Potential Prognostic Value of Native T1 in Pulmonary Hypertension Patients

Native T1, extracellular volume fraction (ECV), and late gadolinium enhancement (LGE) characterize myocardial tissue and relate to patient prognosis in a variety of diseases, including pulmonary hypertension. The purpose of this study was to evaluate if left ventricle (LV) fibrosis measurements have prognostic value for cardiac outcomes in pulmonary hypertension subgroups. 54 patients with suspected pulmonary hypertension underwent right-heart catheterization and were classified into pulmonary hypertension subgroups: pre-capillary component (PreCompPH) and isolated post-capillary (IpcPH). Cardiac magnetic resonance imaging (MRI) scans were performed with the acquisition of balanced cine steady-state free precession, native T1, and LGE pulse sequences to measure cardiac volumes and myocardial fibrosis. Associations between cardiac events and cardiac MRI measurements were analyzed within PreCompPH and IpcPH patients. IpcPH: LV native T1 was higher in patients who experienced a cardiac event within two years vs. those who did not. In patients with LV native T1 > 1050 ms, the rate of cardiac events was higher. ECV and quantitative LGE did not differ between groups. PreCompPH: native T1, ECV, and quantitative/qualitative LGE did not differ between patients who experienced a cardiac event within two years vs. those who did not. LV native T1 may have potential value for forecasting cardiac events in IpcPH, but not in PreCompPH, patients.

Left Ventricular Fibrosis Assessment by Native T1, ECV, and LGE in Pulmonary Hypertension Patients

Cardiac magnetic resonance imaging (MRI) is emerging as an alternative to right heart catheterization for the evaluation of pulmonary hypertension (PH) patients. The aim of this study was to compare cardiac MRI-derived left ventricle fibrosis indices between pre-capillary PH (PrePH) and isolated post-capillary PH (IpcPH) patients and assess their associations with measures of ventricle function. Global and segmental late gadolinium enhancement (LGE), longitudinal relaxation time (native T1) maps, and extracellular volume fraction (ECV) were compared among healthy controls (N = 25; 37% female; 52 ± 13 years), PH patients (N = 48; 60% female; 60 ± 14 years), and PH subgroups (PrePH: N = 29; 65% female; 55 ± 12 years, IpcPH: N = 19; 53% female; 66 ± 13 years). Cardiac cine measured ejection fraction, end diastolic, and end systolic volumes and were assessed for correlations with fibrosis. LGE mural location was qualitatively assessed on a segmental basis for all subjects. PrePH patients had elevated (apical-, mid-antero-, and mid-infero) septal left ventricle native T1 values (1080 ± 74 ms, 1077 ± 39 ms, and 1082 ± 47 ms) compared to IpcPH patients (1028 ± 53 ms, 1046 ± 36 ms, 1051 ± 44 ms) (p < 0.05). PrePH had a higher amount of insertional point LGE (69%) and LGE patterns characteristic of non-vascular fibrosis (77%) compared to IpcPH (37% and 46%, respectively) (p < 0.05; p < 0.05). Assessment of global LGE, native T1, and ECV burdens did not show a statistically significant difference between PrePH (1.9 ± 2.7%, 1056.2 ± 36.3 ms, 31.2 ± 3.7%) and IpcPH (2.7 ± 2.7%, 1042.4 ± 28.1 ms, 30.7 ± 4.7%) (p = 0.102; p = 0.229 p = 0.756). Global native T1 and ECV were higher in patients (1050.9 ± 33.8 and 31.0 ± 4.1%) than controls (28.2 ± 3.7% and 1012.9 ± 29.4 ms) (p < 0.05). Cardiac MRI-based tissue characterization may augment understanding of cardiac involvement and become a tool to facilitate PH patient classification.

