Endoscopic Removal of Intrauterine Contraceptive Device Perforating Into the Bladder: A Case Report and Review of Literature.

Intrauterine contraceptive device (IUCD) is a commonly used contraceptive method with the advantage of being a long-acting and reversible contraceptive method. However, its insertion can be rarely associated with serious complications such as uterine perforation, which can more rarely result in injury of the nearby viscus. In this report, we document a rare case of IUCD perforation of the uterus and bladder, its diagnosis using transvaginal ultrasonography and hysteroscopy, and management using a minimally invasive approach with a satisfactory patient outcome.

Continuous Positive Airway Pressure for the Treatment of Supine Hypertension and Orthostatic Hypotension in Autonomic Failure.

BACKGROUND: Supine hypertension affects most patients with orthostatic hypotension (OH) due to autonomic failure, but it is often untreated for fear of worsening OH. We hypothesized that increasing intrathoracic pressure with continuous positive airway pressure (CPAP) had a Valsalva-like blood-pressure-lowering effect that could be used to treat nocturnal supine hypertension in these patients, while reducing nocturnal pressure diuresis and improving daytime OH. METHODS: In Protocol 1, we determined the acute hemodynamic effects of increasing levels of CPAP (0, 4, 8, 12, and 16 cm H2O, 3 minutes each) in 26 patients with autonomic failure and supine hypertension studied while awake and supine. In Protocol 2 (n=11), we compared the effects of overnight therapy with CPAP (8-12 cm H2O for 8 hours) versus placebo on nocturnal supine hypertension, nocturnal diuresis and daytime OH in a 2-night crossover study. RESULTS: In Protocol 1, acute CPAP (4-16 cm H2O) decreased systolic blood pressure in a dose-dependent manner (maximal drop 22±4 mmHg with CPAP 16) due to reductions in stroke volume (-16+3%) and cardiac output (-14±3%). Systemic vascular resistance and heart rate remained unchanged. In Protocol 2, overnight CPAP lowered nighttime systolic blood pressure (maximal change -23±5 versus placebo -1±7 mmHg; P=0.023) and was associated with lower nighttime diuresis (609±84 versus placebo 1004±160 mL; P=0.004) and improved morning orthostatic tolerance (AUC upright SBP 642±121 versus placebo 410±109 mmHg*min; P=0.014). CONCLUSIONS: CPAP is a novel nonpharmacologic approach to treat the supine hypertension of autonomic failure while improving nocturia and daytime OH. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03312556.

Management of Orthostatic Hypotension in the Hospitalized Patient: A Narrative Review.

Orthostatic hypotension is a frequent cause of falls and syncope, impairing quality of life. It is an independent risk factor of mortality and a common cause of hospitalizations, which exponentially increases in the geriatric population. We present a management plan based on a systematic literature review and understanding of the underlying pathophysiology and relevant clinical pharmacology. Initial treatment measures include removing offending medications and avoiding large meals. Clinical assessment of the patients' residual sympathetic tone can aid in the selection of initial therapy between norepinephrine "enhancers" or "replacers." Role of splanchnic venous pooling is overlooked, and applying abdominal binders to improve venous return may be effective. The treatment goal is not normalizing upright blood pressure but increasing it above the cerebral autoregulation threshold required to improve symptoms. Hypertension is the most common associated comorbidity, and confining patients to bed while using pressor agents only increases supine blood pressure, leading to worsening pressure diuresis and orthostatic hypotension. Avoiding bedrest deconditioning and using pressors as part of an orthostatic rehab program are crucial in reducing hospital stay.

Hysteroscopic management of intramural ectopic pregnancy.

The uterine myometrium is the rarest location for an ectopic pregnancy resulting in the so-called 'intramural or intramyometrial ectopic pregnancy'. It presents a particular diagnostic and therapeutic challenge for the treating physician. If passed undiagnosed can lead to life-threatening uterine rupture, which may warrant hysterectomy, leaving the woman with irreversible infertility. Different treatment modalities have been proposed for the management of this condition. In this case report, we are describing a rare case of intramural ectopic pregnancy and reporting the use of hysteroscopy for the surgical management of this case for the first time in the literature.

