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Shrestha GS, Nepal G, Prust ML. Developing Systems of Emergency and Inpatient Neurologic Care in Resource-Limited Settings. Semin Neurol 2024; 44:105-118. [PMID: 38485125 DOI: 10.1055/s-0043-1778638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Neurologic diseases represent a significant global health challenge, leading to disability and mortality worldwide. Healthcare systems in low- and middle-income countries are disproportionally affected. In these resource-limited settings, numerous barriers hinder the effective delivery of emergency and inpatient neurologic care, including shortages of trained personnel, limited access to diagnostics and essential medications, inadequate facilities, and absence of rehabilitation services. Disparities in the neurology workforce, limited access to neuroimaging, and availability of acute interventions further exacerbate the problem. This article explores strategies to enhance global capacity for inpatient neurologic care, emphasizing the importance of workforce development, context-specific protocols, telehealth solutions, advocacy efforts, and collaborations.
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Affiliation(s)
- Gentle Sunder Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Gaurav Nepal
- Department of General Medicine, Rani Primary Healthcare Centre, Rani, Biratnagar, Nepal
| | - Morgan Lippitt Prust
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
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Gajurel BP, Yadav SK, Nepal G, Pant S, Yadav M, Shah R, Shah S. Neurological manifestations and complications of COVID-19 in patients admitted to a tertiary care center in Nepal during the second wave. Medicine (Baltimore) 2024; 103:e36017. [PMID: 38363915 PMCID: PMC10869060 DOI: 10.1097/md.0000000000036017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/18/2023] [Indexed: 02/18/2024] Open
Abstract
Neurological symptoms and signs of Coronavirus disease-19 (COVID-19) can accompany, follow, or precede respiratory symptoms and signs; hence, they are important in the diagnosis and management of COVID-19 patients. In this retrospective study conducted during the second wave of COVID-19, we included all patients diagnosed with COVID-19 using real-time polymerase chain reaction and admitted to the Tribhuvan University Teaching Hospital between June 2021 and October 2021. The patients were categorized into 2 groups: group A (with neurological manifestations or complications) and Group-B (without neurological manifestations or complications). The 2 groups were compared in terms of intensive care unit (ICU) admission, need for ventilatory support, length of hospital stay, and various outcomes. The study included 235 participants ranging in age from 13 to 102 years (mean age = 54 years, standard deviation = 18). Among the participants, 54.50% were male. The proportion of individuals in group A was higher (59.15%, N = 139) than that in Group-B (40.85%, N = 96). Notably, a significantly greater number of patients were admitted to the ICU in Group B than in Group A. However, there were no statistically significant differences in the need for ventilatory support or hospital stay between the 2 groups. Interestingly, group A showed a higher rate of improvement (Z = -3.1145, P = .00188, 95% CI), while Group-B had a higher rate of mortality (Z = 4.5562, P < .00001, 95% CI). Altered mental status and stroke have been specifically linked to poorer outcomes, whereas typical neurological manifestations, such as hyposmia, hypogeusia, dizziness, headache, and myalgia, are associated with better outcomes.
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Affiliation(s)
- Bikram Prasad Gajurel
- Department of Neurology Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Sushil Kumar Yadav
- Maharajgunj Medical Campus, Tribhuvan University, Institute of Medicine, Kathmandu, Nepal
| | - Gaurav Nepal
- Maharajgunj Medical Campus, Tribhuvan University, Institute of Medicine, Kathmandu, Nepal
| | - Sobin Pant
- Maharajgunj Medical Campus, Tribhuvan University, Institute of Medicine, Kathmandu, Nepal
| | - Manish Yadav
- Maharajgunj Medical Campus, Tribhuvan University, Institute of Medicine, Kathmandu, Nepal
| | - Ravi Shah
- Maharajgunj Medical Campus, Tribhuvan University, Institute of Medicine, Kathmandu, Nepal
| | - Sumit Shah
- Maharajgunj Medical Campus, Tribhuvan University, Institute of Medicine, Kathmandu, Nepal
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Mainali S, Nepal G, Webb A, Fadda P, Mirebrahimi D, Nana-Sinkam P, Worrall B, Woo D, Johnson N, Hamed M. MicroRNA Expression Profile in Acute Ischemic Stroke. Res Sq 2024:rs.3.rs-3754883. [PMID: 38260305 PMCID: PMC10802726 DOI: 10.21203/rs.3.rs-3754883/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Introduction Acute ischemic stroke with large vessel occlusion (LVO) continues to present a considerable challenge to global health, marked by substantial morbidity and mortality rates. Although definitive diagnostic markers exist in the form of neuroimaging, their expense, limited availability, and potential for diagnostic delay can often result in missed opportunities for life-saving interventions. Despite several past attempts, research efforts to date have been fraught with challenges likely due to multiple factors such as inclusion of diverse stroke types, variable onset intervals, differing pathobiologies, and a range of infarct sizes, all contributing to inconsistent circulating biomarker levels. In this context, microRNAs (miRNAs) have emerged as a promising biomarker, demonstrating potential as biomarkers across various diseases, including cancer, cardiovascular conditions, and neurological disorders. These circulating miRNAs embody a wide spectrum of pathophysiological processes, encompassing cell death, inflammation, angiogenesis, neuroprotection, brain plasticity, and blood-brain barrier integrity. This pilot study explores the utility of circulating exosome-enriched extracellular vesicle (EV) miRNAs as potential biomarkers for anterior circulation LVO (acLVO) stroke. Methods In our longitudinal prospective cohort study, we collected data from acute large vessel occlusion (acLVO) stroke patients at four critical time intervals post-symptom onset: 0-6 hours, 6-12 hours, 12-24 hours, and 5-7 days. For comparative analysis, healthy individuals were included as control subjects. In this study, extracellular vesicles (EVs) were isolated from the plasma of participants, and the miRNAs within these EVs were profiled utilizing the NanoString nCounter system. Complementing this, a scoping review was conducted to examine the roles of specific miRNAs such as miR-140-5p, miR-210-3p, and miR-7-5p in acute ischemic stroke (AIS). This review involved a targeted PubMed search to assess their influence on crucial pathophysiological pathways in AIS, and their potential applications in diagnosis, treatment, and prognosis. The review also included an assessment of additional miRNAs linked to stroke. Results Within the first 6 hours of symptom onset, three specific miRNAs (miR-7-5p, miR-140-5p, and miR-210-3p) exhibited significant differential expression compared to other time points and healthy controls. These miRNAs have previously been associated with neuroprotection, cellular stress responses, and tissue damage, suggesting their potential as early markers of acute ischemic stroke. Conclusion This study highlights the potential of circulating miRNAs as blood-based biomarkers for hyperacute acLVO ischemic stroke. However, further validation in a larger, risk-matched cohort is required. Additionally, investigations are needed to assess the prognostic relevance of these miRNAs by linking their expression profiles with radiological and functional outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | - Daniel Woo
- University of Cincinnati College of Medicine
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Pandit K, Rawal A, Maskey HMS, Nepal G. Neurological and neuro-ophthalmological manifestations of snake bite: a systematic review. Ann Med Surg (Lond) 2024; 86:392-400. [PMID: 38222724 PMCID: PMC10783398 DOI: 10.1097/ms9.0000000000001523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/09/2023] [Indexed: 01/16/2024] Open
Abstract
Objective Snakebites, a major health concern in developing countries, affect rural farming communities. Venom, primarily neurotoxin, injected during a snake bite disrupts the nervous system, causing symptoms like muscle weakness, paralysis, altered sensation, and coordination issues. This review focuses on evaluating neurological and neuro-ophthalmological manifestations associated with snakebites. Methods A database search was conducted in EMBASE and PubMed for studies published from 2000 to 2023. The investigation centered on examining neurological and neuro-ophthalmological symptoms and signs, treatment approaches, treatment outcomes, and long-term complications of snake bites. Results Neurological and neuro-ophthalmological symptoms were common in both neurotoxic and hemotoxic snake bites, especially in neurotoxic cases. Ptosis was a prevalent manifestation across various snake bites, along with respiratory paralysis, limb weakness, dysphasia, and visual disturbances in some instances. However, most patients improved without residual neurological symptoms after treatment. Conclusions Understanding patterns of neurological manifestations contributes valuable insights for the comprehensive management of snakebite.
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Affiliation(s)
- Kamal Pandit
- Department of Ophthalmology, Maharjgunj Medical Campus, Tribhuvan University, Institute of Medicine, Maharajgunj, Kathmandu
| | - Aastha Rawal
- Department of Pharmacy, Manmohan Memorial Medical College and Teaching Hospital, Kathmandu, Nepal
| | - Himang Man Singh Maskey
- Department of Ophthalmology, Maharjgunj Medical Campus, Tribhuvan University, Institute of Medicine, Maharajgunj, Kathmandu
| | - Gaurav Nepal
- Department of Internal Medicine, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
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Bartlett ES, Lim A, Kivlehan S, Losonczy LI, Murthy S, Lowsby R, Papali A, Raees M, Seth B, Cobb N, Brotherton J, Dippenaar E, Nepal G, Shrestha GS, Kuo SCE, Skrabal JR, Davis M, Lay C, Yi S, Jaung M, Chaffay B, Sefa N, Yang ML, Stephens PA, Rashed A, Benzoni N, Velasco B, Adhikari NK, Reynolds T. Critical care delivery across health care systems in low-income and low-middle-income country settings: A systematic review. J Glob Health 2023; 13:04141. [PMID: 38033248 PMCID: PMC10691174 DOI: 10.7189/jogh.13.04141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023] Open
Abstract
Background Prior research has demonstrated that low- and low-middle-income countries (LLMICs) bear a higher burden of critical illness and have a higher rate of mortality from critical illness than high-income countries (HICs). There is a pressing need for improved critical care delivery in LLMICs to reduce this inequity. This systematic review aimed to characterise the range of critical care interventions and services delivered within LLMIC health care systems as reported in the literature. Methods A search strategy using terms related to critical care in LLMICs was implemented in multiple databases. We included English language articles with human subjects describing at least one critical care intervention or service in an LLMIC setting published between 1 January 2008 and 1 January 2020. Results A total of 1620 studies met the inclusion criteria. Among the included studies, 45% of studies reported on pediatric patients, 43% on adults, 23% on infants, 8.9% on geriatric patients and 4.2% on maternal patients. Most of the care described (94%) was delivered in-hospital, with the remainder (6.2%) taking place in out-of-hospital care settings. Overall, 49% of critical care described was delivered outside of a designated intensive care unit. Specialist physicians delivered critical care in 60% of the included studies. Additional critical care was delivered by general physicians (40%), as well as specialist physician trainees (22%), pharmacists (16%), advanced nursing or midlevel practitioners (8.9%), ambulance providers (3.3%) and respiratory therapists (3.1%). Conclusions This review represents a comprehensive synthesis of critical care delivery in LLMIC settings. Approximately 50% of critical care interventions and services were delivered outside of a designated intensive care unit. Specialist physicians were the most common health care professionals involved in care delivery in the included studies, however generalist physicians were commonly reported to provide critical care interventions and services. This study additionally characterised the quality of the published evidence guiding critical care practice in LLMICs, demonstrating a paucity of interventional and cost-effectiveness studies. Future research is needed to understand better how to optimise critical care interventions, services, care delivery and costs in these settings. Registration PROSPERO CRD42019146802.