Correlation of Multidetector Computed Tomography Peripheral Angiography with Color Duplex Sonography in Peripheral Arterial Disease

BACKGROUND

With aging of the global population peripheral arterial disease is increasingly common. Arteriography, computed tomography angiography and magnetic resonance angiography are common modalities used for evaluation of peripheral arterial disease. However, they have limitations of being invasive, costly, limited availability or contraindicated in patients with renal impairment or contrast allergy. Duplex imaging, a method of evaluation of peripheral arterial disease is cost effective, widely available and safe even in patients with renal impairment and contrast allergy.

METHODS

A prospective cross sectional descriptive study involving 114 patients was conducted from November 2015 to October 2016. The patients were evaluated by Doppler ultrasound following multi-detector computed angiography in Department of Radiology, Tribhuvan University Teaching Hospital. The lower limb arteries were divided into 10 segments and stenosis or occlusion of each segment in Computed Tomography angiography were compared with findings in Doppler, Computed Tomography angiography being considered the gold standard. Data was collected in predesigned proforma in Microsoft Excel spread sheet.

RESULTS

Duplex imaging showed sensitivity 94.94%, specificity 98.54%, accuracy 97.54%, positive predictive value 96.15 % and negative predictive value 98.06 %. In assessment of 22 segments, partial stenosis seen in Computed Tomography angiography was overestimated as complete stenosis in Doppler. There was significant positive correlation of velocity ratio with degree of partial occlusion (r=0.918 for right lower limb and r=0.895 for left lower limb, p <0.01).

CONCLUSIONS

Duplex imaging is safe cost effective and reliable method of evaluation of patients with peripheral arterial diseases.

Pulmonary Arteriovenous Malformation presenting as hemothorax in pregnancy: A case report

Introduction: Pulmonary arteriovenous malformation (PAVM) is a rare anomaly, mostly congenital, that tends to increase in size with the influence of various factors. Case report: A primigravida at 37 weeks of gestation presented with acute onset of dyspnea due to right sided hemothorax. Computed tomography showed abnormal vessels with pseudoaneurysm in the right lower lobe and shunting between subsegmental branch of right descending pulmonary artery and right inferior pulmonary vein. Embolization of the lesion was planned after immediate cesarean section. Coil embolization with complete occlusion of supplying artery of the lesion was done. Conclusion: PAVM, although rare can result in fatal complications if untreated. Less invasive image guided coil embolization is a promising treatment modality.

Impact of Community Diagnosis Programme on Undergraduate Students at BP Koirala Institute of Health Sciences

Background Community Diagnosis Programme (CDP) aims to demonstrate the importance of teamwork in health care to understand the comprehensive health needs of the rural people and conceive about the research. Objective To assess the impact of community diagnosis program on undergraduate students of BP Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal. Method A cross sectional study with mixed design (quantitative and qualitative) was conducted among the undergraduate students of batch 2017 participating in community diagnosis programme of BP Koirala Institute of Health Sciences, Dharan, Nepal. Eight questions assessed the students' perceptions regarding their abilities about community diagnosis program using six point Likert Scale and four open ended questions were used to know the students' experience and perception of community diagnosis programme. Result Overall mean ± SD score for pre-exposure response was 30.47 ± 6.18 and for the post-exposure response was 40.49 ± 5.16. The overall mean ± SD score of the students categorized according to streams showed similar results in both pre-exposure response and post-exposure responses. Qualitative analysis revealed the themes like "Research, a reflection of community and new method of learning to medical students"; "method of developing confidence and good communication skills", "learning to work as a team" and "exposure to rural area"; "Research an adjunct to medical profession". Conclusion Community diagnosis programme had a positive impact on the students about basic survey process, learnt to communicate with rural people, understood the type of data and were willing to participate in similar projects in future. Qualitative analysis showed most of the students had positive experience with some negative experience of community diagnosis programme.