High-sodium diet does not worsen endothelial function in female patients with postural tachycardia syndrome.

PURPOSE: Postural tachycardia syndrome (POTS), a syndrome characterized by orthostatic symptoms and a heart rate increase of at least 30 beats per minute in the absence of hypotension upon standing, is often accompanied by increased sympathetic activity and low blood volume. A common non-pharmacologic recommendation for patients with POTS is a high-sodium (HS) diet with the goal of bolstering circulating blood volume. The objective of this study is to assess the effects of 6 days of a HS diet on endothelial function in POTS. METHODS: A total of 14 patients with POTS and 13 age-matched healthy controls, all females, were studied following 6 days on a low-sodium (LS) diet (10 mEq/day) and 6 days on a HS diet (300 mEq/day) in a crossover design. We measured endothelial function following reactive hyperemia in the brachial artery using flow-mediated dilation (FMD), leg blood flow (LBF) using strain gauge plethysmography in the calf, and reactive hyperemic index (RHI) in the microcirculation of the hand using pulsatile arterial tonometry. RESULTS: On the LS diet, FMD% did not differ between patients with POTS and the healthy controls although peak brachial artery diameter was lower for the patient group. RHI was higher for the patient group than for the controls, but there were no differences in post-ischemic LBF increase. On the HS diet, there were no between-group differences in FMD%, LBF increase, or RHI. CONCLUSION: In summary, a HS diet for 6 days did not induce endothelial dysfunction. This non-pharmacologic treatment used for patients with POTS does not negatively affect endothelial function when used for a sub-acute duration. TRIAL REGISTRATION: ClinicalTrials.gov NCT01550315; March 9, 2012.

A Rare Interlabial Mass in a 9-Month-Old Infant: A Case Report and Review of Literature.

BACKGROUND: Interlabial masses in infants and children are quite rare. One of their rarest causes is urethral polyp or urethral caruncle. It is a benign fleshy outgrowth at the urethral meatus. Certain etiology is still unknown. CASE: A healthy 9-month-old female infant presented with a mass protruding from the vulva with no other complaints. Examination with the patient under general anesthesia revealed an interlabial mass appearing as a pedunculated pinkish polyp, originating from the posterior lip of the external urethral meatus. Surgical excision of the mass was done and histopathology confirmed it to be a urethral polyp. SUMMARY AND CONCLUSION: Urethral polyps are rare in the pediatric age group. Their occurrence in this age group might support a congenital etiology. Surgical resection of polyps allows histopathological examination and a high cure rate with no risk of recurrence.

Impaired Endothelial Function in Patients With Postural Tachycardia Syndrome.

The purpose of this study is to evaluate endothelial function in postural tachycardia syndrome (PoTS), a poorly understood chronic condition characterized by a state of consistent orthostatic tachycardia (delta heart rate ≥30 beats per minute) upon standing without orthostatic hypotension. Nineteen patients with PoTS and 9 healthy controls were studied after 3 days of a fixed, caffeine-free, normal sodium (150 milliequivalents/day) diet. All participants underwent autonomic function testing, including sinus arrhythmia, valsalva maneuver, hyperventilation, cold pressor, handgrip, and a standing test with catecholamine measurements, followed by endothelial function testing. We analyzed 3 measures of endothelial function: percent brachial flow-mediated dilation, digital pulsatile arterial tonometry, and postischemic percent leg blood flow. Flow-mediated dilation was significantly lower in patients with PoTS (6.23±3.54% for PoTS) than in healthy controls (10.6±4.37% for controls versus, P=0.014). PoTS and controls had similar digital pulsatile arterial tonometry (1.93±0.40 arbitrary units for controls versus 2.13±0.63 arbitrary units for PoTS). PoTS had similar but suggestive percent leg blood flow to controls (313±158% for PoTS versus 468±236% for controls, P=0.098). Patients with PoTS have significantly reduced flow-mediated dilation compared with healthy controls, suggesting that PoTS is characterized by endothelial dysfunction in conduit arteries. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01308099.

Physical endometrial manipulation and its impact on success rate and live birth rate in ICSI in patients with unexplained infertility after recurrent ICSI failure, a double blinded randomized controlled trial.