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Affiliation(s)
- Emily S Bartlett
- Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Andrew Lim
- Section of Critical Care Medicine, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Sean Kivlehan
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Humanitarian Initiative, Cambridge, Massachuesetts, USA
| | - Lia I Losonczy
- Department of Emergency Medicine, Department of Anaesthesia and Critical Care Medicine, George Washington University Medical Center, Washington, District of Columbia, USA
| | - Srinivas Murthy
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Richard Lowsby
- Department of Critical Care Medicine, Department of Emergency Medicine, Mid Cheshire Hospitals National health Service Foundation Trust, Cheshire, UK
| | - Alfred Papali
- Pulmonary and Critical Care Medicine, Atrium Health, Pineville, North Carolina, USA
| | - Madiha Raees
- Division of Critical Care Medicine, Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Bhavna Seth
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Natalie Cobb
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Jason Brotherton
- Department of Internal Medicine and Paediatrics, Africa Inland Church Kijabe Hospital, Kijabe Kenya
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Gaurav Nepal
- Ministry of Health and Population, Kathmandu, Nepal
| | - Gentle S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Shih-Chiang E Kuo
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - J Ryan Skrabal
- Department of Emergency Medicine, George Washington University, Washington, District of Columbia, USA
| | - Margaret Davis
- Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
| | - Cappi Lay
- Department of Neurosurgery, Department of Emergency Medicine, The Mount Sinai Hospital, New York, New York, USA
| | - Sojung Yi
- Stanford University, Stanford, California, USA
| | - Michael Jaung
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Brandon Chaffay
- Department of Emergency Medicine, George Washington University, Washington, District of Columbia, USA
| | - Nana Sefa
- Department of Emergency Medicine, Department of Critical Care, Medstar Washington Hospital Center, Washington, District of Columbia, USA
| | - Marc Lc Yang
- Accident and Emergency Medicine, The Chinese University of Hong Kong Faculty of Medicine, Hong Kong
| | - P Andrew Stephens
- Department of Emergency Medicine, Intensive Care & Resuscitation, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Amir Rashed
- Albert Einstein College of Medicine, New York, New York, USA
| | - Nicole Benzoni
- Critical Care Medicine, Virginia Mason Franciscan Health, Silverdale, Washington, USA
| | - Bernadett Velasco
- Department of Emergency Medicine, East Avenue Medical Center, Quezon City, National Capital Region, Philippines
| | - Neill Kj Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| | - Teri Reynolds
- Department of Integrated Health Services, World Health Organization, Geneva, Switzerland
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Gajurel BP, Nepal G, Jaiswal V, Ang SP, Nain P, Shama N, Ruchika F, Bohara S, Kharel S, Yadav JK, Medina JRT, Shrestha AB. Utilization rates of intravenous thrombolysis for acute ischemic stroke in Asian countries:: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e35560. [PMID: 37861564 PMCID: PMC10589571 DOI: 10.1097/md.0000000000035560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/18/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Despite intravenous thrombolysis (IVT) being used for the treatment of acute ischemic stroke (AIS) for over two decades, its accessibility remains limited in various regions of the world. The Asian region, which experiences the highest age-standardized incidence of AIS, currently lacks comprehensive data on the utilization of IVT. AIMS This study aimed to provide precise estimates of IVT usage for AIS in Asian countries. METHODS A literature search was conducted on PubMed and Google using appropriate search terms. English language, peer reviewed articles published after 2010 were included in the analysis. The pooled proportion was calculated utilizing the DerSimonian and Laird random-effects model. Additionally, a subgroup analysis was conducted, taking into account factors such as the study's country, the economic status of the country, specific Asian regions, publication year (before 2015 and from 2015 onwards), study location, study setting, hospital stroke protocol, and national stroke guidelines. RESULTS 67 observational studies with 778,046 patients with AIS were included in the meta-analysis. The overall utilization rate of IVT was found to be 9.1%. High-income countries had a higher rate (11.3%) compared to lower-middle-income (8.1%) and upper-middle-income countries (9%). Central and North Asia had the highest rate (17.5%) and Southeast Asia had the lowest rate (6.8%). Studies conducted after 2015 had a higher thrombolysis rate (11.3%) compared to those before 2015 (1.5%). Presence of hospital stroke protocols (10.7%) and national stroke guidelines (10.1%) were associated with higher thrombolysis rates. CONCLUSION The overall utilization rate of IVT for AIS in Asia stood at 9.1%, showcasing noteworthy disparities across countries, regions, and income brackets. To improve thrombolysis rates in the region, addressing prehospital delays, increasing public awareness, and implementing stroke protocols and national guidelines are key strategies.
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Affiliation(s)
- Bikram Prasad Gajurel
- Department of Neurology, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - Gaurav Nepal
- Department of General Medicine, Rani Primary Healthcare Centre, Biratnagar, Nepal
| | | | - Song Peng Ang
- Division of Internal Medicine, Rutgers Health/Community Medical Center, NJ
| | - Priyanshu Nain
- Department of Medicine, Maulana Azad Medical College, New Delhi, India
| | - Nishat Shama
- Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders, Dhaka, Bangladesh
| | - F.N.U. Ruchika
- Department of Surgery, JJM Medical College, Davangere, India
| | - Sujan Bohara
- Department of Internal Medicine, Nepalese Army Institute of Health Science, Kathmandu, Nepal
| | - Sanjeev Kharel
- Department of Internal Medicine, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | | | - Jillian Reeze T. Medina
- Manila Central University - Filemon D. Tanchoco Medical Foundation College of Medicine, Philippines
| | - Abhigan Babu Shrestha
- Department of Internal Medicine, M Abdur Rahim Medical College, Dinajpur, Bangladesh
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Shrestha GS, Nepal G, Prabhakar H, Prust ML. Cost-effectiveness of neurocritical care in settings with limited resources. Lancet Glob Health 2023; 11:e1343. [PMID: 37591582 DOI: 10.1016/s2214-109x(23)00326-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/07/2023] [Indexed: 08/19/2023]
Affiliation(s)
- Gentle Sunder Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Kathmandu 44600, Nepal.
| | - Gaurav Nepal
- Department of General Medicine, Rani Primary Healthcare Centre, Biratnagar, Nepal
| | - Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute Of Medical Sciences, New Delhi, India
| | - Morgan L Prust
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, Yale University, New Haven, CT, USA
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Adhikari A, Yadav SK, Kafle Y, Yadav K, Nepal G, Ojha R. Post-COVID-19 acute disseminated encephalomyelitis in a 51-year-old female from Nepal: A case report with literature review. SAGE Open Med Case Rep 2023; 11:2050313X231183579. [PMID: 37434901 PMCID: PMC10333554 DOI: 10.1177/2050313x231183579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 06/05/2023] [Indexed: 07/13/2023] Open
Abstract
There have been a growing number of acute disseminated encephalomyelitis cases following coronavirus disease-19 (COVID-19) infection. Given the rare occurrence, studies eliciting the clinical features, treatment response, and outcomes are still limited. In patients recovering from COVID-19, multifocal neurologic symptoms in the presence or absence of encephalopathy must be closely evaluated by neurologists and physicians. Early radiographic evaluation using magnetic resonance imaging and timely administration of glucocorticoid-based treatment reduces mortality and leads to satisfactory outcomes.
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Affiliation(s)
- Aayush Adhikari
- Maharajgunj Medical Campus, Institute
of Medicine, Kathmandu, Nepal
| | | | | | - Kundan Yadav
- Maharajgunj Medical Campus, Institute
of Medicine, Kathmandu, Nepal
| | - Gaurav Nepal
- Maharajgunj Medical Campus, Institute
of Medicine, Kathmandu, Nepal
| | - Rajeeb Ojha
- Department of Neurology, Tribhuvan
University Teaching Hospital, Kathmandu, Nepal
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Sharma N, Tiwari SB, Gaire P, Manandhar U, Bohara S, Nepal G. An institutional experience of hydatidosis and cysticercosis in Nepal: a retrospective chart review. Ann Med Surg (Lond) 2023; 85:2598-2602. [PMID: 37363564 PMCID: PMC10289776 DOI: 10.1097/ms9.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/03/2023] [Indexed: 06/28/2023] Open
Abstract
This study aimed to investigate the demographic characteristics, anatomical distribution, and histopathological features of hydatidosis and cysticercosis in a Nepalese population presenting to a tertiary care hospital. The study also aimed to provide a better understanding of the clinical and pathological aspects of these diseases in the local context. Methods This retrospective study analyzed all cases of hydatidosis and cysticercosis reported in the Department of Pathology at Tribhuvan University Teaching Hospital between January 2013 and December 2019. Demographic, clinical, radiological, and histopathological data were collected and analyzed from hospital charts. Results During the 7-year study period, the authors identified 112 cases of hydatid cysts and 26 cases of cysticercosis. The mean age of patients with hydatidosis was 33.86 years (range: 5-74 years), while the mean age of patients with cysticercosis was 25.39 years (range: 4-63 years). Females were more commonly affected with hydatidosis (68, 61.7%) than males (44, 39.3%), resulting in a male-to-female ratio of 0.6:1. In contrast, there was no significant sex difference in cysticercosis cases, with 14 (53.85%) males and 12 (46.15%) females affected. The most commonly affected site for hydatid cysts was the lung (47 cases, 42%), followed by the liver (41 cases, 36.6%). The study identified three cases of neurocysticercosis. The average diameter of hydatid cysts and cysticercosis was 8.7 cm and 1.7 cm, respectively. Conclusion In conclusion, our study provides important insights into the clinical and pathological features of hydatidosis and cysticercosis in a Nepalese population. These zoonotic diseases pose a significant health burden, particularly among the poor and marginalized populations. Our findings highlight the need to integrate prevention and control measures into the healthcare system to decrease the overall burden of these diseases.
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Affiliation(s)
| | | | - Prabin Gaire
- Department of Pathology, Bheri Hospital, Nepalgunj
| | | | - Sujan Bohara
- Department of General and Gastrointestinal Surgery, Nepal Mediciti Hospital, Lalitpur
| | - Gaurav Nepal
- Department of Internal Medicine, Maharajgunj Medical Campus, Tribhuwan University
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Paudel K, Prasad T, Gyawali P, Nepal G, Jaiswal V. Schizencephaly diagnosed after an episode of seizure during labor: A case report. Clin Case Rep 2023; 11:e7328. [PMID: 37151943 PMCID: PMC10160810 DOI: 10.1002/ccr3.7328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 04/24/2023] [Indexed: 05/09/2023] Open
Abstract
Schizencephaly, an extremely rare anomaly of the cortex, is characterized by abnormal clefts in the cerebral cortex. Very often, this condition is diagnosed early in the childhood period but few instances exist in literature where schizencephaly-associated seizures and hemiparesis have presented later in life too. Here, we report a rare case scenario of a lady in her late 30s who initially presented to us with obstetric concerns wherein schizencephaly remained an incidental finding despite the significantly large cortical cleft along with lobar holoprosencephaly and lissencephaly.
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Affiliation(s)
- Kusum Paudel
- Dhuikhel HospitalKathmandu University School of Medical SciencesPanautiNepal
| | - Tanisha Prasad
- Royal College of Surgeons in Ireland, University of Medicine and Health Sciences
| | - Prashant Gyawali
- Institute of MedicineTribhuwan University Teaching HospitalKathmanduNepal
| | - Gaurav Nepal
- Institute of MedicineTribhuwan University Teaching HospitalKathmanduNepal
| | - Vikash Jaiswal
- Department of ResearchLarkin Community HospitalSouth MiamiFloridaUSA
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Kharel S, Nepal G, Joshi PR, Yadav JK, Shrestha TM. Safety and efficacy of low-cost alternative urokinase in acute ischemic stroke: A systematic review and meta-analysis. J Clin Neurosci 2022; 106:103-109. [PMID: 36274296 DOI: 10.1016/j.jocn.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/03/2022] [Accepted: 09/20/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Use of intravenous thrombolysis (IVT) for treatment of acute ischemic stroke (AIS) varies greatly between countries, ranging from 10% to 15% in high-income countries to less than 2% in low- and middle income countries (LMICs). This is because alteplase is expensive and has been cited as one of the most common barriers to IVT in LMICs. Urokinase (UK) is a thrombolytic agent which is almost 50 times cheaper with easier production and purification than alteplase. UK may become a cost-effective option for IVT in LMICs if it is found to be safe and effective. We conducted this study to assess the existing evidence on the safety and efficacy of UK vs alteplase for IVT in AIS. METHODS The study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and meta-Analyses) guideline. Systematic literature search was done in PubMed, EMBASE, and Google Scholar for English literature published from 2010 to 2021. RESULTS A total of 4061 participants in the alteplase and 2062 participants in the UK group were included in the final statistical analysis. After IVT, a good functional outcome at last follow-up was found among 80.57 % of patients in the alteplase group compared to 73.79 % of patients in the UK group (OR: 1.11; 95 % CI: 0.95- 1.31; I2 = 0 %; P = 0.18). Symptomatic Intracerebral Hemorrhage (sICH) was found among 1.77 % of patients in the alteplase group compared to 2.83 % of patients in the UK group (OR: 0.84; 95 % CI: 0.56- 1.26; I2 = 0 %; P = 0.41). Similarly, mortality was found among 5.03 % of patients in the alteplase group compared to 5.42 % of patients in the UK group (OR: 0.87; 95 % CI: 0.66-1.14; I2 = 0 %; P = 0.30). CONCLUSION Our meta-analysis found that intravenous UK is not inferior to alteplase in terms of safety and efficacy and can be a viable alternative for IVT in AIS patients in LMICs.
