Rare case of rectal perforation by an intrauterine device: Case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Intrauterine devices (IUDs) are safe, highly effective and reversible forms of contraception. Reliance on IUD has been increasing and as such, it is the responsibility of the healthcare provider to be aware of the complications associated with it. IUD rectal migration is one of the rare but serious complications that may lead to detrimental sequelae. CASE PRESENTATION: A 30-year-old asymptomatic woman presented to the gynaecology clinic two months after a difficult insertion of an IUD. On examination, the device was not localised in utero with transvaginal sonography. Computed tomography scan and colonoscopy revealed the position of the IUD within the rectum. It was successfully retrieved with a combined laparoscopic-colonoscopic approach. Follow-up flexible sigmoidoscopy showed a well-healed rectal wall. CLINICAL DISCUSSION: IUD perforation can increase the risk of morbidity and necessitates early surgical intervention even if the patient is asymptomatic. Combined laparoscopic-colonoscopic approach allows for safe retrieval of IUD that has perforated the intraperitoneal rectal segment or is firmly embedded within the mucosa. Recognising the risk factors and adhering to the principles of IUD insertion could significantly lower the risk of perforation. CONCLUSION: This case report highlights the importance of a physician's vigilance regarding a perforating IUD in a patient with a history of a difficult insertion. It is imperative to undertake additional steps to rule out such a complication in these cases. Uterine perforation can be avoided with implementation of safe IUD insertion practice.

Fabrication of ciprofloxacin-loaded chitosan/polyethylene oxide/silica nanofibers for wound dressing application: In vitro and in vivo evaluations.

Silica plays an effective role in collagen creation; hence, the degradation products of silica-based materials accelerate wound healing. In this regard, chitosan/polyethylene oxide/silica hybrid nanofibers were prepared by the combining the sol-gel method with electrospinning technique to accelerate the wound healing process. Ciprofloxacin, as an antibacterial drug, was then added to the electrospinning mixture. The nanofibers were characterized by SEM, EDX, X-ray mapping, TEM, TGA, FTIR, and XRD analysis. The degradation, swelling ratio, and release of ciprofloxacin were investigated in PBS. The prepared nanofiber could absorb water, maintain its morphological integrity during the degradation process, and gradually release ciprofloxacin. The nanofibers revealed an efficient antibacterial activity against Escherichia coli and Staphylococcus aureus. Cell viability assays showed that the nanofibers had no cytotoxicity against L929 mouse fibroblast and HFFF2 human foreskin fibroblast cell lines. The potential of the chitosan/polyethylene oxide/silica/ciprofloxacin nanofiber for healing full-thickness wound was assessed by applying the scaffold in the dorsal cutaneous wounds of the Balb/C mice. The white blood cell counts of the animals indicated the nanofiber-treated mice compared with the untreated ones had less infection and inflammation. According to the histopathologic data, the prepared nanofiber accelerated and enhanced tissue regeneration by increasing fibroblast cells and angiogenesis as well as decreasing the inflammation phase. The findings suggest that the prepared antibacterial scaffold with drug delivery properties could be an appropriate candidate for many medical and hygienic applications, especially as a bio-compatible and bio-degradable wound dressing.

Correction: Lidocaine-Induced Systemic Toxicity: A Case Report and Review of Literature.

[This corrects the article DOI: 10.7759/cureus.1275.].

A clinical predictive model for post-hospitalisation venous thromboembolism in patients with inflammatory bowel disease.

BACKGROUND: Patients with inflammatory bowel disease (IBD) are at increased risk of venous thromboembolism (VTE) during hospitalisation and potentially post-discharge. AIMS: To determine the incidence and risk factors for post-discharge VTE in IBD patients and create a point of care predictive model to assess VTE risk. METHODS: Hospitalised IBD patients were identified from our institutional discharge database between 2009 and 2016, and were assessed for VTE by chart review. Risk factors for VTE within 3 months of discharge were determined by univariable and multivariable logistic regression. A point of care model was created using variables from the univariate analysis with P < 0.05, and internally validated by bootstrap methods. RESULTS: Sixty-six of 2161 eligible discharges (3%) were associated with VTE within 6 months of hospitalisation. The median time to event was 37 days (range 3-182 days). On multivariable analysis age >45 years (OR 3.76; 95% CI 1.80-7.89) and multiple admissions (OR 2.62; 95% CI 1.34-5.11) were independently associated with VTE risk. Our final model incorporated age >45 years, multiple admissions, intensive care unit admission, length of admission >7 days and central catheter and was able to discriminate between discharges associated with and without VTE (optimism-corrected c-statistic, 0.70; 95% CI 0.58-0.77). By limiting treatment to a high-risk group, extended thromboprophylaxis could be avoided in 92% of discharges with a miss rate of 1.6% (32/1982 discharges). CONCLUSION: Patients with IBD remain at risk of VTE after hospital discharge. Our model may help clinicians stratify which patients will benefit most from extended thrombophrophylaxis.