Background: Unexplained infertility is a rising problem and endometrial manipulation could be one of the solutions for enhancing the pregnancy rate and live birth rate in such circumstances.Aims: To evaluate the influence of local endometrial physical manipulation with specializd method for endometrial and tubal hydration (Elgazzar and Alalfy technique) on ICSI outcome and in increasing chemical, clinical, and live birth rate in ICSI after previous recurrent ICSI failure in patients with unexplained infertility.Results: When comparing group 1 (hydrotubation group) and group 2 (the control group with no intervention) with regards to the biochemical, clinical, and live birth rate, the hydrotubation group revealed higher rates and a better ICSI outcome.Conclusion: Hydrotubation is useful in increasing biochemical, clinical, and live birth rates after recurrent failed ICSI trials with a specialized method for hydration of endometrium and tubes (Elgazzar and Alalfy technique).

Complicated Infective Endocarditis Limited to a Chiari Network.

INTRODUCTION: The Chiari network is an uncommon vestigial structure of the heart that is often clinically insignificant. We present an unusual case of infective endocarditis affecting only the Chiari network in a patient who presented with septic emboli to the lungs and brain. CASE SUMMARY: A 61-year-old man was admitted with a 2-month history of hemoptysis, pleuritic chest pain, and right upper extremity numbness and weakness. He was found to have multifocal bilateral pulmonary opacities and an abscess collection in the brain. Blood cultures grew Streptococcus intermedius and transthoracic echocardiogram (TTE) was normal. Subsequent transesophageal echocardiogram (TEE) revealed an 8.3 × 4.6 mm vegetation arising from the Chiari network, close to the right atrial appendage, without involvement of the tricuspid valve or any of the other valves. There were no atrial or ventricular septal defects. He was treated with appropriate antibiotics with improvement of symptoms. Repeat imaging showed improvement of the lung opacities, but not the brain abscess, warranting transfer to another hospital for neurosurgical intervention. CONCLUSION: The diagnosis and management of isolated Chiari network endocarditis require a high index of clinical suspicion. A multidisciplinary approach incorporating both medical and surgical approaches where necessary is essential for optimal outcome.

Follicular sensitivity index (FSI): a novel tool to predict clinical pregnancy rate in IVF/ICSI cycles.

PURPOSE: This study aims to introduce a new tool (the Follicular Sensitivity Index; FSI) for objective assessment of follicular responsiveness to exogenous gonadotropins and to evaluate its ability to predict the clinical pregnancy rate in women with unexplained infertility or tubal factor undergoing IVF/ICSI. METHODS: FSI was calculated as preovulatory follicle count (PFC) × 100,000/[antral follicle count (AFC) × total received FSH doses]. One thousand women were included and were divided according to the FSI tertile values into three groups. The primary outcome was clinical pregnancy defined by the presence of an intrauterine gestational sac 5 weeks after embryo transfer. RESULTS: There was progressive increase in the clinical pregnancy rate from the low to the high FSI groups (0.27 ± 0.4 vs 0.4 ± 0.4 and 0.58 ± 0.4; p < 0.001). Receiver operator curves showed that FSI had a greater area under the curve than those of the AFC, PFC, and the FSH dose (0.638 vs 0.509, 0.538, and 0.589 respectively). Multivariate logistic regression analysis showed that the correlation between FSI and pregnancy was independent of potential confounding factors like age and body mass index (p < 0.001). CONCLUSION: FSI can predict the clinical pregnancy rate in women with unexplained infertility or tubal factor undergoing IVF/ICSI using GnRH agonist protocol. Higher FSI values had significantly higher oocyte yield and fertilization and clinical pregnancy rates. Wider implications of these findings include the potential use of FSI to define absolute criteria of poor/good ovarian response in IVF/ICSI cycles, guide future IVF cycle management for the same couples, and guide cycle cancelation criteria for poor ovarian response.

A randomized double-blind controlled trial of different filling pressures in operative outpatient hysteroscopy.

