Chylolymphatic mesenteric cyst: A rare differential diagnosis of cystic mass in abdomen: A case report

INTRODUCTION

Mesenteric cysts are the rare benign intraperitoneal tumor, which are common in the mesentery of the terminal ileum. Though mesenteric cysts are frequently seen, chylolymphatic mesenteric cysts in children are rare entities.

CASE PRESENTATION

Our case is a case of a 3-year-old female child presenting to our center with a complain of abdominal pain. Ultrasonography (USG) of the abdomen revealed a cystic lesion in the right upper abdomen, and computed tomography (CT) scan showed a large homogenous fluid density lesion in the right upper abdomen, giving a provisional diagnosis of mesenteric cyst. She was managed surgically: the cyst was excised, the involved segment of bowel was resected and the remaining was anastomosed. On histopathology, the final diagnosis of a chylolymphatic mesenteric cyst was made.

DISCUSSION

Clinical presentations may vary from asymptomatic abdominal lump to features of acute abdomen. Imaging modalities like ultrasonography and computed tomography scans are the mainstay of investigations. Surgical management with excision of cyst, and resection of the involved bowel segment is the treatment of choice, as done in our patient. The final diagnosis is made after the histopathologic examination of the excised specimen.

CONCLUSION

Chylolymphatic mesenteric cysts are rare, and have varied clinical presentations. Although rare, chylolymphatic mesenteric cysts should be considered a differential diagnosis in patients presenting with cystic masses in the abdomen.

Clinical Outcome for Lumbar Disc Herniation Treatment with Intradiscal Oxygen-ozone Therapy

BACKGROUND

Low back pain due to disc herniation is a common problem causing frequent hospital visits and loss of working days with major socio-economic impact. Conservative treatments like analgesics, physiotherapy do not work in all patients. Surgical treatment has been the mainstay of treatment when indicated but is associated with anesthetic and surgical complications. Intradiscal oxygen-ozone chemonucleolysis is a minimally invasive procedure done under local anesthesia and has promising role in shrinking the bulged disc and reducing nerve root compression and related symptoms. This retrospective study was done to see how intradiscal oxygen-ozone chemonucleolysis reduces pain severity in patients with discogenic low back pain.

METHODS

Retrospective data were retrieved of those patients who underwent fluoroscopy guided intradiscal oxygen-ozone chemonucleolysis with 5-6 ml of an O2-O3 mixture (concentration of 30 microgram/ml) during a period of two years in Nepal pain care and research center. Numerical pain scale (NRS) at various follow ups were compared to preprocedural NRS.

RESULTS

Preprocedural NRS was 8± 13. NRS at three hours, one week, one month, three months and six months were 2± 13 (73 percent reduction), 2± 53 (68 percent reduction), 2± 27 (72 percent reduction), 1± 08 (77 percent reduction) and 1± 67 (79 percent reduction) respectively.

CONCLUSIONS

Intradiscal oxygen-ozone chemonucleolysis can be a useful modality of treatment for discogenic low back pain in patients who fail to respond to conservative management and in whom surgery is not indicated.

Respiratory Morbidity and Mortality of Traumatic Cervical Spinal Injury

BACKGROUND

Traumatic cervical spinal injuries can severely affect respiratory function and cause significant morbidity and mortality. The typical respiratory morbidity in cervical spine injury is Atelectasis, Ventilator-associated pneumonia, acute respiratory distress syndrome and delayed weaning, etc. The study aims to see the prevalence of respiratory morbidity as well as mortality associated with cervical spine injury.

METHODS

Cross sectional study based on retrospective data was conducted on the X Sciences with the existing hospital record during the period of 3 years to find out the prevalence respiratory morbidity like Ventilatory Associated Pneumonia, delayed weaning, ARDS, atelectasis of traumatic cervical spine injury, determine the prevalence, type, and impact of respiratory morbidity and mortality in this population.

RESULTS

Total no 76 patients data meeting the inclusion criteria included in study. Male patients were more prone to develop traumatic cervical spinal injuries (SCI). The prevalence of respiratory morbidity in term of VAP(57.89), delayed weaning(46.05) and Atelectasis(22.36) was high. Patients with Asia A Neurology has higher association for VAP and delayed weaning, while Asia E Neurology patients had no respiratory morbidity. The study found a significant positive association between respiratory morbidity with hospital stay, and ventilator days (p-value: 0.019 and 0.048). A total of 15 patients died, 28.95% were discharged on request and 40.8% leaving the hospital against medical advice.

CONCLUSIONS

The prevalence of respiratory morbidity higher in cervical spine injury. Furthermore, it has associated with prolonged ICU and ventilator days and increase in mortality.

Knowledge and practice regarding cancer screening in Nepal: a systematic review and meta-analysis

Background

Cancer screening utilization can aid in the early diagnosis and treatment of cancer. However, the current scenario of the knowledge and practice regarding cancer screening remains unclear as the authors do not have sufficient studies. Hence, the authors conducted this systematic review and meta-analysis to assess the situation of cancer screening utilization and knowledge.

Methods

A systematic literature review was conducted to identify all studies on knowledge and practice regarding cancer screening in the Nepalese population. Data extraction and analysis were done with SPSS and CMA-3.

Results

The authors identified a total of 5238 studies after database searching, and 19 studies were included in a narrative synthesis. Lack of awareness and knowledge was the major barrier in cervical, breast, and testicular cancer screening. In cervical cancer screening, the most common reason for screening was the advice of health personnel in 85% of respondents, and the barrier was lack of awareness in 49.33% of participants.

Conclusion

The knowledge and practice of cancer screening is lacking in Nepal, as shown by our review. More educational and awareness programs, easy access to screening services, and elimination of sociocultural barriers are necessary to increase the utilization of screening services.

Delayed presentation of traumatic diaphragmatic hernia complicated by bowel obstruction and perforation: a case report

Post-traumatic diaphragmatic hernia is a rare but life-threatening condition resulting from a traumatic injury to the diaphragm. We present a case of a 48-year-old man with a history of fall injury and a delayed presentation of a right-sided diaphragmatic hernia with subsequent bowel obstruction and perforation in a patient with a history of trauma and tuberculosis. The patient underwent exploratory laparotomy with manual reduction of the herniated bowel, primary repair of the diaphragmatic defect, and the creation of a double-barrel ileostomy. This case highlights the importance of considering traumatic diaphragmatic hernia in patients with a history of trauma presenting with abdominal symptoms. Timely diagnosis and surgical intervention are crucial in preventing serious complications associated with this condition.

Organizing pneumonia as an initial presentation in a male lupus: A rare case report

Organizing pneumonia (OP) is one of the rare pulmonary manifestations of systemic lupus erythematosus (SLE) which is infrequently reported as a presenting manifestation. Early diagnosis of lupus-related OP with the help of imaging, can drive to prompt initiation of immunosuppressive therapy leading to a better prognosis. We present a case of a 34-year-old young male who presented with fever, myalgia, and a dry cough for 1 month and was later diagnosed as SLE-related organizing pneumonia.

