Extracorporeal shockwave lithotripsy in the management of urinary stones: New concepts and techniques to improve outcomes

Objective: Extracorporeal shockwave lithotripsy (SWL) currently plays an important role in the treatment of urinary tract lithiasis. The purpose of this article was to describe new concepts and procedural strategies that would improve results using SWL as a treatment for urolithiasis, thereby achieving better clinical practice.Methods: A systematic review process was carried in PubMed/PMC from January 2003 to March 2023. A narrative synthesis of the most important aspects has been made.Results: The important recommendations for the adequate selection of the candidate patient for treatment with SWL are summarized, as well as the new strategies for a better application of the technique. Aspects about intraoperative position, stone localization and monitoring, analgesic control, machine and energy settings, and measures aiming at reduced risk of complications are described.Conclusion: To achieve the therapeutic goal of efficient stone disintegration without increasing the risk of complications, it is necessary to make an adequate selection of patients and to pay special attention to several important factors in the application of treatment. Technological development in later generation devices will help to improve current SWL results.

Natural history of asymptomatic gallbladder stones in clinic without beds:A long-term prognosis over 10 years

BACKGROUND Several studies have explored the long-term prognosis of patients with asymp-tomatic gallbladder stones.These reports were primarily conducted in facilities equipped with beds for addressing symptomatic cases.AIM To report the long-term prognosis of patients with asymptomatic gallbladder stones in clinics without bed facilities.METHODS We investigated the prognoses of 237 patients diagnosed with asymptomatic gallbladder stones in clinics without beds between March 2010 and October 2022.When symptoms developed,patients were transferred to hospitals where appropriate treatment was possible.We investigated the asymptomatic and survival periods during the follow-up.RESULTS Among the 237 patients,214(90.3%)remained asymptomatic,with a mean asymptomatic period of 3898.9279±46.871 d(50-4111 d,10.7 years on average).Biliary complications developed in 23 patients(9.7%),with a mean survival period of 4010.0285±31.2788 d(53-4112 d,10.9 years on average).No patient died of biliary complications.CONCLUSION The long-term prognosis of asymptomatic gallbladder stones in clinics without beds was favorable.When the condition became symptomatic,the patients were transferred to hospitals with beds that could address it;thus,no deaths related to biliary complications were reported.This finding suggests that follow-up care in clinics without beds is possible.

Parkland trees on smallholder farms ameliorate soil physical-chemical properties in the semi-arid area of Tigray,Ethiopia

Proposed agroforestry options should begin with the species that farmers are most familiar with,which would be the native multipurpose trees that have evolved under smallholder farms and socioeconomic conditions.The African birch(Anogeissus leiocarpa(DC.)Guill.&Perr.)and pink jacaranda(Stereospermum kunthianum Cham.)trees are the dominant species in the agroforestry parkland system in the drylands of Tigray,Ethiopia.Smallholder farmers highly value these trees for their multifunctional uses including timber,firewood,charcoal,medicine,etc.These trees also could improve soil fertility.However,the amount of soil physical and chemical properties enhanced by the two species must be determined to maintain the sustainable conservation of the species in the parklands and to scale up to similar agroecological systems.Hence,we selected twelve isolated trees,six from each species that had similar dendrometric characteristics and were growing in similar environmental conditions.We divided the canopy cover of each tree into three radial distances:mid-canopy,canopy edge,and canopy gap(control).At each distance,we took soil samples from three different depths.We collected 216 soil samples(half disturbed and the other half undisturbed)from each canopy position and soil depth.Bulk density(BD),soil moisture content(SMC),soil organic carbon(SOC),total nitrogen(TN),available phosphorus(AP),available potassium(AK),p H,electrical conductivity(EC),and cation exchange capacity(CEC)were analysed.Results revealed that soil physical and chemical properties significantly improved except for soil texture and EC under both species,CEC under A.leiocarpus,and soil p H under S.kunthianum,all the studied soils were improved under both species canopy as compared with canopy gap.SMC,TN,AP,and AK under canopy of these trees were respectively 24.1%,11.1%,55.0%,and 9.3% higher than those soils under control.The two parkland agroforestry species significantly enhanced soil fertility near the canopy of topsoil through improving soil physical and chemical properties.These two species were recommended in the drylands with similar agro-ecological systems.

