Search

Caffey disease is a rare, self limiting condition which usually presents in early infancy. The clinical features include fever, irritability, inflammatory swelling of soft tissue due to acute inflammation of the periosteum and subperiosteal new bone formation. Possible differential diagnoses are osteomyelitis, hypervitaminosis A, scurvy, bone tumours, prolonged use of Prostaglandin E1 (PGE1) and child abuse. Although self-limiting, it can cause diagnostic dilemma leading to delayed diagnosis and unnecessary investigations. Here, we report a case of two month old male infant presenting with painful left scapular mass.

Among patients with atrial fibrillation (AF) who have high risk of bleeding secondary to haematologic disorders, left atrial appendage (LAA) occlusion therapy has been shown to be an excellent alternative to long-term use of oral anticoagulation for thromboembolic stroke prevention. However, there remains a major concern of device-associated thrombosis post-procedure, that can lead to life-threatening embolic events. To this date, there is no systematic guideline for the selection and management of patients with haematological disorders with LAA occlusion therapy, especially in those with platelet disorders such as immune thrombocytopenia (ITP). Patients with platelet disorders are at a higher risk for bleeding; however, that does not prevent such patients from thromboembolic events secondary to AF. We present a case of ITP with permanent AF, where an LAA device was complicated by thrombus formation due to challenges faced with anticoagulation therapy.

To systematically evaluate the clinicopathological and prognostic value of extra-hepatic bile duct resection (EHBDR) in the surgical management of patients with gallbladder carcinoma (GBC), especially in non-jaundiced patients.PubMed, EMBASE and the Cochrane Library were searched up to March 1EHBDR did not correlate with a better overall survival (OS) (P = 0.17) or disease-free survival (P = 0.27). No survival benefit was also observed in patients with T2N1 (P = 0.4), T3N0 (P = 0.14) disease and node-positive patients (P = 0.75), rather, EHBDR was even harmful for patients with T2N0 (P = 0.01) and node-negative disease (P = 0.02). Significantly higher incidences of recurrent disease (P = 0.0007), postoperative complications (P 0.00001) and positive margins (P = 0.02) were detected in the bile duct-resected group. The duration of postoperative hospital stay between the two groups was comparable (P = 0.58). Selection bias was also detected in our analysis that a significantly higher proportion of advanced lesions with T3-4 or III-IV disease was observed in the bile duct-resected group (P 0.00001). EHBDR only contributed to a greater lymph yield (P = 0.01).EHBDR has no survival advantage for patients with GBC, especially for those with non-jaundiced disease. Considering the unfairness of comparing OS between jaundiced patients receiving EHBDR with non-jaundiced patients without EHBDR, we could only conclude that routine EHBDR in non-jaundiced patients is not recommended and future well-designed studies with more specific subgroup analyses are required for further validation.

Introduction:Despite the effectiveness of blue light cystoscopy (BLC) in the management of bladder cancer, the adoption of BLC since its approval has been limited. We evaluated the perceive...

Tumor budding is a significant prognostic indicator for poor survival of several solid tumors. However, due to the lack of a standard scoring system, its clinical application for biliary tract cancer (BTC) is limited.To identify the prognostic significance of tumor budding in BTC.Tumor budding was associated with poor histologic differentiation, lymphovascular invasion, perineural invasion, lymph node metastasis, positive surgical margin, etc. Tumor budding was a predictor of poor OS in univariate (HR: 4.36; 95% CI 3.15 to 6.02; P 0.001) and multivariate (HR: 2.95; 95% CI 2.28 to 3.80; P 0.001) analysis. Similarly, it was also a predictor of poor DFS in univariate (HR: 3.26; 95% CI 2.12 to 4.99; P 0.001) and multivariate (HR: 3.21; 95% CI 1.90 to 5.40; P 0.001) analysis. In addition, tumor budding was also associated with advanced T-stage, poor histologic differentiation, lymph node metastasis, positive resection margin, lymphatic invasion, vascular invasion, and perineural invasion.Results of our study have shown that tumor budding is a strong predictor of poor survival for BTC. The clinical utility of tumor budding as a prognostic marker for BTC should be considered after developing a standard international consensus based on the current evidence.

Summary: Previous studies have explored the role of laparoscopic surgery (LS) in the surgical management of gallbladder carcinoma (GBC) and obtained satisfactory outcomes versus conventional open surgery. However, most of them either included a small number of patients or mainly focused on the early-staged lesions. Therefore, their results were less statistical powerful and a more comprehensive evaluation on the role of LS in GBC is warranted. A thorough database searching was performed in PubMed, EMBASE and Cochrane Library for comparative studies between the laparoscopic and open approach in the surgical management of GBC and 18 comparative studies were finally identified. RevMan 5.3 and Stata 13.0 software were used for statistical analyses. Pooled results revealed that patients in the laparoscopic group recovered faster with less intraoperative hemorrhage and less postoperative morbidity. Comparable operative time, overall recurrence rate, R0 resection rate, lymph node yield, intraoperative gallbladder violation rate and postoperative survival outcomes were also acquired. Regarding the debating issue of port-site recurrence, a significantly higher incidence of port-site recurrence was observed in laparoscopic group. However, having excluded studies on incidental gallbladder carcinoma, the subsequent pooled result showed no significant difference. Considering the inherent inconsistency of the surgical indication between laparoscopic and open surgeries and the deficiency of advanced lesions, we drew a conclusion that laparoscopic surgery seems to be only safe and feasible for early- or middle-staged lesions. Upcoming random controlled trials or comparative studies with equivalent surgical indication focused on advanced lesions are warranted for further evaluation.

Literature regarding outcomes and predictors of complications secondary to infective endocarditis (IE) is limited. We aimed to study the outcomes and predictors of complications of IE. Data from a national emergency department sample, which constitutes 20% sample of hospital-owned emergency departments in the USA, were analyzed for hospital visits for IE. Complications of endocarditis were obtained by using ICD codes. Multivariable generalized linear method was used to evaluate predictors of in-hospital mortality and complications. Out of 255,838 adult IE patients (mean age 60.3 ± 20.1 years, 48.5% females), 97,803 (38.2%) patients developed one or more major complications. The major complications were cardiovascular system complications [57,900 (22.6%)], neurologic [42,851 (16.7%)] complications, and renal [16,236 (6.4%)] complications. These included cardiogenic shock [3873 (1.5%)], septic shock [25,798 (10.1%)], acute heart failure [35,602 (14%)], systemic thromboembolism (STE) [21,390 (8.36%)], heart block [11,430 (4.47%)], in-hospital dialysis [2880 (1.1%)], and disseminated intravascular coagulation (DIC) [2704 (1.1%)]. Patients with complicated IE had risk of mortality (adjusted RR 1.12, 95% CI 1.11–1.13, p