Study of the Outcome Differences among the Ischemic Stroke Subtypes basedon TOAST Classificationat Tribhuvan University Teaching Hospital, Nepal

The objective of this study was to explore the outcome differences among is chemic stroke sub types based on “Trial of ORG 10172 in Acute Stroke Treatment (TOAST)” system in a tertiary referral hospital. A hospital based prospectiv elongitudinal study was conducted involving 182 patients. Modified Rank in Scale (MRS) was used to assess functional out come, Kaplan-Meierproduct- limit method and Coxproportional hazards regression analys is were used to evaluate rates and identify predictors of survival and recurrent stroke. MRS were statistically different across stroke subtypesat 30 days and 6 months (p<0.0001 and (p<0.0001) respectively). Lacunar stroke was associated with milder deficits. Estimated rates of recurrent stroke were significantly different at 30 days (p<0.0001) and at 6 months (p=0.009). Before adjusting forage, sex, stroke severity, and diabetes mellitus, infarct subtype was not an independent determinant of recurrent stroke within 30 days (p=0.057);but was at 6 months (p=0.024), how ever after same adjustment it was independent determinant both at 30 days (p=0.030) and at 6 months (p=0.025). Estimated death rates were significantly different both a t 3 0 days (p=0.026) and at 6 months (p=0.009). Ischemic stroke subtype was an independent determinant of 6-month survival both before (p=0.016) and after (p=0.027) adjustment for different parameters; however, was not of 30-day survival both before (p=0.054) and after (p=0.993) same adjustment. Early recurrencerates were highest among large artery atherosclerotic stroke. Lacunar stroke has better post stroke functional status. Survival is poorest among cardioembolic stroke.

Gallbladder Ascariasis : A Rare Case Report

 Ascariasis is the most prevalent helminthic infection to infest human beings caused by Ascaris lumbricoides. Rarely the worm migrates through ampulla of Vater and may enter common bile duct. This is a case report of live Ascaris lumbricodes in gallbladder, on USG. Med Phoenix. Vol. 3, Issue. 1, 2018, Page: 95-97                                                         

Determinants of Fever in Acute Stroke Patients

The aim of this study was to determine the frequency and origin of fever in patients admitted with acute stroke and the characteristics associated with the development of fever.This was a cross sectional observational study involving 151 patients admitted with acute stroke. The various attributes associated with the development of fever were documented and their characteristics were analyzed.Fever was noted in 21.2% of 151 patients; 11.9% had a documented infection and 9.3% had no documented infection. Older age was associated with the presence of fever (P = 0.009). The development of fever was associated with haemorrhage rather than ischemic infarct (P = 0.0001), presence of mass effect (P =0.03), and larger size of ischaemic infarct and haemorrhage (P = 0.002 and 0.0001, respectively). Patients with fever had lower scores on admission on the Glasgow Coma Scale (GCS) (P = 0.009) and higher score on the National Institute of Health Stroke Scale (NIHSS) (P = 0.0001). The development of fever was associated with prior use of an invasive technique (P =0.0001), particularly urinary catheterization and endotracheal intubation (P = 0.0001 and 0.0001). In multivariate analysis, age, NIHSS and endotracheal intubation were found to be significantly associated with fever (P = 0.018, P = 0.001 and P = 0.0001, respectively). Patients with fever without documented infection had an earlier onset than those with infection (P = 0.012).Fever in acute stroke patients is associated with older age, severity of stroke and the use of invasive techniques. Urinary tract and respiratory infections are the most common infections. Fever starts earlier where a focus of infection is not identified.Nepal Journal of Neuroscience 12:20-25, 2015

Unusual case of failure to thrive: Type III Bartter syndrome

Bartter syndrome Type III is a rare autosomal recessive disorder resulting from an inherited defect in the thick ascending limb of the loop of henle of the nephrons in kidney. The typical clinical manifestations in childhood are failure to thrive and recurrent episodes of vomiting. Typical laboratory findings which help in the diagnosis are hypokalemic metabolic alkalosis, hypomagnesemia and hypercalciuria. We report a case of Type III Bartter syndrome not responding to repeated conventional treatment of failure to thrive.