Percutaneous antegrade management of large proximal ureteral stones using non-papillary puncture

Objective:To evaluate the feasibility and the safety of medial non-papillary percutaneous nephrolithotomy(npPCNL)for the management of large proximal ureteral stones.Methods:We evaluated prospectively collected data of 37 patients with large proximal ureteral stones more than 1.5 cm in diameter treated by prone npPCNL.Depending on stone size,in-toto stone removal or lithotripsy using the Lithoclast®Trilogy(EMS Medical,Nyon,Switzerland)was performed.Perioperative parameters including operative time(from start of puncture to the skin suturing),stone extraction time(from the first insertion of the nephroscope to the extraction of all stone fragments),and the stone-free rate were evaluated.Results:Twenty-one males and 16 females underwent npPCNL for the management of large upper ureteral calculi.The median age and stone size of treated patients were 58(interquartile range[IQR]:51-69)years and 19.3(IQR:18.0-22.0)mm,respectively.The median operative time and stone extraction time were 25(IQR:21-29)min and 8(IQR:7-10)min,respectively.One case(2.7%)of postoperative bleeding and two cases(5.4%)of prolonged fever were managed conservatively.The stone-free rate at a 1-month follow-up was 94.6%.Conclusion:The npPCNL provides a straight route to the ureteropelvic junction and proximal ureter.Approaching from a dilated portion of the ureter under low irrigation pressure with larger diameter instruments results in effective and safe stone extraction within a few minutes.

Tree mycorrhizal associations determine how biodiversity,large trees,and environmental factors drive aboveground carbon stock in temperate forests

Biodiversity,large trees,and environmental conditions such as climate and soil have important effects on forest carbon stocks.However,recent studies in temperate forests suggest that the relative importance of these factors depends on tree mycorrhizal associations,whereby large-tree effects may be driven by ectomycorrhizal(EM)trees,diversity effects may be driven by arbuscular mycorrhizal(AM)trees,and environment effects may depend on differential climate and soil preferences of AM and EM trees.To test this hypothesis,we used forest-inventory data consisting of over 80,000 trees from 631 temperate-forest plots(30 m×30 m)across Northeast China to examine how biodiversity(species diversity and ecological uniqueness),large trees(top 1%of tree diameters),and environmental factors(climate and soil nutrients)differently regulate aboveground carbon stocks of AM trees,EM trees,and AM and EM trees combined(i.e.total aboveground carbon stock).We found that large trees had a positive effect on both AM and EM tree carbon stocks.However,biodiversity and environmental factors had opposite effects on AM vs.EM tree carbon stocks.Specifically,the two components of biodiversity had positive effects on AM tree carbon stocks,but negative effects on EM tree carbon stocks.Environmental heterogeneity(mean annual temperature and soil nutrients)also exhibited contrasting effects on AM and EM tree carbon stocks.Consequently,for the total carbon stock,the positive large-tree effect far surpasses the diversity and environment effect.This is mainly because when integrating AM and EM tree carbon stock into total carbon stock,the opposite diversity-effect(also environment-effect)on AM vs.EM tree carbon stock counteracts each other while the consistent positive large-tree effect on AM and EM tree carbon stock is amplified.In summary,this study emphasized a mycorrhizal viewpoint to better understand the determinants of overarching aboveground carbon profile across regional forests.

Oxalate regulates crystal-cell adhesion and macrophage metabolism via JPT2/PI3K/AKT signaling to promote the progression of kidney stones

