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Purpose: This study was conducted to assess patients’ outcome and satisfaction with the eye care received with telemedicine and physical consultation at a tertiary care hospital during and after the coronavirus disease 2019 (COVID-19) pandemic. Methods: A descriptive study was carried out on 6052 patients who consulted for eye illness at a tertiary care hospital between April 2020 and December 2022. An outcome scoring system was developed and validated for the assessment of patient outcome after providing treatment on telemedicine consultation and physical consultation. Outcome scores for various symptoms were compared pretreatment and posttreatment. Telehealth Usability Questionnaire (TUQ) was used through an online survey to assess patients’ satisfaction with teleophthalmology services during the COVID-19 pandemic. An 18-item Patient Satisfaction Questionnaire (PSQ-18) was used to assess the same with physical consultation. Results: A total of 6052 patients were included in the study. Physical consultation group had 2485 patients (41.06%) and the telemedicine group had 3567 patients (58.93%). Male patients constituted 63.11% and females were 36.89%. There was a significant improvement in outcome scores for pain and redness in both physical and telemedicine consultation groups (P < 0.0001). All subgroups of TUQ had significantly high scores (including usefulness, ease of use and learnability, interface quality, interaction quality, and satisfaction and future use), except one subgroup (reliability). Uneducated patients were significantly more satisfied with telemedicine compared to educated patients (P = 0.044). Conclusion: Majority of patients expressed satisfaction with teleophthalmology services. The recent pandemic paved the way for the future integration of telemedicine in ophthalmology, especially if virtual eye examinations attain a higher level of reliability.

Background: Gallstone disease is one of the most prevalent gastrointestinal diseases with a substantial burden to health-care systems. Patients present with right upper quadrant pain, dyspepsia, nausea or vomiting. Owing to the side effects of allopathic drugs, many patients resort to homeopathic treatment for relief of pain. There are several homeopathic drugs that decrease the pain of cholecystitis as well as high cholesterol in these patients but cannot cure them off the disease. Finally, they come to general surgeon for cholecystectomy. We have noticed that performing laparoscopic cholecystectomy (LC) in these patients is difficult and time consuming. Aims and Objectives: To determine whether or not homeopathic medicine intake for treatment of cholelithiasis act as an independent factor that leads to intraoperative difficulties during LC. Materials and Methods: Study design: A prospective randomized comparative study. Study period: July 2022–December 2023 (18 months). Study groups: Group H = Patients with history of (H/O) intake of homeopathic medicines for treatment of cholelithiasis = 60 patients, Group N = Patients with no H/O homeopathic medicine intake = 60 patients. Results: Twenty-six (43.33%) patients in Group H and 11 (18.33%) patients in Group N had a difficult LC. 7 (11.67%) patients in Group H and 1 (1.67%) patient in Group N had dense adhesions around the gallbladder (GB). 13 (21.67%) patients of Group H and 3 (5%) patients of Group N had a Frozen Calot’s Triangle (fibrosis and difficult Calot’s triangle dissection). This was statistically significant. Conclusion: Our study proved that intake of homeopathic medications for the treatment of cholelithiasis leads to dense adhesions around GB as well as fibrotic adhesions leading to difficult Calot’s triangle dissection leading to a difficult LC.

Alzheimer's disease is the most common form of dementia. Its aetiology is characterized by the misfolding and aggregation of amyloid-β (Aβ) peptides into β-sheet-rich Aβ oligomers/fibrils. Although multiple experimental studies have suggested that Aβ oligomers/fibrils interact with the cell membranes and perturb their structures and dynamics, the molecular mechanism of this interaction is still not fully understood. In the present work, we have performed a total of 120 μs-long simulations to investigate the interaction between trimeric or hexameric Aβ1–40 fibrils with either a 100% DPPC bilayer, a 70% DPPC-30% cholesterol bilayer or a 50% DPPC-50% cholesterol bilayer. Our simulation data capture the spontaneous binding of the aqueous Aβ1–40 fibrils with the membranes and show that the central hydrophobic amino acid cluster, the lysine residue adjacent to it and the C-terminal hydrophobic residues are all involved in the process. Moreover, our data show that while the Aβ1–40 fibril does not bind to the 100% DPPC bilayer, its binding affinity for the membrane increases with the amount of cholesterol. Overall, our data suggest that two clusters of hydrophobic residues and one lysine help Aβ1–40 fibrils establish stable interactions with a cholesterol-rich DPPC bilayer. These residues are likely to represent potential target regions for the design of inhibitors, thus opening new avenues in structure-based drug design against Aβ oligomer/fibril-membrane interaction.