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Affiliation(s)
- Sanjeev Kharel
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal.
| | - Gaurav Nepal
- Rani Primary Health Care Centre, Biratnagar, Nepal.
| | - Padam Raj Joshi
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - Jayant Kumar Yadav
- Department of Neurology, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal.
| | - Tirtha Man Shrestha
- Department of General Practice, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
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Zhang Z, Yang H, Tu Z, Nepal G, Ojha R, Xi Y, Qiao J, Hu M, Li C, Lin F, Zhou L, Jin P, Hou S. Multicentre registration of wake-up stroke in China (MCRWUSC): a protocol for a prospective, multicentre, registry-based cohort study. BMJ Open 2022; 12:e060818. [PMID: 36357004 PMCID: PMC9660665 DOI: 10.1136/bmjopen-2022-060818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Wake-up stroke (WUS) is a type of acute ischaemic stroke (AIS) that occurs during sleep with unknown time of symptom onset. The best treatment is usually not suitable for WUS, as thrombolysis is usually provided to patients who had a symptomatic AIS within a definite 4.5 hours, and WUS remains a therapeutic quandary. Efforts to explore the onset time characteristics of patients who had a WUS and the risk factors affecting poor prognosis support a role for providing new insights by performing multicentre cohort study. METHODS AND ANALYSIS This multicentre, nationwide prospective registry will include 21 comprehensive stroke centres, with a goal of recruiting 550 patients who had a WUS in China. In this study, clinical data including patient's clinical characteristics, stroke onset time, imaging findings, therapeutic interventions and prognosis (the National Institutes of Health Stroke Scale Score and the modified Rankin Scale Score at different time points) will be used to develop prediction models for stroke onset time and prognostic evaluation using the fast-processing of ischemic stroke software. The purpose of this study is to identify risk factors influencing prognosis, to investigate the relationship between the time when the symptoms are found and the actual onset time and to establish an artificial intelligence-based model to predict the prognosis of patients who had a WUS. ETHICS AND DISSEMINATION This study is approved by the ethics committee of Shanghai Pudong Hospital (Shanghai, China) and rest of all participating centres. The findings will be disseminated through peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER ChiCTR2100049133.
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Affiliation(s)
- Zengyu Zhang
- Department of Neurology, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Hualan Yang
- Department of Neurology, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Zhilan Tu
- Department of Neurology, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Gaurav Nepal
- Department of Internal Medicine, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Rajeev Ojha
- Department of Neurology, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Yan Xi
- Department of Radiology, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Jianlan Qiao
- Department of Radiology, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Mengting Hu
- Department of Neurology, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Chao Li
- School of Pharmacy, Hubei University of Science and Technology, Hubei, China
| | - Fuchun Lin
- Department of Neurology, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Lili Zhou
- Department of Neurology, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Pengpeng Jin
- Department of Chronic Disease Management, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Shuangxing Hou
- Department of Neurology, Shanghai Pudong Hospital, Fudan University, Shanghai, China
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Joshi U, Subedi R, Nepal G, Gyawali S, Agrawal V, Poudyal BS, Bhatt VR, D'Angelo CR. EFFICACY OF AUTOLOGOUS STEM CELL TRANSPLANTATION IN ADULT BURKITT/BURKITT-LIKE LYMPHOMA: A SYSTEMATIC REVIEW. Exp Oncol 2022; 44:190-197. [PMID: 36325697 DOI: 10.32471/exp-oncology.2312-8852.vol-44-no-3.18599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Burkitt and Burkitt like lymphoma (BL/BLL) are highly proliferative germinal or post-germinal B cell tumors. Few studies have evaluated the impact of autologous stem cell transplantation (ASCT) on disease outcomes. AIM We performed a systematic review to analyze the efficacy of ASCT as frontline consolidation and for treatment of relapsed/refractory cases in adult BL/BLL. MATERIALS AND METHODS Eligible studies with clear outcome measures on the efficacy of ASCT in adult patients with BL/BLL were identified through systematic search. The overall survival (OS), progression-free survival (PFS), complete response (CR), partial response (PR), and progression/relapse were used to assess the efficacy. RESULTS For patients who underwent ASCT in first CR, 5-year PFS and OS ranged between 70-78% and 70-83% respectively. For relapsed/refractory disease, 5-year PFS and OS were 27% and 31%, respectively. Patients undergoing ASCT for chemoresistant disease fared poorly with 3-year OS of 7% vs 37% for chemosensitive disease (p ≤ 0.00001). The overall response rate to ASCT for patients transplanted in first CR ranged between 71% and 93% and was 37% for patients who were transplanted in disease status other than first CR. Disease progression/relapse was observed in 16-29% of the patients transplanted in first CR, and 55% to 60% in relapsed disease. CONCLUSION We found insufficient evidence to support ASCT over chemotherapy alone in the first remission for adult BL/BLL. Evidence supports guidelines recommending ASCT for chemosensitive disease but suggests there is no benefit to ASCT for chemoresistant disease.
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Affiliation(s)
- U Joshi
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY 14621, USA
| | - R Subedi
- Department of Internal Medicine, Unity Hospital - Rochester Regional Health, Rochester, NY 14626, USA
| | - G Nepal
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu 44600, Nepal
| | - S Gyawali
- Department of Internal Medicine, Sukraraj Tropical and Infectious Disease Hospital, Kathmandu 44600, Nepal
| | - V Agrawal
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu 44600, Nepal
| | - B S Poudyal
- Clinical Hematology and Bone Marrow Transplant Unit, Civil Service Hospital, Kathmandu 44600, Nepal
| | - V R Bhatt
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
- Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Ch R D'Angelo
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
- Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE 68198, USA
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14
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Nepal G, Kharel S, Bhagat R, Coghlan MA, Yadav JK, Goeschl S, Lamichhane R, Phuyal S, Ojha R, Shrestha GS. Safety and efficacy of endovascular thrombectomy in patients with severe cerebral venous thrombosis: A meta-analysis. J Cent Nerv Syst Dis 2022; 14:11795735221131736. [PMID: 36204279 PMCID: PMC9530583 DOI: 10.1177/11795735221131736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 09/08/2022] [Indexed: 11/06/2022] Open
Abstract
Background Cerebral venous thrombosis (CVT) is a rare thrombotic condition which is traditionally
treated with anti-coagulation therapy. Subsets of patients with severe CVT have been
treated with endovascular thrombectomy (EVT). Despite the high estimated mortality
associated with severe CVT, there has been only one randomized control trial done
regarding safety and efficacy of EVT in severe CVT compared to standard medical
management. Evidence in this area is lacking. Objective The aim of this systematic review is to analyze all existing literature and generate
robust information regarding the role of EVT in the management of patients with severe
CVT. Methods This systematic review and meta-analysis followed PRISMA guideline. PubMed, Embase,
Google Scholar, and CNKI were searched for eligible studies from 2007 to 2021. Safety
and efficacy of EVT were evaluated by meta-analyzing recanalization status, the good
functional outcome at follow-up, recurrent CVT, new hematoma. A pooled proportion with a
95% confidence interval was derived from a meta-analysis of various outcomes (CI). Results A total of 33 studies comprising 610 patients treated with EVT were included for
analysis which comprised one randomized control trial, one prospective study and 31
retrospective studies. Based on pooled data, 85% of patients had good functional
outcome, 62% had complete recanalization, 5% had all-cause mortality, and 3% had
catheter related complications. The efficacy outcomes in this analysis had a significant
heterogeneity and a subgroup analysis was also done to explain these findings. The
minimum time of follow up was 3 months and varied EVT techniques were used across the
studies. Conclusion This meta-analysis suggests EVT may be safe and efficacious in treating patients with
severe CVT. Registration Our protocol was registered with PROSPERO: International prospective register of
systematic reviews with the registration number CRD42021254760.
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Affiliation(s)
- Gaurav Nepal
- Department of Internal Medicine,
Maharajgunj Medical Campus, Tribhuvan University Institute of
Medicine, Maharajgunj, Nepal
| | - Sanjeev Kharel
- Department of Internal Medicine,
Maharajgunj Medical Campus, Tribhuvan University Institute of
Medicine, Maharajgunj, Nepal
| | - Riwaj Bhagat
- Department of Neurology, Boston University Medical Center, Boston, MA, USA
| | - Megan A Coghlan
- Department of Neurology, University of Louisville School of
Medicine, Louisville, KY, USA
| | - Jayant K Yadav
- Department of Internal Medicine,
Maharajgunj Medical Campus, Tribhuvan University Institute of
Medicine, Maharajgunj, Nepal
| | - Stella Goeschl
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Rajan Lamichhane
- Department of Internal Medicine,
Maharajgunj Medical Campus, Tribhuvan University Institute of
Medicine, Maharajgunj, Nepal
| | - Subash Phuyal
- Department of Neuroimaging and
Interventional Neuroradiology, Upendra Devkota Memorial National Institute of
Neurological and Allied Sciences, Bansbari, Nepal
| | - Rajeev Ojha
- Department of Neurology, Tribhuvan University Teaching
Hospital, Maharajgunj, Nepal
| | - Gentle S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching
Hospital, Maharajgunj, Nepal,Gentle S Shrestha, Department of Critical Care
Medicine, Tribhuvan University Teaching Hospital, Maharajgunj 44600, Kathmandu, Nepal.
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15
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Nepal G, Kharel S, Coghlan MA, Yadav JK, Parajuli P, Pandit K, Shing YK, Ojha R. Amyotrophic lateral sclerosis and retinal changes in optical coherence tomography: A systematic review and meta-analysis. Brain Behav 2022; 12:e2741. [PMID: 35996223 PMCID: PMC9480919 DOI: 10.1002/brb3.2741] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/20/2022] [Accepted: 07/26/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Increasing evidence suggests Amyotrophic Lateral Sclerosis (ALS) as a widespread pathological process comprising nonmotor features like fatigue, mild sensory symptoms, cognitive decline, and visual impairment. Measurements of retinal nerve fiber layer (RNFL) thickness using Optical Coherence Tomography (OCT) may correlate with the neurodegeneration associated with ALS. In addition to RNFL thickness, other OCT parameters have been explored in the context of diagnosing ALS and predicting disease severity. In this study, we explore the possibility that OCT parameters of patients with ALS may differ significantly from those of healthy controls and thus serve as biomarkers for the disease and its progression. MATERIALS AND METHODS Between 2010 and 2021, the PubMed and EMBASE databases were examined for English language literature. ALS severity was assessed using the revised ALS functional rating scale (ALSFRS-R). The pooled mean differences in RNFL thickness between ALS patients and controls were calculated using the Standard Mean Difference (Hedges's g) with a 95% confidence interval (CI) in STATA software version 16. RESULTS Eleven studies were reviewed for data collection. RNFL thickness was not statistically significantly different between ALS patients (n = 412) and controls (n = 376) (Hedges's g = -0.22; 95% CI: -0.51 to 0.07, I2 = 73.04%, p = .14). However, the thickness of inner nuclear layer was significantly different between ALS patients and controls (Hedges's g = -0.38; 95% CI: -0.61 to 0.14, I2 = 14.85%, p = .00). CONCLUSION Our meta-analysis found that RNFL thickness as a whole or by individual quadrants was not significantly different between ALS patients and controls while the inner nuclear layer (INL) was substantially thinner.
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Affiliation(s)
- Gaurav Nepal
- Department of Internal Medicine, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - Sanjeev Kharel
- Department of Internal Medicine, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - Megan Ariel Coghlan
- Department of Neurology, University of Louisville School of Medicine, Louisville, Kentucky, US
| | - Jayant Kumar Yadav
- Department of Internal Medicine, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - Pawan Parajuli
- Department of Internal Medicine, Koshi Hospital, Biratnagar, Nepal
| | - Kamal Pandit
- Department of Ophthalmology, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - Yow Ka Shing
- Department of Internal Medicine, National University Hospital, Singapore, Singapore
| | - Rajeev Ojha
- Department of Internal Medicine, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
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Nepal G, Kharel S, Kumar Yadav J, Kumar Yadav S, Bhagat R, Ka Shing Y, Coghlan M, Lal Bhattarai S, Sigdel K, Chandra Mahat B. Low-dose alteplase for the management of acute ischemic stroke in South Asians: A systematic review on cost, efficacy and safety. J Clin Neurosci 2022; 103:92-99. [PMID: 35853390 DOI: 10.1016/j.jocn.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/27/2022] [Accepted: 07/09/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION South Asia is responsible for more than 40% of the stroke burden and stroke mortality in the developing world. South Asia, which is home to one-fourth of the world's population, is the most densely populated and one of the poorest regions. The majority of patients in this region are unable to afford intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). If low-dose alteplase proves effective and safe in South Asians, it may be a more cost-effective treatment option. METHODS The study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and meta-Analyses) guideline. Researchers searched PubMed, EMBASE, and Google Scholar for English literature from 2005 to 2021. END, ENI, good functional outcome, SICH, and all-cause mortality were used to assess efficacy and safety. RESULTS In the low-dose alteplase treated patients, different studies reported 32 to 57% ENI 24 h after IVT, and 7% to 9.7% END. At 3 months follow-up, good functional outcome was achieved by 48%-76.92% of low-dose alteplase treated patients. SICH rates ranged from 0% to 16.6% across studies. Asymptomatic ICH occurred in 5-14% of patients. The mortality rate in all included studies varied from none to 25%. CONCLUSION Our systematic review demonstrates that the use of low-dose alteplase for AIS in the South Asians offer comparable efficacy and reduced risk of SICH at a significantly lower cost than standard alteplase dose. Future well-randomized clinical trials are necessary to validate the findings of our study.
