the group with the lowest likelihood score (score 0-3) was 9%, compared with 82% in the highest likelihood score group (score 7-8). Using the MISOPRED score, approximately 15% of patients previously planned to receive misoprostol treatment can be referred for surgical management. MISOPRED score can be utilized as an adjunct tool for clinical decision-making in cases of Early pregnancy loss. To our knowledge, this is the first scoring system suggested to predict the success rate in these cases.

Termination of Pregnancy: Misoprostol Versus Prostaglandin E2

Objective: To compare the efficacy of vaginal Misoprostol and vaginal prostaglandin E2 in termination of pregnancy.&#x0D; Study Design: Quasi-experimental study.&#x0D; Place and Duration of Study: Department of Obstetrics &amp; Gynecology, Fauji Foundation Hospital, Islamabad, Pakistan, from Apr to Oct 2021.&#x0D; Methodology: After taking informed consent, a total of 80 women between the age of 20-40 years were included in the study for termination of pregnancy. Molar or ectopic pregnancy, signs of septic abortion, Chronic Liver Disease, and bleeding disorders were excluded. In group A, a 200µgm tablet of Misoprostol was inserted intravaginal every 6 hours, a total of 4 doses, while in group B patients, a PGE2 3 mg tablet was inserted intravaginal, a total of 4 doses. All patients in both groups were evaluated after 24 hours, at which efficacy was noted. &#x0D; Results: The mean age of women in Group-A was 27.18±3.81 years, and in Group-B was 27.18±4.96 years. The mean gestational age in Group-A was 11.83±3.24 weeks, and in Group-B was 12.20±3.30 weeks. In this study, efficacy (complete expulsion of the fetus within 24 hours of medication) was seen in 37 (92.50%) women in Group-A (Vaginal Misoprostol) and 29 (72.50%) women in Group-B (Vaginal prostaglandin E2) with a p-value of 0.019.&#x0D; Conclusion: This study concluded that the efficacy of vaginal Misoprostol is better in termination of pregnancy as compared to vaginal prostaglandin E2.

Dynamics of a Plasma Cloud Generated by a Compact Coaxial Gun upon Expansion into Vacuum and Large-Volume Background Plasma in an External Magnetic Field

Results of experiments on injection of dense plasma clouds created by a small-scale coaxial generator into vacuum and large-volume background plasma in an ambient magnetic field are presented. The regime of an “infinite” background medium that allows studying the plasma-cloud dynamics on the scale of about one meter in the directions perpendicular and parallel to a quasi-uniform magnetic field is realized on “Krot” plasma device. The dynamics of the diamagnetic cavity appearing upon magnetic-field expulsion by a plasma blob, the electromagnetic noise appearing in the cavity, along with the evolution of plasma-cloud structure during injection and at the stage of its decay, were studied. It is demonstrated that the key properties of the cloud dynamics that are typical of the active space and high-energy laboratory experiments, including complete expulsion of the magnetic field from the cloud and development of the flute instability at its boundary, are reproduced at low injection speed (below 30 km/s) and low plasma energy (on the order of 0.1 J).

A comparison of misoprostol with and without methylergometrine and oxytocin in outpatient medical abortion: a phase III randomized controlled trial