Background: Nerve Conduction Velocities (NCVs) measures electrical changes and speed in the nerve. Objectives of this study were: to compare mean velocities, to find rank of importance of different velocities and to frame equation to classify severely acute malnourished (SAM) children with normal children. Material & Methods: Present case- control study was conducted on 50 SAM children and 50 normal children aged 6 months to 59 months. Independent t test and Discriminant analysis was performed. Standardized discriminant coefficient, canonical correlation and Wilks’ Lambda was calculated and p value was judges at 5% level of significance. Results: NCVs were observed significantly lower among the cases as compared with the controls. Sural Sensory Nerve Velocity holds first position followed by Sensory Nerve Velocity. So, in final discriminant model 3 variables i.e., Sural Sensory Nerve Velocity; Median Sensory Nerve Velocity; Tibial Motor Nerve Velocity were used and 42.1 % of the total variance in the discriminant scores not explained by differences among the groups by the three-variable model. Model is able to classify 82.5% cases correctly. Conclusion: Sural Sensory Nerve Velocity; Median Sensory Nerve Velocity; Tibial Motor Nerve Velocity were found as most important nerve conduction velocities with a good classification ability.

PAP248-286 peptides, which are highly abundant in human semen, aggregate and form amyloid fibrils that enhance HIV infection. Previous experimental studies have shown that the infection-promoting activity of PAP248-286 begins to increase well before amyloid formation takes place and that pH plays a key role in the enhancement of PAP248-286-related infection. Hence, understanding the early stages of misfolding of the PAP2482-86 peptide is crucial. To this end, we have performed 60 independent MD simulations for a total of 24 µs at two different pH values (4.2 and 7.2). Our data shows that early stages of misfolding of the PAP248-286 peptide is a multistage process and that the first step of the process is a transition from an “I-shaped” structure to a “U-shaped” structure. We further observed that the structure of PAP248-286 at the two different pH values shows significantly different features. At pH 4.2, the peptide has less intra-molecular H-bonds and a reduced α-helical content than at pH 7.2. Moreover, differences in intra-peptide residues contacts are also observed at the two pH values. Finally, free energy landscape analysis shows that there are more local minima in the energy surface of the peptide at pH 7.2 than at pH 4.2. Overall, the present study elucidates the early stages of misfolding of the PAP248-286 peptide at the atomic level, thus possibly opening new avenues in structure-based drug discovery against HIV infection.

Malignancy is the third major cause of death among transplant recipients. Patient and kidney transplant outcomes after the diagnosis of malignancy are not well described. We reviewed incidences and outcomes of colorectal, lung, PTLD, and renal malignancy after transplant among patients who received a transplant from January 2000 to December 2018 using the UNOS/OPTN database. Incidence of each malignancy was measured at 5 years and 10 years of transplant. The Kaplan–Meier curve was used for time-to-event analysis (graft and patient outcomes). Additionally, we sought to identify the causes of graft failure among these recipients. We found that 12,764 (5.5%) patients suffered malignancy, excluding squamous and basal cell skin carcinoma after transplant. During the first 5 years of transplant, incidence of colorectal, lung, PTLD, and renal malignancies was 2.99, 9.21, 15.61, and 8.55 per 10,000 person-years, respectively. Rates of graft failure were 10.3%, 7.6%, 19.9%, and 18.8%, respectively, among these patients at 5 years. Mortality rate was highest among patients who suffered lung malignancy (84%), followed by colorectal (61.5%), PTLD (49.1%), and renal (35.5%) at 5 years after diagnosis of malignancy. In conclusion, kidney transplant recipients diagnosed with lung malignancy have the lowest graft survival, compared to PTLD, colorectal, and renal malignancy. PTLD has the highest incidence rate in the first 5 years of transplant.