A Practice Improvement Project to Increase Advance Care Planning in a Dementia Specialty Practice.

This study was conducted to enhance the rate of advance care planning (ACP) conversations and documentation in a dementia specialty practice by increasing physician knowledge, attitudes, and skills. We used a pre- and postintervention paired design for physicians and 2 independent groups for patients. The ACP dementia educational program encompassed 3 objectives: (1) to understand the relevance of ACP to the dementia specialty practice, (2) to provide a framework to discuss ACP with patients and caregivers, and (3) to discuss ways to improve ACP documentation and billing in the electronic medical record. A 10-item survey was utilized pre- and posteducational intervention to assess knowledge, attitudes, and skill. The prevalence of ACP documentation was assessed through chart review 3 months pre- and postintervention. The educational intervention was associated with increased confidence in ability to discuss ACP (P = .033), belief that ACP improves outcomes in dementia (P = .035), knowledge about ACP Medicare billing codes and requirements (P = .002), and belief that they have support from other personnel to implement ACP (P = .017). In 2 independent groups of patients with dementia, documentation rates of an advance directive increased from 13.6% to 19.7% (P = .045) and the Medical Order for Life-Sustaining Treatment (MOLST) increased from 11.0% to 19.0% (P = .006). The MOLST documentation in 2 independent groups of patients with nondementia increased from 7.3% to 10.7% (P = .046). Continuing efforts to initiate educational interventions are warranted to increase the effectiveness ACP documentation and future care of persons with dementia.

Delayed neurological deficits after endovascular placement of a pipeline embolisation device: clinical manifestation and treatment.

Endovascular treatment has been the mainstay of therapy for repair of both ruptured and unruptured cerebral aneurysms. Flow diverter devices offer a new option for the treatment of complex aneurysms that were previously not amenable to coiling. Procedural adverse effects include intracranial haemorrhage and ischaemic stroke, which usually occur on the same day. Delayed complications are rare. We report a case of a patient who underwent placement of a pipeline embolisation device and developed delayed neurological deficits, which were thought to be an inflammatory reaction to the hydrophilic coating used in guidewires and microcatheters. Our patient was treated with a course of steroids, with improvement of her neurological deficits and resolution of MRI findings. As the use of flow diverter devices has increased, variable and delayed complications of such therapy are increasingly being reported in the literature.

Lidocaine-Induced Systemic Toxicity: A Case Report and Review of Literature.

For the past 50 years, local anesthetics such as lidocaine have been commonly used in various clinical settings. Its use is not just limited to anesthesia and surgery but is also frequently utilized in internal medicine and in primary care setting for bedside procedures. Despite its widespread use, most physicians are not familiar with the life-threatening manifestations of lidocaine toxicity and its treatment. Our case demonstrates a successful resuscitation after cardiac arrest in a healthy 33-year-old female with systemic lidocaine toxicity after she received lidocaine as a local anesthetic. Our goal is to educate general internists and primary care physicians of the possible hazards of lidocaine use. We also aim to create mindfulness of the symptoms of lidocaine toxicity and the use of intravenous lipid emulsion as an antidote.

Chylous Ascites in Systemic Lupus Erythematosus: A Diagnostic Challenge.

Systemic lupus erythematous (SLE) is a chronic inflammatory disease of unknown etiology. It can affect nearly any organ. Gastrointestinal (GI) involvement in SLE is frequent but is mostly related to medication side effects and concomitant infections. Chylous ascites is a rare form of ascites that is milky appearing due to the high concentration of triglycerides. Chylous ascites as a complication of SLE is atypical. Our case highlights an extremely rare presentation of chylous ascites in SLE as an initial manifestation of the disease itself, posing diagnostic and therapeutic challenges. Through this case, we aim to raise awareness of SLE as a rare but reversible cause of chylous ascites.