ObjectiveThe complications associated with miscarriages have surfaced as a major concern in maintaining women’s physical and mental health. The present study evaluated the efficacy of three medication regimes for the complete expulsion of retained intrauterine tissues in patients who underwent a miscarriage.MethodsIn this randomized clinical trial, 90 patients participated with their gestational age below 12 weeks, each having undergone a recent miscarriage. After being screened for underlying diseases and coagulative blood disorders, they were randomly allocated into three groups. For the first group, labeled as the control group, misoprostol was administered alone. In contrast, the combination of misoprostol plus methylergometrine and misoprostol plus oxytocin was prescribed for the second and third groups, respectively. Further, the data obtained were analyzed by descriptive and inferential statistics using Stata software version 14.ResultsThe mean age of participants and gestational age were 29.76 ± 5.53 years and 8.23 ± 2.29 weeks, respectively. There was no significant difference between the three treatment groups regarding the amount of bleeding after the abortion(P = 0.627). Regarding pain severity, the group that received Misoprostol plus Methylergometrine had less pain intensity than the other two groups(p = 0.004). The mean rate of RPOC expulsion was in the Misoprostol plus Oxytocin (9.68 ± 10.36) group, Misoprostol plus Methylergometrine (11.73 ± 12.86), and Misoprostol groups (19.07 ± 14.31)(p = 0.013). The success rate in outpatient medical abortion in the misoprostol plus oxytocin and misoprostol plus methylergonovine group was 93.33%, but in patients treated by misoprostol alone was 83.33%.ConclusionThe effectiveness of the drugs in the two drug groups combined with oxytocin and methylergometrine is higher than the misoprostol group alone. An outpatient approach was deemed more satisfactory against surgical maneuvers and hospitalizations by patients since family support influenced their pain coping mechanism.Trial registrationThe trial was registered in the Iranian registry of clinical trials on 04/10/2019. (https://fa.irct.ir/trial/34519; registration number: IRCT20150407021653N19).

Spontaneous expulsive choroidal hemorrhage in an elderly female with microbial keratitis.

To report spontaneous choroidal hemorrhage with the expulsion of intraocular contents in an elderly female as a complication of microbial keratitis. Retrospective case report along with imaging. A 60-year-old female on treatment for microbial keratitis, presented with protrusion of intraocular contents and no perception of light in the right eye. Ophthalmic ultrasound demonstrated choroidal hemorrhage with coexistent retinal detachment and vitreous hemorrhage. She underwent uneventful evisceration for her condition. Microbial keratitis needs aggressive medical treatment to prevent associated stromal infiltration and corneal weakening. In cases of microbial keratitis, if spontaneous choroidal hemorrhage occurs, due to thinning of the cornea and compromised integrity of the eyeball, it can lead to the complete expulsion of intraocular contents with unsalvageable loss of vision.

Exceptionnel Complication after Intramedullary Nailing of the Tibia

Management of tibia fractures by intramedullary nails, has become the gold standard for diaphyseal fractures. High rate of union, acceptable alignment in all planes, and a low complication rate have been reported. A 52 - year - old women with a surgical antecedent fracture of the right leg operated 20 years ago, presented to the traumatology clinic for the removal of osteosynthesis materials from the leg. There was no history of recent injury and no information was available about the patient’s subsequent progress, Examination revealed a frail old lady whose mobility was restricted by quasi complete expulsion of nail from right leg showing that blocked extension; signs of a moderately severe cellulitis over the lower part of leg. The fracture was well consolidated and showed no sign of complication radiographs showed a complete expulsion of nail proximally; we performed an ablation under spinal anesthesia with bone biopsy, who was normal at immediately after surgery, the patient was able to walk without difficulty with a walker without pain. the patient was lost sight of after. To the best of our knowledge, this is the first report of complete expulsion of nail in a patient after centromedullary nailing of the tibia.

Efficacy of an Oral Solution Containing Five Herbal Extracts in the Treatment of Urolithiasis: A Randomized, Single-blind, Placebo-controlled Clinical Trial.

The high prevalence of urolithiasis and its recurrence entail the preparation of an efficient drug with the least side effects. Tribulus terrestris, Urtica dioica, Adiantum capillus-veneris, Stigma maydis (corn silk), and Cucumis melo are herbal remedies utilized in traditional medicine for urolithiasis. This study aimed to assess the efficiency of these plants' extracts in treating urolithiasis. In a randomized, single-blind, placebo-controlled clinical trial, participants meeting inclusion criteria were randomly allocated to the drug (n = 27) and placebo (n = 27) groups to take herbal or placebo solutions, respectively, at a dose of 60 drops 3 times daily for 4 weeks with standard treatment. Before and after the intervention, 24-h urine volume and the quantities of calcium, sodium, citrate, oxalate, urea, creatinine, and uric acid in 24-h urine, and urinary pH were measured. The number and size (diameter in mm) of stones were determined by ultrasonography and recorded for each patient. Except for 24 h urine volume, other urinary parameters did not alter significantly at the end of the intervention compared to baseline. Furthermore, the two groups had no significant difference regarding these indices. Regarding stone parameters, the stone size decreased significantly in the drug group compared to the placebo group (P = 0.049). The number of cases with complete stone expulsion in the drug group was significantly higher than in the placebo group (12 cases vs. 4 cases, respectively, P = 0.017). Oral consumption of the herbal solution causes stone size reduction and stone expulsion in patients with urolithiasis.