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Affiliation(s)
- Gaurav Nepal
- Rani Primary Health Care Centre, Biratnagar, Nepal.
| | - Sanjeev Kharel
- Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal.
| | - Jayant Kumar Yadav
- Department of Neurology, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal.
| | - Sushil Kumar Yadav
- Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal.
| | - Riwaj Bhagat
- Department of Neurology, Boston University Medical Center, Boston, MA, USA
| | - Yow Ka Shing
- Department of Internal Medicine, National University Hospital, Singapore, Singapore.
| | - Megan Coghlan
- University of Louisville School of Medicine, Louisville, KY, USA
| | | | - Kaushal Sigdel
- Nobel Medical College and Teaching Hospital, Biratnagar, Nepal
| | - Bishow Chandra Mahat
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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17
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Karmacharya RM, Vaidya S, Bhatt S, Tamang A, Shrestha RB, Bhandari N, Paudel B, Shah M, Nepal G. Klippel-Trenaunay Syndrome: Case series from a university hospital of Nepal. Ann Med Surg (Lond) 2022; 78:103732. [PMID: 35600200 PMCID: PMC9114462 DOI: 10.1016/j.amsu.2022.103732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/28/2022] [Accepted: 05/03/2022] [Indexed: 01/19/2023] Open
Abstract
Introduction Klippel Trenaunay Syndrome (KTS) is a rare congenital malformation with capillary and venous malformations and soft tissue/bony overgrowth with or without lymphatic malformation. Cutaneous vascular stain, varicosities and tissue hypertrophy represent its main clinical features. Besides, the patient can develop thromboembolic pathologies, recurrent bouts of infection, stasis eczema, limb length discrepancy and intolerable pain typical of intraosseous involvement. Methods Here, we report a case series of seven patients aged 10–45 who presented to our centre with clinical features suggestive of KTS. Out of them, six patients had involvement of unilateral lower limb, while only one had involvement of bilateral lower limb. They all had typical cutaneous vascular stains and underlying venous malformation, while one patient had developed complications with multiple ulcer formation. Outcomes An interdisciplinary team of vascular surgeons, dermatologists, interventional radiologists, orthopaedics, and physiotherapists managed the cases. We performed an individualized treatment as per the patient's presentation, which included a combination of supportive, medical, interventional radiologic, and surgical interventions. The follow-up outcomes of all the patients revealed significant resolution of symptoms. Conclusion Patients with KTS can have diverse presentations. Therefore, clinicians should ensure an individualized treatment with the involvement of a multidisciplinary team for proper management and prevention of complications. Compilation of eight cases of lower limb Klippel-Trenaunay Syndrome (KTS) successfully managed by a multidisciplinary approach. Primary complaints include pain, geographic vascular stain and, prominent dilated veins. Demonstration of individualized management algorithm, which yields a good outcome.
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Affiliation(s)
- Robin Man Karmacharya
- Unit Chief, Cardio Thoracic and Vascular Surgery Unit, Department of Surgery, Kathmandu University School of Medical Sciences, Dhulikhel, 45210, Nepal
| | - Satish Vaidya
- Cardio Thoracic and Vascular Surgery Unit, Department of Surgery, Kathmandu University School of Medical Sciences, Dhulikhel, 45210, Nepal
| | - Swechha Bhatt
- Kathmandu University School of Medical Sciences, Dhulikhel Hospital, Dhulikhel, 45210, Nepal
- Corresponding author.
| | - Ashish Tamang
- Kathmandu University School of Medical Sciences, Dhulikhel Hospital, Dhulikhel, 45210, Nepal
| | - Rohit Bhasink Shrestha
- Kathmandu University School of Medical Sciences, Dhulikhel Hospital, Dhulikhel, 45210, Nepal
| | - Niroj Bhandari
- Kathmandu University School of Medical Sciences, Dhulikhel Hospital, Dhulikhel, 45210, Nepal
| | - Bijaya Paudel
- Kathmandu University School of Medical Sciences, Dhulikhel Hospital, Dhulikhel, 45210, Nepal
| | - Manish Shah
- Kathmandu University School of Medical Sciences, Dhulikhel Hospital, Dhulikhel, 45210, Nepal
| | - Gaurav Nepal
- Institute of Medicine (IOM), Kathmandu, 44600, Nepal
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18
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Anjum Z, Iyer C, Naz S, Jaiswal V, Nepal G, Laguio‐vila M, Anandaram S, Thapaliya S. Guillain‐Barré syndrome after mRNA‐1273 (Moderna) COVID‐19 vaccination: A case report. Clin Case Rep 2022; 10:e05733. [PMID: 35441015 PMCID: PMC9010569 DOI: 10.1002/ccr3.5733] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 02/13/2022] [Accepted: 03/07/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
| | - Charoo Iyer
- Rochester General Hospital Rochester New York USA
| | - Sidra Naz
- Harvard Medical School Boston Massachusetts USA
| | | | - Gaurav Nepal
- Tribhuvan University Institute of Medicine Kathmandu Nepal
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19
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Gajurel BP, Nepal G, Kharel S, Yadav JK, Yadav SK, Shing YK, Goeschl S, Thapaliya S. Safety and efficacy of intravenous thrombolysis in acute ischemic stroke patients with a history of intracranial hemorrhage: A systematic review and meta-analysis. Clin Neurol Neurosurg 2022; 215:107205. [DOI: 10.1016/j.clineuro.2022.107205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/06/2022] [Accepted: 03/07/2022] [Indexed: 11/03/2022]
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Rayamajhi P, Nepal G, Ojha R, Rajbhandari R, Gajurel BP, Karn R. Evaluating cognitive outcomes in adult patients with acute encephalitis syndrome: a prospective study from a tertiary care center in Nepal. Encephalitis 2022; 2:36-44. [PMID: 37469649 PMCID: PMC10295914 DOI: 10.47936/encephalitis.2021.00157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 10/22/2021] [Accepted: 11/08/2021] [Indexed: 07/21/2023] Open
Abstract
Purpose Although cognitive impairment is a known complication of acute encephalitis syndrome (AES), few studies have evaluated cognitive outcomes in patients with encephalitis. The primary objective of this study was to assess the cognitive profiles of patients diagnosed with AES, which is pivotal for improving rehabilitation strategies and prognostic measures. Methods This study was conducted at the Tribhuvan University Teaching Hospital. Adult patients with AES who met inclusion criteria were enrolled. The Montreal Cognitive Assessment (MoCA) tool was used to assess cognitive function at admission, discharge, and 3-month follow-up. Results Thirty-six patients were enrolled in our study. The mean age of the participants was 43 ± 18 years. Fourteen patients (38.9%) were female, and 22 (61.1%) were male. Tuberculous (TB) meningoencephalitis was present in 14 cases (38.9%), with herpes simplex virus (HSV) encephalitis in 14 (38.9%), bacterial meningoencephalitis in 4 (11.1%), autoimmune encephalitis in 2 (5.6%), and Japanese encephalitis in 2 (5.6%). Patients with bacterial meningoencephalitis had the highest MoCA scores at admission, whereas those with HSV encephalitis had the highest scores at discharge and follow-up. Compared with the scores at admission, the scores at discharge and follow-up increased significantly in patients with TB meningoencephalitis and HSV encephalitis. The MoCA score at discharge was established as a significant predictor of cognitive function at follow-up. Conclusion We found that active treatment can improve the outcomes of AES patients with cognitive impairment. Although infectious etiologies are most common in low-income countries such as Nepal, autoimmune etiologies should not be overlooked.
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Affiliation(s)
- Parash Rayamajhi
- Department of Neurology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Gaurav Nepal
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Rajeev Ojha
- Department of Neurology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Reema Rajbhandari
- Department of Neurology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | | | - Ragesh Karn
- Department of Neurology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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21
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Ireifej B, Dhamrah U, Song D, Bitar J, Jaiswal V, Nepal G, Pathak N, Freijat M. Cerebellar infarction as the initial presentation of IgG4‐related disease. Clin Case Rep 2022; 10:e05614. [PMID: 35340659 PMCID: PMC8931459 DOI: 10.1002/ccr3.5614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/21/2022] Open
Abstract
Although IgG4‐RD has CNS manifestations, cerebellar involvement has only been reported in three cases. Our patient presented with cerebellar symptoms, several cerebellar infarcts were evident on the brain MRI, and CT abdomen revealed retroperitoneal tumor. Endoscopic biopsy confirmed IgG4‐RD. Steroids are the first‐line therapy for IgG4‐RD, but our patient was lost to follow‐up before treatment.
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Affiliation(s)
- Branden Ireifej
- Department of Internal Medicine Icahn School of Medicine at Mount Sinai Elmhurst Hospital Center New York City New York USA
| | - Umaima Dhamrah
- Department of Internal Medicine Icahn School of Medicine at Mount Sinai Elmhurst Hospital Center New York City New York USA
| | - David Song
- Department of Internal Medicine Icahn School of Medicine at Mount Sinai Elmhurst Hospital Center New York City New York USA
| | - Joyce Bitar
- Metropolitan Hospital Center New York City New York USA
| | | | - Gaurav Nepal
- Department of Internal Medicine Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Nibesh Pathak
- Department of Internal Medicine Tribhuvan University Institute of Medicine Kathmandu Nepal
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22
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Song D, Geetha HS, Jain S, Reyes JV, Jaiswal V, Nepal G, Lieber J. Delayed presentation of cannabis induced pancreatitis. Clin Case Rep 2022; 10:e05595. [PMID: 35340657 PMCID: PMC8929280 DOI: 10.1002/ccr3.5595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 11/07/2022] Open
Abstract
A thorough history and identifying risk factors are pivotal in establishing the cause of pancreatitis and preventing recurrences to curb the incidence of chronic pancreatitis and/or pancreatic cancer.
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Affiliation(s)
- David Song
- Department of Internal Medicine Icahn School of Medicine at Mount Sinai Elmhurst Hospital Center New York New York USA
| | | | - Samkit Jain
- Department of Internal Medicine Icahn School of Medicine at Mount Sinai Elmhurst Hospital Center New York New York USA
| | - Jonathan Vincent Reyes
- Department of Internal Medicine Icahn School of Medicine at Mount Sinai Elmhurst Hospital Center New York New York USA
| | | | - Gaurav Nepal
- Rani Primary Health Care Centre Biratnagar Nepal
| | - Joseph Lieber
- Department of Internal Medicine Icahn School of Medicine at Mount Sinai Elmhurst Hospital Center New York New York USA
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23
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Nepal G, Kharel S, Coghlan MA, Rayamajhi P, Ojha R. Safety and efficacy of rituximab for relapse prevention in myelin oligodendrocyte glycoprotein immunoglobulin G (MOG-IgG)-associated disorders (MOGAD): A systematic review and meta-analysis. J Neuroimmunol 2022; 364:577812. [DOI: 10.1016/j.jneuroim.2022.577812] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/01/2022] [Accepted: 01/09/2022] [Indexed: 12/24/2022]
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24
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Yadav JK, Nepal G, Thapa A, Jaiswal S, Thapa S, Chandra A. Bilateral thalamic infarction following cerebral venous thrombosis in a patient with ulcerative colitis. Clin Case Rep 2022; 10:e05404. [PMID: 35223008 PMCID: PMC8847414 DOI: 10.1002/ccr3.5404] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/13/2022] [Accepted: 01/25/2022] [Indexed: 01/13/2023] Open
Abstract
Cerebral Venous Thrombosis is a rare extra‐intestinal manifestation of ulcerative colitis. Ulcerative colitis is a hypercoagulable state and, if poorly managed, can predispose to thrombosis, including thrombosis of the cerebral veins.
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Affiliation(s)
- Jayant Kumar Yadav
- Department of Neurology Annapurna Neurological Institute and Allied Sciences Kathmandu Nepal
| | - Gaurav Nepal
- Department of Internal Medicine Maharajgunj Medical CampusTribhuvan University Institute of Medicine Kathmandu Nepal
| | - Aakar Thapa
- Department of Internal Medicine Patan Academy of Health Sciences Lagankhel Nepal
| | - Sandip Jaiswal
- Department of Neurology Annapurna Neurological Institute and Allied Sciences Kathmandu Nepal
| | - Shreejana Thapa
- Department of Neurology Annapurna Neurological Institute and Allied Sciences Kathmandu Nepal
| | - Avinash Chandra
- Department of Neurology Annapurna Neurological Institute and Allied Sciences Kathmandu Nepal
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25
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Acharya S, Yadav SK, Nepal G, Bhandari S, Lal Bhattarai S, Pathak S, Kandel B, Gautam J, Bhandari R. Pseudohypoparathyroidism type 1 B mimicking Fahr’s disease in a 28‐year‐old female: A case report. Clin Case Rep 2022; 10:e05418. [PMID: 35145694 PMCID: PMC8818286 DOI: 10.1002/ccr3.5418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 01/03/2022] [Accepted: 01/25/2022] [Indexed: 11/21/2022] Open
Abstract
In virtue of precise clinical history, physical examinations, and biochemical/radiological investigations, pseudohypoparathyroidism can be effectively diagnosed, and its types can be differentiated even without exorbitant tests.