The food-energy-water-carbon nexus of the rice-wheat production system in the western Indo-Gangetic Plain of India: An impact of irrigation system, conservational tillage and residue management

The conventional rice-wheat system in the western Indo-Gangetic plain of India is energy and water intensive with high carbon footprint. The transition towards resource-efficient eco-friendly production technologies with lower footprint is required for inclusive ecological sustenance. A five-year (2016-17 to 2020-21) field experiment was conducted in RWS with hypothesis that pressurized irrigation systems [drip (DRIP) and mini-sprinkler (MSIS)] in conservation tillage [reduced (RT)/zero (ZT)] and crop residue management [incorporation (RI)/mulch (RM)] might result in higher resource use efficiency with lesser carbon footprint compared to conventional system. Experiment consisted five treatments namely (1) puddled transplanted rice followed by conventionally tilled wheat (PTR/CTW), (2) DRIP irrigated reduced till direct seeded rice (RTDSR) followed by zero-till wheat with 100 % rice residue mulching (ZTW + RM) (DRIP-RTDSR/ZTW + RM), (3) surface irrigated RTDSR followed by ZTW + RM (SIS-RTDSR/ZTW + RM), (4) MSIS irrigated RTDSR followed by ZTW + RM (MSIS-RTDSR/ZTW + RM), and (5) MSIS irrigated RTDSR with 1/3rd wheat residue incorporation followed by ZTW + RM (MSIS-RTDSR + RI/ZTW + RM). The pressurized irrigation system in RWS established under conservational tillage and residue management (DRIP-RTDSR/ZTW + RM and MSIS-DSR + RI/ZTW + RM) produced at par system productivity compared to PTR/CTW. Substantial nitrogen (79-114 ka ha^-1) and irrigation water (536-680 mm) savings under pressurized irrigation systems resulted in 41-64 % higher partial factor productivity of nitrogen with 48-61 % lower water footprint. These systems had lower energy consumption attaining 15-21 % higher net energy, 44-61 % higher energy use efficiency, and 31-38 % lower specific energy. Efficient utilization of farm inputs caused lower greenhouse gas emission (39-44 %) and enhanced carbon sequestration (35-62 %) resulting 63-76 % lower carbon footprint over PTR/CTW. The information generated here might useful in developing policies for resource and climate-smart food production system aiming livelihood security and ecological sustainability in the region. Further, trials are needed for wider adaptability under different climate, soil and agronomic practices to develop site-specific climate smart practices.

Pembrolizumab-induced encephalitis in a patient with renal cell carcinoma post nephrectomy: A case report

A new category of immune-related adverse effects has been identified due to increasing use of immune checkpoint inhibitor therapy to treat solid organ cancers. Pembrolizumab approved for renal cell carcinoma also has neurological immune-related adverse effects causing long-term morbidity. We here present a case of renal cell carcinoma post nephrectomy with suspected pembrolizumab (anti-PD-1)-induced encephalitis presenting as light headedness and dizziness treated with high dose of corticosteroid and intravenous immunoglobulin. Lumbar puncture was performed which showed elevated protein, nucleated cells with lymphocyte predominant, suggestive of chemical meningitis. Scans were found to be normal while electroencephalogram showed diffuse cerebral dysfunction indicating encephalopathy. The patient was under pembrolizumab treatment so encephalitis was suspected. Clinical attention is necessary when patients receiving immune checkpoint inhibitors appear with new neurological symptoms to prevent long-term morbidity or even possible mortality.

Right breast schwannoma in a male: A rare case report

Introduction

Schwannoma are benign neoplasms of peripheral nerve sheath. They usually occur in the head, neck and the extremities. Breast is a rare location of Schwannoma.

Case presentation

Our case describes the occurrence of Schwannoma in the right breast, in a 60-year-old male, who has had a breast lump since the last 6 years. After ultrasonography (showed 3.4 × 2.3 × 2.0 cm heteroechoic mass in the upper outer quadrant of the right breast), and mammography (showed 2.5 × 3.2 cm sized high density mass in upper outer quadrant of right breast), an excisional biopsy was performed, and on histopathologic examination, the diagnosis of breast schwannoma was confirmed.

Discussion

Clinical and pathological features resemble that of other benign tumors. On ultrasonography they present a well-defined, solid, hypoechoic mass, with some degree of posterior acoustic enhancement. Diagnosis is usually based on histopathologic examination. Microscopically, it exhibits hypercellular antony A areas along with hypocellular antony B areas. Treatment is usually surgical excision.

Conclusion

Though Schwannomas in breast are rare, they must be considered as differential diagnoses in patients presenting with breast lumps.

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Schwannomas are rare benign tumors of peripheral nerve sheath.

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Male breast is a rare location for schwannoma.

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Diagnosis is usually based on the histopathological findings.

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It mimics with other benign and malignant lumps occurring in breast, and must be considered as a differential diagnoses of breast lump.

Study on Status of Serum Biochemical and Hematological Parameters in COVID-19 Positive Patients Attending a Tertiary Care Hospital

Background Coronavirus disease 2019 (COVID-19) presents clinically a variety of pathological and clinical organ dysfunctions, ranging in severity from asymptomatic to fatal. The care and monitoring of COVID-19 patients may benefit from the use of biochemical and hematological markers. Objective To observe the alteration of serum biochemical and hematological parameters in COVID-19 positive patients, attending a Tertiary Care Hospital. Method A descriptive cross-sectional study was conducted on all COVID-19 positive patients attending Nobel Medical College Teaching Hospital, Biratnagar, Nepal from 15th December 2021 to 15th February 2022. The test results of different serum biochemical and hematological parameters done for these patients were recorded in clinical laboratory services and obtained retrospectively for the analysis. The data were entered in MS excel and analyzed by SPSS version 20. Result Out of 1537 COVID-11699 declared positive patients, 712 (46.32%) were male and 825 (53.68%) female. Mean age of COVID positive patients was 40.03±20.08 years. The level of serum SGOT, SGPT, ALP and GGT was significantly elevated in 39.9%, 42.8%, 32.3% and 47.2% of COVID positive patients respectively. Blood Urea, creatinine, uric acid and sugar level were significantly elevated in 63%, 56.1%, 33.1% and 47.6% patients respectively. The serum level of LDH, D-dimer, CRP and procalcitonin (PCT) were significantly increased in 52.1%, 75.9%, 71.6% and 61.2% of patients respectively. The serum value of total cholesterol, triglyceride, HDL and LDL were significantly lowered in 52.2%, 43.8%, 70.1% and 60.3% of patients respectively. RBC concentration and level of hemoglobin was reduced in 56.6% and 53.6% of COVID positive patients respectively whereas total leukocyte count was elevated in 80.7% with increase in neutrophil in 87.9% and decrease in lymphocyte in 79.4%. Conclusion A portion of COVID-19 positive patients showed drastically altered test results for various serum biochemical and hematological markers, although many of them had normal findings.

Ultrasound Guided Nerve Blocks for Anterior Cutaneous Nerve Entrapment Syndrome an Overlooked Cause of Chronic Abdominal Pain: A Case Series

Entrapment abdominal neuropathy is not a common diagnosis in our context. Chronic Abdominal wall pain is often mistaken for gastritis, gynecological issue, thoracic spinal radiculopathy, rectus sheath hematoma, abdominal muscle injury or psychiatric disorder. Anterior cutaneous nerve entrapment syndrome is one of the frequent causes of abdominal wall pain occurring due to trapped thoracic intercostal nerves between abdominal muscles. History and bedside Carnett's sign can elicit the diagnosis. Injection of the local anesthetics with steroids in the junction between the rectus sheath and abdominal muscle under ultrasound guidance can provide sustained pain relief. We should consider Anterior cutaneous nerve entrapment syndrome as a differential diagnosis while evaluating the abdominal wall pain. Keywords: ACENE; carnett's test; chronic abdominal pain; entrapment neuropathy; hydrodissection.