EVALUATION OF THE EFFECTIVENESS OF ORAL AND VAGINAL MISOPROSTOL FOR INTRAUTERINE FETAL DEATH AND FETAL ANOMALY IN SECOND TRIMESTER PREGNANCY TERMINATION: A RANDOMIZED CLINICAL TRIAL

Background: which method of the expulsion of intrauterine fetal death and fetal anomaly in second trimester is effective, safe, and suitable for pregnant women. Objectives: to evaluate the effectiveness of oral misoprostol and vaginal misoprostol for intrauterine fetal death and fetal anomaly in second trimester pregnancy termination. Materials and Methods: a clinical trial in 108 women experiencing intrauterine fetal death and fetal anomaly during the second trimester in the obstetric department, Can Tho central general hospital in 2014. Excluded criteria: multiple pregnancies, uterus cesarean section scar, and misoprostol contraindication. Intervention: randomized division into two groups: group 1: misoprostol oral, group 2: vaginal misoprostol; dosage as recommended by FIGO. Success was defined as a complete and natural fetal and placenta expulsion without dilation and curettage or other treatment; and healthy hospital discharge. Results: the success rate of group 1 was 75.9%; group 2 was 83.3%. The success rates for fetal conditions of intrauterine fetal death were 74.6%, and the fetal anomaly was 86.7%. In group 1, the success rate in intrauterine fetal death was 63%, fetal anomaly was 88.9%. In group 2, the success rate in intrauterine fetal death was 81.3% and fetal anomaly was 86.4%. The rate of expulsion in the first 24 hours was 78.1% in group 1; 88.9% in group 2, which was not different statistically. Some side effects encountered in the study such as headache, nausea, diarrhea, fever/chills, rash were mainly seen in the oral misoprostol group; all side effects and complications were mild and transient. Related factors to complete expulsion in both groups were gestational age, parity, and fetal conditions. Conclusion: vaginal misoprostol has the same effectiveness and fewer complications than oral misoprostol.

Pregnancy outcomes following ultrasound-guided high-intensity focused ultrasound in submucous leiomyomas: a retrospective study

Objective To investigate the impact of ultrasound-guided high-intensity focused ultrasound (USgHIFU) on pregnancy in submucous leiomyomas. Materials and methods Between October 2015 and October 2021, a retrospective observational study was conducted at the Affiliated Hospital of North Sichuan Medical College, China, for 32 women with submucous leiomyomas who became pregnant after USgHIFU. Pregnancy outcomes, submucous leiomyomas characteristics, and USgHIFU parameters were analyzed. Results A total of 17 (53.1%) deliveries were successfully achieved, with full-term delivery in 16 (94.1%) patients and preterm delivery in 1 (5.9%). After USgHIFU, the effective volume in the uterus cavity and the volume of submucous leiomyomas shrank in all 32 patients. The median time to achieve pregnancy after USgHIFU was 11.0 months. Before pregnancy, myoma type was downgraded in 13 (40.6%) patients, stable in 10 (31.3%) and upgraded in 9 (28.1%). The vaginal expulsion rate of submucous leiomyomas was 28.1%, with complete expulsion in 3 (9.4%) patients and partial expulsion in 6 (18.8%). After USgHIFU, the size of submucous leiomyomas did not increase in each trimester (all p > 0.05). The high complications rate during pregnancy (7/17, 41.2%) was associated with advanced maternal age, with only one (5.9%) premature rupture of membranes possibly associated with submucous leiomyomas. There were 6 (35.5%) vaginal delivery and 11 (64.7%) cesarean sections. All 17 newborns developed well, with a mean birth weight of 3482 g. Conclusions In patients with submucous leiomyomas, pregnancies and full-term deliveries can be successfully achieved following USgHIFU, with few related complications.