(1) Background: Malaria, a vector-borne infectious disease, is caused by parasites of the Plasmodium genus, responsible for increased extreme morbidity and mortality rates. Despite advances in approved vaccines, full protection has not yet been achieved upon vaccination, thus the development of more potent and safe immuno-stimulating agents for malaria prevention is a goal to be urgently accomplished. We have focused our research on a strategy to identify Plasmodium spp. epitopes by naturally acquired human antibodies and rodent malaria infection models immunized with site-directed non-natural antigens. (2) Methods: Some predictive algorithms and bioinformatics tools resembling different biological environments, such as phagosome-lysosome proteolytic degradation, affinity, and the high frequency of malaria-resistant and -sensitive HLA-II alleles were regarded for the proper selection of epitopes and potential testing. Each epitope’s binding profile to both host cells and HLA-II molecules was considered for such initial screening. (3) Results: Once selected, we define each epitope-peptide to be synthesized in terms of size and hydrophobicity, and introduced peptide-bond surrogates and non-natural amino acids in a site-directed fashion, and then they were produced by solid-phase peptide synthesis. Molecules were then tested by their antigenic and immunogenic properties compared to human sera from Colombian malaria-endemic areas. The antigenicity and protective capacity of each epitope-peptide in a rodent infection model were examined. The ability of vaccinated mice after being challenged with P. berghei ANKA and P. yoelii 17XL to control malaria led to the determination of an immune stimulation involving Th1 and Th1/Th2 mechanisms. In silico molecular dynamics and modeling provided some interactions insights, leading to possible explanations for protection due to immunization. (4) Conclusions: We have found evidence for proposing MSP1-modified epitopes to be considered as neutralizing antibody stimulators that are useful as probes for the detection of Plasmodium parasites, as well as for sub-unit components of a site-directed designed malaria vaccine candidate.

Introduction: Laparoscopic cholecystectomy (LC) in patients with extrahepatic portal vein obstruction causing portal cavernoma (PC) is considered high risk because of portosystemic collateral veins in the hepatocystic triangle. The literature is limited to isolated case reports. We describe our experience of LC in patients with PC. Patients and Methods: Data of patients with PC who underwent LC for symptomatic gallstones or related complications was reviewed. Patients with simultaneous cholecystectomy with splenorenal shunt and open cholecystectomy were excluded. Pre-operative evaluation consisted of complete blood count, international normalisation ratio and liver function tests, ultrasound of the abdomen with Doppler, contrast-enhanced computerised tomography, magnetic resonance cholangiopancreatography and esophagogastroscopy as indicated. A standard four-port LC was performed. The technical principles followed were to avoid injury to the collateral veins, liberal use of energy sources and division of dominant collateral veins between clips. Results: Seven adult patients including three females underwent LC. Three patients had thrombosis of previous surgical shunt with persistent PC. The remaining four patients did not have any indication for shunt surgery. Successful LC was performed in six patients. The median duration of surgery was 170 (130–250 min). Blood transfusion was not required. All the patients had uneventful post-operative recovery. The histopathology of gall bladder consists of acute cholecystitis in three patients and chronic cholecystitis in four. Conclusion: LC is feasible in patients with PC at a centre with experience in both laparoscopic and portal hypertension surgeries. Excellent outcome with low rate of conversion to open surgery can be achieved.

The effectiveness of hemodialysis is completely dependent on the quality of the patient’s vascular access; thus, appropriate assessment of ateriovenous fistulas and grafts is of critical importance. Point of care ultrasound (POCUS) can be an additional useful skill at the bedside for assessment of the hemodialysis vascular access. In this paper we discuss the basic terminology and techniques that can be employed in the POCUS exam of vascular accesses. We also delineate the current recognized criteria for access maturation and common issues that can be diagnosed with the support of POCUS.

Cerebral arterio-venous malformations tend to present most commonly with neurological manifestations like headache, intracranial hemorrhage, seizures, or focal neurologic deficit. Intracranial vascular malformations with aggressive imaging features manifesting only with mild unilateral proptosis are very rare with sparse literature available on it. This report stresses upon the fact that even mild to moderate proptosis may be the primary and solitary presenting feature of a large intracranial extra-orbital pial arterio-venous malformation (AVM). Another feature highlighted in this case of unruptured pial arterio-venous malformation is the presence of hydrocephalus which is secondary to extrinsic compression of the cerebral aqueduct by dilated and tortuous draining vein.