Clinical Characteristics and outcome analysis of SARS-CoV-2 patients admitted to different Critical Care Units in Nepal

BACKGROUND

The clinical presentation, biochemical characteristics, and outcomes of patients infected with SARS-CoV-2 can vary in different populations. The purpose of the study is to assess the clinical presentation and identify predictors of mortality among patients with severe acute respiratory distress syndrome admitted to different critical care units in Nepal.

METHODS

An observational study was conducted among the confirmed SARS-CoV-2 patients admitted to different critical care units in seven provinces of Nepal. Retrospective data was collected for the period of three months (April 14, 2021 to July 15, 2021) in relation to the peak of the second wave of COVID-19 pandemic in Nepal. Clinical, biochemical and mortality data were collected from the admitted patients of different critical care units. Univariate logistic regression analysis was done among the selected variables at 5% significance. Final predictor variables were identified after multiple regression analysis.

RESULTS

Out of total of 646 patients admitted to critical care units of different provinces of Nepal, there was a male predominance 420 (65%). A total of 232(35.91 %) patients were non-survivors with the majority of mortality occurring in patients > 50 years of age. Cough (72.3 %), shortness of breath (70.9%) and fever (56 %) were the most common presenting clinical features. Increasing age, presence of comorbidity, critical COVID-19 cases, respiratory rate, temperature, serum urea and alanine aminotransferase were identified as predictors of mortality after multiple regression analysis.

CONCLUSIONS

Approximately 36 % of the confirmed SARS-CoV-2 patient admitted to critical care units did not survive. There was a male preponderance with most casualties occurring in patients more than 50 years of age. Cough, shortness of breath and fever were the most common presenting features. After multiple regression analysis of the identified clinical and biochemical factors, age, presence of comorbidity, respiratory rate, temperature, severity grade as per the World Health Organization classification, serum urea and alanine aminotransferase were identified as the predictors of mortality.

Renal Outcomes of Pregnancy-Related Acute Kidney Injury: a Single Centre Experience in India

Objective:This study aimed to investigate the incidence, clinical characteristics, and outcomes of acute kidney injury (AKI) during pregnancy in Indian population. Materials and methods:A prospective observational study was conducted in pregnant patients admitted to Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India. Acute kidney injury was assessed using Risk, Injury, Failure, Loss of function, and End-stage renal disease (RIFLE) criteria. Patients were analyzed on the basis of demographic data, detailed history, clinical examination, and laboratory investigations. The primary outcome was maternal renal outcome, including return to normal renal function and progression to chronic kidney disease (CKD). The secondary outcomes included the mode of delivery, complications of pregnancy, intensive care unit (ICU) admission, and maternal death. Results:A total of 51 patients with an average age of 29.5 years were included in the present study. About 49.9% of subjects had severe anemia and 41.2% were primigravida. The main cause of AKI was pre-eclampsia and postpartum hemorrhage. There was a marked improvement in renal outcome with 33 patients having complete renal recovery and six patients developed CKD was observed during three months follow-up period. The peaked median value of blood urea was 62.0 mg% in patients with normal renal function, 178.5 mg% in those with CKD and 120.0 mg% in expired patients (P=0.001). A statistically significant change in serum potassium (P=0.010) and creatinine levels (P<0.001) was observed during the follow-up period. Liver enzymes, including serum glutamic oxaloacetic transaminase and serum glutamic pyruvic transaminase, were high in all patients at the time of admission, but decreased to normal on follow-up. Conclusion:Our study indicates that pregnancy-related AKI patients present with multiorgan complications and many of them require mechanical ventilation and renal replacement therapy. Most of these patients have poor outcome. Hence, the management of pregnancy-related AKI presents a challenge that requires proper evaluation of causative factors to facilitate appropriate treatment.

Seed and seedling diversity delimitation and differentiation of Indian populations of Melia dubia cav

Melia dubia is one of the most important industrial tree species in the South East Asia. In last few decades, the populations of M. dubia has rapidly expanded in the Indian sub-continents, leading to an increase in the genetic diversity of species. However, very less information is available on intra-specific variation in Melia under the Indian subcontinent. Therefore, a present investigation was undertaken, to assess the level of diversity in seed and saplings of the Melia populations (ecotypes) collected from three agro-ecological regions of India. Results revealed that the seed and saplings of all the ecotypes are significantly different for all the traits, except for number of branches per plant, and the maximum variability was recorded in germination percentage, seed weight, internodal length, and sapling height of the species. The high heritability for seed weight (0.99), length (0.99), and width (0.97), and germination percentage (0.99) indicated that selection and genetic gain for these traits would be effective during the commencement of improvement program. Trait association analysis explained that higher seed weight significantly reduced sapling height, collar diameter, number of leaves per plant, internodal length, petiole length, and germination percentage (r = −0.86; p < 0.001) that ultimately reduced the seedling vigor in Melia dubia. Interestingly, the number of branches per plant were not associated with any of the morphological traits. The first principal component explained 50.09% of the entire variation and all the traits contributed greatly to the variation for this principal component, except for number of branches, leaf width and seed length. The clustering approach assorted geographic variation of M. dubia populations into three main sub-clusters i.e. South, North, and North East populations each consisting of five, seven and one populations (including cultivar), respectively. Among different ecotypes, Bahumukhi, Varsha and US Nagar seed sources outperformed all others in seedling vigour (sapling height) and rest of the growth parameters. Overall, findings explained that considerable scope exists for the development of superior planting material of M. dubia through exploration of seeds and selection at the early seedling stage.

Performance of custom made videolaryngoscope for endotracheal intubation: A systematic review

Introduction

Videolaryngoscope is regarded as the standard of care for airway management in well-resourced setups however the technology is largely inaccessible and costly in middle and low-income countries. An improvised and cost-effective form of customized videolaryngoscope was proposed and studied for patient care in underprivileged areas however there were no distinct conclusions on its performances.

Method

The study follows PRISMA guidelines for systematic review and the protocol in International Prospective Register for Systematic Reviews. The primary aim was to assess the first attempt success of customized videolaryngoscope for endotracheal intubation. The secondary objective was to evaluate the number of attempts, laryngoscopic view in terms of Cormack Lehane score and Percentage of glottic opening, use of external laryngeal maneuver and stylet and, the airway injuries after the endotracheal intubation.

Result

Five studies were analyzed for risk of bias using the National Institute of Health Quality Assessment Tool for cross-sectional studies. Most of the studies had a poor to a fair level of evidence with only one study with a good level of evidence. Certainty of evidence was “very low” for all eligible studies when graded using the Grading of Recommendation, Assessment, Development and Evaluation approach for systematic review.

Conclusions

The certainty of the evidence regarding performance of custom-made videolaryngoscope compared to conventional laryngoscope was very low and the study was performed in small numbers with fair to the poor risk of bias. It was difficult to establish and do further analysis regarding whether the customized form of videolaryngoscope will improve the first attempt success rate for tracheal intubation, reduce the number of attempts, improve the laryngoscopic view, require fewer external aids and reduce the incidences of airway injury with the given low-grade evidence. Some properly conducted randomised clinical trials will be required to further analyze the outcome and make the strong recommendations.