OBJECTIVE: To identify the optimal filling pressure during operative outpatient hysteroscopy that allows completion of the procedure while minimizing pain. METHODS: A double-blind randomized controlled trial of women aged 20-60 years undergoing operative hysteroscopy (including biopsy sampling, polypectomy, septum excision, adhesiolysis, or intrauterine device removal) was undertaken at a university hospital in Egypt between May 2014 and July 2016. Using a computer-generated randomization sequence, patients were randomly assigned into three equal groups: filling pressures of 40 mm Hg (group 1), 60 mm Hg (group 2), and 80 mm Hg (group 3; control). The primary outcome was the proportion of successfully completed procedures. Analyses were by intention to treat. RESULTS: Each group contained 80 women. The procedure was completed for 63 (79%) women in group 1, 73 (91%) in group 2, and 76 (95%) in group 3 (P=0.004). The proportion of completed procedures in group 3 was significantly different from that in group 1 (P=0.002), but did not differ significantly from that in group 2 (P=0.349). CONCLUSION: A uterine filling pressure of 60 mm Hg does not reduce the frequency of completion when compared with 80 mm Hg in operative outpatient hysteroscopy. CLINICALTRIALS. GOV REGISTRATION: NCT02142673.

3D ultrasound assessment of endometrial junctional zone anatomy as a predictor of the outcome of ICSI cycles.

OBJECTIVE: To study the relation between junctional zone thickness (JZ) and success of implantation in IVF/ICSI cycles. STUDY DESIGN: A prospective study included 100 infertility patients undergoing ICSI. The long protocol was used in all patients. JZ was measured using 3D ultrasound, in the coronal section, at three places, on two occasions. First measurement was done before HMG was started (i.e. when down regulation was achieved). Second measurement was done on the day of ovum pick up (OPU). Follow up after treatment was done to determine the rate of implantation. RESULTS: There was a highly significant difference between pregnant and non pregnant treated women regarding the measurement of JZ at the day of OPU at all sites named fundal (0.27±0.1 vs. 0.38±0.14), anterior (0.28±0.07 vs. 0.36±0.09), posterior (0.32±0.1 vs. 0.37±0.09) and average (0.29±0.08 vs. 0.37±0.09) respectively. The cut off value, sensitivity and specificity of measurement of JZ at fundus were (≤0.31,90% and 66.7%), at anterior wall were (≤0.35,90% and 60%), at posterior wall (≤0.25, 50% and 93.3%) and average were (≤0.32,70% and 70%) respectively. CONCLUSION: The thinner the junctional zone at day of OPU, the higher the implantation rate and the difference between JZ measured at the day of down regulation and the day of OPU is a predictor of the outcome of ICSI cycles.

Impact of Uterine Scar on Pain Experienced During Outpatient Hysteroscopy: A Prospective Blinded Comparative Study.

STUDY OBJECTIVE: To study the impact of uterine scar on pain experienced during outpatient hysteroscopy. DESIGN: A prospective blinded comparative study (Canadian Task Force classification II-1). SETTING: Outpatient hysteroscopy clinic at a university hospital. PATIENTS: We included 140 women in the childbearing period attending an outpatient hysteroscopy clinic. Patients were divided into 2 groups. Group A included patients with previous uterine scar (n = 70) and Group B included those with unscarred uterus (n = 70). None of the patients had a previous attempt of a vaginal delivery. INTERVENTION: Diagnostic outpatient hysteroscopy without the use of anesthesia or analgesia. MEASUREMENTS: We assessed pain experienced during and immediately after the procedure using a 100-mm visual analog scale. We also evaluated the successful completion of the procedure. RESULTS: There were no statistically significant differences in the pain scores between patients with scarred uterus and those with unscarred uterus during or immediately after the procedure. The procedure was aborted in only 1 case in the scarred uterus group. This patient had a history of surgical site infection, which may denote a weak scar. There were no statistically significant differences in pain scores between patients with cesarean scar and those with myomectomy scar. No statistically significant differences in pain scores were found between patients with 1, 2, 3, or 4 cesarean deliveries. CONCLUSION: Uncomplicated uterine scars do not have an impact on pain experienced during or immediately after diagnostic outpatient hysteroscopy using a 3.8-mm hysteroscope.