Oxalate is an organic dicarboxylic acid that is a common component of plant foods.The kidneys are essential organs for oxalate excretion,but excessive oxalates may induce kidney stones.Jupiter microtubule associated homolog 2(JPT2)is a critical molecule in Ca^(2+)mobilization,and its intrinsic mechanism in oxalate exposure and kidney stones remains unclear.This study aimed to reveal the mechanism of JPT2 in oxalate exposure and kidney stones.Genetic approaches were used to control JPT2 expression in cells and mice,and the JPT2 mechanism of action was analyzed using transcriptomics and untargeted metabolomics.The results showed that oxalate exposure triggered the upregulation of JPT2,which is involved in nicotinic acid adenine dinucleotide phosphate(NAADP)-mediated Ca^(2+)mobilization.Transcriptomic analysis revealed that cell adhesion and macrophage inflammatory polarization were inhibited by JPT2 knockdown,and these were dominated by phosphatidylinositol 3-kinase(PI3K)/AKT signaling,respectively.Untargeted metabolomics indicated that JPT2 knockdown inhibited the production of succinic acid semialdehyde(SSA)in macrophages.Furthermore,JPT2 deficiency in mice inhibited kidney stones mineralization.In conclusion,this study demonstrates that oxalate exposure facilitates kidney stones by promoting crystal-cell adhesion,and modulating macrophage metabolism and inflammatory polarization via JPT2/PI3K/AKT signaling.

Cost-Effectiveness Analysis of Renalof® versus Extracorporeal Shockwave Lithotripsy (ESWL) for the Treatment of Kidney Stones ≤ 1 cm in Nicaragua

Objectives: To assess the efficiency in terms of cost-effectiveness (CE) of oral Renalof® treatment versus extracorporeal shockwave lithotripsy (ESWL) in the treatment of kidney stones ≤ 1 cm in Nicaragua. Methods: A cost-effectiveness economic evaluation was carried out based on the results obtained in the randomised, prospective, observational, single-blind, prospective, phase 2 clinical trial. Cost-effectiveness and the incremental cost-effectiveness ratio (ICER) were calculated. Economic data were obtained from the Economics Department of Clínica Senior in Managua, Nicaragua. The monetary cost was expressed in US dollars (USD). Results: Treatment with Renalof® yielded a CE of $1,323.08/% remission, while ESWL was $9,498.54/% remission. The ICER shows that, in order to achieve a high percentage of kidney stone remission with ESWL, an extra $4,734.70 per patient must be invested. Conclusions: The use of Renalof® is shown to be a more cost-effective option than ESWL. It is recommended for the treatment of kidney stones ≤ 1 cm in size.

Laparoscopic cholecystectomy plus common bile duct exploration for extrahepatic bile duct stones and postoperative recurrenceassociated risk factors

BACKGROUND There remain controversies regarding the surgical treatment of extrahepatic bile duct stones(EHBDSs)in clinical practice.AIM To explore the curative effect of laparoscopic cholecystectomy(LC)plus common bile duct exploration(CBDE)for the surgical treatment of EHBDSs and to analyze the risk factors that affect postoperative stone recurrence.METHODS Eighty-two patients with EHBDSs admitted between March 2017 and March 2023 were selected.Among them,patients treated with open choledocholithotomy plus LC or open cholecystectomy(OC)were set as the control group(n=40),and those treated with LC plus CBDE served as the observation group(n=42).The surgical outcomes of the two groups were compared,the surgical complications and Gas-trointestinal Quality of Life Index(GIQLI)scores were counted,and the one-year prognostic recurrence was recorded.Independent factors for postoperative re-currence were determined using univariate and multivariate analyses.RESULTS The two groups were comparable in the stone residual rate(P>0.05).The ope-ration time(P<0.05),intraoperative bleeding(P<0.05),and total complication rate(P=0.005)were lower in the observation group than in the control group.The observation group exhibited a marked increase in the GIQLI score,which was higher than the control group(P<0.05).A lower one-year recurrence rate was determined in the observation group vs the control group(P=0.027).Sphincter of Oddi dysfunction[odds ratio(OR)=5.712,P=0.007]and the treatment scheme of open choledocholithotomy plus LC or OC(OR=6.771,P=0.008)were the independent risk factors for one-year recurrence in patients after surgery.CONCLUSION LC plus CBDE for patients with EHBDSs can reduce stone residuals,intraoperative bleeding,complications,and postoperative recurrence.