Microwave observations reveal the deep extent and structure of Jupiter's atmospheric vortices

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Frequency of Osteoporosis among Chronic Obstructive Pulmonary Disease Patients Attending Respiratory Medicine Out Patient Department, BSMMU

Osteoporosis is an important systemic manifestation of Chronic Obstructive Pulmonary Disease (COPD). Osteoporosis is a systemic disease of bone which may present as low bone mass and micro-architectural disarray that increases the risk of fracture. The World Health Organization defines osteoporosis as bone density ≥2.5 standard deviations below the bone density of a normal young adult. Osteopenia, a less severe form of bone loss, is defined as a bone density between 1 and 2.5 standard deviations below that reference point. The aetiology of osteoporosis in COPD patients remain unclear, but several factors significantly correspond to reduced bone density in COPD, including older age, female sex and body mass index (BMI). However, the relationship to other factors, such as FEV₁, tobacco smoking, physical inactivity and corticosteroid therapy, are still an unresolved issue. This cross-sectional study was done in the Department of Respiratory Medicine, BSMMU from March 2018 to March 2019. A total of 86 patients of which prevalence of osteoporosis is 29.1%, osteopenia 50% and normal BMD in 20.9%, majority of them was belonging to age group 51-60 years. Male were predominant with male-female ratio of 3.5:1. The frequency of osteoporosis was 32.0%, 64.0% and 4.0% in moderate, severe and in very severe COPD patients, respectively. The frequency of osteopenia was 14.0% in mild, 53.5% in moderate, 20.9% in severe and 11.6% were in very severe COPD patients. The p value (p=0.018) was significant for prevalence osteoporosis and osteopenia with increase in severity of COPD. The prevalence of osteoporosis and osteopenia was high in COPD patients under study. The frequency of osteoporosis and osteopenia was more with severity of COPD.

Ultrasound Guided Thoracic Paravertebral Block as an Analgesic Technique for Tracheoesophageal Fistula repair : A Case Report

Ultrasound has now become an eye of anaesthesiologist and has encouraged for its pervasive use. Its considerable use in the perioperative period for various invasive purposes has added an extra caution to prevent unforeseen complications over blind blocks. The ultrasound-guided thoracic paravertebral block provides excellent perioperative analgesia following thoracic surgery. It can be given as a single shot or a continuous infusion technique placing a catheter. Here the local anesthetic agent is deposited in the paravertebral space from where the spinal nerve emerges which are devoid of coverings and are sensitive to local anesthetics. Even a single-shot block provides analgesia of 4-6 dermatomal levels. The use of local anesthetics using ultrasound not only adds safety measures to minimize procedural complications but also reduces the perioperative requirement of opioids. It also helps in the reduction of postoperative pulmonary complications and early extubation following thoracic surgery. We report a case series where single-shot ultrasound-guided unilateral paravertebral blocks were used as an analgesic technique for the repair of tracheoesophageal fistula in neonates. After delivering anesthesia and confirming the correct placement of the endotracheal tube the neonate was kept on the left lateral position to undergo right thoracotomy and repair of fistula. Scanning at T4 level with a linear probe was done to identify the transverse process, pleura, costotransverse ligament, intercostal muscle, and the paravertebral space where the local anesthetic agent was deposited under aseptic precautions. Tenting of pleura was the endpoint for the completion of the block. The extensive use of various regional anesthetic technique has significantly improved the postoperative outcome of the patients along with adequate perioperative pain management.

Clinical Outcome of Cooled Radiofrequency Ablation in Chronic Knee Pain Osteoarthritis: An Initial Experience from Nepal

BACKGROUND

Cooled Radiofrequency ablation is a newer technique for management of chronic knee pain in osteoarthritis. The aim of the study is to evaluate the clinical outcomes in patients with chronic osteoarthritis in terms of pain scores for first six months of cooled radiofrequency ablation using ultrasound guidance.

METHODS

A cross-sectional study with retrospective review of database was evaluated to analyze the change in the Numerical Rating Scale from baseline scores at 1 day, 1 month and 6 months after the Cooled Radiofrequency ablation of genicular nerves around knee in patients with chronic knee osteoarthritis.

RESULTS

Median age was 71 years [ 61-73 years (IQR: 25-75)] with more female preponderance. Numerical Rating Scale (Mean ± S.D.) was significantly less at 1 day (1.87 ± 1.22), 1 month (3.03 ± 0.99) and 6 months (3.37 ± 1.098) from baseline values (6.77 ± 1.00). No soreness and numbness were noted.

CONCLUSIONS

Cooled Radiofrequency using Ultrasound guidance for management of knee pain in chronic osteoarthritis is promising and reduces Numerical Rating Score significantly from baseline at 1 month and 6 months respectively.

Anaesthesia for Antenatal Diagnosed Duodenal Atresia with Undiagnosed Persistent Pulmonary Hypertension of Neonate

Conversion of fetal circulation to adult-type occurs immediately after birth but neonates with problems in the development of pulmonary vasculature are prone to revert back to fetal circulation. This phenomenon is known as flip-flop circulation which may be induced perioperatively and as such anesthesiologist are central to its management. We report a case of term neonate planned for repair of duodenal atresia that despite having no respiratory symptom preoperatively developed severe hypoxemia under anesthesia that was even unresponsive to 100% oxygen. The intraoperative hemodynamics of the neonate was managed along with supportive care successfully. A postoperative echocardiogram confirmed the evidence of persistent pulmonary hypertension of the newborn. Keywords: Duodenal atresia; flip flop circulation; neonates; persistent pulmonary hypertension of newborn.

Biochemical and functional attributes of raw and boiled potato flesh and peel powders for suitability in food applications

Four different potato cultivars, namely, Kufri Chipsona 1 and Kufri Frysona (processing purpose), Kufri Jyoti and Kufri Bahar (table purpose) were converted into flesh and peel powder (raw and after boiling) and studied for their respective biochemical and functional attributes to get an idea of possible dynamics of their utilization in different food formulation as bioadditives. The 16 variants of powder obtained retained less than 10% moisture content and demonstrated 'very good' to 'fair' flowability. Peel powders recorded a higher total mineral, fiber, phenolic contents and total antioxidant activity than the flesh powders which were significantly affected by boiling. Among raw and boiled flesh powders, highest reducing and total sugars were recorded for Kufri Bahar while least was observed in Kufri Chipsona 1. Colour coordinate showed that boiling imparts brightness to flesh powder while peel powder got darkened. Boiling of the tubers resulted in an increase in the resistant starch (~ 29% maximum) and flavour (~ 180% maximum) component. Peel exhibited a total glycoalkaloid content in the range of 0.75 (Kufri Frysona) to 1.7 mg/100 g (Kufri Bahar) that is well within the acceptable limits. Rheological study of the flesh powders revealed a reduction of about 11-18 °C in pasting temperature and about 87-90% in peak viscosity, setback, breakdown value and final viscosity upon boiling. This study revealed that the traditional processing method such as boiling can significantly modify the techno-functional characteristics of potato flesh and peel powders which can further govern their end use in various food formulations.

