Comparative study regarding effect of pH on Misoprostol in induction of labor in full term primigravida pregnant women, a double blind randomized controlled trial

OBJECTIVES

To evaluate the effect of altering vaginal pH on induction of labor in full-term pregnancies using Misoprostol.

METHODS

This randomized controlled trial was conducted at Kasralainy Hospital, Cairo University, Egypt and Algezeera Hospital, Egypt. A total of 218 healthy term primigravida pregnant women who were scheduled for pregnancy termination were recruited in the study. The included patients were divided into three groups; Group A: Those who received normal saline vaginal wash (0.9% NaCl), Group B: those who received alkaline vaginal wash (5% sodium bicarbonate) and Group C: those who received acidic vaginal wash (5% acetic acid). Patients received 25 μg of Misoprostol E1 (Vagiprost® Adwia Pharmaceuticals, Egypt) every 6 h for a maximum of 24 h (total of four potential doses).

RESULTS

The 'acid' group participants took a mean time of 20.46 h to reach active stage of labor, followed by the 'normal saline' group with 21.45 h and the 'alkaline' group with 22.59 h. The difference between the groups was statistically significant, with a p-value of 0.013.

CONCLUSIONS

Douching the vagina with acidic solution seems to supplement the effect of Misoprostol on inducing labor in full-term pregnancies, as evidenced by having the shortest mean time needed to reach active stage of labor.

The Bio-inspired Artificial Pancreas for Type 1 Diabetes Control in the Home: System Architecture and Preliminary Results

BACKGROUND

Artificial pancreas (AP) technology has been proven to improve glucose and patient-centered outcomes for people with type 1 diabetes (T1D). Several approaches to implement the AP have been described, clinically evaluated, and in one case, commercialized. However, none of these approaches has shown a clear superiority with respect to others. In addition, several challenges still need to be solved before achieving a fully automated AP that fulfills the users' expectations. We have introduced the Bio-inspired Artificial Pancreas (BiAP), a hybrid adaptive closed-loop control system based on beta-cell physiology and implemented directly in hardware to provide an embedded low-power solution in a dedicated handheld device. In coordination with the closed-loop controller, the BiAP system incorporates a novel adaptive bolus calculator which aims at improving postprandial glycemic control. This paper focuses on the latest developments of the BiAP system for its utilization in the home environment.

METHODS

The hardware and software architectures of the BiAP system designed to be used in the home environment are described. Then, the clinical trial design proposed to evaluate the BiAP system in an ambulatory setting is introduced. Finally, preliminary results corresponding to two participants enrolled in the trial are presented.

RESULTS

Apart from minor technical issues, mainly due to wireless communications between devices, the BiAP system performed well (~88% of the time in closed-loop) during the clinical trials conducted so far. Preliminary results show that the BiAP system might achieve comparable glycemic outcomes to the existing AP systems (~73% time in target range 70-180 mg/dL).

CONCLUSION

The BiAP system is a viable platform to conduct ambulatory clinical trials and a potential solution for people with T1D to control their glucose control in a home environment.

Early versus delayed removal of indwelling urinary catheter after elective cesarean delivery: systematic review and meta-analysis of randomized controlled trials