Clinical efficacy of laparoscopic cholecystectomy combined with endoscopic papillary balloon dilation in treatment of gallbladder stones with common bile duct stones: A retrospective study

BACKGROUND The incidence of cholelithiasis has been on the rise in recent years,but the choice of procedure is controversial.AIM To investigate the efficacy of laparoscopic cholecystectomy(LC)combined with endoscopic papillary balloon dilation(EPBD)in patients with gallbladder stones(GS)with common bile duct stones(CBDS).METHODS The clinical data of 102 patients with GS combined with CBDS were selected for retrospective analysis and divided into either an LC+EPBD group(n=50)or an LC+endoscopic sphincterotomy(EST)group(n=52)according to surgical methods.Surgery-related indexes,postoperative recovery,postoperative complications,and expression levels of inflammatory response indexes were compared between the two groups.RESULTS Total surgical time,stone free rate,rate of conversion to laparotomy,and successful stone extraction rate did not differ significantly between the LC+EPBD group and LC+EST group.Intraoperative hemorrhage,time to ambulation,and length of hospitalization in the LC+EPBD group were lower than those of the LC+EST group(P<0.05).The rate of total complications of the two groups was 9.80%and 17.65%,respectively,and the difference was not statistically significant.No serious complications occurred in either group.At 48 h postoperatively,the expression levels of interleukin-6,tumor necrosis factor-α,high-sensitivity Creactive protein,and procalcitonin were lower in the LC+EPBD group than in the LC+EST group(P<0.05).At 3 d postoperatively,the expression levels of aspartate transaminase,alanine transaminase,and total bilirubin were lower in the LC+EPBD group than in the LC+EST group(P<0.05).CONCLUSION LC combined with EPBD and LC combined with EST are both effective procedures for the treatment of GS with CBDS,in which LC combined with EPBD is beneficial to shorten the patient’s hospitalization time,reduce the magnitude of elevated inflammatory response indexes,and promote postoperative recovery.

Is fluoroscopy-free single-use flexible ureteroscopy a feasible treatment for kidney stones with abnormal renal anatomy?

ObjectiveThis study aimed to evaluate the feasibility of the fluoroscopy-free single-use flexible ureteroscopy procedure in the treatment of kidney stones with abnormal renal anatomy compared to normal renal anatomy.MethodsForty patients with abnormal (Group A) and 80 patients with normal (Group B) renal anatomy who had 10–20 mm renal stones were included. They were treated with LithoVue single-use flexible ureteroscopy (Boston Scientific, Marlborough, MA, USA) after ureteric dilatation by two different size semi-rigid ureteroscopes. This technique was chosen as the aim was to exclude any ureteric pathology (e.g., stone or stricture), confirm the placement of a safe guidewire, avoid balloon dilatation of the ureter, and achieve safe insertion of a 12 Fr, 35/45 cm ureteric access sheath with optical and tactile sign and without fluoroscopy image for guidance.ResultsThe mean ages were 43 years and 45 years in Group A and Group B, respectively. The mean stone burden was 14.62 (standard deviation: 5.35) mm^(3) and 14.79 (standard deviation: 4.58) mm^(3) in Group A and Group B, respectively. There is no significant difference between both groups according to the mean operative time, hospital stay, or stone-free rate. The stone-free rate was about 93% in both groups when the stone size was between 10 mm and 15 mm, and less than 54% when the stone size was more than 15 mm to 20 mm. In the majority of cases (80.0% in Group A and 92.5% in Group B), we completed the procedure without fluoroscopy. The perioperative complication rates were comparable in the two groups.ConclusionFluoroscopy-free single-use flexible ureteroscopy, when performed by expert urologists, is a feasible treatment for pre-stented patients with kidney calculi of ≤15 mm with abnormal renal anatomy.