Ultrasound Guided Continuous Quadratus Lumborum Block as a Perioperative Analgesic Technique for Pyeloplasty in a Paediatric Patient : A Case Report

With the use of ultrasound, peripheral nerve blocks can be more precise and deposition of local anesthetics under direct vision reduces drug volume and minimizes untoward toxicity. Its extensive use in peri-operative period add a safety measures to reduce procedural complications. Pain in children's are often under recognized and under treated which can lead to emotional, psychological trauma for rest of their life. Peripheral nerve blocks have the advantage of greater overall safety and efficacy for lower abdominal surgeries. An abdominal truncal block technique known as Quadratus Lumborum block has emerged recently with a goal of anesthetizing the thoracolumbar nerves for somatic as well as visceral analgesia of both lower and upper abdomen. A sound knowledge of sensory supply to the genitourinary system is important for the success of regional anesthesia. We report a case of four years old child who was diagnosed as left sided pelvic ureteric junction obstruction and was planned for pyeloplasty where continuous quadratus lumborum block was used as a mode of post operative analgesia which showed a promising result. Antibiotic resistance and lack of newer effective antibiotic against multidrug resistant bacteria like Acinetobacter baumannii is a common problem in intensive care unit. Trimethoprim -Sulfamethoxazole may help in combating this problem.

Salicylic acid and thiourea mitigate the salinity and drought stress on physiological traits governing yield in pearl millet- wheat

Plant growth is often affected with hampered physiological and cellular functioning due to salinity and drought stress. To assess the effectiveness of plant bioregulators (PBRs) in mitigating abiotic stresses, a double spilt plot field study was conducted with three replications at ICAR-CSSRI, research farm, Nain, Panipat. The study comprised of three deficit irrigation regimes viz., 100, 80 and 60% of crop evapo-transpiration (ET_c) (I₁, I₂ and I₃), four levels of irrigation water salinity i.e. 2, 4, 8, 12 dS m⁻¹ (S₀, S₁, S₂ and S₃) and two PBRs salicylic acid (SA; G₁) and thiourea (TU; G₂). Irrigations, as per regimes and salinity, were applied at identified critical stages of wheat and if needed in pearl millet. PBRs were applied as seed priming and foliar sprays at two sensitive stages of respective crops. The trend of plant height, and physiological and biochemical traits was similar under different treatments at both stages, but differed significantly only at reproductive stage. Water deficit caused significant reduction in pearl millet (5.1%) and wheat (6.7%) grain yields. The reduction in grain yield under 8 and 12 dS m⁻¹ was 12.90 and 22.43% in pearl millet and 7.68 and 32.93% in wheat, respectively compared to 2 dS m⁻¹. Application of either SA (G₁) or TU (G₂) significantly enhanced plant height and grain yield, but magnitude of the increment was higher with SA in pearl millet and with TU in wheat. Application of SA and TU increased grain yield by 14.42 and 12.98 in pearl millet, and 12.90 and 17.36% in wheat, respectively. The plant height, RWC, TC, MI, LP, proline, Fv/Fm and Na/K ratio significantly reduced by salinity stress in pearl millet and both water and salinity stress in wheat. Application of both PBRs proved beneficial to mitigate adverse effect of water deficit and salt stress by significantly improving physiological traits, biochemical traits and ultimately grain yield in both crops.

Prosthetic Management of Microstomia with Customized Dynamic Splint

Microstomia is a clinical condition of reduced mouth opening that can be acquired or congenital in origin. Problems associated with microstomia can be related to function, esthetics, or both. Management of microstomia due to facial burns is complex due to the presence of hypertrophic and contracture scars. Available treatment options can be broadly classified as surgical, nonsurgical, or both. Splints can be used to prevent the contraction of perioral musculature or to recuperate lost mouth opening. Various intraoral or extraoral, tooth-borne or tissue-borne, and static or dynamic appliances are in clinical use, but their designs are case specific. This case report explains the management of microstomia secondary to facial burns by using a dynamic splint in combination with intralesional injections of triamcinolone acetonide and hyaluronidase.

Can Ultrasound Guided Regional Anesthesia Improve Rural Anesthesia Services and Address Safety Issues in Low Income Country? Perspective from Nepal

Provision of anesthesia services in a deprived area particularly in low income countries is a major challenge all over the globe. Along with issues of manpower, logistics, services, there lies agendas of safety and accuracy while delivering the services. With rise in ultrasound use in regional anesthesia, pain and perioperative care, it is prudent that some of these issues can be addressed with proper training, mentoring and monitoring. The global idea needs to be implemented locally to reach out to huge volume of patients who are inadequately treated for the various painful conditions. A group of regional enthusiasts from Nepal takes the vision and mission in Nepalese context to address the issues. Keywords: Low income country; rural anesthesia; safety; ultrasound guided regional anesthesia.

Appendicitis in the Elderly Patient with Multiple Co-Morbid Conditions: Case Report

Acute appendicitis is commonly encountered surgical emergency worldwide.  Although, it is commonly found in young and middle aged groups, the incidence of the diseases in geriatric age group is very rare and possesses a great challenge to safe technique of anesthesia due to co-existing comorbid conditions and medications used. Geriatric population are more susceptible to complications of appendicitis. This is a case report of 82 years old male patient, presented with appendicular perforation with localized abscess formation in a septic state with multiple comorbid condition. Routinely performed Spinal and general anaesthesia adds further challenge in management of this patient during and after surgery. Therefore, we performed the case in regional nerve block; paravertebral, ilioinguinal- iliohypogastric (ILIH) and coeliac plexus block and sedation.

Prevalence of Depression, Anxiety and Insomnia in Chronic Kidney Disease Patients and their Co-Relation with the Demographic Variables

BACKGROUND

Chronic kidney disease (CKD) is an emerging health problem in both developed and developing countries. Depression, anxiety and sleep disturbances are highly prevalent in patients with chronic disease, but remain undertreated despite significant negative consequences on patients' health. Assessment of key components of mental health early in disease course will help to identify high risk subjects in whom modifying these predictors will help in providing active and healthy life in CKD patients.

METHODS

We did a cross sectional study in 200 patients of CKD stage III to V-D fulfilling the eligibility criteria who were on follow up in a single tertiary care center in the state of Haryana, India. We assessed the prevalence of anxiety, depression and insomnia and their correlation with demographic variables in these patients. The structured questionnaire used in this study gathered information on respondent demographic and disease characteristics, and information obtained from the HADS and PSQI questionnaire. Factors associated with anxiety, depression and insomnia were examined by a multiple logistic regression analysis.

RESULTS

The prevalence of anxiety, depression and insomnia were found to be 71%, 69% and 86.5% respectively. As the CKD stage advanced, the prevalence as well as severity of these parameters increased. Anxiety, depression and sleep quality were found to be significantly correlated to unemployment, low income, low education, urban residence and presence of co-morbidities. The anxiety, depression and insomnia scores were found to have a strong negative correlation with eGFR, hemoglobin, serum calcium (p <0.01) and a positive correlation with TLC, blood urea, serum creatinine and serum phosphate (p <0.05).

CONCLUSION

We observed a high prevalence of anxiety, depression and insomnia in CKD patients. There is a need to develop strategies to accurately identify "high risk" subjects who may benefit from preventive measures before complications occur. By identifying CKD patients with high risk of developing these mental health related issues, healthcare provider may be better able to ensure the provision of appropriate rehabilitation to this population.