Introduction: Gallbladder diseases are prevalent worldwide and present with a diverse histopathological spectrum. Mucosal irritation and chronic inflammation is considered as an important etiological factor for the mechanical or functional dysfunction of emptying of the gallbladder. This study aims to find the prevalence of non-neoplastic lesions of gallbladder among cholecystectomy specimens of a tertiary care center. Methods: A descriptive cross-sectional study was conducted in the Department of Pathology, of a tertiary care center from January 2005 to December 2020. Ethical approval was taken from the Institutional Review Committee. All the patients who had undergone cholecystectomy procedures which showed non-neoplastic lesions were enrolled in the study. Convenient sampling was done. Statistical Package for Social Sciences version 21 and Microsoft Excel were used for data analysis. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion forbinary data. Results: Out of 4914 cholecystectomy specimens, 4852 (98.73%) (95% Confidence Interval= 98.42- 99.04) were non-neoplastic lesions. There were 1252 (25.8%) males and 3600 (74.2%) females with a male to female ratio of 1:2.87. Age ranged from 2 to 89 years with a mean age of 45±14.48 years. Gallbladder lesions were observed maximum in age group 41-50 years with 1200 (24.7%) cases. Among the non-neoplastic lesions, cholecystitis without any specific finding was the most common finding with 3028 (62.4%) cases followed by cholelithiasis with 1478 (30.5%) cases. Conclusions: The prevalence of non-neoplastic lesions of gallbladder is similar to other studies done in similar setings. Female predominance was noted in non-neoplastic lesions.

Cardiovascular diseases are the leading cause of death in hemodialysis patients. We aimed to evaluate non-traditional cardiovascular risk factors: homocysteine, high sensitive C-reactive protein, oxidized LDL antibodies, phosphate, and red cell distribution width in chronic kidney disease patients under maintenance hemodialysis along with traditional cardiovascular risk factors like age, hypertension, diabetes mellitus, among others. A total of 78 diagnosed chronic kidney disease patients under maintenance hemodialysis visiting a tertiary care center were included in the study, of which 59% were male. Hyperhomocysteinemia was present in 79.5% of the participants, with the median homocysteine level being 28.43 μmol/L. The median hsCRP level was 4.74 mg/L, and 59% and 24.4% of the total participants were at high and moderate cardiovascular risk respectively. The median oxidized LDL antibody level was 4235 U/mL, which is within the reference range. The median red cell distribution width was 14.05%, which is within the normal range. Left ventricular hypertrophy, a common cardiovascular disease in such patients, was found in 55.13% of the participants. Serum homocysteine level was significantly higher in patients with left ventricular hypertrophy, whereas serum C- reactive protein level was significantly lower in patients with left ventricular hypertrophy. The mean serum phosphate was 6.23 mg/dL (i.e. higher than normal) and hyperphosphatemia was seen among 76.9% of the patients. The mean age of the patients was 47.5 years, which is distinctly lower when compared to the hemodialysis patients in the Western population. The prevalence of hypertension, diabetes mellitus, and anemia were 95%, 18.25%, and 92.3%, respectively.

Literature regarding trends of incidence, mortality, and complications of acute exacerbation of chronic obstructive pulmonary disease (COPD) in the emergency departments (ED) is limited. What are trends of COPD exacerbation in ED? Data were obtained from the Nationwide Emergency Department Sample (NEDS) that constitutes a 20% sample of hospital-owned EDs and inpatient sample in the US. All ED encounters were included in the analysis. Complications of AECOPD were obtained by using ICD codes. Out of 1.082 billion ED encounters, 5,295,408 (mean age 63.31 ± 12.63 years, females 55%) presented with COPD exacerbation. Among these patients, 353,563(6.7%) had AECOPD-plus (features of pulmonary embolism, acute heart failure and/or pneumonia) while 4,941,845 (93.3%) had exacerbation without associated features or precipitating factors which we grouped as AECOPD. The AECOPD-plus group was associated with statistically significantly higher proportion of cardiovascular complications including AF (5.6% vs 3.5%; p < 0.001), VT/VF (0.14% vs 0.06%; p < 0.001), STEMI (0.22% vs 0.11%; p < 0.001) and NSTEMI (0.65% vs 0.2%; p < 0.001). The in-hospital mortality rates were greater in the AECOPD-plus population (0.7% vs 0.1%; p < 0.001). The incidence of both AECOPD and AECOPD-plus had worsened (p-trend 0.004 and 0.0003) and the trend of mortality had improved (p-trend 0.0055 and 0.003, respectively). The prevalence of smoking for among all COPD patients had increased (p-value 0.004), however, the prevalence trend of smoking among AECOPD groups was static over the years 2010-2018. There was an increasing trend of COPD exacerbation in conjunction with smoking; however, mortality trends improved significantly. Moreover, the rising burden of AECOPD would suggest improvement in diagnostics and policy making regarding management.

Background: Electrical injury and its consequences after exposure to electric shock has been associated with an increased risk of developing immediate and delayed cardiac arrhythmias. The aim of this study was to evaluate the prevalence of cardiac arrhythmias and different symptoms in patient with high voltage and low voltage electrical injury. Methods: All 50 consecutive patients who were admitted in Chitwan Medical College from April 2018 to March 2020 were prospectively studied. Patients were categorized into high and low voltage injury group and their variables were compared. Results: The mean age of the patients was 32.3±10.4 years among them 41 (82%) were male. Patients who sustain high voltage electrical injury (>1000V) were 18 (36%) and low voltage injury (

OBJECTIVE: To review the recent milestones in MRI and PET based imaging and evaluate their evolving role in the setting of elevated PSA as well as localized prostate cancer. BACKGROUND: The importance of multiparametric MRI (mpMRI) and PET based imaging for the diagnosis and staging of prostate cancer cannot be understated. Accurate staging has become another significant milestone with the use of PET scans, particularly with prostate specific radiotracers like 68-Gallium Prostate Specific Membrane Antigen (68Ga-PSMA). Integrated PET/MRI systems are commercially available and can be modulated to evaluate the unique needs of localized as well as recurrent prostate cancer. METHODS: A literature search was performed using PubMed and Google Scholar using the MeSH compliant and other keywords that included prostate cancer, PSA, mpMRI, PET CT, PET/MRI. CONCLUSIONS: mpMRI has now established itself as the gold-standard of local prostate imaging and has been incorporated into international guidelines as part of the diagnostic work-up of prostate cancer. PSMA PET/CT has shown superiority over conventional imaging even in staging of localized prostate cancer based on recent randomized control data. Imaging parameters from PET/MRI have been shown to be associated with malignancy, Gleason score and tumour volume. As mpMRI and PSMA PET/CT become more ubiquitous and established; we can anticipate more high-quality data, cost optimization and increasing availability of PET/MRI to be ready for primetime in localized prostate cancer.