Summary:. Optimizing prosthetic function and tolerance are key principles of performing an elective upper extremity amputation. It is common for upper extremity amputees to experience issues related to nonoptimal prosthetic control and pain. Targeted muscle reinnervation and regenerative peripheral nerve interfaces in elective transhumeral amputations have been introduced as techniques to address the paucity of signals that may exist for myoelectric control postamputation. These techniques require the denervation of muscle and rely on delayed muscle reinnervation to provide eventual signal amplification for prosthetic function. In addition, the fascicles cannot be separated enough to provide signals to each individual muscle. Use of native innervated forearm musculature can provide more immediate and specific signals for prosthetic use. These native muscles are often not available for use due to trauma, denervation, or dysvascularization. In elective amputations, they can be used as spare parts to provide more signals for the sensors on a myoelectric prosthetic. The concept has been used in partial hand amputations and allowed for individual digital control at the terminal prosthetic device. In this study, we describe a novel technique used for an elective transhumeral amputation utilizing native innervated, vascularized musculature to provide intuitive control of a myoelectric prosthetic.

Background Immune checkpoint inhibitors (ICI) have emerged as a front-line therapy for a variety of solid tumors. With the widespread use of these agents, immune-associated toxicities are increasingly being recognized, including fatal myocarditis. There are limited data on the outcomes and prognostic utility of biomarkers associated with ICI-associated myocarditis. Our objective was to examine the associations between clinical biomarkers of cardiomyocyte damage and mortality in patients with cancer treated with ICIs.Methods We retrospectively studied 23 patients who developed symptomatic and asymptomatic troponin elevations while receiving ICI therapy at a National Cancer Institute-designated comprehensive cancer center. We obtained serial ECGs, troponin I, and creatine kinase-MD (CK-MB), in addition to other conventional clinical biomarkers, and compared covariates between survivors and non-survivors.Results Among patients with myocarditis, higher troponin I (p=0.037) and CK-MB (p=0.034) levels on presentation correlated with progression to severe myocarditis. Higher troponin I (p=0.016), CK (p=0.013), and CK-MB (p=0.034) levels were associated with increased mortality, while the presence of advanced atrioventricular block on presentation (p=0.088) trended toward increased mortality. Weekly troponin monitoring lead to earlier hospitalization for potential myocarditis (p=0.022) and was associated with decreased time to steroid initiation (p=0.053) and improved outcomes.Conclusions Routine troponin surveillance may be helpful in predicting mortality in ICI-treated patients with cancer in the early phase of ICI therapy initiation. Early detection of troponin elevation is associated with earlier intervention and improved outcomes in ICI-associated myocarditis. The recommended assessment and diagnostic studies guiding treatment decisions are presented.

CONTEXT: Inflammatory pseudotumor (IPT) of the liver is a rare, tumor-like lesion that is considered to be biologically benign but often mimics malignancy. AIMS: The aim of the study was construe clinicopathological features, imaging findings, differential diagnosis, management, and follow-up of IPT involving the liver. SETTINGS AND DESIGN: It is a retrospective study. SUBJECTS AND METHODS: Cases included were of IPT, diagnosed on histopathology, at our center from June 2009 to December 2016. Details studied were clinical presentation, imaging studies, laboratory investigations, pathological features, treatment, and follow-up of the cases and compared with reports in the literature. RESULTS: A total of cases of IPT included were 17. The age of the patients ranged from 21 to 62 years. Common presenting features were intermittent fever, upper abdominal pain, and weight loss. Radiological diagnosis varied from neoplastic (13) to infectious etiologies (4), with hepatocellular carcinoma being the most common differential (7/17). Laboratory investigations revealed leukocytosis, hyperbilirubinemia, raised transaminases, and raised serum alkaline phosphatase. Core biopsy of a tumor conceded increased fibrosis along with mixed inflammatory cell infiltrates. Eleven cases were managed conservatively and showed regression or complete recovery. Six patients underwent surgical resection. None of these had any recurrence in median follow-up of 22 months. CONCLUSIONS: IPT of the liver can masquerade as a fatality, either primary or metastatic. It will be well managed with conservative modalities and can avoid redundant hepatectomy, reserved for complicated cases. For this intent, accurate preoperative diagnosis is the requisite, and needle biopsy with or without fine-needle aspiration cytology plays as a significant rescuer in this field.