Trees support functional soils in a dryland agricultural area

Trees provide multiple ecosystem services such as carbon sequestration,hydrological regulation and habitat for arboreal animals.However,they are often removed to support agricultural enterprises.Despite the importance of tree remnants,we know relatively little about how soils differ across sites of varying condition.Here,we describe a study where we examined the relative effects of trees,compared with unvegetated interspaces,on soil functions in remnant patches at sites in good and poor condition in two eucalypt communities in an irrigation area in eastern Australia.We found that,in general,carbon and nutrient cycling were relatively greater beneath trees,and in surface soils,but there were no clear trends in relation to site condition.The values of most soil attributes(e.g.,soluble and exchangeable cations,nitrogen,phosphorus)were greater beneath trees,indicating strong fertile island effects in both communities.Overall,our study confirms the importance of trees in remnant patches in agricultural landscapes,particularly those in sites of poor condition.It also suggests that soil processes may still be relatively intact,even in sites in poor condition.Our study reinforces the need to protect trees in remnant woodland reserves to maintain critical ecosystem functions related to nutrient retention.These remnants are important for achieving sustainable management of agricultural systems.

Role of outdoor trees on pedestrian wind and thermal conditions around a pre-education building for sustainable energy management

Finding sustainable energy resources is essential to face the increasing energy demand.Trees are an important part of ancient architecture but are becoming rare in urban areas.Trees can control and tune the pedestrian-level wind velocity and thermal condition.In this study,a numerical investigation is employed to assess the role of trees planted in the windward direction of the building complex on the thermal and pedestrian wind velocity conditions around/inside a pre-education building located in the center of the complex.Compared to the previous studies(which considered only outside buildings),this work considers the effects of trees on microclimate change both inside/outside buildings.Effects of different parameters including the leaf area density and number of trees,number of rows,far-field velocity magnitude,and thermal condition around the main building are assessed.The results show that the flow velocity in the spacing between the first-row buildings is reduced by 30%-40% when the one-row trees with 2 m height are planted 15 m farther than the buildings.Furthermore,two rows of trees are more effective in higher velocities and reduce the maximum velocity by about 50%.The investigation shows that trees also could reduce the temperature by about 1℃around the building.

Enhanced Cooling Efficiency of Urban Trees on Hotter Summer Days in 70 Cities of China

Increasing the urban tree cover percentage(TCP) is widely recognized as an efficient way to mitigate the urban heat island effect. The cooling efficiency of urban trees can be either enhanced or attenuated on hotter days, depending on the physiological response of urban trees to rising ambient temperature. However, the response of urban trees' cooling efficiency to rising urban temperature remains poorly quantified for China's cities. In this study, we quantify the response of urban trees' cooling efficiency to rising urban temperature at noontime [~1330 LT(local time), LT=UTC+8] in 17summers(June, July, and August) from 2003–19 in 70 economically developed cities of China based on satellite observations. The results show that urban trees have stronger cooling efficiency with increasing temperature, suggesting additional cooling benefits provided by urban trees on hotter days. The enhanced cooling efficiency values of urban trees range from 0.002 to 0.055℃ %-1 per 1℃ increase in temperature across the selected cities, with larger values for the lowTCP-level cities. The response is also regulated by background temperature and precipitation, as the additional cooling benefit tends to be larger in warmer and wetter cities at the same TCP level. The positive response of urban trees' cooling efficiency to rising urban temperature is explained mainly by the stronger evapotranspiration of urban trees on hotter days.These results have important implications for alleviating urban heat risk by utilizing urban trees, particularly considering that extreme hot days are becoming more frequent in cities under global warming.

Exploring Trees Diversity and Ecological Value of Mountain Forests in the Blue Nile Region of Sudan

We carried out this research at Abu-Gaddaf Natural Forest Reserve (ANFR) which is located east of Blue Nile River, in Blue Nile State, Sudan. It aims at exploring tree composition assessing their diversity indices, and ecological importance values. For survey of types and estimation of density of tree species in the forest, we randomly distributed 97 circular sample plots (0.1 hectare (ha)). In each sample plot we identified all trees to the species level, recorded their frequencies and computed species diversity and importance value indices (IVI). A total of 13 tree species, which belong to 12 genera and nine families, were identified in the tree layer of the forest. Mean tree density in ANFR was 116 trees/ha, composed mainly of Boswellia papyrifera (Del.) Hochst. (48), followed by Combretum hartmannianu (19) and Lannea fruticosa (18). Fabaceae was the most common family followed by Combretaceae and Malvaceae. B. papyrifera Delile Hochst was the most abundant while Acacia seyal was the least abundant species. Species richness (R = 1.71), evenness (E = 0.69), dominance (0.24) indices and Simpson’s Index of Diversity (D' = 0.76) suggest a moderate diversity, moderate numbers of individuals in each species and a moderate community stability. The research provides empirical results on diversity and ecological importance value of species, signifies the urging need to safeguard threatened species and to prioritize them for conservation, as well as the need to promote management of abundant species to provide multiple forest ecosystem services.