Bronchoalveolar Lavage (BAL) is a medical technique by which cells and fluids from bronchioles and lung alveoli are withdrawn for diagnosis of disease or evaluation of treatment. Patients with various pulmonary infections follow the procedure of BAL for the disease diagnosis as it has high sensitivity and reliability in diagnosis. To examine the bacterial etiology of BAL fluids among tertiary care patients with pulmonary infections, a cross-sectional study was conducted over a period of three months from August to November 2018. A total of 149 BAL fluid samples were examined and the bacterial agents were isolated and identified by conventional microbiological methods. Out of the 149 samples, 142 samples were culture positive. Among 6 different isolates (4 Gram-negative and 2 Gram-positive), Pseudomonas aeruginosa (45 %) was predominant followed by Klebsiella pneumoniae (25.3 %). A higher infection rate was seen among males (62.4 %) and in the age group 60-70 years (30.0 %). In addition, 25.4 % (36/149) samples were positive in Acid Fast staining. Bacterial recovery from the BAL fluid was significantly associated with the gender and age of the patients (p

Introduction: Nutritional assessment of the newborn gives the reflection of the growth process in the intrauterine period. The Clinical Assessment of Fetal Nutritional Status score (CAN score) method is only the method to assess the fetal malnutrition which includes the clinical observation for the presence of the sign of malnutrition in newborns. Since the fetal growth is related to availability of intrauterine nutrition and placental function, there may be several maternal factors associated with the fetal malnutrition. Objectives: The main objective of the study was to determine the prevalance of Fetal Malnutrition in term newborns and the role of maternal factors in the etiology of fetal malnutrition (FM) in the Neonatal and Maternity Units of B.P Koirala Institute of Health Sciences, Dharan. Methodology: This was a hospital based observational cross sectional study of consecutive, singleton, term live babies delivered between September 2019 to March 2020. Fetal malnutrition was diagnosed using Clinical Assessment of Fetal Nutritional Status score (CAN score) developed by Metcoff. The maternal history was obtained from the mother which included age, parity, socioeconomic class, pre pregnancy weight, number of antenatal care during pregnancy, history of maternal illness and drugs taken during pregnancy. Nutritional status of the mother was determined using weight, height, mid arm circumference (MAC) and the body mass index (BMI). Collected data was entered in Microsoft excel 2010 and converted it into SPSS 23 version software, for statistical analysis. Results: Of the 400 studied newborns, 73 [18%] had FM. The prevalence of teenage pregnancy, primiparity, lower maternal mid arm circumference and vegetarian diets were higher in the mothers of the babies who had suffered fetal malnutrition than the mothers of the babies without FM (p value

Fei Liu,* Hai-Jie Hu,* Parbatraj Regmi, Yan-Wen Jin, Wen-Jie Ma, Jun-Ke Wang, Rui-Qi Zou, Fu-Yu Li Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, People’s Republic of China*These authors contributed equally to this workCorrespondence: Fu-Yu LiDepartment of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, People’s Republic of ChinaTel/Fax +86 02885422465Email lfy_74@hotmail.comBackground: Previous studies have demonstrated that platelet distribution width (PDW) is a reliable predictor of prognosis of a variety of tumors. Nevertheless, the prognostic value of PDW in gallbladder carcinoma (GBC) remains unknown. We aimed to explore the correlation between PDW and prognosis in patients with GBC.Methods: A total of 303 patients with GBC who underwent curative surgery between January 2005 and February 2017 were enrolled. The relationship between PDW and clinicopathological features was analyzed. Receiver operating characteristic (ROC) curve was used to identify the optimal cutoff value of PDW. The overall survival (OS) rate was estimated by Kaplan–Meier method. Meanwhile, univariable and multivariable Cox regression model were used to evaluate the risk factors for OS.Results: There was significant correlation between elevated PDW and AJCC stage. In addition, survival analysis revealed that the patients with PDW> 14.95 have a worse prognosis than patients with PDW 14.95 (P < 0.001). The multivariable Cox regression model analysis demonstrated that PDW was an independent prognostic factor in GBC patients (hazard ratio=1.976, 95% confidence interval:1.474– 2.650, P< 0.001).Conclusion: Elevated PDW can predict poor prognosis in GBC patients, and further studies are needed to verify the reliability and clarify the exact molecular mechanistic of PDW in GBC.Keywords: gallbladder carcinoma, platelet distribution width, prognosis

There has been much discussion recently that better healthcare systems lead to increased service access and utilisation. However, there are still concerns raised among the refugee and immigrant communities about barriers to access and utilisation of primary healthcare services in the UK. This study aimed to explore with refugee and immigrant community health champions (CHCs) their perceptions about such barriers based on feedback in their own discussions with fellow refugees, asylum-seekers and immigrants in the West Midlands, UK. A total of 42 refugees and immigrants were recruited. Qualitative design-focused group discussions were conducted among purposively selected participants. These discussions were conducted between May and September 2019, and data were analysed using thematic analysis. The barriers to service access and utilisation are categorised into four themes: (i) knowledge about health issues that most affected refugees and immigrants; (ii) community indications of factors that obstructed service access; (iii) challenges in identifying local teams involved in service provision; and (iv) accurate knowledge about the different teams and their roles in facilitating access. This study higlighted that the levels of service access and utilisation would depend on the competence and effectiveness of the health system. Urgency and seriousness of individuals’ healthcare needs were the factors that were perceived to strongly influence refugees and immigrants to seek and utilise local services. We identified a number of potential barriers and challenges to service access and utilisation that should be overcome if primary healthcare service is to be planned and delivered effectively, efficiently and equitably in the West Midlands.

Correction: The second author, Sanjib Mani Regmi, was added to the website version on 13th August 2021. It omitted by mistake. The PDF of the article was correct. Background: The infection of tonsil may occur primarily or secondarily as a result of upper respiratory tract infection, usually preceded by a viral infection. Bacterial tonsillitis is most commonly caused by Streptococcus pyogenes. Penicillin remains the treatment of choice for S. pyogenes tonsillitis. The present study aimed to identify the bacterial pathogen in acute tonsillitis and their sensitivity to antibiotics. Material and Methods: This prospective study was conducted in the Department of Otolaryngology and Head & Neck Surgery and Department of Microbiology, Gandaki Medical College, Pokhara Nepal from January 2018 to January 2019. Ninety-six patients who presented with acute tonsillitis and admitted in the hospital were included in the study. Results: The commonest age group of acute tonsillitis was found to be between 21-30 years. S. pyogenes was the commonest isolate 32(33.3%) followed by S. aureus 19(19.8%). Streptococcus pyogenes was sensitive to Ampicillin (65.6%) and Cloxacillin (68.7%) while the isolates were more sensitive to levofloxacin and doxycycline. Carbapenem were found to be most effective drugs for intravenous treatment. Conclusion: The most common bacterial isolates were Streptococcus pyogenes. The sensitivity of organism shift from ampicillin group to fluroquinolones and tetracycline. Identification of bacterial isolates and their antibiotics sensitivity patterns could prevent resistance of bacteria to drugs and help in the proper management of acute tonsillitis.

Introduction: Vascular access are a prerequisite for hemodialysis and good care by nurses is key to their longevity. A pattern of vascular access use has not been assessed previously nor the competency of nurses to identify the gaps in knowledge and skills. This study aims to describe vascular access use and nursing competency at National Kidney Centre. Materials and Methods: A cross-sectional study was done to obtain demographic information and history of vascular access of patients. Vascular access was examined. Demographic and professional information of nurses were collected. A quiz based on KDOQI Clinical Practice Guidelines and a visual analogue scale to indicate confidence in managing vascular access were administered to the nurses. Results: Four-hundred seventy-two patients and 70 nurses were recruited. The proportion of patients with an arteriovenous fistula, arteriovenous graft, tunneled catheter, and non-tunneled catheter at the time of initiation of hemodialysis were 24.36%, 0.64%, 1.27%, and 73.73%, respectively, and after conversion was 67.23%, 5.08%, 1.98%, and 19.77%, respectively. The cost at initiation was lower for catheters and the arteriovenous access in long run. Nurses had received vascular access training during their hemodialysis course (95.71%), but a few received further training (38.57%). They did well in sections related to preparation for permanent access and treatment of complications. Conclusions: Most of the patients initiated hemodialysis via a non-tunneled catheter. The prevalence of arteriovenous fistula was high. Continued training of nurses was lacking. Nurses were confident in managing arteriovenous fistula and non-tunneled catheters.