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Affiliation(s)
- Suman Acharya
- Department of Internal Medicine, Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Sushil Kumar Yadav
- Department of Internal Medicine, Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Gaurav Nepal
- Department of Internal Medicine, Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Siddhartha Bhandari
- Department of Internal Medicine, Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Shiva Lal Bhattarai
- Department of Internal Medicine, Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Santosh Pathak
- Department of Internal Medicine, Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Bipin Kandel
- Department of Internal Medicine, Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Jeevan Gautam
- Department of Internal Medicine, Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Roshan Bhandari
- Department of Internal Medicine, Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
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26
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Poudyal P, Nepal G, Yadav SK, Neupane Y, Dutta H, Pokhrel S, Gaire P. Keratosis obturans: A rare cause of facial nerve palsy. Clin Case Rep 2022; 10:e05410. [PMID: 35154726 PMCID: PMC8819644 DOI: 10.1002/ccr3.5410] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 01/13/2022] [Accepted: 01/25/2022] [Indexed: 11/06/2022] Open
Abstract
Keratosis obturans, caused by the deposition of desquamated keratin plug in the external auditory canal can present with facial palsy. Young patients presenting with facial palsy, earache, and gradual hearing loss should be suspected for Keratosis obturans.
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Affiliation(s)
- Prasanta Poudyal
- Department of Otorhinolaryngology‐Head and Neck SurgeryTribhuvan University Teaching HospitalKathmanduNepal
| | - Gaurav Nepal
- Department of Internal MedicineTribhuvan University Teaching HospitalKathmanduNepal
| | - Sushil Kumar Yadav
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineKathmanduNepal
| | - Yogesh Neupane
- Department of Otorhinolaryngology‐Head and Neck SurgeryTribhuvan University Teaching HospitalKathmanduNepal
| | - Heempali Dutta
- Department of Otorhinolaryngology‐Head and Neck SurgeryTribhuvan University Teaching HospitalKathmanduNepal
| | - Shishir Pokhrel
- Department of Otorhinolaryngology‐Head and Neck SurgeryTribhuvan University Teaching HospitalKathmanduNepal
| | - Prabin Gaire
- Department of PathologyMaharajgunj Medical CampusTribhuvan University Institute of MedicineKathmanduNepal
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27
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Jaiswal V, Nepal G, Dijamco P, Ishak A, Dagar M, Sarfraz Z, Shama N, Sarfraz A, Lnu K, Mitra S, Agarwala P, Naz S, Song D, Jaiswal A. Cerebral Venous Sinus Thrombosis Following COVID-19 Vaccination: A Systematic Review. J Prim Care Community Health 2022; 13:21501319221074450. [PMID: 35142234 PMCID: PMC8841914 DOI: 10.1177/21501319221074450] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Introduction: COVID-19 vaccines became available after being carefully monitored in clinical trials with safety and efficacy on the human body. However, a few recipients developed unusual side effects, including cerebral venous sinus thrombosis (CVST). We aim to systematically review the baseline features, clinical characteristics, treatment, and outcomes in patients developing CVST post-COVID-19 vaccination. Methods: This study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) 2020 guideline. Investigators independently searched PubMed, Embase, and Google Scholar for English language articles published from inception up until September 10, 2021, reporting the incidence of CVST post-COVID-19 vaccines. We analyzed CVST patients’ baseline data, type of vaccines, clinical findings, treatment, and outcomes. Our systematic review process yielded patient-level data. Result: The final analysis included 25 studies that identified 80 patients who developed CVST after the COVID-19 vaccination. Of the 80 CVST cases, 31 (39.24%) patients died. There was no significant relationship between mortality and age (P = .733), sex (P = .095), vaccine type (P = .798), platelet count (P = .93), and comorbidities such as hypertension (P = .734) and diabetes mellitus (P = .758). However, mortality was associated with the duration of onset of CVST symptoms after vaccination (P = .022). Patients with CVST post-COVID-19 vaccination were more likely to survive if treated with an anticoagulant (P = .039). Patients who developed intracranial hemorrhage (P = .012) or thrombosis in the cortical vein (P = .021) were more likely to die. Conclusion: COVID-19 vaccine-associated CVST is associated with high mortality rate. Timely diagnosis and management can be lifesaving for patients.
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Affiliation(s)
| | - Gaurav Nepal
- Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Patricia Dijamco
- St. Luke's Medical Center College of Medicine, Quezon City, Philippines
| | - Angela Ishak
- European University Cyprus School of Medicine, Nicosia, Cyprus
| | - Mehak Dagar
- Himalayan Institute of Medical Science, Dehradun, Uttarakhand, India
| | - Zouina Sarfraz
- Fatima Jinnah Medical University, Lahore, Punjab, Pakistan
| | - Nishat Shama
- Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders, Dhaka, Bangladesh
| | | | - Kriti Lnu
- UPMC Harrisburg, Harrisburg, PA, USA
| | - Saloni Mitra
- Bogomolets National Medical University, Kyiv, Ukraine
| | | | - Sidra Naz
- Harvard Medical School, Boston, MA, USA
| | - David Song
- Icahn School of Medicine at Mount Sinai, NY, USA
| | - Akash Jaiswal
- All India Institute of Medical Science, New Delhi, India
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28
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Nepal G, Kharel S, Bhagat R, Ka Shing Y, Ariel Coghlan M, Poudyal P, Ojha R, Sunder Shrestha G. Safety and efficacy of Direct Oral Anticoagulants in cerebral venous thrombosis: A meta-analysis. Acta Neurol Scand 2022; 145:10-23. [PMID: 34287841 DOI: 10.1111/ane.13506] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/25/2021] [Accepted: 07/11/2021] [Indexed: 12/14/2022]
Abstract
Cerebral venous thrombosis (CVT) is caused by partial or complete occlusion of the major cerebral venous sinuses or the smaller feeding cortical veins which predispose to the risk of venous infarction and hemorrhage. Current guidelines recommend treating CVT with either low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) followed by an oral vitamin K antagonist (VKA) for 3-12 months. Direct oral anticoagulants (DOACs) have already established benefit over warfarin as a long-term treatment of symptomatic venous thromboembolic disorder like deep vein thrombosis (DVT), and pulmonary embolism (PE) given its equal efficacy and better safety profile. The benefit of DOACs over warfarin as a long-term anticoagulation for CVT has likewise been extensively studied, yet it has not been approved as first-line therapy in the current practice. We therefore performed a systematic review and meta-analysis of relevant studies to generate robust evidence regarding the safety and efficacy of DOACs in CVT. This meta-analysis demonstrates that the use of DOACs in CVT has similar efficacy and safety compared to VKAs with better recanalization rate.
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Affiliation(s)
- Gaurav Nepal
- Department of Internal Medicine Maharajgunj Medical CampusTribhuvan University Institute of Medicine Maharajgunj, Kathmandu Nepal
| | - Sanjeev Kharel
- Department of Internal Medicine Maharajgunj Medical CampusTribhuvan University Institute of Medicine Maharajgunj, Kathmandu Nepal
| | - Riwaj Bhagat
- Department of Neurology University of Louisville School of Medicine Louisville KY USA
| | - Yow Ka Shing
- Department of Internal Medicine National University Hospital Singapore Singapore
| | - Megan Ariel Coghlan
- Department of Neurology University of Louisville School of Medicine Louisville KY USA
| | - Prasanta Poudyal
- Department of Otorhinolaryngology Tribhuvan University Teaching Hospital Maharajgunj Kathmandu Nepal
| | - Rajeev Ojha
- Department of Neurology Tribhuvan University Teaching Hospital Maharajgunj Kathmandu Nepal
| | - Gentle Sunder Shrestha
- Department of Anesthesiology Tribhuvan University Teaching Hospital Maharajgunj Kathmandu Nepal
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29
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Nepal G. Low-cost alternatives for the management of acute ischemic stroke in low and middle-income countries. Ann Med Surg (Lond) 2021; 72:102969. [PMID: 34992776 PMCID: PMC8712992 DOI: 10.1016/j.amsu.2021.102969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 10/16/2021] [Accepted: 10/16/2021] [Indexed: 11/20/2022] Open
Abstract
Acute ischemic stroke (AIS) patients arriving within a suitable time frame are treated with recanalization therapy i.e. intravenous thrombolysis (IVT) with alteplase and/or mechanical thrombectomy (MT). IVT with alteplase is indicated in AIS patients presenting within 4.5 hours of onset regardless of vascular territory involved. MT is indicated in AIS patients presenting within 24 hours of onset with large vessel occlusion in the anterior circulation. However, MT is ludicrously expensive and requires exorbitant setup, devices, and expertise which is not currently feasible in LMICs. Therefore, in LMICs the only feasible recanalization option left for AIS patients is IVT. The cost of IVT varies across the LMICs, however, most of them cost around 2000-5000 USD. Apart from IVT, patients with AIS often have other significant medical costs including those for neuroimaging, intensive care, and prolonged rehabilitative treatment. In LMICs, these costs can only be afforded by a handful of patients. The majority of the LMICs have health insurance in their infancy and family members of AIS patients opt-out IVT due to the economic burden. In general, the current treatment guidelines for AIS are not very useful in LMICs because of cost-related issues among several other factors. In this editorial, we discuss evidence for alternative treatment strategies that can help tackle the rising epidemic of AIS in poor countries by improvising on existing clinical guidelines and seeking alternative treatment regimens.
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Affiliation(s)
- Gaurav Nepal
- Department of Internal Medicine, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, 44600, Nepal
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30
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Yadav JK, Nepal G, Shing YK, Banerji RR, Gajurel BP. An opportunity to improve Acute Ischemic Stroke care in the South Asian region through telestroke services. Ann Med Surg (Lond) 2021; 72:103115. [PMID: 34888047 PMCID: PMC8636765 DOI: 10.1016/j.amsu.2021.103115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 11/21/2021] [Indexed: 11/13/2022] Open
Abstract
The South Asian region accounts for more than 40% of the stroke burden of the developing world and is the highest contributor to global stroke mortality. Despite proven treatment guidelines, the limited number of neurologists, the number of dedicated stroke centers and the fact that most of these facilities are urban-centric renders poor access to thrombolysis in this region, especially in the rural areas. Studies have shown that thrombolysis using telestroke services are comparable to face-to-face thrombolysis. Telestroke, conducted through low-cost media such as smartphones or laptops, may form a cost-effective solution to improve access to appropriate stroke care in a resource-limited setting such as that of the South Asian region.
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Affiliation(s)
- Jayant Kumar Yadav
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Gaurav Nepal
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Yow Ka Shing
- Department of Internal Medicine, National University Hospital, Singapore
| | - Rohit Raman Banerji
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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31
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Jaiswal V, Hanif M, Sarfraz Z, Nepal G, Naz S, Mukherjee D, Ruxmohan S. Hemimegalencephaly: A rare congenital malformation of cortical development. Clin Case Rep 2021; 9:e05238. [PMID: 34976397 PMCID: PMC8684578 DOI: 10.1002/ccr3.5238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/09/2021] [Accepted: 12/11/2021] [Indexed: 12/02/2022] Open
Abstract
Hemimegalencephaly is a rare congenital malformation of cortical development usually associated with developmental delay and refractory epilepsy that sooner or later require hemispherectomy.