Rapid prototyping technology for cranioplasty: A case series

Cranial vault defects may be acquired or congenital in origin. Rehabilitation of these patients often poses challenge to the operating team and prosthodontist. Polymethylmethacrylate is a commonly used alloplastic graft material which is used for the fabrication of cranial prosthesis. Nowadays, with the advancement in the bioengineering, custom-made template and cranial prosthesis can be made by rapid prototyping technology (RPT) by patient three-dimensional (3D) computed tomography (CT) scan images. This series of two cases explained two different techniques for the rehabilitation of the patient with frontotemporoparietal cranial defect. Case 1 had a history of cerebrovascular accident, followed by decompression craniotomy which led to frontotemporoparietal defect of the left side. This defect area was associated with the cerebrospinal fluid accumulation which made delineation of underlying bony margins difficult and interfered with conventional impression procedures. Case 2 had a road traffic accident which led to intracerebral hemorrhage followed by decompression craniotomy which resulted in frontotemporoparietal defect of the right side. The patient had a poor neuromuscular control which impedes with the upright posture of the head during impression making of the defect area. Therefore, these cases were planned to rehabilitate by RPT. In these techniques, the prosthesis was made using custom-made skull template produced by RPT, using the data of 3D-CT scan images. This technique resulted in the prosthesis with good esthetics and better fit of the prosthesis. The contours of the prosthesis were replicated in the same manner as compared to the contralateral side. RPT is an additive manufacturing technology which is now used in the field of dentistry too. This technique is easy to use; fabricate prosthesis with high precision is less time-consuming and has fewer chances of error.

Municipal solid waste (MSW): Strategies to improve salt affected soil sustainability: A review

Salt-induced soil degradation is a serious threat to global agriculture which is responsible for diminished productivity of agro-ecosystems. Irrigation with poor quality water and indiscriminate use of chemical fertilizers to increase crop productivity creates salt accumulation in soil profile thereby reducing crop sustainability. High concentration of salts in soil inhibits plant growth due to low osmotic potential of the soil solution, ion toxicity and imbalance reduces nutrient uptake, crop yields. Low productivity of saline soils is not only due to salt toxicity or excess amounts of soluble salts but also lack of available mineral nutrients especially nitrogen, phosphorus, potassium and soil organic matter. Hence, sustainable management of salt-affected soils are paramount importance to meet the demands of food grain production for an ever-rising population in the world. Recently, municipal solid waste has gained importance as an organic amendment for restoring soil fertility and finally contributing to productivity of salt-affected soils. This paper compares extant waste generation, their properties and standards pertinent to municipal solid waste in different countries and explores the unique recent history in some countries that shows high environmental regard and rapid changes and also suggests policy experiencing from high environmental regard and rapid changes from other countries, so that policy makers can propose new or revise current municipal solid waste standards for salt affected soils. Municipal solid waste compost improves soil biological, physical and chemical properties because of high soil organic matter and lower concentration of pollutants. Therefore, the use of municipal solid waste in salt-affected soils could be an alternative to costly chemical amendments as well as reduce the reliance on chemical fertilizers for increasing productivity of salt-affected soil. The municipal solid wastes significantly improve crop yields. However, further long-term experimental investigations are needed to re-validate the application of municipal solid waste compost in improving physical, chemical and biological properties and to step up organic fertilization use in a wide range of both saline and sodic soils. In future, research should be directed to address these issues globally to minimise ecological disturbances and to set environmental standards, and evaluate the feasibility of the policies in different countries and their impact on socio-economic conditions of local people.

Ultrasound Guided Thoracic Paravertebral and Coeliac Plexus Block for Open Cholecystectomy in a Patient with Multiple Co-Morbidities : A Case Report

Ultrasound guided nerve blocks are gaining popularity these days due to its higher accuracy and reduced incidence of complications. Ultrasound guided unilateral paravertebral block in combination with unilateral coeliac plexus block and unilateral Rectus sheath block in patients with multiple co-morbidities provides adequate anesthesia for surgery and it also reduces incidences of mortality, morbidity and hospital stay in comparison to General anesthesia and spinal / epidural anesthesia. Paravertebral block , Coeliac plexus block and Rectus sheath blocks can be performed with higher success rate with the use of ultrasound.  BJHS 2018;3(2)6:508-510.

Prevalence and Clinical Correlates of Microalbuminuria in Patients with Essential Hypertension - A Tertiary Care Center Cross Sectional Study

INTRODUCTION

Albuminuria is predictor of target organ damage and worse cardiovascular outcomes. Microalbuminuria has been found in a large number of patients with essential hypertension. Aim of our study was to evaluate the frequency of microalbuminuria in essential hypertension and to study its correlation with severity of hypertension and target organ damage.

MATERIALS AND METHODS

This cross-sectional study was conducted at the outpatient clinic of General Medicine department of Pt. B D Sharma PGIMS, Rohtak. Hundred patients of essential hypertension (group A) in the age group of 18-65 years were included in the study. A control group (group B) consisting of hundred healthy normotensive, age and sex matched volunteers were also entered into the study. Arterial blood pressure was measured by digital sphygmomanometer after five minutes of rest; the values reported represented the average of three consecutive measurements taken over a 15-minute period. Urine albumin excretion (UAE) was estimated by an immunoturbidometry method. Microalbuminuria was defined as UAE between 30 and 300 mg/24 hours. Statistical analysis was performed by standard methods to measure rates and proportions; chi square test was used for analyzing the associations between the variables.

RESULTS

In this study it was observed that prevalence of microalbuminuria in essential hypertension was 47%. Risk factors for microalbuminuria included higher age, SBP and MAP. Microalbuminuria was associated with dyslipidemia, deranged renal parameters and end organ damage in form of LVH, ischemic changes, hypertensive retinopathy and renal dysfunction. In conclusion, this study confirmed that increased urinary albumin excretion is associated with a worse pattern of cardiovascular risk factors and is a marker of concomitant cardiovascular damage in essential hypertension.

CONCLUSION

Microalbuminuria can therefore be regarded as a useful, relatively inexpensive, integrated marker to help identify patients at higher cardiovascular risk for whom more aggressive preventive strategies and additional treatment measures may be advisable.

Long-term impact of manuring and fertilization on enrichment, stability and quality of organic carbon in Inceptisol under two potato-based cropping systems

Soil organic matter (SOM) stability is a prerequisite for long-term C sequestration. The long-term effect of manuring and fertilization on stability of SOM in rice-potato-wheat (R-P-W) and maize-potato-onion (M-P-O) cropping systems was studied in an Inceptisol of semi-arid subtropical India. Soil samples were collected (0-15 and 15-30cm soil depths) from the following treatments: control, 100% NPK-Fertilizer, 100% N-Vermicompost (VC), 50% NPK-Fertilizer+50%N-Vermicompost (VC), 100%NPK-Fertilizer+crop residue (CR), 100% N-VC+CR. The stability of SOM was studied by correlating the ammonium oxalate extractable Fe, Al and Si with stable soil organic C (SOC). Application of 100% N-VC and 100% N-VC+CR increased the SOC stock by 66% and 32%, respectively over 100% NPK in R-P-W cropping system, while in M-P-O system, the above treatments increased the SOC stock by 28% and 12%. As compared to 100%NPK, the integrated use of 50%NPK+50%N-VC increased the SOC stock by 58% and 35% in R-P-W and M-P-O system, respectively. The extractable Fe, Al and Si significantly correlated with stable OC and the multiple regression model developed between these parameters could well predict the stable OC in soil. Complete or partial substitution of chemical fertilizer N with VC could be a promising nutrient management strategy for enhancing the SOC stock in Inceptisol under potato-based cropping systems of semi-arid sub-tropical India. However, the integrated use of 50%NPK+50%N-VC could be promising due to lowest yield reductions and moderate SOC sequestration potential. The enrichment (47%), as well as quality (81%) of SOC was higher in R-P-W system than in M-P-O system. The organic treatments like 100%NPK+CR and 100%N-VC+CR showed higher stability of SOC in R-P-W (31% and 26%) than in M-P-O cropping system. The stability of SOC could well be predicted by extractable amorphous and poorly crystalline Fe, Al and Si and SOC in both the cropping systems.