Paediatric Stroke: A Rare Presentation of Iron Deficiency Anemia in a Four Year Old Child

Paediatric stroke is an uncommon syndrome with even lesser annual incidence rates of arterial ischemic stroke in infants and children. In children the diagnosis of stroke is frequently delayed or missed. This is due to subtle and nonspecific clinical presentations, a complicated differential diagnosis and a lack of awareness by physicians and also delay in the seeking of medical attention as in our case. We report you a rare case of a four year old child from remote Nepal who presented to our Out Patient Department after a long gap of around four months after the sudden onset of loss of consciousness and decreased movement of right limbs who after detailed history examination and lab investigations and imaging revealed ischemic stroke due to iron deficiency anemia.

Pompe Disease: Cyanosed Hypotonic Infant with Normal Respiratory Rate

Infantile hypotonia or floppy infant is a diagnostic challenge when it presents with other presenting complaints such as fever, cough or diarrhea. Many times the hypotonia goes unnoticed when other symptom covers the hypotonia and child continues to receive the treatment for other symptoms. We report a rare case from Nepal of infantile Pompe disease who presented with the history of fever and cough in the recent earthquake disaster camp at remote part of Sindhupalchowk, Nepal. He was being treated as a case of pneumonia. Pompe disease can be diagnosed clinically by taking detailed history and correlating the clinical findings during the presentation with other symptoms. In our case the normal respiratory rate, reduced Spo2 and presence of crackles dominated the hypotonia and was mistreated as pneumonia. High index of suspicion is necessary in diagnosing Pompe disease.

Morphological Changes in Degenerative Disc Disease on Magnetic Resonance Imaging: Comparison Between Young and Elderly

BACKGROUND

Morphological changes implicated in low back are complicated by additional age related degenerative changes in spine, which increases with aging. This study aims to compare the morphological MRI findings in young and elderly patients with low back pain and also correlate them with the clinical symptoms.

METHODS

The study was a retrospective hospital record based comparative study carried out in a Teaching Hospital. MRI performed for patients with low back pain during May 2012 to October 2012 were reviewed. The MRI findings were compared between below 60 years and at and above 60 years and were also correlated with symptoms.

RESULTS

A total of 301 MRI met the inclusion criteria out of which 228(75.74%) were young adults and 73(24.25%) were elderly adults. Degenerative changes and disc bulge was more common in elderly. Disc herniations including disc prolapse was more common in young adults. Disc protrusion involving L4-L5 was most common in the elderly while L5-S1 was most common in young adults. Nerve root compression was noted more commonly in the young adults. Radiculopathy was associated with grade III nerve root compression and paramedian disc protrusion in young adults while no such association was noted in elderly. No association of radiculopathy with presence of degenerative changes, spinal stenosis was noted in both groups.

CONCLUSIONS

Degenerative changes are more common in elderly while disc herniations are more common in young adults. Morphologic changes do correlate with symptoms in young adults to some extent while they do not correlate in elderly.

Inclusion of Three-Vessel View in Routine Fetal Cardiac Screening

Aims: The purpose of this study was to study the feasibility of inclusion of 3-vessel view (3-VV) of the fetal upper mediastinum in routine fetal anomaly screening; and to study the size relationship of these vessels namely, main pulmonary artery (MPA), ascending aorta (AA) and the superior venacava (SVC) in fetuses between 17 and 24 weeks of pregnancy by antenatal ultrasound. Methods: This was a prospective cross sectional study involving 106 pregnant ladies between 17 and 24 weeks of gestation. The time burden to the examination due to addition of 3-VV in routine anomaly screening was recorded. The relationships of the three great vessels of the fetal upper mediastinum were studied and their diameters were obtained. Regression equations were used to construct the reference ranges for all the parameters of statistical significance. Results: The 3-VV could be easily obtained in all but eight patients within five minutes (the difficulty in these eight patients was due to fetal position). The MPA, AA and SVC were aligned in a straight line from left to right respectively, the MPA being the largest vessel, the SVC being the smallest vessel and the AA having an intermediate diameter. All of these three vessels showed significant correlation of size with advancing gestational age. Conclusions: 3-VV is easily obtained in fetuses at the time of routine anomaly screening. This should be routinely included in the screening ultrasound of fetal heart along with the four-chamber view to detect the anomalies of the outflow tract. DOI: http://dx.doi.org/10.3126/njog.v9i1.11197 NJOG 2014 Jan-Jun; 2(1):82-86