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Affiliation(s)
| | | | | | | | - Sidra Naz
- Larkin Community HospitalSouth MiamiFloridaUSA
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32
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Nepal G, Shrestha GS, Shing YK, Yadav JK, Coghlan MA, Ojha R. Low‐cost alternatives for the management of Guillain‐Barré syndrome in low‐ and middle‐income countries. World Med & Health Policy 2021. [DOI: 10.1002/wmh3.474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Gaurav Nepal
- Department of Internal Medicine, Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Maharajgunj Kathmandu Nepal
| | - Gentle S. Shrestha
- Department of Anesthesiology Tribhuvan University Teaching Hospital Maharajgunj Kathmandu Nepal
| | - Yow K. Shing
- Department of Internal Medicine National University Hospital Singapore Singapore
| | - Jayant K. Yadav
- Department of Internal Medicine, Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Maharajgunj Kathmandu Nepal
| | - Megan A. Coghlan
- Department of Neurology University of Louisville School of Medicine Louisville Kentucky USA
| | - Rajeev Ojha
- Department of Neurology Tribhuvan University Teaching Hospital Maharajgunj Kathmandu Nepal
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33
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Basnet B, Yadav JK, Gajurel BP, Shing YK, Kandel B, Nepal G. Role of female community health volunteers in ischemic stroke prevention, identification, referral and rehabilitation in Nepal. Ann Med Surg (Lond) 2021; 72:102893. [PMID: 34992775 PMCID: PMC8712991 DOI: 10.1016/j.amsu.2021.102893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/26/2021] [Indexed: 01/01/2023] Open
Abstract
For the past three decades, female community health volunteers (FCHVs) have been at the forefront of Nepal's health map and have contributed significantly to its improving health indicators such as maternal mortality rate and infant mortality rate. Given the changing epidemiology of Nepal and the shift of burden from communicable to non-communicable diseases (NCDs), it is important to revitalize their role with the changing times. The prevalence of ischemic stroke in Nepal is on the rise. However, very few people make it to the hospital within the time frame for thrombolysis and the patient's knowledge about ischemic stroke seems to play a major part. FCHVs can play a significant role in improving ischemic stroke care by raising awareness about the condition, its risk factors, and informing the public about the need for timely treatment. They can help screen for common risk factors such as obesity, hypertension and diabetes as well as monitor for treatment in previously diagnosed individuals. Randomized controlled trials have shown to yield favorable results in NCDs with engagement of FCHVs. With proper training and support, they can play an important role in improving ischemic stroke care in low- and middle-income countries like Nepal.
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Affiliation(s)
- Babin Basnet
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Jayant Kumar Yadav
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | | | - Yow Ka Shing
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Bipin Kandel
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Gaurav Nepal
- Rani Primary Health Care Center, Biratnagar 56613, Morang, Nepal
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34
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Acharya S, Yadav SK, Singh PB, Bhandari S, Gautam J, Pathak S, Nepal G, Sah R, Ojha R. Cryptococcal meningitis in an immunocompetent individual: A case report. Clin Case Rep 2021; 9:e04894. [PMID: 34631078 PMCID: PMC8489394 DOI: 10.1002/ccr3.4894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/14/2021] [Accepted: 09/16/2021] [Indexed: 11/30/2022] Open
Abstract
Cryptococcal meningitis (CM) is mostly seen in immune-compromised patients and rarely occurs in immune-competent individuals. Immunocompetent individuals with CM present with indolent neurological disease and have better clinical outcomes after treatment. However, misdiagnosis is common and these patients may suffer from serious complications with high mortality.
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Affiliation(s)
- Suman Acharya
- Department of Internal Medicine Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Maharajgunj Kathmandu Nepal
| | - Sushil Kumar Yadav
- Department of Internal Medicine Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Maharajgunj Kathmandu Nepal
| | - Prabesh Bikram Singh
- Department of Internal Medicine Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Maharajgunj Kathmandu Nepal
| | - Siddhartha Bhandari
- Department of Internal Medicine Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Maharajgunj Kathmandu Nepal
| | - Jeevan Gautam
- Department of Internal Medicine Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Maharajgunj Kathmandu Nepal
| | - Santosh Pathak
- Department of Internal Medicine Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Maharajgunj Kathmandu Nepal
| | - Gaurav Nepal
- Department of Internal Medicine Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Maharajgunj Kathmandu Nepal
| | - Ranjit Sah
- Department of Microbiology Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Maharajgunj Kathmandu Nepal
| | - Rajeev Ojha
- Department of Neurology Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Maharajgunj Kathmandu Nepal
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35
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Nepal G, Shrestha GS, Shing YK, Muha A, Bhagat R. Systolic blood pressure variability following endovascular thrombectomy and clinical outcome in acute ischemic stroke: A meta-analysis. Acta Neurol Scand 2021; 144:343-354. [PMID: 34110006 DOI: 10.1111/ane.13480] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/26/2021] [Accepted: 05/14/2021] [Indexed: 12/11/2022]
Abstract
Blood pressure variability (BPV) has been linked with the outcome of acute ischemic stroke (AIS) after endovascular thrombectomy (EVT). However, the association of the stroke outcome with specific short-term BPV parameters is unclear. We did a systematic literature search for studies published from January 2010 to September 2020. Eligibility criteria included studies with (1) AIS patients treated with EVT with or without thrombolysis; and (2) analysis of the association between short-term systolic BPV parameter and clinical outcomes. Systolic BPV parameters included standard deviation (SD), coefficient of Variation (CoV), successive Variation (SV), and Variation independent of mean. A total of 11 studies were meta-analyzed, comprising 3520 patients who underwent EVT. Lower odds of achieving good functional outcome at 3 months; that is, modified Rankin Scale (mRS) score ≤2 was associated with SD (OR, 0.854; p = .02), CoV (OR, 0.572; p = .04), SV (OR 0.41; p = .00) of systolic blood pressure (SBP). Likewise, higher odds of one-point increase in mRS score was associated with SD (OR 1.42; p = .03), CoV (OR 1.464; p = .00) and SV (OR 2.605; p = .00) of SBP. However, high BPV was not associated with symptomatic intracranial hemorrhage and all-cause mortality at 90 days. The association of BPV and early neurological deterioration was inconclusive. Based on the available studies, short-term systolic BPV is indicative of the clinical outcome of patients following EVT in AIS. Further research should focus on personalized blood pressure management strategies, rather than a one-size-fits-all approach.
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Affiliation(s)
- Gaurav Nepal
- Department of Internal Medicine Tribhuvan University Institute of Medicine Kathmandu Nepal
| | | | - Yow Ka Shing
- Department of Internal Medicine National University Hospital Singapore City Singapore
| | - Allison Muha
- Department of Neurology University of Louisville School of Medicine Louisville KY USA
| | - Riwaj Bhagat
- Department of Neurology University of Louisville School of Medicine Louisville KY USA
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36
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Shrestha GS, Basnet B, Nepal G, Lamichhane R, Gaire P, Shrestha R, Thapalia S. EDTA-dependent pseudo thrombocytopenia mimicking dengue fever-associated persistent thrombocytopenia: A case report. Clin Case Rep 2021; 9:e04999. [PMID: 34721861 PMCID: PMC8538016 DOI: 10.1002/ccr3.4999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/08/2021] [Indexed: 11/08/2022] Open
Abstract
No hemorrhagic manifestations, presence of platelet clumps on the peripheral blood smear, normal manual count, and normal autoanalyzer count after collecting blood in citrate vial help confirm the diagnosis of EDTA-dependent thrombocytopenia.
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Affiliation(s)
| | - Babin Basnet
- Bhimphedi Primary Health Care CenterBhimphediNepal
| | | | - Rajan Lamichhane
- Department of Internal MedicineTribhuvan University Institute of MedicineMaharajgunjNepal
| | - Prabin Gaire
- Department of PathologyTribhuvan University Institute of MedicineMaharajgunjNepal
| | - Rayana Shrestha
- Department of Internal MedicineTribhuvan University Institute of MedicineMaharajgunjNepal
| | - Sabin Thapalia
- Department of Internal MedicineTribhuvan University Institute of MedicineMaharajgunjNepal
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37
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Nepal G, Coghlan MA, Yadav JK, Kharel S, Ka Shing Y, Ojha R, Xing HS, Bo Y, Zhi Lan T. Safety and efficacy of Magnesium Sulfate in the management of Tetanus: A systematic review. Trop Med Int Health 2021; 26:1200-1209. [PMID: 34403179 DOI: 10.1111/tmi.13667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Tetanus is a rare life-threatening condition often complicated by repetitive spasms, dysautonomia and neuromuscular respiratory failure contributing to high fatality rates in its severe form. Benzodiazepines used to treat muscle spasms pose a high risk of respiratory failure requiring mechanical ventilation, which is unaffordable and inaccessible for many. Magnesium sulfate, a cheap and widely available medication in all urban and rural health centres of LMICs for the treatment of eclampsia, can be used to control muscle spasms and dysautonomia. We thus conducted a systematic review of evidence to assess the safety and efficacy of magnesium sulfate in the treatment of tetanus. Any study published before April 15, 2021, discussing the efficacy and/or safety of MgSO4 infusion in the treatment of tetanus was systemically reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Our systematic review included data from 13 studies, three were randomised, double-blind and controlled trials. The remaining ten studies were observational; six prospective and four retrospective studies. Our review showed no mortality benefit associated with the use of magnesium sulfate. However, magnesium sulfate was found to be effective in reducing spasms along with diazepam, leading to better control of dysautonomia, reduced need for mechanical ventilation and shorter hospital stay by 3-7 days. The incidence of magnesium toxicity was very low in the studies included.
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Affiliation(s)
- Gaurav Nepal
- Department of Neurology, Shanghai Pudong Hospital, Shanghai, China.,Department of Internal Medicine, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - Megan Ariel Coghlan
- Department of Neurology, University of Louisville School of Medicine, Louisville, USA
| | - Jayant Kumar Yadav
- Department of Internal Medicine, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - Sanjeev Kharel
- Department of Internal Medicine, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - Yow Ka Shing
- Department of Internal Medicine, National University Hospital, Singapore, Singapore
| | - Rajeev Ojha
- Department of Neurology, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - Hou Shuang Xing
- Department of Neurology, Shanghai Pudong Hospital, Shanghai, China
| | - Yu Bo
- Department of General Surgery, Shanghai Pudong Hospital, Shanghai, China
| | - Tu Zhi Lan
- Department of Neurology, Shanghai Pudong Hospital, Shanghai, China
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Nepal G, Balayar R, Bhatta S, Acharya S, Gajurel BP, Karn R, Rajbhandari R, Paudel S, Gautam N, Shrestha A, Ojha R. Neurobrucellosis: A differential not to be missed in patients presenting with neuropsychiatric features. Clin Case Rep 2021; 9:e04190. [PMID: 34194775 PMCID: PMC8222759 DOI: 10.1002/ccr3.4190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/31/2021] [Accepted: 04/06/2021] [Indexed: 12/22/2022] Open
Abstract
When a patient presents with undulating fever and neuropsychiatric features, neurobrucellosis should be considered as a differential diagnosis. If diagnosed early, neurobrucellosis is a treatable disease with a favorable outcome.
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Affiliation(s)
- Gaurav Nepal
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineMaharajgunjNepal
| | - Ramesh Balayar
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineMaharajgunjNepal
| | - Suraj Bhatta
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineMaharajgunjNepal
| | - Sulav Acharya
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineMaharajgunjNepal
| | | | - Ragesh Karn
- Department of NeurologyTribhuvan University Teaching HospitalMaharajgunjNepal
| | - Reema Rajbhandari
- Department of NeurologyTribhuvan University Teaching HospitalMaharajgunjNepal
| | - Sunanda Paudel
- Department of NeurologyTribhuvan University Teaching HospitalMaharajgunjNepal
| | - Niraj Gautam
- Department of NeurologyTribhuvan University Teaching HospitalMaharajgunjNepal
| | - Ashish Shrestha
- Department of NeurologyTribhuvan University Teaching HospitalMaharajgunjNepal
| | - Rajeev Ojha
- Department of NeurologyTribhuvan University Teaching HospitalMaharajgunjNepal
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Nepal G, Shrestha GS, Rehrig JH, Gajurel BP, Ojha R, Agrawal A, Panthi S, Khatri B, Adhikari I. Neurological Manifestations of COVID-19 Associated Multi-system Inflammatory Syndrome in Children: A Systematic Review and Meta-analysis. J Nepal Health Res Counc 2021; 19:10-18. [PMID: 33934126 DOI: 10.33314/jnhrc.v19i1.3410] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/23/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Children comprise only 1-5% of COVID-19 cases. Recent studies have shown that COVID-19 associated multisystem inflammatory syndrome in children (MIS-C) can present with neurological signs and symptoms. In this systematic review and meta-analysis, we have reviewed neurological involvement in these patients. METHODS A comprehensive electronic literature search was done on PubMed, Google Scholar, Embase, Cochrane database, and SCOPUS for the published English language articles from December 1, 2019, to February 28, 2021. A meta-analysis of the proportion was expressed as a pooled proportion with a 95% confidence interval (CI). Representative forest plots showing individual studies and the combined effect size were generated to provide an overview of the results. RESULTS This systematic review and meta-analysis analyzed 15 published MIS-C studies with a total of 785 patients. Neurological manifestations in patients with MIS-C was found in 27.1%. We found that 27% developed headaches, 17.1% developed meningism/meningitis and 7.6 % developed encephalopathy. Other uncommon neurological manifestations of MIS-C includes anosmia, seizures, cerebellar ataxia, global proximal muscle weakness and bulbar palsy. In MIS-C patients with neurological feature, neuroimaging showed signal changes in the splenium of the corpus callosum. Electroencephalography showed slow wave pattern and nerve conduction studies and electromyography showed mild myopathic and neuropathic changes. CONCLUSIONS Our study revealed that neurological manifestations are not uncommon in patients with MIS-C. Further large prospective studies are needed to better explore the disease spectrum and to unravel the underlying pathophysiology.