Abstract Background Improved cancer survival in patients treated with thoracic ionizing radiation (XRT) has resulted in unanticipated surge of aortic stenosis. Transcatheter aortic valve replacement (TAVR) has revolutionized the management of severe aortic stenosis. However, long-term clinical outcomes in radiation-exposed cohorts undergoing TAVR are unknown. We compared the all-cause mortality and major adverse cardiac events (MACE) in patients with prior chest XRT (C-XRT) undergoing TAVR. Methods This is an observational cohort study in subjects who underwent TAVR for symptomatic severe aortic stenosis from 2012 to 2017 in a tertiary care referral center. We examined the all-cause mortality and MACE using cox proportional hazard analysis to identify the clinical predictors of survival in the cohort of patients who had a history of prior C-XRT for malignancy. Results Of the 610 patients who underwent TAVR for symptomatic severe aortic stenosis, 75 had prior C-XRT. The majority of C-XRT patients had prior breast cancer (44%) followed by Hodgkin’s lymphoma (31%), with the median time from XRT to TAVR of 19.0 years. During a mean follow up of 17.1 months after TAVR, all-cause mortality was 17%. Those with prior C-XRT had higher all-cause mortality (XRT: 29%; non-XRT:15%, p

The development of immune checkpoint inhibitors (ICIs) has revolutionized the treatment of patients with advanced stage cancers. However, immune-related adverse events are frequently observed. Cardiac toxicity from ICI therapy can range from asymptomatic troponin-I elevations to conduction abnormalities of the heart and even fulminant myocarditis. Although rare, myocarditis is a potentially fatal adverse effect of ICI therapy. We present a series of five cases of ICI-related cardio-toxicity diagnosed and managed at Roswell Park Comprehensive Cancer Center along with a review of published case reports in the literature. Our series highlights the importance of high clinical suspicion, early diagnosis of myocarditis, and prompt initiation of immunosuppressive therapy.

The nationwide focus on patient safety and the health of residents has increased the demand for educational tools outside the operating room. Simulation is a valuable tool for assessing and developing surgical skills in a controlled and safe environment. The use of simulation as a formal component of training has been increasing in various surgical subspecialties. In general surgery, simulation examinations such as the Fundamentals of Laparoscopic Surgery and Fundamentals of Endoscopic Surgery have become a prerequisite to board certification. Although formal simulation examinations in plastic surgery are not universal, there has been an increase in the use of simulation to increase resident competency in the operating room. For now, we will review the current state of simulation in craniofacial, hand, microvascular, and esthetic surgery and discuss applications for the future. We will also discuss the evolving role of artificial intelligence, virtual reality, and augmented reality in plastic surgery training and testing.

Surgery remains the standard treatment for acute cholecystitis except in high-risk candidates where percutaneous transhepatic gallbladder drainage (PT-GBD), endoscopic transpapillary cystic duct stenting (ET-CDS), and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) are potential choices. PT-GBD is contraindicated in patients with coagulopathy or ascites and is not preferred by patients owing to aesthetic reasons. ET-CDS is successful only if the cystic duct can be visualized and cannulated. For 189 patients who underwent EUS-GBD via insertion of a lumen-apposing metal stent (LAMS), the composite technical success rate was 95.2%, which increased to 96.8% when LAMS was combined with co-axial self-expandable metal stent (SEMS). The composite clinical success rate was 96.7%. We observed a small risk of recurrent cholecystitis (5.1%), gastrointestinal bleeding (2.6%) and stent migration (1.1%). Cautery enhanced LAMS significantly decreases the stent deployment time compared to non-cautery enhanced LAMS. Prophylactic placement of a pigtail stent or SEMS through the LAMS avoids re-interventions, particularly in patients, where it is intended to remain in situ indefinitely. Limited evidence suggests that the efficacy of EUS-GBD via LAMS is comparable to that of PT-GBD with the former showing better results in postoperative pain, length of hospitalization, and need for antibiotics. EUS-GBD via LAMS is a safe and efficacious option when performed by experts.