Health-related quality of life in different stages of chronic kidney disease

INTRODUCTION

Improved survival of chronic kidney disease (CKD) patients has led to an increased focus on health-related quality of life (HRQoL) for evaluating treatment effectiveness and assessing health outcomes of these patients.

OBJECTIVE

To evaluate HRQoL in patients in different stages of CKD and to explore possible correlating and influencing factors.

METHODS

Cross-sectional design with 200 patients from India in CKD stages 1-5 assessed for HRQoL through 36-item short-form together with biomarkers. Patients were divided into four groups according to their estimated Glomerular Filtration Rate (eGFR); group A with GFR range > 90 ml/min/1.73 m², group B with GFR range 30-59 ml/min/1.73 m², group C with GFR range 15-29 ml/min/1.73 m² and group D with GFR < 15 ml/min/1.73 m² RESULTS: HRQoL scores in all dimensions impaired progressively and significantly across renal function levels and CKD stages. A statistically significant decreasing trend in physical composite summary and mental composite summary scores was found in patients from group A to D (P< 0.001). Patients with eGFR < 30 ml/min/1.73 m², Diabetes Mellitus, Cardio vascular disease (CVD), C-reactive protein (CRP) ≥ 5 mg/l, Hemoglobin  ≤ 90 g/l, erythrocyte sedimentation rate  ≥ 20 and mean arterial pressure  ≥ 100 mm hg had significantly lower scores on all HRQoL dimensions. Among these CRP, reduced GFR and CVD were the most important predictors of impaired HRQoL.

CONCLUSION

Considering the worldwide growing prevalence of CKD and increasing importance of HRQoL in chronic diseases, improving our knowledge about HRQoL and its predictors in CKD patients is important. Assessment of HRQoL early in disease course will help to identify high risk patients in whom modifying these factors may help them lead an active and healthy life.

Systemic lupus erythematosus presenting as fulminant lupus pneumonitis: a rare case report

We report a case of 19 year-old female patient diagnosed as systemic lupus erythematosus (SLE) presented with fever and diffuse cutaneous lesions. During the hospital stay she had acute pneumonia, pleural effusion and respiratory failure, which required intensive care unit (ICU) care and mechanical ventilator support. A fulminant course of the disease, decreased values of complement levels and positive antinuclear antibodies (ANA) in pleural fluid and repeated negative sputum for acid-fast bacillus, blood cultures enabled diagnosis of fulminant lupus pneumonitis. Fulminant lupus pneumonitis is a rare but potentially life threatening complication of SLE. Management requires involvement of multiple specialties and rigorous efforts in reviving the patient.

A study of coronary artery variants and anomalies observed at a tertiary care armed forces hospital using 64-slice MDCT

BACKGROUND

Isolated coronary artery anomalies are usually clinically silent and mostly detected incidentally during angiography or autopsy. However, few of them may be implicated in cases of sudden cardiac death even in the absence of additional heart abnormalities. Prior knowledge of such variants and anomalies is necessary for planning various interventional procedures. Multiple detector computed tomography coronary angiography has proved a very useful non-invasive modality in this field given its superiority over conventional coronary angiography in providing detailed coronary artery anatomy.

METHODS

A retrospective review of the coronary CT angiography studies was carried out at our center between August 2014 and December 2015 with the purpose of describing the coronary artery variants and anomalies that we came across in our cohort.

RESULTS

In our cohort, about 77% (n=391) of the patients had a right dominant system while left dominant and co-dominant systems were seen in 12% (n=61) and 11% (n=56) respectively. Coronary CT angiography was successful in visualizing smaller branches, such as the conus artery (96.25%, n=489), the sinus node artery (83.07%, n=422), and the septal branches (95.27%, n=484). Coronary anomalies were observed in the 10.04% of our population (n=51). Eleven anomalies of origin and course were found.

CONCLUSION

Coronary CT angiography gives us a good understanding of the variations and anomalies of the anatomy of the coronary arteries. This can be of immense help to the clinician planning interventional procedures.

Accumulation of Metals in Soils, Groundwater and Edible Parts of Crops Grown Under Long-Term Irrigation with Sewage Mixed Industrial Effluents

Farmers in developing countries irrigate crops using raw urban and industrial effluents with consequent risks from metal contamination. Therefore, soils, crops and groundwater from an effluent irrigation use site were assessed for Cd, Cr, Ni and Pb. Total and available contents of metals in soil followed the order Pb>Ni>Cr>Cd. Crops accumulated more Pb, followed by Cd, Ni and Cr. Pb exceeded the permissible limit with wastewater irrigation only, but Cd exceeded the limit even with combined irrigations of wastewater and groundwater. Among crops, sugar beet assimilated highest Cd (3.14 μg g(-1)) and Pb (6.42 μg g(-1)) concentrations. Legumes accumulated more metals than cereals. Long-term use of wastewater and its conjunctive use with groundwater led to toxic accumulations of Cd, Pb, Ni and Cr. Cd with higher availability and mobility indices and lower toxicity limit, posed the maximum risk of food-chain contamination.

Antimicrobial activity and identification of potential antimicrobial compounds from aquatic pteridophyte, Azolla microphylla Kaulf

Azolla microphylla Kaulf. is an aquatic nitrogen fixing pteridophyte commonly found in aquatic habitats including paddy fields. Methanolic extract of the fronds of A. microphylla was subjected to partial purification by solvent partitioning with diethyl ether and ethyl acetate followed by hydrolysis, and further partitioning with ethyl acetate. The two fractions, thus obtained were tested for antibacterial activity. It was observed that the ethyl acetate fraction inhibited the growth of the pathogenic bacterium Xanthomonas oryzae. The GC-MS analysis of the ethyl acetate fraction showed several prominent peaks with retention time ranging from 8.83 to 45.54 min. A comparison of these peaks with the GC-MS libraries revealed that it could be eicosenes and heptadecanes with potential of antimicrobial activity.

A comparative study of efficacy of epidural versus interpleural bupivacaine for post operative analgesia after open cholecystectomy

Background The conventional methods of administering the prescribed doses of intramuscular or intravenous analgesics at fixed time intervals results in widely fluctuating and inadequate plasma level leads to poor post operative pain relief. Despite all advances made in the field of medicine, this symptom called “Pain” has not been combated well. Objective The present study was carried out to compare the efficacy of epidural verses interpleural administration of bupivacaine(0.5%) with adrenaline for post operative pain relieve in patients undergoing open cholecystectomy. Methods We prospectively randomized and compared the post operative pain relieve with the reference of visual analog score (VAS) in patients undergoing elective open cholecystectomy in college of medical sciences-teaching hospital, Bharatpur, Chitwan. Forty adult patients undergoing elective cholecystectomy were divided into two groups. Twenty patients in each group were subjected to a different technique of post-operative analgesia, namely thoracic epidural and interpleural instillation of 0.5% bupivacaine. These two groups were then compared in relation to changes produced in the pain scores, vital parameters and complication and side effects associated with the two techniques. The study was conducted for 24 hour postoperatively. Observation: Both thoracic epidural and interpleural instillation of 0.5% bupivacaine compared favorably with regard to analgesia in the present study. In general, the pain relief following thoracic epidural was more complete compared to interpleural but this was not clinically significant. Conclusion The present study shows that both the techniques are equally effective in providing analgesia following cholecystectomy. However, neither technique rendered the patients completely pain free at all times during first 24 hours. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-4, 15-23 DOI: http://dx.doi.org/10.3126/jcmsn.v9i4.10232

Retinal nerve fiber layer evaluation of spectral domain optical coherence tomograph and scanning laser polarimeter to diagnose glaucoma

PURPOSE

To compare the abilities of retinal nerve fiber layer (RNFL) parameters of spectral domain optical coherence tomograph (SDOCT) and scanning laser polarimeter (GDx enhanced corneal compensation; ECC) in detecting glaucoma.