BACKGROUND: Assessing transmission of SARS-CoV-2 by children in schools is of crucial importance to inform public health action. We assessed frequency of acquisition of SARS-CoV-2 by contacts of pupils with COVID-19 in schools and households, and quantified SARS-CoV-2 shedding into air and onto fomites in both settings. METHODS: We did a prospective cohort and environmental sampling study in London, UK in eight schools. Schools reporting new cases of SARS-CoV-2 infection to local health protection teams were invited to take part if a child index case had been attending school in the 48 h before a positive SARS-CoV-2 PCR test. At the time of the study, PCR testing was available to symptomatic individuals only. Children aged 2-14 years (extended to

The use of laparoscopic liver resection for curative surgery of intrahepatic cholangiocarcinoma (ICC) is not well established. Herein, we perform a meta-analysis to compare the differences between laparoscopic liver resection (LLR) and open liver resection (OLR) for ICC.Multiple electronic databases were searched and 8 relevant studies containing 552 patients treated by LLR and 2320 treated by OLR were identified. The fixed effects and a random-effects model were used to perform a meta-analysis.Compared with OLR, LLR for ICC was associated with less blood transfusion (7.14% versus 17.11%; OR: 0.32; 95% CI 0.15 to 0.71; P 0.05), higher R0 resection (85.63% versus 74.69%; OR: 1.48; 95% CI 1.13 to 1.95; P 0.05), shorter length of stay (LOS) (SMD: -0.40; 95% CI -0.80 to 0.00; P = 0.05), less overall morbidities (20% versus 32.69%; OR: 0.50; 95% CI 0.33 to 0.78; P 0.05), and less death due to tumor recurrence (22.39% versus 35.48%; OR: 0.50; 95% CI 0.29 to 0.86; P0.05); but LLR was associated with smaller ICC, fewer major hepatectomies, less lymph node (LN) dissection rate, and inferior 5-year overall survival (OS) (P 0.05). Duration of operation, blood loss, average LN retrieved, LN metastasis, major morbidities, mortality, tumor recurrence, 3-year OS and disease free survival (DFS), and 5-year DFS were comparable (P0.05).LLR for ICC is in the initial phase of exploration. More evidence is necessary to validate LLR for ICC.

Introduction: Nepal started the first phase of COVID-19 vaccination for frontline healthcare workers in January 2021 with the ChAdOx1 nCoV-19 (COVISHIELD) vaccine. We conducted active surveillance of Adverse Effect Following Immunization (AEFI) after the first dose of the vaccine administered at one of the sentinel sites for vaccination, Patan Academy of Health Sciences (PAHS). Method: All the 5591 first dose ‘COVISHIELD’ vaccine recipients between 27 Jan -5 Feb 2021 at PAHS, were approached through phone calls to collect data on AEFI. Incidence of common AEFIs in different age groups, gender and those with previous history of COVID-19 were analyzed. Presence of any Adverse Events of Special Interest (AESI) were evaluated. Result: Out of 5591 vaccines recipient, 3991 (71.3%) responded to the phone call and AEFI was noted in 3394 (85.04%) of them. Minor AEFI was seen in 3391 (84.9%), severe Minor AEFI in 1 (0.02%) and Serious AEFI in 2 (0.05%). Out of 807 vaccine recipients with previous history of COVID-19, 709 (87.9%) had AEFI while of the 3184 with no past history of COVID-19, 2685 (84.3%) had AEFI. However, some of the systemic AEFIs were noted more frequently in those with past COVID-19 infection. A total of 1886 (55.6%) took self-medication for symptom relief, 278 (8.2%) took leave from work while 26 (0.76%) visited health facility for the AEFIs. Conclusion: Most AEFIs following the first dose of COVISHIELD vaccine were mild and resolved within a few days. Except for one case of anaphylaxis, no other AESI were encountered.

Actinomyces are a part of the normal flora of the cervicofacial region, gastrointestinal tract, and urogenital tract, but can cause infections when the normal mucosal barrier is lost. Herein, we report a rare case of actinomycosis of the gallbladder in a 60-years-old-female. The patient presented with right hypochondrium pain since three months; ultrasonography showed cholelithiasis with thick oedematous wall. An open cholecystectomy was carried out. Histological examination revealed an inflamed gallbladder with colonies of radiating filamentous structures having numerous sulphur granules which on gram staining showed filamentous gram-positive rods. The diagnosis of Actinomycosis of gallbladder was made. After cholecystectomy, prolonged antimicrobial therapy is recommended for patient with actinomycosis to prevent recurrence and even mortality.

Time-restricted feeding (TRF) initiated early during the dark phase prevents the metabolic consequences of a high-fat diet in rodent models. However, the metabolic consequences of delaying the initiation of TRF, akin to breakfast skipping in humans, is unclear. We assigned 8-week-old male C57BL/6J mice (n = 192) to chow or high-fat diet ad libitum (AL) for 4 weeks, before randomization to continue AL or 10 h of TRF, initiated at lights off (TRFe) or 4-h after lights off (TRFd) for a further 8 weeks. Oral glucose tolerance tests (1 g/kg), metabolic monitoring and body composition by echoMRI were performed, and tissues were collected at six time points. TRF reduced weight and fat mass vs AL, with a greater reduction in TRFe vs TRFd. TRF improved glucose tolerance and protected mice from high-fat diet-induced hepatosteatosis vs AL, with no difference between TRFe and TRFd. TRF increased the amplitude of Bmal1, Cry1, Per2, Nampt, and Nocturnin mRNA levels in liver. A phase delay in Bmal1, Cry1, Per2, Reverbα, Nampt, NAD, Sirt1, and Nocturnin was observed in TRFd. Thus, delaying TRF limited the weight benefit and induced a phase delay in the hepatic clock, but improved metabolic health. Allowing more flexibility in when TRF is initiated may increase the translational potential of this dietary approach in humans.

The present study aims to describe the effect of the COVID-19 pandemic and the government imposed lockdown on the business activities of pharmacy shop owners (as small business operators) in the locality of Dharan-18. A sample survey was carried out in 32 participants using a self-designed and self-administered questionnaire comprising participants ‘demographic details and 14 question items concerning the impact of the pandemic and lockdown on their businesses. All the participants responded. The results show that all the pharmacy operators were adversely affected by the pandemic and the imposed lockdown. Most of the businesses temporarily suspended their operations while some stopped operating. The essential supplies and access to goods and services as well as financial access have been severely hindered; however, no remarkable price hike has been observed. The expectations of the participants about changes in near future lack consistencies. The participants have expressed lack of confidence in carrying out business in the forthcoming days. In conclusion, the COVID-19 pandemic and the government-imposed lockdown has affected almost all of the pharmacy operators in the locality of Dharan-18.