Abstract Background Permanent pacemaker implantation is the most common complication after Transcatheter aortic valve replacement (TAVR) and is associated with worse outcomes and mortality. However, its impact on quality‐of‐life (QoL) outcomes remains unknown. Methods We included 383 consecutive patients undergoing TAVR from January 2012 to 2016 who completed a baseline Kansas City Cardiomyopathy Questionnaire (KCCQ‐12) health survey. The clinical, laboratory, angiographic, QoL, mortality, and occurrence of poor outcomes (KCCQ‐12 score < 45 or KCCQ decrease of ≥10 points) were obtained. Results The mean age was 83 ± 8 years, 51% were men, and majority were Caucasians (n = 364, 95%). Permanent pacemaker (PPM) was implanted in 11.5% of patients post‐TAVR. PPM patients were more likely to have prior conduction disease including RBBB (25% vs 12%, P = .02) and PQ interval >250 ms (11% vs 5%, P = .07). One‐month median KCCQ‐12 scores were significantly lower among PPM patients (84.7 vs 68.8, P = .04), but did not differ significantly at 1‐year (86.5 vs 90.6, P = .5) post‐TAVR. Occurrence of poor outcomes did not differ significantly among those with or without PPM at 1 month (11% vs 7%, P = .39) and 1 year (13% vs 9%, P = .45), respectively. However, patients with poor QoL outcomes at 1 month post‐TAVR also had significantly worse mortality during follow‐up in unadjusted (31.3% vs 4.5%, P < .001) and adjusted (HR = 5.30, 95% [CI: 1.85‐15.22, P = .002])analyses, respectively. Conclusion Permanent pacemaker implantation is associated with short‐term reduction in QoL without long‐term implications post‐TAVR. Patients with poor QoL post‐TAVR also have significantly higher mortality.

Introduction: Gallstones are an etiological factor in 23%–54% of patients with acute pancreatitis. A small proportion of these patients will also have intestinal complications requiring necrosectomy with diverting loop ileostomy. Later, these patients require cholecystectomy and ileostomy reversal. Laparoscopic cholecystectomy is fraught with difficulty in these patients due to dense intra-abdominal adhesions, and many surgeons resort to an open approach. We describe a technique which takes advantage of the ileostomy site for initial access. Materials and Surgical Technique: Ileostomy reversal is done and a SILS™ (Covidien, Mansfield, Massachusetts, USA) port is inserted under direct vision, through the ileostomy site. Adhesiolysis is done through the SILS™ port. Additional ports are inserted and standard steps are followed for cholecystectomy. Conclusion: The use of ileostomy incision as the first port facilitates adhesiolysis and subsequent port placement in the hostile abdomen encountered in these patients. We describe a novel technique of ileostomy reversal and laparoscopic cholecystectomy using SILS™ port.

Ulcerative colitis (UC) is a chronic systemic inflammatory condition primarily involving the large bowel mucosa with relapsing and remitting episodes. It is also associated with multiple extra-intestinal manifestations [EIM], including skeletal muscle involvement which is rare. Review of the literature reported only a few cases of inflammatory myositis in association with UC. We report an unusual presentation of recurrent inflammatory myositis of lower extremities in a 28-year-old male with quiescent UC and on long-term mesalamine therapy.

Cardiac dysrhythmia and sudden death account for a large proportion of cardiac mortality in dialysis patients. Risk factors for sudden death that are specific to dialysis patients include fluid and electrolyte imbalances during hemodialysis, particularly those of potassium. The risk of arrhythmia may be related to changes in serum K+ concentration during dialysis, and thus close attention should be paid to the dialysate K+ concentration and the serum–dialysate concentration gradient. Potassium profiling is a technique where the dialysate K+ concentration is gradually reduced to keep the gradient between blood and dialysate at a non-fluctuating low level. We provide a review of studies that compare constant potassium concentration in dialysate to gradual reduction in dialysate potassium concentration. These studies illustrate that adequate and more gradual potassium removal can be achieved with potassium profiling techniques, while having lower cardiac irritability.

Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) are included on the WHO high priority list of pathogens that require urgent intervention. Hence emphasis needs to be placed on developing novel class of molecules to tackle these pathogens. Teixobactin is a new class of antibiotic that has demonstrated antimicrobial activity against common bacteria. Here we examined the antimicrobial properties of three Teixobactin derivatives against clinically relevant bacterial isolates taken from South African patients. The minimum inhibitory concentration (MIC), the minimal bactericidal concentration (MBC), the effect of serum on MICs and the time-kill kinetics studies of our synthesized Teixobactin derivatives (3, 4, and 5) were ascertained following the CLSI 2017 guidelines and using the broth microdilution method. Haemolysis on red blood cells (RBCs) and cytotoxicity on peripheral blood mononuclear cells (PBMCs) were performed to determine the safety of these compounds. The MICs of 3, 4, and 5 against reference strains were 4–64 μg/ml, 2–64 μg/ml, and 0.5–64 μg/ml, respectively. The MICs observed for MRSA were (3) 32 μg/ml, (4) 2–4 μg/ml and (5) 2–4 μg/ml whilst those for VRE were (3) 8–16 μg/ml, (4) 4 μg/ml and (5) 2–16 μg/ml, respectively. In the presence of 50% human serum, there was no significant effect on the MICs. The compounds did not exhibit any effect on cell viability at their effective concentrations. Teixobactin derivatives (3, 4, and 5) inhibited bacterial growth in drug-resistant bacteria and hence emerge as potential antimicrobial agents. Molecular dynamic simulations suggested that the most dominant binding mode of Lys10-teixobactin (4) to lipid II is through the amide protons of the cycle, which is identical to data described in the literature for the natural teixobactin hence predicting the possibility of a similar mechanism of action.

Introduction: To understand and report the prevalence of meconium aspiration syndrome and the clinico-radiological features in a tertiary care hospital of western Nepal. Methods: An observational study carried out for a year in 2014-15 in all babies with MAS. Clinical and radiological profiles of MAS in relation to gender, gestational age, mode of delivery, birth weight, Apgar score, thickness of meconium, age at admission and the immediate outcome were studied. Results: Out of 584 admitted newborns (male=389; female=186) during the study period, 78 (13.4%) had meconium aspiration syndrome with male: female ratio of 1.2:1. Majority of babies admitted to NICU had thick meconium [n=52 (66.7%)]. There was no statistical significant difference in various parameters such as Apgar score at 1 and 5 minutes, respiratory distress, birth asphyxia, duration of oxygen use, MAS severity and chest x-ray in those with thick MAS compared to thin. Among all newborns with MAS, 59% (n=46) had abnormal radiological findings with over two-folds in those with thick MAS (71.7%)] compared to thin (28%). Hyperinflation (47.8%), diffuse patchy infiltration (37%), consolidation (21.7%) collapse (8.7%), right lung fissure (6.5%) and pneumothorax (8.7%) were the abnormal radiological findings seen in MAS babies. The odds of having APGAR score at 1 minute at least 7 or more was twice unlikely in those having thick meconium compared to thin (P=0.02) Conclusions: Thick meconium is relatively common with more significant abnormal radiological findings and low Apgar score.

Peritonitis is a very serious complication encountered in patients undergoing peritoneal dialysis and healthcare providers involved in the management should be very vigilant. Gram-positive organisms are the frequent cause of peritonitis compared to gram-negative organisms. There has been recognition of peritonitis caused by uncommon organisms because of improved microbiological detection techniques. We report a case of peritonitis caused by Moraxella osloensis (M. osloensis), which is an unusual cause of infections in humans. A 68-year-old male, who has been on peritoneal dialysis for 2 years, presented with abdominal pain and cloudy effluent. Peritoneal fluid analysis was consistent with peritonitis and peritoneal fluid culture grew gram-negative bacteria. M. osloensis was identified by 16 S PCR phenotypic and sequencing techniques. Patient responded well to the treatment, with intraperitoneal cephalosporin, and repeat peritoneal fluid culture yielded no growth. M. osloensis rarely causes infection in humans and responds well to treatment, as reported in literature.