Nursing Effect of Rapid Rehabilitation Surgery Concept in Laparoscopic Surgery for Extrahepatic Bile Duct Stones

Objective: To explore the application value of rapid rehabilitation concept in patients with extrahepatic bile duct stones under laparoscopy during perioperative period. Methods: 90 patients with extrahepatic bile duct stones treated in our hospital from January 2022 to February 2023 were selected as the research object and randomly divided into the study group and the control group. The control group was given routine care, and the observation group was given rapid surgical rehabilitation care. The postoperative anal exhaust time, first meal time, early activity time, pain time, abdominal drainage tube removal time, hospitalization time and complication rate were compared between the two groups. The independent sample T test was used for the measurement data, and the x2 test was used for the counting data, and the difference was statistically significant (P Results: The postoperative anal exhaust time, first meal time, early activity time, pain time, abdominal drainage tube removal time and hospitalization time in the study group were shorter than those in the control group (all P Conclusion: The concept of rapid rehabilitation can significantly improve the perioperative nursing effect of patients with extrahepatic bile duct stones and accelerate their rehabilitation, which is worth improving and popularizing.

Enhancing PDF Malware Detection through Logistic Model Trees

Malware is an ever-present and dynamic threat to networks and computer systems in cybersecurity,and because of its complexity and evasiveness,it is challenging to identify using traditional signature-based detection approaches.The study article discusses the growing danger to cybersecurity that malware hidden in PDF files poses,highlighting the shortcomings of conventional detection techniques and the difficulties presented by adversarial methodologies.The article presents a new method that improves PDF virus detection by using document analysis and a Logistic Model Tree.Using a dataset from the Canadian Institute for Cybersecurity,a comparative analysis is carried out with well-known machine learning models,such as Credal Decision Tree,Naïve Bayes,Average One Dependency Estimator,Locally Weighted Learning,and Stochastic Gradient Descent.Beyond traditional structural and JavaScript-centric PDF analysis,the research makes a substantial contribution to the area by boosting precision and resilience in malware detection.The use of Logistic Model Tree,a thorough feature selection approach,and increased focus on PDF file attributes all contribute to the efficiency of PDF virus detection.The paper emphasizes Logistic Model Tree’s critical role in tackling increasing cybersecurity threats and proposes a viable answer to practical issues in the sector.The results reveal that the Logistic Model Tree is superior,with improved accuracy of 97.46%when compared to benchmark models,demonstrating its usefulness in addressing the ever-changing threat landscape.

Development of a novel difficulty scoring system for laparoscopic liver resection procedure in patients with intrahepatic duct stones

BACKGROUND For intrahepatic duct(IHD)stones,laparoscopic liver resection(LLR)is currently a reliable treatment.However,the current LLR difficulty scoring system(DSS)is only available for patients with hepatocellular carcinoma.AIM To explore the development of a DSS for IHD stone patients with LLR and the validation of its reliability.METHODS We used clinical data from 80 patients who received LLR for IHD stones.Forty-six of these patients were used in multiple linear regression to construct a scoring system.Another 34 patients from different centers were used as external validation.The completeness of our DSS was then evaluated in patients with varying degrees of surgical difficulty based on documented surgical outcomes in the study group of patients.RESULTS The following five predictors were ultimately included and scored by calculating the weighted contribution of each factor to the prediction of operative time in the training cohort:Location of stones,number of stones≥3,stones located in the bile ducts of several grades,previous biliary surgery less than twice,distal bile duct atrophy.Subsequently,the data set was validated using a DSS developed from the variables.The following variables were identified as statistically significant in external validation:Operative time,blood loss,intraoperative transfusion,postoperative alanine aminotransferase,and Clavien-Dindo grading≥3.These variables demonstrated statistically significant differences in patients with three or more grades.CONCLUSION Patients with IHD stones have varying degrees of surgical difficulty,and the newly developed DSS can be validated with external data to effectively predict risks and complications after LLR surgery.