Introduction: Ultrasound is a safe, highly cost effective and non-invasive imaging technique without any absolute contraindication. It is also one of the most useful investigations in all medical specialities worldwide. The trend of use of ultrasound in the diagnosis and management of various musculoskeletal disorders (MSD) is tremendously rising in orthopedics practice in Nepal over the last few years. Objectives: The study was conducted to fulfill the existing lacunae in medical literature about use and benefits of ultrasound in context of Nepal. The objective of the study was to assess the effectiveness of ultrasound in the diagnosis of MSD among patients attending orthopedic department. Methodology: All the consecutive patients who visited department of orthopedics and received the diagnosis of MSD and had undergone ultrasonography from February 2017 to February 2019 were included in the study. The effectiveness of ultrasound was evaluated by assessing the correlation between clinical and ultrasound based diagnosis. Results: Out of 420 patients, majorities were female (55%). Out of 6 different anatomical sites identified, maximum patients had problem around wrist and hand (31%) followed by ankle and foot (22.9%). Similarly the most common diagnosis was related to tendon pathology including tendonitis, tenosynovitis and tendinopathy (31.9%). There was statistically significant correlation between ultrasound and clinical diagnosis with P value

Introduction: Hypertension and Diabetes are two major risk factors for atherosclerotic disease. Carotid artery intima media thickness(cIMT) is considered a reliable surrogate measure for diagnosing subclinical atherosclerosis, its progression and regression. Paucity of available data regarding mean value of cIMT highlights the importance of defining the cut off value of cIMT in a specified population. Very limited studies have been done on sonographic evaluation of mean cIMT and carotid artery injury in hypertension and diabetes in Nepalese population. This study, therefore aims to determine mean cIMT in Nepalese population and to analyze effect of Hypertension and diabetes on cIMT. Methods: Cross-sectional hospital based study was conducted within the period of 18 months. B-mode ultrasound was used to measure cIMT in bilateral common carotid arteries. Comparison of mean cIMT was done amongst healthy, hypertensive and diabetes with hypertensive patients. Duration of disease was also considered. Data analysis was done with “R” analytical study. Results were expressed as mean ± standard deviation. Results: Total1005 (508 female and 497 male) adult patients with age range of 30 to 85 years were assessed. Among these 329(32.74%) were healthy adults, 341(33.93%) were hypertensive and 335(33.33%) were diabetes with hypertensive patients. The mean cIMT in cases was more than controls (P < 0.001) bilaterally with diabetes having an additive effect. There was also positive correlation of measured value with duration of disease and age of patients. Conclusion: The present study found that mean cIMT in cases was more than controls. There is an additional effect of Diabetes on cIMT in hypertensive patient. Age and duration of disease can accelerate atherosclerosis.

Background: Helicobacter pylori (H. pylori) is associated with the pathogenicity of gastro-duodenal ulcers and gastric cancers. Combination of several antimicrobial therapies and regimens have been advised for H. pylori treatment. But, resistance to various antibiotics regimens are being documented worldwide. The present study was undertaken to study the efficacy of commonly used 3 different regimens for eradication of H.pylori infection in Nepalese patients. Methods: A cross-sectional, hospital based study comprising of 405 subjects, was conducted. Each study patient underwent upper gastro-intestinal endoscopy followed by rapid urease test or histopathology from the biopsy sample for H. pylori detection. Patients were randomly subjected to 3 different H. pylori eradication regimen. After 4 weeks of therapy, patients were re-evaluated for persistence of H. pylori infection either by repeat UGI endoscopy followed by RUT or C14- Urea Breadth Test. Data analysis was done by SPSS 20. Results: Mean age of the patients was 34.4±8.72 years (M: F=1.5:1) with male predominance. H. pylori eradication rate was only 65.9% in patients using standard triple regimen using Amoxicillin, Clarithromycin and PPI (Group A). Eradication rate was greater (77.8%) with Levofloxacin based regimen (Group B) and 83.3%. with sequential regimen containing Amoxicillin followed by Clarithromycin and Tinidazole with PPI (Group C). Conclusion: The study demonstrates that the current standard Amoxicillin and Claritrhromycin based triple regimen has lowest eradication rate followed by levofloxacin based regimen. The sequential regimen was the most efficacious among the 3 different regimens for H. pylori eradication.

Purpose This work aims to validate new 6D couch features and their implementation for seated radiotherapy in RayStation (RS) treatment planning system (TPS). Materials and methods In RS TPS, new 6D couch features are (i) chair support device, (ii) patient treatment option of “Sitting: face towards the front of the chair”, and (iii) patient support pitch and roll capabilities. The validation of pitch and roll was performed by comparing TPS generated DRRs with planar x-rays. Dosimetric tests through measurement by 2D ion chamber array were performed for beams created with varied scanning and treatment orientation and 6D couch rotations. For the implementation of 6D couch features for treatments in a seated position, the TPS and oncology information system (Mosaiq) settings are described for a commercial chair. An end-to-end test using an anthropomorphic phantom was performed to test the complete workflow from simulation to treatment delivery. Results The 6D couch features were found to have a consistent implementation that met IEC 61712 standard. The DRRs were found to have an acceptable agreement with planar x-rays based on visual inspection. For dose map comparison between measured and calculated, the gamma index analysis for all the beams was >95% at a 3% dose-difference and 3 mm distance-to-agreement tolerances. For an end-to end-testing, the phantom was successfully set up at isocenter in the seated position and treatment was delivered. Conclusions Chair-based treatments in a seated position can be implemented in RayStation through the use of newly released 6D couch features.

Background and Aims: Rheumatic Heart Disease (RHD) is the most common heart disease among children and young adults in Nepal. Identifying the prevalence of RHD is important in planning RHD prevention program. There are few studies on RHD conducted among children of unreached population of Nepal. This study aimed to determine the epidemiological status of RHD among school going children living in rural and underdeveloped community of Jajarkot, Nepal. Methods: This is a cross-sectional study of 6,147 school going children of age group 5 to 16 years from 24 randomly selected schools of Jajarkot in the month of May, 2018. A team of cardiologists from Nepal Heart Foundation examined the children. Diagnosis of RHD was confirmed by echocardiography. Selected socio-demographic data were collected. All positive cases were reviewed by senior cardiologist. Information obtained were analyzed. Frequency and percentage for the categorical data were calculated. Prevalence was reported as cases per thousand school children. Results: The overall prevalence of RHD was 7.32 per 1000 schoolchildren. Borderline RHD was 1.30 per 1000 and definite RHD 6.02 per 1000. On severity scale, mild RHD was 6.18, moderate RHD 0.81 and severe RHD 0.33 per 1000 respectively. Prevalence of RHD varied with age, sex, ethnicity, and severity. RHD was found higher among males, 10-16 years age group and underprivileged children. Conclusion: Jajarkot is found to be a RHD endemic zone in Nepal where prevention efforts should be initiated urgently.