A novel approach to the management of carotid blowout syndrome: the use of thrombin in a case of failed covered stenting.

Acute hemorrhage relating to an expanding pseudoaneurysm of the carotid artery is referred to as carotid blowout syndrome (CBS). CBS is associated with a high morbidity and mortality. We describe the case of a patient who presented with dysphagia and a pulsatile mass in the neck. Imaging revealed a pseudoaneurysm originating from the bifurcation of the distal right common carotid artery. On neuroangiography the patient lacked sufficient collaterals to allow for vessel sacrifice. A decision was made to use covered stents to prevent flow into the pseudoaneurysm while maintaining vessel patency. Despite placement of multiple covered stents there was residual slow filling of the pseudoaneurysm. We augmented this therapy with direct percutaneous thrombin injection into the pseudoaneurysm. This resulted in complete thrombosis of the pseudoaneurysm. For recalcitrant lesions in which the usual methods of stopping blood flow to the pseudoaneurysmal sac fail, an adjuvant approach with thrombin should be considered.

A novel approach to the management of carotid blowout syndrome: the use of thrombin in a case of failed covered stenting.

Acute hemorrhage relating to an expanding pseudoaneurysm of the carotid artery is referred to as carotid blowout syndrome (CBS). CBS is associated with a high morbidity and mortality. We describe the case of a patient who presented with dysphagia and a pulsatile mass in the neck. Imaging revealed a pseudoaneurysm originating from the bifurcation of the distal right common carotid artery. On neuroangiography the patient lacked sufficient collaterals to allow for vessel sacrifice. A decision was made to use covered stents to prevent flow into the pseudoaneurysm while maintaining vessel patency. Despite placement of multiple covered stents there was residual slow filling of the pseudoaneurysm. We augmented this therapy with direct percutaneous thrombin injection into the pseudoaneurysm. This resulted in complete thrombosis of the pseudoaneurysm. For recalcitrant lesions in which the usual methods of stopping blood flow to the pseudoaneurysmal sac fail, an adjuvant approach with thrombin should be considered.

Absolute and Relative Carnitine Deficiency in Patients on Hemodialysis and Peritoneal Dialysis.

INTRODUCTION: Carnitine deficiency is commonly seen in dialysis patients. This study assessed the association dialysis and pediatric patients' characteristics with plasma carnitines levels. MATERIALS AND METHODS: Plasma carnitine concentrations were measured by tandem mass spectrometry in 46 children on hemodialysis or peritoneal dialysis. The total carnitine, free carnitine (FC), and L-acyl carnitine (AC) levels of 40 µmol/L and less, less than 7 µmol/L, and less than 15 µmol/L were defined low, respectively. An FC less than 20 µmol/L and an AC/FC ratio greater than 0.4 were considered as absolute and relative carnitine deficiencies. The correlation between carnitines levels and AC/FC ratio and age, duration of dialysis, characteristics of dialysis, and blood urea nitrogen and serum albumin concentrations were assessed. RESULTS: Absolute carnitine deficiency, low total carnitine, and low AC concentrations were found in 66.7%, 82.6%, and 51% of the patients, respectively. All of the patients had relative carnitine deficiency. Carnitine measurements were not significantly different between the hemodialysis and peritoneal dialysis groups. More severe relative carnitine deficiency was found in those with lower blood urea nitrogen levels and those on peritoneal dialysis. No linear correlation was found between carnitine levels and age, duration of dialysis, characteristics of dialysis, serum albumin level, or blood urea nitrogen level. CONCLUSIONS: Absolute and relative carnitine deficiencies are common among children on dialysis. Patients with lower blood urea nitrogen levels and peritoneal dialysis patients are more prone to severe relative carnitine deficiency.

Home-based educational interventions for children with asthma.