Early vs Interval Postpartum Intrauterine Device Placement

The early postpartum period, 2 to 4 weeks after birth, may be a convenient time for intrauterine device (IUD) placement; the placement could then coincide with early postpartum or well-baby visits. To determine expulsion rates for IUDs placed early postpartum compared with those placed at the standard interval 6-week visit. In this randomized noninferiority trial, people who had a vaginal or cesarean birth were randomly assigned to undergo early (14-28 days) or interval (42-56 days) postpartum IUD placement. Clinicians blinded to participant study group used transvaginal ultrasonography to confirm IUD presence and position at the 6-month postpartum follow-up. The study assessed 642 postpartum people from 4 US medical centers, enrolled a consecutive sample of 404 participants from March 2018 to July 2021, and followed up each participant for 6 months postpartum. Early postpartum IUD placement, at 2 to 4 weeks postpartum, vs standard interval placement 6 to 8 weeks postpartum. The primary outcome was complete IUD expulsion by 6 months postpartum; the prespecified noninferiority margin was 6%. Secondary outcomes were partial IUD expulsion, IUD removal, pelvic infection, patient satisfaction, uterine perforation, pregnancy, and IUD use at 6 months postpartum. IUD malposition was an exploratory outcome. Among 404 enrolled participants, 203 participants were randomly assigned to undergo early IUD placement and 201 to undergo interval IUD placement (mean [SD] age, 29.9 [5.4] years; 46 [11.4%] were Black, 228 [56.4%] were White, and 175 [43.3%] were Hispanic). By 6 months postpartum, 53 participants (13%) never had an IUD placed and 57 (14%) were lost to follow-up. Among the 294 participants (73%) who received an IUD and completed 6-month follow-up, complete expulsion rates were 3 of 149 (2.0% [95% CI, 0.4%-5.8%]) in the early placement group and 0 of 145 (0% [95% CI, 0.0%-2.5%]) in the interval placement group (between-group difference, 2.0 [95% CI, -0.5 to 5.7] percentage points). Partial expulsion occurred in 14 (9.4% [95% CI, 5.2%-15.3%]) participants in the early placement group and 11 (7.6% [95% CI, 3.9%-13.2%]) participants in the interval placement group (between-group difference, 1.8 [95% CI, -4.8 to 8.6] percentage points). IUD use at 6 months was similar between the groups: 141 (69.5% [95% CI, 62.6%-75.7%]) participants in the early group vs 139 (67.2% [95% CI, 60.2%-73.6%]) in the interval group. Early IUD placement at 2 to 4 weeks postpartum compared with 6 to 8 weeks postpartum was noninferior for complete expulsion, but not partial expulsion. Understanding the risk of expulsion at these time points may help patients and clinicians make informed choices about the timing of IUD placement. ClinicalTrials.gov Identifier: NCT03462758.

"In Situ" Methotrexate Injection Followed by Hysteroscopic Resection for Caesarean Scar Pregnancy: A Single-Center Experience.

We evaluated the efficacy of local methotrexate (MTX) treatment followed by hysteroscopic resection for caesarean scar pregnancy and its impact on future fertility. Monocentric, prospective, observational study performed in the Haykel Hospital between June 2016 and December 2020. Twenty-one women with caesarean scar pregnancy underwent a transcutaneous ultrasound-guided direct injection of MTX into the gestational sac in an outpatient setting. Hysteroscopic resection of residual trophoblastic retention was then performed according to perisaccular blood flow. Two patients had complete spontaneous trophoblast expulsion after MTX injection, and hysteroscopy was performed in 19 patients for residual trophoblastic retention 1 to 12 weeks after MTX injection. Successful preservation of a healthy uterus with the combined procedure was obtained in 94.8% of patients. Hemostatic hysterectomy was required in one patient. Mean hospitalization duration was 1.5 days. Three patients had spontaneous pregnancy after the procedure. Direct MTX injection into the gestational sac for caesarean scar pregnancy followed by hysteroscopic resection was an effective technique with a short hospitalization, fertility preservation and a low major complication rate compared with other modalities of treatment reported in the literature. Further larger prospective comparative studies are needed to confirm the efficacy of this procedure.