Background: Timing of removal of the indwelling urinary catheter after elective cesarean delivery (CD) is controversial. Early removal could be associated with fewer urinary symptoms.Objective: This review aims to evaluate the evidence from published randomized clinical trials (RCTs) about the outcomes of early versus delayed removal of indwelling urinary catheter after elective cesarean delivery (CD).Data sources: Electronic databases were searched using the following MeSH terms (early Or Late Or immediate OR delayed removal) AND (Urinary catheter) AND (cesarean section OR cesarean delivery OR CS)Methods of study selection: All RCTs assessing the timing of removal of urinary catheter were considered for this meta-analysis. One hundred seventy-two studies were identified of which three studies deemed eligible for this review. Quality and risk of bias assessment were performed for all studies.Data extraction: Two researchers independently extracted the data from the individual articles and entered into RevMan software. The relative risk (RR), the weighted mean difference (WMD) and 95% confidence interval (CI) were calculated. The extracted outcomes were significant bacteriuria, urinary symptoms (urinary retention necessitating re-catheterization, dysuria, urinary frequency, urgency) postoperative oral rehydration and length of hospital stay.Results: Three RCTs (early removal: n = 298 and delayed removal: n = 311) were included. The pooled estimate showed that early removal significantly reduced dysuria (RR = 0.60, 95% CI [0.38, 0.95], p=.03), urinary frequency (RR = 0.32, 95% CI [0.16, 0.66], p=.002) and significant bacteriuria (RR = 0.49, 95% CI [0.30, 0.83], p=.007) than delayed removal.Conclusions: This meta-analysis suggests that early removal of the indwelling urinary catheter in patients who underwent elective CD showed significant less dysuria, less urinary frequency and a decrease in the incidence of significant bacteriuria.

The effect of mechanical cervical dilatation during scheduled cesarean section on the blood loss: a randomized controlled trial

Objective: This study evaluates the effects of mechanical cervical dilatation during scheduled cesarean section (CS) on intra- and postoperative blood loss.Methods: A single-center randomized double-blind controlled trial (NCT03444792) conducted at a tertiary University Hospital in the period between 1 April 2017 and 31 March 2018 included all women scheduled for scheduled CS under spinal anesthesia if they met our inclusion criteria. Eligible participants were randomized to one of two groups. Group (I): Women with intraoperative cervical dilatation and Group (II): women with no intraoperative cervical dilatation. The primary outcome of this study was the mean volume of total blood loss during CS. The secondary outcomes included the mean reduction in the hemoglobin and hematocrit, the rate of primary postpartum hemorrhage, the duration of surgery, the duration of hospital stay, the rate of wound infection and endometritis.Results: No statistical significant difference between both study groups regarding the baseline characteristics. No significant difference in the intraoperative blood loss between both groups (p = .21); however, there was significantly more postoperative blood loss in group II (p = .001). The total blood loss was significantly higher in group II (912.6 ± 242.1 versus 845.8 ± 188.9 mL) in group I (p = .029). There were significantly lower postoperative hemoglobin and hematocrit levels in group II (p = .014 and .033 respectively). The mean duration of CS was significantly shorter in the cervical dilatation group (p = .002). No difference between both groups regarding the rate of postpartum hemorrhage (PPH) (p = .21), the duration of hospital stay (p = .17), the rate of wound infection (p = .32), the rate of endometritis (p = .82).Conclusions: Mechanical cervical dilatation during scheduled CS could be associated with lower postoperative blood loss, higher postoperative hemoglobin & hematocrit levels and shorter duration of CS.

Effect of clomiphene citrate on uterine hemodynamics in women with unexplained infertility

Purpose

The aim of the study was to evaluate the effect of clomiphene citrate on uterine artery blood flow using pulsed Doppler and endometrial and subendometrial micro vascularization using 3D power Doppler in unexplained infertility.

Patients and methods

In a prospective observational study at a university teaching hospital, the mid-luteal (peri-implantation) endometrial thickness and volume, uterine artery pulsatility index (PI) and resistance index (RI), endometrial and subendometrial vascularization index (VI), flow index (FI), and vascularization flow index (VFI), and serum estradiol and progesterone levels were compared between natural and clomiphene citrate stimulated cycles in the same group of 50 patients with unexplained infertility. Statistical analysis was done using paired t-test to compare different study variables.