Surgical strategies for challenging common bile duct stones in the endoscopic era: A comprehensive review of current evidence

While endoscopic retrograde cholangiopancreatography(ERCP)remains the primary treatment modality for common bile duct stones(CBDS)or choledocho-lithiasis due to advancements in instruments,surgical intervention,known as common bile duct exploration(CBDE),is still necessary in cases of difficult CBDS,failed endoscopic treatment,or altered anatomy.Recent evidence also supports CBDE in patients requesting single-step cholecystectomy and bile duct stone removal with comparable outcomes.This review elucidates relevant clinical anatomy,selection indications,and outcomes to enhance surgical understanding.The selection between trans-cystic(TC)vs trans-choledochal(TD)approaches is described,along with stone removal techniques and ductal closure.Detailed surgical techniques and strategies for both the TC and TD approaches,including instrument selection,is also provided.Additionally,this review comprehensively addresses operation-specific complications such as bile leakage,stricture,and entrapment,and focuses on preventive measures and treatment strategies.This review aims to optimize the management of CBDS through laparoscopic CBDE,with the goal of improving patient outcomes and minimizing risks.

Seedling potential of trees species along the elevational gradient in temperate hill forest of central Nepal

Regeneration status of tree species along elevation gradient in temperate hill forest was not understood greatly.Present research examined the tree diversity and its regeneration patterns along an elevation gradient in temperate hill forest,central Nepal.Data were collected from 300 sample plots within vertical elevation bands of 10,ranging from 1365 to 2450 m asl.A random sampling method was used for data collection in three seasons,winter,pre-monsoon and post monsoon seasons.Diameter at breast height(DBH)was used to broadly categorize the plant individual into trees,saplings and seedlings.The tree species richness ranged from 12 to 25 with density of 350 to 1200 individuals per hectare.Species richness of tree and sapling showed statistically significant unimodal pattern,which peaked at mid-elevation.Elevation showed a strong and positive linear correlation with the seedling density(Deviance=0.99,p<0.001)and a significant hump-shaped relationship with sapling density(Deviance=0.95,p<0.001).Similarly,elevations showed a statistically significant negative hump-shaped relationship with all trees,saplings and seedling stages(Deviances=0.89,0.87 and 0.57).The highest values of the Shannon-Wiener index and the lowest value of the Simpson index were found at mid-elevation for all growth forms.Nearly 92%of tree species were found at regenerating stage;49%in a good renewal regeneration status,32%in fair renewal regeneration,and 11%at a poor regenerating condition.Nevertheless,4%of tree species were reported as non-regenerating stages and 4%were newly introduced species.Hence,the regeneration status of the study area was considered fairly well since sapling(78.5%)>seedling(10.6%)≤mature(10.9%).Among tested environmental variables,elevation and annual mean rainfall were the most influential factors in the regeneration of tree species.

Multiple pulp stones emerge across all teeth during mixed dentition:A case report

BACKGROUND This paper reports a rare presentation of multiple pulp stones(PSs)emerging in all teeth during mixed dentition.It offers valuable insights into the clinical diagnosis,treatment,and prognosis of multiple PSs,shedding light on their occurrence during the mixed dentition period.CASE SUMMARY A 10-year-old girl presented with repeated pain in the mandibular right posterior teeth.Intraoral examination revealed carious lesions,abnormal tooth shapes,and anomalies in tooth number.Radiographic examinations showed multiple PSs with diverse shapes,sizes,and quantities in all teeth,alongside anomalies in tooth shape and number.Root canal therapy was initiated,but the patient initially lacked timely follow-up.Upon return for treatment completion,an extracted tooth revealed irregular calculus within the pulp cavity.CONCLUSION This case underscores the importance of considering multiple PSs in mixed dentition,necessitating comprehensive evaluation and management strategies.