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Affiliation(s)
- Gaurav Nepal
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Gentle Sunder Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Jessica Holly Rehrig
- Department of Neurology, North Shore University Hospital, 300 Community Drive, Manhasset, NY, USA
| | | | - Rajeev Ojha
- Department of Neurology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Aditi Agrawal
- Department of Neurology, Annapurna Neurological Institute and Allied Sciences, Kathmandu, Nepal
| | - Sandesh Panthi
- Department of Anatomy, Univesity of Otago, Dunedin, New Zealand
| | - Bharat Khatri
- Department of Internal Medicine, B. P. Koirala Institue of Health Sciences, Dharan, Nepal
| | - Ishan Adhikari
- Department of Neurology, University Medicine Associates/ University Health System/ University of Texas Health, San Antonio, Texas, USA
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Paudel S, Nepal G, Guragain S, Shah S, Paudel BS, Ojha R, Rajbhandari R, Karn R, Gajurel BP, Paudel S. Longitudinally Extensive Transverse Myelitis: A Retrospective Study Differentiating Neuromyelitis Optica Spectrum Disorder From Other Etiologies. Cureus 2021; 13:e13968. [PMID: 33884229 PMCID: PMC8054834 DOI: 10.7759/cureus.13968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Longitudinally extensive transverse myelitis (LETM) is characterized by contiguous immune-mediated inflammatory lesion of the spinal cord extending more than three vertebral segments. Neuromyelitis optica spectrum disorder (NMOSD) is the most common and important cause of LETM. This study aims to evaluate the demographic profile, clinical presentations, neuroimaging features, laboratory parameters, and etiologies of LETM and differentiates NMOSD from other etiologies of LETM. Methodology This retrospective cross-sectional study was conducted at the Department of Neurology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal. After receiving clearance from the ethical committee, a retrospective chart review was conducted and records of all the inpatient LETM cases admitted from March 2018 to June 2020 were obtained. From the patient records, the following information was extracted: the demographic profile, clinical presentations, neuroimaging features, cerebrospinal fluid analysis, serum anti-aquaporin-4 (AQP4) immunoglobulin G status, hemogram, infectious disease profile, inflammatory markers, and auto-immune panels. Descriptive analysis of data was performed with SPSS statistics 23.0 version (IBM Corp, Armonk, NY, USA). Results In our study, the mean age of LETM patients was 36.58 years, and 12 out of 19 (63.15%) patients were young, with an age less than 40 years. A total of 13 (68.40%) patients were male, with a male-to-female ratio of 2.16. Seven (36.80%) patients had a clinical diagnosis of NMOSD with anti-AQP4 antibody-positive status, four (21.10%) had unknown etiology, three (15.8%) had post-infectious transverse myelitis, and three (15.80%) had a diagnosis of idiopathic transverse myelitis. There was a single case (5.30%) of cervical spondylotic myelopathy and leukemic transverse myelitis each. The common presenting symptoms of LETM were bladder dysfunction, paraparesis, quadriparesis, and visual impairment. Visual involvement, either unilateral or bilateral, was common in NMOSD and LETM of unknown etiology category. Similarly, brain lesion was common in patients with NMOSD and LETM of unknown etiology category. Conclusion LETM is a heterogeneous disorder with diverse etiologies and clinical presentations. NMOSD is an important cause of LETM that predominantly affects females. Optic neuritis can be seen in LETM of various etiologies, but it is more common in anti-AQP4-positive NMOSD patients. Brain lesions in LETM are common in anti-AQP4-positive NMOSD.
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Affiliation(s)
- Sunanda Paudel
- Neurology, Tribhuvan University Teaching Hospital, Kathmandu, NPL
| | - Gaurav Nepal
- Internal Medicine, Tribhuvan University Institute of Medicine, Kathmandu, NPL
| | - Sandesh Guragain
- Neurology, Nepal Medical College Teaching Hospital, Kathmandu, NPL
| | - Sangam Shah
- Neurology, Maharajgunj Medical Campus, Kathmandu, NPL
| | | | - Rajeev Ojha
- Neurology, Tribhuvan University Teaching Hospital, Kathmandu, NPL
| | - Reema Rajbhandari
- Neurology, Tribhuvan University Institute of Medicine, Kathmandu, NPL
| | - Ragesh Karn
- Neurology, Tribhuvan University Institute of Medicine, Kathmandu, NPL
| | - Bikram P Gajurel
- Vascular Neurology, Tribhuvan University Teaching Hospital, Kathmandu, NPL
| | - Sunanda Paudel
- Neurology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, NPL
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Bastola A, Sah R, Nepal G, Gajurel BP, Rajbhandari SK, Chalise BS, Shrestha B, Nepal R, Maharjan K, Dhama K, Rodríguez‐Morales. AJ. Bell's palsy as a possible neurological complication of COVID-19: A case report. Clin Case Rep 2021; 9:747-750. [PMID: 33598238 PMCID: PMC7869308 DOI: 10.1002/ccr3.3631] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/27/2020] [Indexed: 12/19/2022] Open
Abstract
COVID-19 has been associated with several neurological complications. We presented a case of Bell's palsy as a possible neurological complication of COVID-19 infection. Further research should be conducted to clarify the association, correlation, or causality between COVID-19 and neuroimmunological diseases.
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Affiliation(s)
- Anup Bastola
- Sukraraj Tropical and Infectious Disease HospitalKathmanduNepal
| | - Ranjit Sah
- Tribhuvan University Institute of MedicineKathmanduNepal
| | - Gaurav Nepal
- Tribhuvan University Institute of MedicineKathmanduNepal
| | | | | | | | - Bikesh Shrestha
- Sukraraj Tropical and Infectious Disease HospitalKathmanduNepal
| | - Richa Nepal
- Sukraraj Tropical and Infectious Disease HospitalKathmanduNepal
| | - Kijan Maharjan
- Sukraraj Tropical and Infectious Disease HospitalKathmanduNepal
| | - Kuldeep Dhama
- Division of PathologyICAR‐Indian Veterinary Research InstituteBareillyIndia
| | - Alfonso J. Rodríguez‐Morales.
- Public Health and Infection Research and Incubator GroupFaculty of Health SciencesUniversidad Tecnológica de PereiraPereiraColombia
- Grupo de Investigación BiomedicinaFaculty of MedicineFundación Universitaria Autónoma de las AméricasPereiraColombia
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Shrestha TM, Bhatta S, Balayar R, Pokhrel S, Pant P, Nepal G. Diesel siphoner's lung: An unusual cause of hydrocarbon pneumonitis. Clin Case Rep 2021; 9:416-419. [PMID: 33505692 PMCID: PMC7813127 DOI: 10.1002/ccr3.3545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/23/2020] [Accepted: 10/25/2020] [Indexed: 11/09/2022] Open
Abstract
The practice of manual siphoning of diesel from fuel tanks is common among automobile mechanics in Nepal. When an automobile mechanic with a history of diesel siphonage presents with respiratory symptoms, the diesel siphoner's lung diagnosis should be considered. Clinical suspicion confirmed by radiological findings can help in early management and prevention of permanent damage.
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Affiliation(s)
- Tirtha Man Shrestha
- Department of General Practice and Emergency MedicineTribhuvan University Teaching HospitalMaharajgunjNepal
| | - Suraj Bhatta
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineMaharajgunjNepal
| | - Ramesh Balayar
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineMaharajgunjNepal
| | - Sagar Pokhrel
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineMaharajgunjNepal
| | - Pankaj Pant
- Department of Pulmonology and Critical careTribhuvan University Teaching HospitalMaharajgunjNepal
| | - Gaurav Nepal
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineMaharajgunjNepal
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Shrestha GS, Khanal S, Sharma S, Nepal G. COVID-19: Current Understanding of Pathophysiology. J Nepal Health Res Counc 2020; 18:351-359. [PMID: 33210623 DOI: 10.33314/jnhrc.v18i3.3028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/13/2020] [Indexed: 06/11/2023]
Abstract
Coronavirus disease 2019 has emerged as a global pandemic, affecting millions of people across the globe. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) enters the human cell after binding to the Angiotensin-Converting Enzyme 2 receptors, that are present in various organs. The involvement of the respiratory system is common and may progress to acute respiratory distress syndrome. Besides the involvement of respiratory system other systems like cardiovascular, renal, gastrointestinal and central nervous are not uncommon. In-depth understanding of the pathophysiological basis of organs and systems involvement and disease progression aids in the safe and effective management of the COVID-19 patients. It also helps to guide future well-designed clinical trials, which is the need of time. This review aims to explore the current understanding of pathophysiological basis of various organ system involvement in patients with COVID-19, that can have relevance for patient management and future research. We reviewed the articles in various databases to assemble the current evidences. Keywords: Coronavirus disease 2019; COVID-19; pathophysiology; severe acute respiratory syndrome coronavirus 2.
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Affiliation(s)
- Gentle Sunder Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Sushil Khanal
- Department of Critical Care Medicine, Grande International Hospital, Kathmandu, Nepal
| | - Sachit Sharma
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Gaurav Nepal
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
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Ojha R, Nepal G, Jamarkattel S, Prasad Gajurel B, Karn R, Rajbhandari R. Sporadic Creutzfeldt-Jakob disease: A case report and review of literature. Clin Case Rep 2020; 8:2240-2244. [PMID: 33235768 PMCID: PMC7669377 DOI: 10.1002/ccr3.3131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/30/2020] [Accepted: 06/12/2020] [Indexed: 01/15/2023] Open
Abstract
Creutzfeldt-Jakob Disease is a rare neurodegenerative disease and earlier diagnosis is usually difficult. Combining clinical features with electroencephalogram, laboratory parameters, and neuroimaging findings will facilitate the diagnosis.
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Affiliation(s)
- Rajeev Ojha
- Department of NeurologyTribhuvan University Teaching HospitalKathmanduNepal
| | - Gaurav Nepal
- Maharajgunj Medical CampusTribhuvan University Institute of MedicineKathmanduNepal
| | - Sujan Jamarkattel
- Department of Internal MedicineLincoln Medical and Mental Health CenterBronxNYUSA
| | | | - Ragesh Karn
- Department of NeurologyTribhuvan University Teaching HospitalKathmanduNepal
| | - Reema Rajbhandari
- Department of NeurologyTribhuvan University Teaching HospitalKathmanduNepal
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Nepal G, Shing YK, Yadav JK, Rehrig JH, Ojha R, Huang DY, Gajurel BP. Efficacy and safety of rituximab in autoimmune encephalitis: A meta-analysis. Acta Neurol Scand 2020; 142:449-459. [PMID: 32484900 DOI: 10.1111/ane.13291] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/10/2020] [Accepted: 05/28/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Autoimmune encephalitis (AE) is a rare but debilitating neurological disease where the body develops antibodies against neuronal cell surface/synaptic proteins. Rituximab is an anti-CD20 chimeric monoclonal antibody which shows promise in AE treatment observational studies. To our knowledge, there has been no previous meta-analysis providing robust evidence on the effectiveness and safety of rituximab as second-line therapy for the treatment for AE. METHODS This study was conducted according to the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis) statement. Investigators independently searched PubMed, Web of Science, Google Scholar, WANFANG, CNKI, and J-STAGE for studies. Meta-analysis via representative forest plots was conducted for good functional outcome (mRS ≤ 2), proportion of relapse, and mRS score change pre- and post-treatment. RESULTS Good functional outcome at last follow-up following rituximab therapy occurred in 72.2% of patients (95% CI: 66.3%-77.4%). Mean mRS score decreased by 2.67 (95% CI: 2.04-3.3; P < .001). Relapses following the rituximab therapy occurred in only 14.2% of patients (95% CI: 9.5%-20.8%). Infusion related reactions, pneumonia, and severe sepsis were seen in 29 (15.7%), 11 (6.0%), and two patients (1.1%), respectively. The efficacy and side effect profile of rituximab are comparable to outcomes seen in rituximab use in other autoimmune and inflammatory CNS disease. CONCLUSION Our meta-analysis showed that rituximab is an effective second-line agent for AE with an acceptable toxicity profile.