Results

The primary outcome, which was the endometrial flow index, was significantly lower in the stimulated cycles (mean ± SD: 23.89±7.96 vs 27.49±8.73, mean difference (95% CI): −3.6 (−2, −5.9); P=0.03). The mean ± SD of endometrial thickness (10.92±3.04 vs 12.46±3.08 mm; P=0.01), volume (4.57±1.28 vs 5.26±1.32 cm³; P=0.009), endometrial VI (0.86±0.15 vs 0.95%±0.21%; P=0.02), VFI (0.25±0.08 vs 0.31±0.12; P=0.004), subendometrial VI (1.93±0.68 vs 2.26%±0.75%; P=0.02), FI (26.81±9.16 vs 30.73±9.87; P=0.04), and VFI (0.68±0.18 vs 0.79±0.21; P=0.006) were significantly lower in the stimulated cycles. However, there were no significant differences in the uterine artery PI (P=0.12) and RI (P=0.08) or serum estradiol (P=0.54) and progesterone (P=0.37) levels between natural and stimulated cycles.

Conclusion

Peri-implantation endometrial perfusion is significantly lower in clomiphene citrate stimulated cycles when compared to natural ones in patients with unexplained infertility.

Enhancing automatic closed-loop glucose control in type 1 diabetes with an adaptive meal bolus calculator - in silico evaluation under intra-day variability

BACKGROUND AND OBJECTIVE

Current prototypes of closed-loop systems for glucose control in type 1 diabetes mellitus, also referred to as artificial pancreas systems, require a pre-meal insulin bolus to compensate for delays in subcutaneous insulin absorption in order to avoid initial post-prandial hyperglycemia. Computing such a meal bolus is a challenging task due to the high intra-subject variability of insulin requirements. Most closed-loop systems compute this pre-meal insulin dose by a standard bolus calculation, as is commonly found in insulin pumps. However, the performance of these calculators is limited due to a lack of adaptiveness in front of dynamic changes in insulin requirements. Despite some initial attempts to include adaptation within these calculators, challenges remain.

METHODS

In this paper we present a new technique to automatically adapt the meal-priming bolus within an artificial pancreas. The technique consists of using a novel adaptive bolus calculator based on Case-Based Reasoning and Run-To-Run control, within a closed-loop controller. Coordination between the adaptive bolus calculator and the controller was required to achieve the desired performance. For testing purposes, the clinically validated Imperial College Artificial Pancreas controller was employed. The proposed system was evaluated against itself but without bolus adaptation. The UVa-Padova T1DM v3.2 system was used to carry out a three-month in silico study on 11 adult and 11 adolescent virtual subjects taking into account inter-and intra-subject variability of insulin requirements and uncertainty on carbohydrate intake.

RESULTS

Overall, the closed-loop controller enhanced by an adaptive bolus calculator improves glycemic control when compared to its non-adaptive counterpart. In particular, the following statistically significant improvements were found (non-adaptive vs. adaptive). Adults: mean glucose 142.2 ± 9.4vs. 131.8 ± 4.2mg/dl; percentage time in target [70, 180]mg/dl, 82.0 ± 7.0vs. 89.5 ± 4.2; percentage time above target 17.7 ± 7.0vs. 10.2 ± 4.1. Adolescents: mean glucose 158.2 ± 21.4vs. 140.5 ± 13.0mg/dl; percentage time in target, 65.9 ± 12.9vs. 77.5 ± 12.2; percentage time above target, 31.7 ± 13.1vs. 19.8 ± 10.2. Note that no increase in percentage time in hypoglycemia was observed.

CONCLUSION

Using an adaptive meal bolus calculator within a closed-loop control system has the potential to improve glycemic control in type 1 diabetes when compared to its non-adaptive counterpart.

Three-dimensional ultrasonography and power Doppler for discrimination between benign and malignant endometrium in premenopausal women with abnormal uterine bleeding

BACKGROUND

Ultrasonography has been extensively used in women suspected of having a gynecological malignancy. The aim of this study is to evaluate the efficacy of 3D ultrasonography and power Doppler for discrimination between benign and malignant endometrium in premenopausal women with abnormal uterine bleeding.

METHODS

This cross-sectional study included 78 premenopausal women with abnormal uterine bleeding scheduled for hysteroscopy and endometrial curettage. The endometrial thickness (ET), uterine artery pulsatility index (PI) and resistance index (RI), and endometrial volume (EV) and 3D power Doppler vascularization index (VI), flow index (FI), and vascularization flow index (VFI) were measured and compared with hysteroscopic and histopathologic findings.

