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Background Chronic subdural hematoma (CSDH) is a neurologic condition characterized as a hematoma in the subdural space with a period >3 weeks that primarily affects the elderly. Glucocorticoid, especially dexamethasone, either alone or combined with surgery, has been used to manage CSDH. We aimed to perform an updated systematic review and meta-analysis of the literature regarding the role of steroids in CSDH. Methods We searched the electronic databases PubMed, PubMed Central, Scopus, and Embase for relevant articles until December 2020. Study characteristics, quality, and end points were extracted, and analysis was performed by RevMan 5.4. Results The odds for subdural hematoma recurrence were decreased by 61% in the steroid group (odds ratio [OR], 0.39; confidence interval [CI], 0.19–0.79) compared with the control group. There was no significant difference in mortality during the study period (OR, 0.66; CI, 0.20–2.18), modified Rankin Scale score 0–3 (OR, 0.87; CI, 0.31–2.40), and modified Rankin Scale score 4–6 (OR, 1.15; CI, 0.42–3.18) between the 2 groups. However, pooling data from 3 studies showed 2.7 times higher odds of occurring adverse effects in steroid groups using the fixed-effect model (OR, 2.70; CI, 1.71–4.28). The treatment success was similar between the steroid and control groups (OR, 2.39; CI, 0.94–6.04). Conclusions Treatment with steroids was associated with a lesser recurrence of CSDH. However, there was no benefit of steroid treatment in CSDH compared with nonsteroid treatment in terms of mortality and treatment success and some but significantly increased risk of adverse events.

In the Western world today, urogenital fistula, including vesicovaginal fistula (VVF), is rare. However, while it remains significant in developing parts of the world due to prolonged and obstructed labor, in this study, we systematically reviewed the existing literature, discussing VVF occurrence, its etiology, and outcomes.We used electronic databases to search relevant articles from 2010-2020. The screening was performed with the help of Covidence. Relevant data from included studies were extracted in excel sheets, and final analysis was done using CMA-3 using proportion with 95% confidence interval (CI).Fifteen studies reported the VVF among the fistula series. The pooled result showed 76.57% cases of VVF (CI, 65.42-84.96), out of which 27.54% were trigonal, 55.70% supra-trigonal, and the rest with a varied description like circumferential, juxta-cervical, juxta-urethral. Obstetric etiology was commonly reported with 19.29% (CI, 13.26-27.21) with cesarean section and 31.14% (CI, 18.23-47.86) with obstructed labor. Hysterectomy was the commonly reported etiology among gynecological etiology (46.52%, CI; 36.17-57.19). Among different surgical treatments employed for fistula closure, 49.50% were by abdominal approach (CI, 37.23-61.82), and 42.31% by vaginal approach (CI, 31.82-53.54). Successful closure of fistula was reported in 87.09% of the surgeries (CI, 84.39-89.38).The vesicovaginal fistula is the most common type of genitourinary fistula. Major causes of fistula are gynecological surgery, obstructed labor, and cesarean section. The vaginal approach and abdominal are common modalities of repair of fistula with favorable outcomes in the majority of the patients.

Ascites is the most common complication of liver cirrhosis. Midodrine is a vasoconstrictor that improves splanchnic and systemic hemodynamics, reduces ascites, and improves clinical outcomes. Here, we aimed to examine the role of midodrine in cirrhosis-related ascites. Scopus, Embase, PubMed, and PubMed Central databases were searched for relevant randomized controlled trials comparing midodrine with other interventions in patients with cirrhotic ascites on November 25, 2020, using appropriate keywords like "midodrine", "ascitic cirrhosis", "peritoneal paracentesis" and suitable Boolean operators. Odds ratio (OR) and mean difference (MD) were used to analyze pool data as appropriate with a 95% confident interval (CI). A total of 14 studies were included in our analysis including 1199 patients. The addition of midodrine resulted in statistically significant improvement in mean arterial pressure (MAP) (MD, 3.95 mmHg; 95% CI, 1.53-6.36) and MELD (Model for End-Stage Liver Disease) score (MD, -1.27; 95% CI, -2.49 to -0.04) compared to standard medical treatment (SMT). There was also a significant improvement in plasma renin activity and plasma aldosterone concentration. However, there was no significant improvement in mortality or serum creatinine compared to SMT. In addition, there was no statistically significant improvement in MAP, plasma renin activity, plasma aldosterone concentration, MELD score, overall mortality, and paracentesis-induced circulatory dysfunction comparing midodrine with albumin. Midodrine alone leads to significant improvement in various clinical parameters in patients with cirrhotic ascites compared to standard medical care. At the same time, it was found to be non-inferior to albumin. Therefore, further well-designed studies need to be carried out on midodrine in addition to albumin for optimal clinical benefits among patients with ascites due to cirrhosis.