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Affiliation(s)
- Gaurav Nepal
- Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Yow K. Shing
- Yong Loo Lin School of Medicine National University of Singapore Singapore Singapore
| | - Jayant K. Yadav
- Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Jessica H. Rehrig
- University of New England College of Osteopathic Medicine Biddeford ME USA
| | - Rajeev Ojha
- Department of Neurology Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
| | - Dong Y Huang
- Department of Neurology Shanghai East Hospital of Tongji University School of Medicine Shanghai China
| | - Bikram P. Gajurel
- Department of Neurology Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Kathmandu Nepal
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Nepal G, Kharel G, Shing YK, Ojha R, Jamarkattel S, Yadav JK, Vyas H, Poudyal D, Sah R. The dangers of mass drug administration of albendazole in Nepal, a Neurocysticercosis-endemic region. Trop Dis Travel Med Vaccines 2020; 6:22. [PMID: 33110612 PMCID: PMC7585209 DOI: 10.1186/s40794-020-00122-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/14/2020] [Indexed: 11/21/2022]
Abstract
The majority of cases of Neurocysticercosis (NCC) are asymptomatic. Injudicious use of antihelmintics like albendazole (ALB) can cause cyst degeneration and perilesional inflammation, thus rendering asymptomatic individuals symptomatic with seizures, headache, vascular events, or cerebral edema. Mass drug administration (MDA) using ALB is a very common practice in developing countries like Nepal to contain transmission of soil-transmitted helminths (STH) and lymphatic filariasis (LF). Although the benefits of ALB-based MDA in the general population cannot be undermined, there can be severe consequences in certain groups, especially those with latent NCC. In this commentary, we discuss the effect it may have on such patients, and suggest potential solutions.
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Affiliation(s)
- Gaurav Nepal
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj Rd, Kathmandu, 44600 Nepal
| | - Ghanshyam Kharel
- Department of Neurology, National Academy of Medical Sciences, Mahaboudha, Kathmandu, 44600 Nepal
| | - Yow Ka Shing
- Department of Internal Medicine, National University Hospital, 5 Lower Kent Ridge Rd, Singapore, 119074 Singapore
| | - Rajeev Ojha
- Department of Neurology, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj Rd, Kathmandu, 44600 Nepal
| | - Sujan Jamarkattel
- Department of Infectious Diseases, Tufts Medical Centre, 800 Washington St, Boston, MA 02111 USA
| | - Jayant Kumar Yadav
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj Rd, Kathmandu, 44600 Nepal
| | - Himani Vyas
- All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, New Delhi, Delhi, 110029 India
| | - Dhiraj Poudyal
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj Rd, Kathmandu, 44600 Nepal
| | - Ranjit Sah
- Department of Microbiology, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj Rd, Kathmandu, 44600 Nepal
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Ojha R, Shahi S, Nepal G, Shakya A, Gajurel BP, Karn R, Rajbhandari R, Gautam N. The diagnostic quandary of magnetic resonance imaging-negative Hirayama disease: a case report. J Med Case Rep 2020; 14:133. [PMID: 32819426 PMCID: PMC7441664 DOI: 10.1186/s13256-020-02453-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/08/2020] [Indexed: 11/10/2022] Open
Abstract
Background Magnetic resonance imaging (MRI) features are typical findings in Hirayama disease (HD) and are useful diagnostic entities but may not be present in all patients. Case presentation We present the case of a 22-year-old Nepalese man who presented with insidious onset of weakness of his right upper limb of more than 5 years duration. His weakness was progressive for the first 3 years, and then remained static. On examination, weakness of the interossei, thenar, hypothenar, flexor, and extensor muscles were present in his right upper limb, power was normal in his left upper and bilateral lower limbs. Minipolymyoclonus was present in both upper limbs, less prominent on the left side. Electrophysiological findings showed motor axonal neuropathy in his right upper limb, neurogenic discharges and fibrillations, and fasciculations in both upper limbs. Contrast magnetic resonance imaging (MRI) of his cervical spine in flexion was normal. Our patient was diagnosed with HD based on clinical and electrophysiological findings. Our patient was advised to use a cervical collar and regular physiotherapy and was found to have subjective benefit. Conclusion A normal cervical MRI does not rule out HD and the diagnosis can also be made based on clinical and electrophysiological studies. Progressive distal upper limb weakness or tremor in young patients should be evaluated for HD, because early diagnosis and intervention might halt the progression.
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Affiliation(s)
- Rajeev Ojha
- Department of Neurology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, 44600, Nepal.
| | - Sumit Shahi
- Department of Medicine, Tribhuvan University Chitwan Medical College, Bharatpur, Chitwan, 44200, Nepal
| | - Gaurav Nepal
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, 44600, Nepal
| | - Arjana Shakya
- BP Koirala Institute of Health Sciences, Dharan, 56700, Nepal
| | - Bikram Prasad Gajurel
- Department of Neurology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, 44600, Nepal
| | - Ragesh Karn
- Department of Neurology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, 44600, Nepal
| | - Reema Rajbhandari
- Department of Neurology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, 44600, Nepal
| | - Niraj Gautam
- Department of Neurology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, 44600, Nepal
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Nepal G, Rehrig JH, Shrestha GS, Shing YK, Yadav JK, Ojha R, Pokhrel G, Tu ZL, Huang DY. Neurological manifestations of COVID-19: a systematic review. Crit Care 2020; 24:421. [PMID: 32660520 PMCID: PMC7356133 DOI: 10.1186/s13054-020-03121-z] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/29/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the global spread of coronavirus disease (COVID-19). Our understanding of the impact this virus has on the nervous system is limited. Our review aims to inform and improve decision-making among the physicians treating COVID-19 by presenting a systematic analysis of the neurological manifestations experienced within these patients. METHODS Any study, released prior to May 20, 2020, that reported neurological manifestations in patients infected by SARS-CoV-2 was systematically reviewed using the PRISMA (Preferred Reporting Items for Systemic review and Meta-Analysis) statement. RESULTS Our systematic review included data from 37 articles: twelve retrospective studies, two prospective studies, and the rest case reports/series. The most commonly reported neurological manifestations of COVID-19 were myalgia, headache, altered sensorium, hyposmia, and hypogeusia. Uncommonly, COVID-19 can also present with central nervous system manifestations such as ischemic stroke, intracerebral hemorrhage, encephalo-myelitis, and acute myelitis, peripheral nervous manifestations such as Guillain-Barré syndrome and Bell's palsy, and skeletal muscle manifestations such as rhabdomyolysis. CONCLUSION While COVID-19 typically presents as a self-limiting respiratory disease, it has been reported in up to 20% of patients to progress to severe illness with multi-organ involvement. The neurological manifestations of COVID-19 are not uncommon, but our study found most resolve with treatment of the underlying infection. Although the timeliness of this review engages current challenges posed by the COVID-19 pandemic, readers must not ignore the limitations and biases intrinsic to an early investigation.
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Affiliation(s)
- Gaurav Nepal
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | | | | | - Yow Ka Shing
- National University Hospital, Singapore, Singapore
| | - Jayant Kumar Yadav
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Rajeev Ojha
- Department of Neurology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Gaurab Pokhrel
- Department of Urology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Zhi Lan Tu
- Department of Neurology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China
| | - Dong Ya Huang
- Department of Neurology, Shanghai East Hospital of Tongji University School of Medicine, Shanghai, China
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Sah R, Nepal G, Sah S, Singla S, Upadhyay P, Rabaan AA, Dhama K, Rodriguez-Morales AJ, Ghimire R. A rare case of brain abscess caused by Actinomyces meyeri. BMC Infect Dis 2020; 20:378. [PMID: 32460724 PMCID: PMC7251899 DOI: 10.1186/s12879-020-05100-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 05/17/2020] [Indexed: 11/29/2022] Open
Abstract
Background Brain abscesses are the rare and most severe form of actinomycosis, which usually manifests as abscesses of the occipital or parietal lobe due to direct expansion from an adjacent area, the oral cavity. In the medical literature, there are only a few reported cases of brain abscess caused by Actinomyces meyeri. In this report, we present a 35-year-old male patient who experienced an insidious headache and left-sided weakness and was diagnosed with an Actinomyces meyeri brain abscess. Case presentation A 35-year-old Nepalese man came to our institute with the primary complaint of insidious onset of headache and left-sided weakness. His physical examination was remarkable for the left-sided weakness with power 2/5 on both upper and lower limbs, hypertonia, hyperreflexia and positive Babinski sign, with intact sensory function. Cardiac examination revealed systolic murmur with regular S1 and S2, and lung examination was normal. The patient had poor dental hygiene. Biochemistry and haematology panel were normal. Urinalysis, chest X-ray and electrocardiogram revealed no abnormality. A transthoracic echocardiogram revealed mitral regurgitation. However, there was no evidence of valvular vegetation. A magnetic resonance imaging (MRI) of the brain was performed, which showed a bi-lobed rim enhancing lesion with a conglomeration of two adjoining round lesions in the right parietal parasagittal region. Perilesional oedema resulting in mass effect over the right lateral ventricle and mid-right uncal herniation with midline shift was noted. Craniotomy was performed, and the lesion was excised. Gram staining of the extracted sample revealed gram variable filamentous rods. Creamy white, moist, confluent colonies were observed after performing anaerobic culture in chocolate agar. On the gram staining, they showed gram-positive filamentous rods. Actinomyces meyeri was identified based on matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) technology. Based on the susceptibilities, he was successfully treated with ampicillin-sulbactam. Conclusions In conclusion, Actinomyces should be considered in the differential diagnosis of brain abscess in patients with poor dental hygiene, and early diagnosis and appropriate treatment can lead to better results.
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Affiliation(s)
- Ranjit Sah
- Tribhuvan University Institute of Medicine, Kathmandu, Nepal. .,Medanta The Medicity, Gurgaon, Haryana, India.
| | - Gaurav Nepal
- Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Sanjit Sah
- Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | | | - Priti Upadhyay
- Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Ali A Rabaan
- Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Kuldeep Dhama
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Izatnagar, Bareilly, Uttar Pradesh, 243 122, India
| | - Alfonso J Rodriguez-Morales
- Public Health and Infection Research Group, Faculty of Health Sciences, Universidad Tecnologica de Pereira, Pereira, Risaralda, Colombia.,Grupo de Investigación Biomedicina, Faculty of Medicine, Fundación Universitaria Autónoma de las Américas, Sede Pereira, Pereira, Risaralda, Colombia
| | - Rabindra Ghimire
- Division of Infectious Disease, East Carolina University Brody School of Medicine, Greenville, NC, USA
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Nepal G, Yadav JK, Rehrig JH, Bhandari N, Baniya S, Ghimire R, Mahotra N. Efficacy and safety of inhaled budesonide on prevention of acute mountain sickness during emergent ascent: a meta-analysis of randomized controlled trials. BMC Emerg Med 2020; 20:38. [PMID: 32404064 PMCID: PMC7222565 DOI: 10.1186/s12873-020-00329-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 04/29/2020] [Indexed: 11/13/2022] Open
Abstract
Background Acute Mountain Sickness (AMS) is a pathophysiologic process that occurs in non-acclimated susceptible individuals rapidly ascending to high-altitude. Barometric pressure falls at high altitude and it translates to a decreased partial pressure of alveolar oxygen (PAO2) and arterial oxygen (PaO2). A gradual staged ascent with sufficient acclimatization can prevent AMS but emergent circumstances requiring exposure to rapid atmospheric pressure changes – such as for climbers, disaster or rescue team procedures, and military operations – establishes a need for effective prophylactic medications. This systematic review and meta-analysis aim to analyze the incidence of AMS during emergent ascent of non-acclimatized individuals receiving inhaled budesonide compared to placebo. Methods This current meta-analysis was conducted according to the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We searched PubMed, Google Scholar and Embase for relevant studies. The efficacy of budesonide in reducing incidence of AMS was evaluated by calculating the pooled ORs and 95% CIs. The efficacy of budesonide in maintaining hemoglobin-oxygen saturation was evaluated by calculating standard mean difference (SMD) and 95% confidence intervals. Results We found that at high altitude, inhaled budesonide was effective in reducing the incidence of mild AMS [OR: 0.37; 95% CI, 0.14 to 0.9, p = 0.042] but was ineffective in reducing the incidence of severe AMS [OR: 0.46; 95% CI, 0.14 to 1.41, p = 0.17]. Inhaled budesonide was also effective in maintaining SpO2 (SMD: 0.47; 95% CI, 0.09 to 0.84, p = 0.014) at high altitude. However, it was not effective in maintaining or improving pulmonary function at high altitude. Systematic-review found no adverse effects of budesoide in the dose used for prophylaxis of AMS. Conclusions Our systematic review showed that prophylactic inhaled budesonide is effective in preventing mild AMS during emergency ascent but not effective in preventing severe AMS. Though statistically significant, authors recommend caution in interpretation of data and questions for further well designed randomized studies to evaluate the role of budesonide in prophylaxis of AMS during an emergent ascent.
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Affiliation(s)
- Gaurav Nepal
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal. .,Mountain Medicine Society of Nepal, Kathmandu, Nepal.
| | - Jayant Kumar Yadav
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal.,Mountain Medicine Society of Nepal, Kathmandu, Nepal
| | | | - Niroj Bhandari
- Kathmandu University School of Medical Sciences, Panauti, Nepal
| | - Santosh Baniya
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal.,Mountain Medicine Society of Nepal, Kathmandu, Nepal
| | - Rakesh Ghimire
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Narayan Mahotra
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
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