BACKGROUND: While guidelines recommend that children with asthma should receive asthma education, it is not known if education delivered in the home is superior to usual care or the same education delivered elsewhere. The home setting allows educators to reach populations (such as the economically disadvantaged) that may experience barriers to care (such as lack of transportation) within a familiar environment. OBJECTIVES: To perform a systematic review on educational interventions for asthma delivered in the home to children, caregivers or both, and to determine the effects of such interventions on asthma-related health outcomes. We also planned to make the education interventions accessible to readers by summarising the content and components. SEARCH STRATEGY: We searched the Cochrane Airways Group Specialised Register of trials, which includes the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO, and handsearched respiratory journals and meeting abstracts. We also searched the Education Resources Information Center database (ERIC), reference lists of trials and review articles (last search January 2011). SELECTION CRITERIA: We included randomised controlled trials of asthma education delivered in the home to children, their caregivers or both. In the first comparison, eligible control groups were provided usual care or the same education delivered outside of the home. For the second comparison, control groups received a less intensive educational intervention delivered in the home. DATA COLLECTION AND ANALYSIS: Two authors independently selected the trials, assessed trial quality and extracted the data. We contacted study authors for additional information. We pooled dichotomous data with fixed-effect odds ratio and continuous data with mean difference (MD) using a fixed-effect where possible. MAIN RESULTS: A total of 12 studies involving 2342 children were included. Eleven out of 12 trials were conducted in North America, within urban or suburban settings involving vulnerable populations. The studies were overall of good methodological quality. They differed markedly in terms of age, severity of asthma, context and content of the educational intervention leading to substantial clinical heterogeneity. Due to this clinical heterogeneity, we did not pool results for our primary outcome, the number of patients with exacerbations requiring emergency department (ED) visit. The mean number of exacerbations requiring ED visits per person at six months was not significantly different between the home-based intervention and control groups (N = 2 studies; MD 0.04; 95% confidence interval (CI) -0.20 to 0.27). Only one trial contributed to our other primary outcome, exacerbations requiring a course of oral corticosteroids. Hospital admissions also demonstrated wide variation between trials with significant changes in some trials in both directions. Quality of life improved in both education and control groups over time.A table summarising some of the key components of the education programmes is included in the review. AUTHORS' CONCLUSIONS: We found inconsistent evidence for home-based asthma educational interventions compared to standard care, education delivered outside of the home or a less intensive educational intervention delivered at home. Although education remains a key component of managing asthma in children, advocated in numerous guidelines, this review does not contribute further information on the fundamental content and optimum setting for such educational interventions.

Sealing ability of mineral trioxide aggregate and Portland cement for furcal perforation repair: a protein leakage study.

The purpose of this study was to compare the sealing ability of gray mineral trioxide aggregate (GMTA), white MTA (WMTA), and both white and gray Portland cement as furcation perforation repair materials. A total of 120 human mandibular first molars were used. After root canal obturation and preparation of furcal perforations the specimens were randomly divided into four groups of 25 teeth each. In groups A, B, C, and D furcation perforations were filled with WMTA, GMTA, white Portland cement, and type II Portland cement, respectively. Ten teeth were used as positive controls with no filling materials in the perforations and 10 teeth with complete coverage with two layers of nail varnish were used as negative controls. A protein leakage model utilizing 22% bovine serum albumin (BSA) was used for evaluation. Leakage was noted when color conversion of the protein reagent was observed. The controls behaved as expected. Leakage was found in the samples from group A (WMTA), group B (GMTA), and in the two other groups (white and gray Portland cement). There were no statistically significant differences between GMTA and WMTA or white and gray Portland cement, but significant differences were observed between the MTA groups and the Portland cement groups. It was concluded that Portland cements have better sealing ability than MTA, and can be recommended for repair of furcation perforation if the present results are supported by other in vivo and in vitro studies.

Kinetic analysis of drug release from nanoparticles.

PURPOSE: Comparative drug release kinetics from nanoparticles was carried out using conventional and our novel models with the aim of finding a general model applicable to multi mechanistic release. Theoretical justification for the two best general models was also provided for the first time. METHODS: Ten conventional models and three models developed in our laboratory were applied to release data of 32 drugs from 106 nanoparticle formulations collected from literature. The accuracy of the models was assessed employing mean percent error (E) of each data set, overall mean percent error (OE) and number of Es less than 10 percent. RESULTS: Among the models the novel reciprocal powered time (RPT), Weibull (W) and log- probability (LP) ones produced OE values of 6.47, 6.39 and 6.77, respectively. The OEs of other models were higher than 10%. Also the number of errors less than 10 percent for the models was 84.9, 80.2 and 78.3 percents of total number of data sets. CONCLUSIONS: Considering the accuracy criteria the reciprocal powered time model could be suggested as a general model for analysis of multi mechanistic drug release from nanoparticles. Also W and LP models were the closest to the suggested model.