Accidental injuries are common during festivals. With time, the traditional practices have been ill-defined and have turned out social misconduct and malpractice. Children and young adults barricade the road to extort money from the passerby in the name of tradition during festivals. Barricading roads occasionally results in loss of control over vehicles and falling down on the road sustaining trauma including neck injuries among the drivers. This is a report of a case of a young male biker who got trapped along the rope tied across the road and nearly strangulated to death.

OBJECTIVE To better understand the risk of genitourinary malignancies in the renal transplant patient. Currently, no consensus exists regarding screening and intervention, with much of the clinical decision-making based on historical practices established before recent progress in immunosuppression protocols and in genitourinary cancer diagnosis and management. METHODS A database of all solid organ transplants performed at the University of Minnesota from 1984 to 2019 was queried for renal transplant recipients in whom development of subsequent urologic malignancies (prostate, bladder, renal, penile, and testicular cancer) was found. RESULTS Among 6172 renal transplant recipients examined, cumulative incidence of all cancers of genitourinary etiology are presented over an average follow-up time of 10 years. Kidney cancer (combined graft and native), prostate cancer, and bladder cancer each demonstrated respective 30-year incidence of 4.6%, 8.7%, and 1.5% from the time of transplant. By comparison, age-matched data from the Surveillance, Epidemiology, and End Results database demonstrated 30-year cumulative incidence of 1.1%, 11.1%, and 1.7% for kidney cancer, prostate cancer, and bladder cancer respectively. The predominant genitourinary cancer was renal cell cancer, both of the native and of the transplanted kidney (native, n = 64; transplanted, n =11), followed by prostate cancer (n = 63), and bladder cancer (n = 37). CONCLUSION In this closely followed cohort of renal transplant recipients, renal cancer occurs at a higher incidence rate than in the non-transplanted population, while a lower rate of prostate cancer was found, with bladder cancer demonstrating a comparable cumulative incidence between transplant patients and the national age-matched population.

Background: Fine Needle Aspiration Cytology has rapidly gained acceptance due to the easy accessibility of target sites and minimally invasive nature. It is a very simple, quick, cost-effective method of sampling alternative to the time consuming complicated and invasive excision biopsy. The study aimed to access the utility of fine needle aspiration cytology in the diagnosis of various head and neck lesions and also to establish the diagnostic accuracy between the cytological and histopathological diagnosis. Materials and Methods: A retrospective observational study of 380 cases of FNACs on head and neck swellings performed in various age groups in the Department of Pathology of a tertiary care hospital from January 2018 to December 2019. Results: Out of 380 patients, the maximum number of cases were seen in the thyroid (40.8%), followed by lymph nodes (39.5%), skin, soft tissue, miscellaneous (10.8%) and salivary glands (8.9%). Benign and non-neoplastic cases outnumbered (88.1%) the malignant (10.8%) cases. Histopathological follow-up was available in 28 (7.4%) cases among which 25 (89.3%) cases were consistent with the cytodiagnosis. The sensitivity, specificity, and diagnostic accuracy were evaluated to be 80%, 94.4%, and 89.3% respectively. Conclusions: The majority of the cases of head and neck swellings were seen in the thyroid followed by lymph nodes, skin, soft tissue, miscellaneous, and salivary glands. In thyroid, colloid goiter and papillary carcinoma were the commonest benign and malignant lesions respectively. In the lymph node, reactive lymphadenitis, and metastatic squamous cell carcinoma were the commonest benign and malignant lesions respectively.

Every year huge crop losses occur due to different pathogens and disease. The traditional method of pathogen detection, which is still in practice, through visual examination is not always precise. Early detection of plant pathogens prior to severe infection is very crucial which is possible through molecular diagnostic approaches and nucleic acid-based tests. As the genetic materials are the ultimate information storage sites in living organism, their exploration through the use of nanotechnology provides the path forward for the three Ds of genomic analysis of pathogens: Diversity, Detection, and Disease diagnosis. Molecular detection method is not only precise and accurate but also faster and easier approach. Pathogen detection through PCR based tests, microarray technology, multiplexing, gene sequencing, genetic markers play a pivotal role in timely detection of causatives and take proper action to prevent the pandemic in plant population and safeguard against possible risks and famine. It is of utmost importance to prioritize such methods to detect plant pathogens, to increase our understanding of ecology and epidemiology and to prevent the spread of inoculum prior to disease spread. The application of novel diagnostic methods to inoculum detection will guide towards better understanding of the temporal and spatial dynamics of epidemic development, and open up new opportunities for disease forecasting and management.

There has been much discussion recently about the potential of Community Health Champions (CHCs) to promote universal health coverage in the United Kingdom. Among refugee and migrant groups, there is concern that untrained community workers miss out on understanding the major causes of poor health outcomes. This study aims to examine the challenges and opportunities that influence the designing of an effective curriculum to help CHCs develop the necessary knowledge and skills. A qualitative evaluation of a collaborative public health curriculum with this primary objective, focused on aspiring CHCs drawn from refugee and migrant populations, was conducted. The 5-week curriculum was delivered as a community partnership between a local university, three metropolises, and three refugee and migrant centers, all located in the West Midlands, United Kingdom. We found no evidence of existing curriculums that target refugees and migrants to develop knowledge and skills for influencing health services utilization by individuals within their own community. It is an opportune time to introduce such a curriculum because health providers occasionally use CHCs for some roles in their activities. Important challenges in this curriculum concerned generating consensus on content, dealing with power structures in negotiating the content, and agreeing on boundaries in curriculum activities. There is evidence of CHCs from refugee and migrant backgrounds having an interest in developing skills for helping reduce health inequalities in the United Kingdom. This study concludes that significant challenges exist in designing a CHC curriculum that all stakeholders can easily accept, but not having consensus on content may be detrimental to their learning.

Angiopoietin-like protein (ANGPTL)8 has been implicated in metabolic syndrome and reported to regulate adipose FA uptake through unknown mechanisms. Here, we studied how complex formation of ANGPTL8 with ANGPTL3 or ANGPTL4 varies with feeding to regulate LPL. In human serum, ANGPTL3/8 and ANGPTL4/8 complexes both increased postprandially, correlated negatively with HDL, and correlated positively with all other metabolic syndrome markers. ANGPTL3/8 also correlated positively with LDL-C and blocked LPL-facilitated hepatocyte VLDL-C uptake. LPL-inhibitory activity of ANGPTL3/8 was >100-fold more potent than that of ANGPTL3, and LPL-inhibitory activity of ANGPTL4/8 was >100-fold less potent than that of ANGPTL4. Quantitative analyses of inhibitory activities and competition experiments among the complexes suggested a model in which localized ANGPTL4/8 blocks the LPL-inhibitory activity of both circulating ANGPTL3/8 and localized ANGPTL4, allowing lipid sequestration into fat rather than muscle during the fed state. Supporting this model, insulin increased ANGPTL3/8 secretion from hepatocytes and ANGPTL4/8 secretion from adipocytes. These results suggest that low ANGPTL8 levels during fasting enable ANGPTL4-mediated LPL inhibition in fat tissue to minimize adipose FA uptake. During feeding, increased ANGPTL8 increases ANGPTL3 inhibition of LPL in muscle via circulating ANGPTL3/8, while decreasing ANGPTL4 inhibition of LPL in adipose tissue through localized ANGPTL4/8, thereby increasing FA uptake into adipose tissue. Excessive caloric intake may shift this system toward the latter conditions, possibly predisposing to metabolic syndrome.