Cost effectiveness of letrozole and purified urinary FSH in treating women with clomiphene citrate-resistant polycystic ovarian syndrome: a randomized controlled trial.

We aimed to compare the cost effectiveness of letrozole versus purified urinary follicle stimulating hormone (FSH) in treating patients with clomiphene citrate (CC)-resistant polycystic ovary syndrome (PCOS). This was a randomized trial conducted in Cairo University and Beni-Suef University Hospitals, Egypt. A cohort of 140 eligible women was randomized to receive either letrozole 2.5 mg twice daily for five days, or FSH using a graduated regimen starting with a dose of 75 IU. Treatment was repeated for three months if pregnancy did not occur. There were no significant differences between the two treatments in the cumulative clinical pregnancy rate (30% vs. 34%; p = 0.578), cumulative ovulation rate (47% vs. 57%; p = 0.236), miscarriage rate (9% vs. 4%, p > 0.999) or multiple pregnancy rate (0% and 8%, p = 0.491) but the FSH cycles were 4.8 times more expensive. Letrozole and FSH were both effective in treating women with CC-resistant PCOS but letrozole was more cost effective.Study registration number: NCT02304107.

Gonadotropin-releasing hormone antagonists versus standard androgen suppression therapy for advanced prostate cancer A systematic review with meta-analysis.

OBJECTIVES: To evaluate efficacy and safety of gonadotropin-releasing hormone (GnRH) antagonists compared to standard androgen suppression therapy for advanced prostate cancer. SETTING: The international review team included methodologists of the German Cochrane Centre and clinical experts. PARTICIPANTS: We searched CENTRAL, MEDLINE, Web of Science, EMBASE, trial registries and conference books for randomised controlled trials (RCT) for effectiveness data analysis, and randomised or non-randomised controlled studies (non-RCT) for safety data analysis (March 2015). Two authors independently screened identified articles, extracted data, evaluated risk of bias and rated quality of evidence according to GRADE. RESULTS: 13 studies (10 RCTs, 3 non-RCTs) were included. No study reported cancer-specific survival or clinical progression. There were no differences in overall mortality (RR 1.35, 95% CI 0.63 to 2.93), treatment failure (RR 0.91, 95% CI 0.70 to 1.17) or prostate-specific antigen progression (RR 0.83, 95% CI 0.64 to 1.06). While there was no difference in quality of life related to urinary symptoms, improved quality of life regarding prostate symptoms, measured with the International Prostate Symptom Score (IPSS), with the use of GnRH antagonists compared with the use of standard androgen suppression therapy (mean score difference -0.40, 95% CI -0.94 to 0.14, and -1.84, 95% CI -3.00 to -0.69, respectively) was found. Quality of evidence for all assessed outcomes was rated low according to GRADE. The risk for injection-site events was increased, but cardiovascular events may occur less often by using GnRH antagonist. Available evidence is hampered by risk of bias, selective reporting and limited follow-up. CONCLUSIONS: There is currently insufficient evidence to make firm conclusive statements on the efficacy of GnRH antagonist compared to standard androgen suppression therapy for advanced prostate cancer. There is need for further high-quality research on GnRH antagonists with long-term follow-up. TRIAL REGISTRATION NUMBER: CRD42012002751.

Abnormal uterine bleeding in midlife: The role of levonorgestrel intrauterine system.

Abnormal uterine bleeding is a common gynecological complaint affecting 10-30% of women in midlife and constitute about one-third of all outpatient gynecological visits. It adversely affects the quality of woman's life and can lead to psychological, social, medical, and sexual problems and thus necessitating appropriate and adequate management. Different treatment modalities for such problems are available, yet the levonorgestrel intrauterine system (LNG-IUS) has recently provided a good treatment option effective in treating such complaints and at the same time, having a reliable contraceptive effect which is desired by such age group. For women in their reproductive years, the LNG-IUS has become one of the most acceptable medical treatments for menorrhagia, reducing referrals to specialists, and decreasing the recourse to operative treatments. It is easy to insert, has a sustained effect, cost-effective, and well tolerated besides providing reliable contraception.