RESULTS

The ET (P <0.001), EV (P <0.001), and endometrial VI (P <0.001) and VFI (P = 0.043) were significantly increased in patients with atypical endometrial hyperplasia and endometrial carcinoma (n = 10) than those with benign endometrium (n = 68); whereas, the uterine artery PI and RI and endometrial FI were not significantly different between the two groups. The best marker for discrimination between benign and malignant endometrium was the VI with an area under the ROC curve of 0.88 at a cutoff value of 0.81%.

CONCLUSION

3D ultrasonography and power Doppler, especially endometrial VI, may be useful for discrimination between benign and malignant endometrium in premenopausal women with abnormal uterine bleeding.

A prospective randomized clinical trial comparing immediate versus delayed removal of urinary catheter following elective cesarean section

OBJECTIVE

To compare immediate and 12h postoperative removal of urinary catheter after elective cesarean section.

STUDY DESIGN

In a prospective clinical trial at a university teaching hospital, 300 eligible women admitted for primary or repeat elective cesarean section were randomized into two equal groups. In group A, the catheter was removed immediately after the procedure; whereas in group B, the catheter was removed 12h postoperatively.

RESULTS

The incidence of postoperative significant bacteruria (p=0.020), dysuria (p=0.030), burning on micturition (p=0.016), urinary frequency (p=0.031), and urgency (p=0.011) were significantly lower in group A compared with group B. The mean postoperative ambulation time (p<0.001), time till the first voiding (p<0.001), and length of hospital stay (p<0.001) were also significantly shorter in group A. There were no significant differences between the two groups in the incidence of urinary retention necessitating recatheterization (p=0.371).

CONCLUSION

Immediate removal of urinary catheter after elective cesarean section is associated with lower risk of urinary infection and earlier postoperative ambulation.

Cholesterol crystal embolization in a Saudi patient after cardiac surgery--a case report

An eroded atheromatous aorta may be a source of cholesterol crystal embolism(CCE). Embolization of atheromatous material accounts for obstruction of distal arterioles around which a foreign-body giant cell granuloma inflammatory reaction develops. The diagnosis is often delayed or un recognized because of varying or misleading clinical signs, such as renal insufficiency, digestive or neurological symptoms, or both or unexplained multiple-system disease. Although CCE can occur spontaneously, it has been increasingly recognized as an iatrogenic complication from an invasive vascular procedure, such as manipulation of the aorta during angiography or vascular surgery. It has also been reported to occur following anticoagulant therapy or thrombolysis. Patients undergoing coronary artery bypass grafting (CABG) often experience a combination of these factors: anticoagulation, intra-arterial angiographic procedures and intraoperative aortic cross-clamping. These multiple factors could account for the acute and severe postoperative clinical and biological findings observed in the case reported here. A 65-year-old Saudi man was admitted to our hospital on July 9, 2008 due to chest pain at rest. He had suffered from type 2 diabetes mellitus on Oral hypoglycemics, hypertension on treatment, impaired renal functions and hypercholesterolemia, he was an ex-smoker with history of diagnosed pulmonary interstitial fibrosis. He had Coronary angiography in another hospital on May 2008 showing a left main lesion 60%, Left anterior descending lesion 90%, circumflex lesion 80% and Right coronary lesion 70%, three weeks later an acute on top of chronic deterioration in renal chemistry was observed for which conservative treatment was chosen.

Measurement of lip posture and interaction between lip posture and resting face height

A method for measurement of lip incompetence is described. Electromyographic techniques were used to obtain relaxation of the muscles of the lip and of a jaw elevator muscle. Standardized photographs were taken of the subject's profile, from which lip separation and face height were measured. Variation was found in successive measurements of lip posture, some of which appeared to depend upon mandibular posture. With the teeth in occlusion, lip separation was reduced. Active maintenance of lip contact by the subject was often associated with a reduction in lower face height, which may have been a direct consequence of the lip muscle activity, or of jaw elevator activity facilitating the lip closure.