Introduction: Urinary incontinence is a common condition in pregnancy and postpartum period. It causes discomfort, embarrassment, loss of confidence and self esteem. This study aimed to determine the occurrence of urinary incontinence in pregnant attending antenatal clinic in a tertiary hospital. Methods: A descriptive observational study was conducted to find out occurrence of urinary incontinence in primiparous attending department of obstetrics and gynecology from August 2014 to August 2015 at B.P.Koirala Institute of Health Sciences. Results: The total of 100 primigravida were enrolled in the study. Out of which six had urinary incontinence with mean age of 23 years. Most of them were in the period of gestation group 38–40 weeks. 22% of total were obese with mean BMI of 26.69 kg/m2. Seventy nine patients had vaginal delivery, four had vacuum assisted vaginal delivery and 17 had cesarean section. Age and Body Mass Index (BMI) was not found to be associated with urinary incontinence. Oxford grading for assessment of perineal muscle after delivery showed decline in pelvic muscle tone which was significantly associated with urinary incontinence. However, the mode of delivery, and birth weight of baby was not found to be significant. Conclusion: The study finding suggested that pregnancy acts a risk factor for development of UI although no preference could be drawn regarding the mode of delivery. Our study also concluded antepartum UI as a risk factor for postpartum UI. Keywords: Primiparity; Postpartum; Urinary incontinence

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19.

The risk of genitourinary cancers following transplantation is increased following majority of solid organ transplants but is best described following renal transplantation. Increasing average age of the transplant recipient as well as increases in post- transplant survival increases the risk of these malignancies. The risk of Kidney cancer is the highest following most solid organ transplants, whereas prostate cancer risk is lower than the general population in multiple large population-based studies. The etiology of increased risk of cancer following transplant is multifactorial with the predominant influence of immunosuppression and direct toxicity of immunosuppressants, however, the significance of end stage disease particularly in the causation of renal cancer in renal transplant recipients is undeniable. Modifications in immunosuppression regimens as well as changes in the standard treatment principles of some cancers may require changes in the management of some post-transplant malignancies. Standard screening guidelines have not been established but screening for renal tumors in renal transplant recipients is the only widely studied entity. Further work is needed to prepare the urologic oncological community with this once rare population group and standardized recommendations need to be established for screening and for the use of new age cancer therapeutics like immunotherapy.

Background: Gestational age and fetal weight estimation by ultrasound is the most effective and accurate method to date pregnancy. Ultrasound has been used to characterize placental position and morphologic changes. Placental thickness could be one additional parameter to assess gestational age and fetal weight. Objectives: This study aims to investigate the relationship between placental thickness with gestational age and fetal weight in third trimester of pregnancy in primigravida. Methodology: Prospective hospital based cross sectional study was conducted including 111 primigravida in third trimester with normal singleton pregnancies in Department of Radiology of Kathmandu Medical College Teaching Hospital from November 2018 to February 2019. Patients with known medical and obstetrical complications were excluded from the study. Placental thickness in millimeters was measured at the level of insertion of the umbilical cord. Pearson’s correlation analysis was used for analyzing variables and p-value

Introduction: Wound infections are significant group of infections in the hospitals worldwide. The wide spread uses of antimicrobial agents lead to emergence of resistant pathogens contributing to increased morbidity and mortality. Accurate and prompt antimicrobial therapy is required to reduce the complications. This study was aimed to investigate pyogenic bacterial pathogens and their susceptibility patterns. Methods: A cross sectional study was carried out at Gandaki Medical College Teaching Hospital from July to December 2018. Wound specimens obtained from adult patients were inoculated onto appropriate media and pathogens were identified using standard microbiological methods. Antimicrobial susceptibility patterns were determined by Kirby-Bauer disc diffusion method following the guidelines of Clinical and Laboratory Standard Institute (CLSI). Results: A total of 264 specimens were included in the study of which 167 (63.3%) were positive for bacterial growth. Of these, polymicrobial growth was observed in two specimens. Gram positive bacteria (119, 70.4%) were the leading cause of infections, Staphylococcus aureus (102, 85.7%) being the most dominant. Among the Gram negative pathogens (50, 29.6%), Escherichia coli (31,62%) was found to be the predominant followed by Pseudomonas aeurogenosa (10, 20%). Overall, the isolates were resistance to Ampicillin (90.7%), Amoxycillin (64.9%), Cloxacillin (68%), Ofloxacin (61.5%) and Cotrimoxazole (55.6%). Lesser rates of resistance were observed to Doxycycline, Erythromycin, Amikacin, Gentamicin and Imipenem. Conclusion: This study revealed the most common pathogens causing pyogenic wound infections in our setting. Again, these pathogens are resistance to commonly used antibiotics. Therefore, this study could be helpful to develop proper guidelines of antibiotics to be used for prophylactic and empiric treatment.

Blastomycosis is a systemic fungal infection which primarily involves the lungs but can disseminate to involve extrapulmonary sites. Current testing that exists includes sputum, urine, serum, and pathological tissue analysis. Radiological testing is often non-specific and highly variable. Here we present five cases of pulmonary blastomycosis with challenging radiographic presentations.

BACKGROUND To outline our experience with the radical resection of hilar cholangiocarcinoma (HCCA) combined with the partial resection of the pancreatic head (RRHCCAPRPH) as a treatment for HCCA with distal bile duct involvement and to appraise the feasibility of this challenging procedure. METHODS Between 2007 and 2017, 205 patients with HCCA who underwent curative surgery at our hospital were included. Among the patients, extrahepatic bile duct resection combined with hepatectomy (EBDRH), RRHCCAPRPH and hepatopancreaticoduodenectomy (HPD) was performed in 168, 21 and 16 patients, respectively. Clinical pathological factors, post-operative complications and survival were compared between the three groups. RESULTS There was a significant difference in operative blood loss, operative time, post-operative hospital stay and tumour size between EBDRH group, RRHCCAPRPH group and HPD group (P

Background: Postoperative atrial fibrillation (POAF) is a relatively common phenomenon, occurring in approximately 20-40% of cases. Previous studies and guidelines from the AHA/ACC recommended initiating anticoagulation in patients with POAF lasting over 48 hours. However, a few recent studies suggest improved outcomes after anticoagulation even at 5 minutes of POAF. Our meta-analysis aims to clarify primary outcomes of ischemic stroke and mortality in patients with POAF and to offer guidance on whether these patients would benefit from chronic anticoagulation. Objective: To assess whether patients with POAF benefit from chronic anticoagulation. Methods: Through PubMed, OVID, and MEDLINE, we performed a literature review of several studies to assess whether patients with short-lived atrial fibrillation benefit from anticoagulation. Although several studies provided valuable information, we selected 6 studies that reported the duration of POAF, risks of ischemic stroke, and mortality. Results: We found that patients that received anticoagulation due to newly diagnosed POAF were 3.5-times less likely to experience an ischemic stroke than patients who did not receive anticoagulation with newly diagnosed POAF (IRR 3.54 (95% CI 2.12-5.91), p=0.001.). There were no statistically significant differences found in mortality outcomes between POAF patients that received anticoagulation as compared to those patients that did not receive anticoagulation (Pooled IRR = 1.1449 (95% CI = 0.738952 to 1.773857, P = 0.5447). Conclusion: Patients with POAF over 24 hours duration were less likely to experience ischemic stroke if they were placed on anticoagulation.We hope that this meta-analysis would promote further prospective studies into the question of length of POAF and how chronic anticoagulation therapy plays a role in decreasing risks of ischemic stroke and/or mortality.