Chylous ascites in cirrhosis-A case report

Chylous ascites is a rare presentation in cirrhotic liver disease but its incidence has increased because of aggressive cardiothoracic/abdominal surgeries and increasing survival of patients with chronic liver disease and cancer. We report here a case presenting with spontaneous chylous ascites in cirrhosis of liver. It has been associated with poor prognosis. Journal of College of Medical Sciences-Nepal,2012,Vol-8,No-2, 42-45 DOI: http://dx.doi.org/10.3126/jcmsn.v8i2.6837

Lipid Profile in a Tertiary Care Center

INTRODUCTION: Lipid profile is changing with changing developmental status and lifestyle in less developed countries and coronary artery disease risk factor is rising. The aim of the study is to find the lipid pattern in Department of Medicine in tertiary care hospital. METHODS: An observational prospective study was conducted in 408 subjects from January 2009 to February 2010. Study subjects were selected irrespective of co-morbid condition and coronary risk factors. RESULTS: The mean triglycerides, cholesterol, LDL, HDL were 138.3 +/- 78.3 mg/dl, 180.2 +/- 53.7 mg/dl, 113.8 +/- 41.2 mg/dl, 40.1 +/- 10.1 mg/dl respectively. The Triglycerides (>140 mg/dl), Cholesterol (>250 mg/dl), LDL (>92 mg/dl), HDL (<45mg/dl) were 35.5%, 7.6%, 67.9%, 76% respectively. CONCLUSIONS: Lipid profile is becoming atherogenic with high triglyceride, high LDL and low HDL being the most common abnormality. An epidemiological study is recommended to understand the true burden of the disease in the community.  KEYWORDS: atherogenic, cholestrol, coronary artery diseases, lipid profile, triglyceride. 

Lipid profile in a tertiary care center

INTRODUCTION

Lipid profile is changing with changing developmental status and lifestyle in less developed countries and coronary artery disease risk factor is rising. The aim of the study is to find the lipid pattern in Department of Medicine in tertiary care hospital.

METHODS

An observational prospective study was conducted in 408 subjects from January 2009 to February 2010. Study subjects were selected irrespective of co-morbid condition and coronary risk factors.

RESULTS

The mean triglycerides, cholesterol, LDL, HDL were 138.3 +/- 78.3 mg/dl, 180.2 +/- 53.7 mg/dl, 113.8 +/- 41.2 mg/dl, 40.1 +/- 10.1 mg/dl respectively. The Triglycerides (>140 mg/dl), Cholesterol (>250 mg/dl), LDL (>92 mg/dl), HDL (<45mg/dl) were 35.5%, 7.6%, 67.9%, 76% respectively.

CONCLUSIONS

Lipid profile is becoming atherogenic with high triglyceride, high LDL and low HDL being the most common abnormality. An epidemiological study is recommended to understand the true burden of the disease in the community.

Evaluation of detection methods for genetically modified traits in genotypes resistant to European corn borer and herbicides

Detection of genetically modified (GM) traits in corn (Zea mays L.) is urgently needed for preservation of genetic identity and marketing GM products. A laboratory study was conducted to evaluate the efficiency, accuracy, and reliability of different analytical methods to detect GM traits in corn. Samples with known fractions of GM concentrations (Bacillus thuringiensis [Bt], Liberty Link [LL] and stacked [Bt/LL] genes) from commercial seed companies and those derived from yellow kernels in a white corn ear, outcrossed by pollen of neighboring Bt hybrid, were tested by lateral flow quick test kits and by enzyme-linked immunosorbent assay (ELISA)-based test strips purchased from different companies. Liberty Link hybrids are resistant to glufosinate (Liberty or Basta) herbicides, whereas Bt corn is developed for the control of European corn borer (Ostrinia nubilalis). Selected samples of GM concentrations were also tested in a commercial laboratory using DNA-based polymerase chain reaction (PCR) test. The results demonstrated that qualitative lateral flow quick tests could detect samples containing 1% or higher Bt and 2% or higher LL concentrations within the recommended time limit of the test. Faint test lines for samples containing 0.5 to 1% Bt or 1 to 2% LL concentrations appeared if samples remained in the test cup overnight. ELISA test strips detected the Bt content semiquantitatively in the range of 0.5 to 2.0%. Grain samples derived from non-Bt corn outcrossed by neighboring Bt pollen had usually lower GM concentrations than commercial GM seed samples. Both ELISA- and DNA-based PCR tests distinguished samples with GM concentrations between 0.1 to 0.5%, but the precision of quantification at this range was very low and results were highly inconsistent.