Hemophagocytic Lympho-histiocytosis (HLH) is a rare life-threatening condition characterized by widespread activation of the immune system leading to tissue damage all over the body.

Waldmann’s disease / Primary intestinal lymphangiectasia, is an unusual cause of protein losing enteropathy primarily characterized by lymphopenia, hypoalbuminemia and hypogammaglobulinemia. However, variable clinical presentation results in diagnostic dilemma and effective management. We present a toddler diagnosed with Waldmann’s disease managed with high protein diet and medium chain triglycerides supplementation.

Background: Problem-based learning focuses on self-directed learning through problem-based approaches. This study was conducted to know the perspectives of medical students towards problem-based learning, along with its advantages and disadvantages, the role of facilitators and participants, and the scenario of problem-based learning in Tribhuvan University (TU) based medical colleges. Methods: This descriptive cross-sectional study was conducted among the first to third-year medical students at Nepalese Army Institute of Health Sciences, Kathmandu via a self-administered questionnaire. Convenience sampling method was used. The collected data was extracted to Microsoft Excel-13 and analyzed with a statistical package for social sciences (SPSS) version-22.Results: Out of 234 study participants, the majority found problem-based learning course interesting and informative (97.5%). More than three-fourths of respondents study more regularly in problem-based learning than lectures (82.5%) and understood applied aspects of course better than that taught via lectures because of problem-based learning (80.8%). Conclusions: The majority of the study participants have found problem-based learning fruitful than traditional lecture learning. Since problem-based learning integrates the basic and clinical knowledge and enhances collaborative learning skills, we strongly recommend frequent problem-based learning sessions in the medical schools of Nepal.

Introduction Paragonimiasis or lung fluke disease is a typical food-borne parasitic zoonosis caused by infection with Paragonimus species. The Paragonimus is a trematode that mainly infects the lungs of humans after eating an infected raw or undercooked crab or crayfish. Case presentation Herein we report a case of peritoneal Paragonimiasis in the gallbladder of a 58-year-old female from Rukum district of Nepal. It was an incidental diagnosis following routine histopathological examination of the cholecystectomy specimen. She presented with the symptoms of abdominal pain, fever, cough, and had a history of consumption of partially cooked river crabs. She responded well to praziquantel and improved thereafter. Clinical discussion Ectopic paragonimiasis is a rare disease and it presents with few clinical symptoms so it is significantly difficult to make a diagnosis and treat the patients. Even if a sputum test and biopsy are performed, the ova or body of Paragonimus parasites may not be detectable due to insufficient amount of specimens. Therefore, thorough history taking should be given importance. The dietary history of partially cooked crab or crayfish should indicate towards a high suspicion of Paragonimiasis. Any such indication should be immediately confirmed, which in our case was done by routine histopathological examination of the cholecystectomy specimen. Conclusion We report the case of a patient with peritoneal paragonimiasis in the gallbladder. Ectopic paragonimiasis is hard to diagnose due to an ignorance of, misdiagnosis, and the rarity of this disease. Thus, thorough history-taking and clinical suspicion of parasitic infection is essential., Highlights • Paragonimiasis is a parasitic zoonosis caused by Paragonimus species due to consumption of raw/partially cooked crustaceans. • Paragonimiasis mainly infects the lungs of humans but ectopic sites like the brain and peritoneum are also seen. • Ectopic paragonimiasis is hard to diagnose due to an ignorance of, misdiagnosis, and the rarity of this disease. • Thorough history-taking and clinical suspicion of parasitic infection is essential for diagnosis of Paragonimiasis. • Gallbladder histopathology after elective cholecystectomy helps in incidental diagnosis of many diseases like Paragonimiasis.