Background. Neurocysticercosis (NCC), a common cause of seizures in children from low and middle income countries (LMICs), if not diagnosed and treated early enough may lead to considerable morbidity and mortality. There is a lack of data on the prevalence of NCC and its clinical characteristics among those with seizure in South-Western Nepal. Aims and Objectives. To study the prevalence and clinical characteristics of NCC in children with seizures. Material and Methods. All children admitted to Universal College of Medical Sciences, a tertiary hospital in South-Western Nepal with seizures during 2014–16, were tested for NCC. NCC was diagnosed by neuroimaging [computerized tomography (CT) scan or magnetic resonance imaging (MRI)]. We used logistic regression to test the association between NCC with participants’ characteristics and clinical symptoms. Results. Among 4962 in-patient children, 168 (104 boys and 64 girls) had seizures (138 with generalized tonic clonic seizures (GTCS) and 30 with focal seizures). 43% of children with seizures had CT scan confirmed NCC. The prevalence of NCC in the oldest children (13–16 years) was significantly greater (57.1% versus 15.6%) compared to the youngest (0–4 years) one (p

Background: Laparoscopic cholecystectomy (LC) has become the procedure of choice for management of symptomatic gallstone disease. At times, it is difficult and takes longer time or has to be converted to an open procedure. This study is undertaken to determine the predictive factors for difficult LC. Aim: The aim was to evaluate a scoring method to predict difficult LC preoperatively. Materials and Methods: There were 30 cases operated by a single experienced surgeon. There are total 15 score from history, clinical and sonological findings. Score up to 5 predicted easy, 6-10 difficult and >10 are very difficult. Results: Prediction came true in 76.4% for easy and 100% difficult cases; there were no cases with a score above 10. The factors like previous history of hospitalization (P - 0.004), clinically palpable gallbladder (GB) (P - 0.009), impacted GB stone (P - 0.001), pericholecystic collection (P - 0.04), and abdominal scar due to previous abdominal surgery (P - 0.009) were found statistically significant in predicting difficult LC. Conclusion: The proposed scoring system is reliable with a sensitivity of 76.47% and specificity of 100%.

Cerebral salt wasting (CSW) syndrome is an important cause of hyponatremia in head injuries apart from syndrome of inappropriate antidiuretic hormone (SIADH). Proper diagnosis and differentiation between these two entities are necessary for management as the treatment is quite opposite in both conditions. Fludrocortisone can help in managing CSW where alone saline infusion does not work. We report a 17-month-old female child with head injury managed successfully with saline infusion and fludrocortisone.

Extrahepatic portal vein stenosis is caused by a variety of benign and malignant diseases and results in development of symptoms due to portal hypertension. Benign post-surgical adhesions causing portal vein stenosis in non-transplant population is an uncommon etiology of portal hypertension. Endovascular treatment of such patients with angioplasty and stenting is uncommonly reported in literature. We report a case of portal hypertension caused by benign postoperative portal vein fibrosis, successfully treated by self-expandable metallic stent.

Transhiatal herniation of abdominal organs after oesophageal resection and reconstruction is rare and sparsely described in the literature. The commonest organ to herniate is the colon. Pancreatic herniation has been reported twice before. We report a case of postoesophagectomy transhiatal pancreatic herniation in an asymptomatic patient.

Clopidogrel is an oral thienopyridine and together with aspirin is a component of dual antiplatelet therapy for the prevention of stent thrombosis after intracoronary stent placement. The common adverse effects from its use are an increased risk of bleeding, neutropenia, and rash. Arthralgia and backache are also known to occur with its use. There have been case reports linking arthritis with the use of clopidogrel. We describe the case of a 64-year-old man who reported symptoms of fever and joint pains following initiation of therapy with clopidogrel. Acute-phase reactants were elevated. Laboratory and radiologic testing were unremarkable. Incidentally, he reported experiencing a similar arthritis after he received a loading dose of clopidogrel prior to a diagnostic coronary angiography in the past. The symptoms improved dramatically on discontinuation of clopidogrel. There was no recurrence of symptoms with prasugrel. This describes possibly the second incidence of recurrent arthritis with clopidogrel therapy.

Gastrointestinal (GI) bleeding is more common in patients with chronic kidney disease and is associated with higher mortality than in the general population. Blood losses in this patient population can be quite severe at times and it is important to differentiate anemia of chronic diseases from anemia due to GI bleeding. We review the literature on common causes of lower gastrointestinal bleeding (LGI) in chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients. We suggest an approach to diagnosis and management of this problem.