Efficacy of Albendazole and Short-Course Prednisolone Treatment in Children with One or Two Ring-Enhancing Lesions of Neurocysticercosis: A Randomized Controlled Trial

Context: Neurocysticercosis is a endemic disease in Nepal causing social and financial burden on society and developmental problem in children. Aims: To determine the efficacy of albendazole plus oral prednisolone in children with 1 or 2 ring-enhancing lesions (by CT) on resolution of lesions and recurrence of seizure. Setting and Design: Randomized controlled open trial. Methods and Materials: Children with 1 or 2 ring-enhancing lesions < 20 mm in diameter on computed tomography scan, likely to have Neurocysticercosis, were assigned to treatment & control groups. Children assigned to the treatment group (n = 50) were given 2.0 mg/kg per day prednisolone orally for 5 days plus 15 mg/kg per day albendazole on third day for 28 days. Anti epileptic drugs were given to both groups {including Control group (n = 51)}. Statistical Analysis: The results were analysed with the use of Epi Info version 6.04 and Stata version;7 software. Results: The lesions resolved completely or partially in more children in the treated group compared with the control group (p = .04 & p = 0.03). The proportion of children who had seizures was significantly lower in the treated group compared with the control group at 6 months (10% versus 33%; p = .006) and 12 months (14% versus 38%; p = .003). Conclusion: Albendazole plus Prednisolone increased resolution of lesions on computed tomography scan and reduced the risk of subsequent recurrence of seizures among children with Neurocysticercosis. Key words: Prednisolone, Albendazole, Neurocysticercosis and Children.   doi:10.3126/jnps.v27i2.1410   J. Nepal Paediatr. Soc. Vol.27(2) p.60-63

Kangaroo Mother Care for Low Birth Weight Babies: A prospective Observational Study

Introduction: Kangaroo Mother Care is the low cost, humane technique for caring low birth weight babies by direct skin to contact with the mother. Objective: The Prospective observational study was done to see the effect of KMC especially on weight gain on low birth weight babies weighing 2000 grams or less at Special Care Baby Unit of Paropakar Maternity and Women's hospital, Kathmandu. Method: The study was conducted in Special Care Baby Unit (SCBU) of Paropakar Maternity and Women's Hospital over 7 months period May 2007 to Nov. 2008 (from Baishakh 2064 to Kartik 2065). The method of care consisted of skin to skin contact between the mother and the infant. Result: It was observed that babies had good weight gain of average 30gms/day and had short duration of hospital stay of average 9 days. Babies had less morbidities like hypothermia, apnea, skin infections and oral thrush. 100% babies had exclusive breast feeding and KMC was acceptable to mothers. Conclusion: Kangaroo Mother Care shows early and good weight gain in low birth weight babies. It is simple, low cost technique and well acceptable by mother and family and can be continued at home. Key words: Kangaroo mother   doi:10.3126/jnps.v29i1.1593 J. Nepal Paediatr. Soc. Vol.29(1) p.6-9

Collodion Baby

DOI = 10.3126/jnps.v28i2.1391J. Nepal Paediatr. Soc. Vol.28(2) 2008 p.68

Thanatophoric Dysplasia

doi:10.3126/jnps.v29i1.1599J. Nepal Paediatr. Soc. Vol.29(1) p.33-34