Late thrombus formation is a rare complication associated with patent foramen ovale (PFO) closure devices. We report the case of an incidental discovery of large thrombi in both atria 9 months after percutaneous PFO occlusion that required cardiac surgery for thrombi removal. (Level of Difficulty: Beginner.), Graphical abstract, Late thrombus formation is a rare complication associated with patent foramen ovale (PFO) closure devices. We report the case of an incidental…

Background: Point of care ultrasonography (POCUS) by non-cardiologist is a safe and rapidly evolving diagnostic modality for the assessment of left ventricular ejection fraction (LVEF). This study aims to correlate the eyeball estimation of LVEF (EBEF) with modified Simpson’s method and linear measurement in M-mode parasternal long axis view (PLAX). Methods: A descriptive cross-sectional study was conducted at Chitwan Medical College. POCUS was performed in all ICU patients on the day of admission with optimal image acquisition and LVEF was estimated by three different methods and correlation of results were analyzed. Results: Out of total 52 patients studied, median age was 58.38 ± 17.58 years (range: 24 – 89 years). There were 28 males (53.8%) and 24 females (46.2%) in this study. LVEF measured by eyeballing method and modified Simpson’s method had excellent correlation (Pearson’s correlation coefficient (r) = 0.956, P

This prospective study has been done to compare the results of treatment of uncomplicated upper ureteral calculi by in situ ESWL and ESWL after push back. Ninety consecutive patients with single upper- ureteric stones of < 1 cm in size with no distal obstruction were selected and divided into two groups. Fifty patients in group 1 were treated by in situ ESWL while 40 patients in group 2 were treated by push back followed by ESWL. In the in situ ESWL group, 56% cases were cleared of stone otter l week of first session, 24% cases required second and 10% cases required third sessions for complete clearance of stone. Overall 90% clearance was achieved after 90 days in this group. In the ESWL after push back group, 52.5% cases were cleared of stone after- 1 week of first session, 30% cases required second and 10% cases required third sessions for complete clearance of stone. Overall 92.5% clearance was achieved after 90 days in this group. Although more clearance rate was achieved in ESWL after push back, it was not statistically significant (p>0.05). The number of average ESWL sessions required was 1.54 for stone cm and 1.77 /or stone of l crn in the in situ ESWL group, where as it was 1.46 and 1.48 respectively for stones - / cm and of 1 cm respectively in the ESWL after push back group, however this difference was not statistically significant. More shock wave and energy was needed in the in situ ESWL group than in ESWL after push back group. The mean shock wave was 1994 + 449 for in situ ESWL group and 1757.5 ± 255 for 17S117, after push back group, which was statistically very significant (p

Objective. To compare the intraoperative and postoperative outcomes of central pancreatectomy (CP) with distal pancreatectomy (DP). Methods. A systematic literature search was performed on electronic databases from MEDLINE, Embase, and PubMed from 1998 to 2018. Statistical analysis and meta-analysis were performed using statistics/data analysis (Stata®) software, version 12.0 (StataCorp LP, College Station, Texas 77845, USA). Dichotomous variables were analyzed by estimation of relative risk (RR) with a 95 percent (%) confidence interval (CI) and continuous variables were analyzed by standardized mean differences (SMD) with 95% CI. Results. Twenty-four studies with 593 CP and 1226 DP were included in the meta-analysis. CP had significantly longer operation time (SMD: 1.03; 95% CI 0.62 to 1.44; P<0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P<0.01). Estimated blood loss was significantly lower in CP (SMD: −0.34; 95% CI −0.58 to −0.09; P=0.007). Overall postoperative morbidity (RR: 1.30; 95% CI: 1.13 to 1.50; P<0.001), overall pancreatic fistula (RR: 1.41; 95% CI: 1.20 to 1.66; P<0.001), clinically relevant fistula (RR: 1.64; 95% CI: 1.25 to 2.16; P<0.001), and postoperative hemorrhage (RR: 1.90; 95% CI: 1.18 to 3.06; P<0.05) were all significantly higher after CP. On long-term follow-up, DP patients were more likely to have postoperative exocrine (RR: 0.56; 95% CI: 0.37 to 0.84; P<0.05) and endocrine (RR: 0.27; 95% CI: 0.18 to 0.40; P<0.001) insufficiency. There was no statistically significant difference in transfusion requirement, postoperative mortality, reoperation, and tumor recurrence. Conclusion. CP is associated with significantly higher morbidity and clinically relevant pancreatic fistula. CP should only be reserved for selected patients who require postoperative pancreatic function preservation.

Introduction: Evolution of laparoscopy has revolutionised the field of gynaecological surgery for more than 40 years.Owing to the long learning curve, added expenses and lack of awareness among patients and surgeons, its introduction and development in Nepal is not upto the timeline. Gynaecologic laparoscopy (GL) seems to be introduced at BP Koirala institute of Health Sciences, Dharan,Nepal (BPKIHS) since 2002. It remained in latency because of widespread lack of equipment and skilled personnel. Some laparoscopic procedures like diagnostic laparoscopy, laparoscopic tubal ligation and very few laparoscopic assisted vaginal hysterectomy (LAVH) were done from 2002 - 2012 (10 years). Since then more gynecologists have been trained in GL which has contributed to expansion of GL. Objective: The objective of this study is to study and share trends of gynaecological laparoscopic surgeries performed at BPKIHS. Methodology: All the patients undergoing GL surgeries have been analyzed for the indication, type of procedure, conversion and its complications. We took data from operation theatre register and patient case sheet from July 2004 to May 2018. We divided this period into two phase viz Phase 1: July 2004-June 2013 and Phase 2: July 2013- till May 2018. Results: Total number of GL done in this period was 427. Out of which 102 cases were from phase one and rest of the cases were done in five years of phase II. Number of operative laparoscopy has increased in phase 2 compared to phase 1. In last five years there was155 (47.6%) cases of adnexal surgery, 77 (23.6%) cases of diagnostic laparoscopy.Total laparoscopic hysterectomy was done in 25 (7.6%) cases. Conversion to laparotomy was done in4.6% (n=15) cases. Overall 12(3.7%) patient had major complications. Oral diet started at 4-6th hour post-operatively, and mobilization started after 24 hours. Seventy percent of patient had a hospital stay of 2days and rest stayed for 3 days. Conclusions: There is rising trend in operative GL at BPKIHS. We are facing less complication with expanding experience. There has been good learning from each case. GL has well demonstrated its advantages of reducing postoperative pain and morbidity, short hospital stay, and less postoperative recovery time. We have plans to get new gadgets and expand services in GL.