METHODS

In a cross-sectional study, 215 eyes of 165 subjects (106 eyes of 79 glaucoma patients and 109 eyes of 86 controls) referred by general ophthalmologists for glaucoma evaluation underwent RNFL imaging with SDOCT and GDx ECC. Ability of RNFL parameters of SDOCT to discriminate glaucoma eyes from control eyes was compared with that of GDx ECC using area under operating characteristic curves (AUCs), sensitivities at fixed specificities, and likelihood ratios (LRs).

RESULTS

AUC of the average RNFL thickness of SDOCT to differentiate glaucoma from control eyes (0.868) was comparable (P=0.32) to that of GDx ECC (0.855). Sensitivity at 95% specificity was 63.2% for average RNFL thickness of SDOCT and 48.1% for the average RNFL measurement of GDx ECC. LRs of outside normal limits category of SDOCT parameters ranged between 5.6 and 7.7 while the same of GDx ECC parameters ranged between 3.1 and 3.7. LRs of within normal limits category of SDOCT parameters ranged between 0.18 and 0.24 while the same of GDx ECC parameters ranged between 0.20 and 0.32.

CONCLUSION

Though AUCs and sensitivities at fixed specificities were comparable between the RNFL parameters of SDOCT and GDx ECC in diagnosing glaucoma, LRs indicated that the RNFL parameters of SDOCT were better in 'ruling in' glaucoma.

A clinical comparison of high dose and low dose of Suxamethonium

Background: Suxamethonium having its rapid onset and short duration of action makes this drug unique amongst the neuromuscular blocking drugs described so far. However, use of suxamethonium is associated with a large number of undesirable side effects. Objective: To evaluate clinical effects of high and low dose of suxamethonium and to determine whether lower dose of suxamethonium can be used for any beneficial effects in terms of its various adverse effects e.g. cardiovascular responses, post-operative muscle pains and intraocular pressure. Methods: A total of 100 patients were included in this prospective study. All these patients on preoperative clinical evaluation were assessed to have adequate airway. All the patients were divided in two groups, low dose group (group I) and High dose group (group II) with 50 patients in each at random. A standard anesthetic technique was adhered to all the patients and following parameters were observed on comparative basis: a. Fasciculation and post operative myalgia. b. Cardiovascular effects, c. Intraocular pressure. Observation: The incidence of post Suxamethonium pain was significantly greater in group II. Increase in heart rate from baseline was significant in both groups. There was no significant difference between the two groups in the diastolic pressure but rise in systolic blood pressure was significant at all assessment times in both groups. This rise from control was statistically significant. Conclusion: Suxamethonium can be used in lower doses (0.5 mg/kg) in elective cases without airway compromise. It gives benefits of reduced muscle pains, cardiovascular responses and intraocular hypertension. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-2, 1-8 DOI: http://dx.doi.org/10.3126/jcmsn.v9i2.9677

A comparison of serum potassium level between high dose and low dose of Succinylcholine

Aims: Succinylcholine is a depolarizing type of neuromuscular blocking drug. Aim of this study is to evaluate and compare serum potassium level with upper dose limit of succinylcholine (1.5mg/kg), which is used normally in anesthetic practice with low dose of succinylcholine (0.5mg/kg). Materials and methods: A total of 100 patients attending for elective surgery in College of Medical Sciences -Teaching Hospital( CMSTH)), Bharatpur, Chitwan, Nepal were studied. Two blood samples were collected, one before surgery and another at 4 min after injection of succinylcholine and send to central lab for estimation of serum potassium level. Result: The serum potassium levels recorded during the study showed that there were neither significant differences observed within the groups nor was there any difference between the groups. Conclusion: In absence of pathological conditions related to raised serum potassium level, both high and low doses of succinylcholine can be used safely as there is no statistically significant differences in serum potassium level between high and low dose of succinylcholine. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-1, 19-22 DOI: http://dx.doi.org/10.3126/jcmsn.v9i1.9669

Low dose ct in chronic sinusitis

Role of low dose CT was assessed in 50 patients of chronic sinusitis. CT easily picks up the disease and predisposing anatomic variants, which were observed, in 78% of cases. The commonest anatomical variants was deviated nasal septum (38%),other variants found were concha bullosa in (28%) and Helle cell in 28% cases. The commonest disease pattern was osteomeatal unit pattern in 36% case. Infundibular pattern was seen in 23%, sphenoethmoidal recess pattern in 12% and sino-nasal polypopsis pattern was present in 16% of the cases. Low dose CT is preferred as it gives as good results as standard CT There is very little chances of irradiation hazard even when it has to be employed repeatedly.

Pheochromocytoma: reporting of two cases with a brief review

Pheochromocytoma arise from the chromaffin cells of adrenal gland or cells of sympathetic ganglion. The tumors secrete excessive adrenaline and nor-adrenaline and may cause severe elevation of blood pressure. Cardinal symptoms of pheochromocytoms are headache, diaphoresis, palpitation and high blood pressure which may be paroxysmal in nature. However, 10% of pheochromocytomas are only incidentally discovered during investigation of the patient for other reasons not related to suprarenal disease. We have reported here two cases of suprarenal tumors (pheochromocytoma), one of which is incidentally found while investigating her chest and epigastric pains. Journal of College of Medical Sciences-Nepal,2011,Vol-7,No-4, 78-86 DOI: http://dx.doi.org/10.3126/jcmsn.v7i4.6817

A Comparative study of efficacy of high dose versus low dose of suxamethonium for endotracheal intubation

As use of suxamethonium is associated with a large number of undesirable and serious side effects, including cardiac arrhythmias and malignant hyperthermia. These undesirable effects have prompted anesthesiologists to restrict use of suxamethonium. The low dose of the drug is expected to have lower side effects without compromising its neuromuscular blocking properties as the dose dependent side effects have been known for long, so the present study carried out to compare the efficacy of high dose (1.5mg/Kg) of suxamethonium to that of low dose (0.5mg/Kg) assessed by intubation condition with neuromuscular blockade. We prospectively randomized and compared the intubating conditions with neuromuscular monitoring in 100 patients undergoing elective abdominal, gynaecological and limb surgery in CMS-TH and found duration of apnoea and time taken for recovery of twitch height was significantly shorter. Without compromising the quality of neuromuscular blockade. Suxamethonium or Succinylcholine can be used in lower doses (0.5 mg/kg) in elective cases without airway compromise to achieve intubation. Journal of College of Medical Sciences-Nepal,2011,Vol-7,No-4, 53-57 DOI: http://dx.doi.org/10.3126/jcmsn.v7i4.6812