The Efficacy of Real-time Computer-aided Detection of Colonic Neoplasia in Community Practice: A Pragmatic Randomized Controlled Trial

BACKGROUND & AIMS

The use of computer-aided detection (CADe) has increased the adenoma detection rates (ADRs) during colorectal cancer (CRC) screening/surveillance in randomized controlled trials (RCTs) but has not shown benefit in real-world implementation studies. We performed a single-center pragmatic RCT to evaluate the impact of real-time CADe on ADRs in colonoscopy performed by community gastroenterologists.

METHODS

We enrolled 1100 patients undergoing colonoscopy for CRC screening, surveillance, positive fecal-immunohistochemical tests, and diagnostic indications at one community-based center from September 2022 to March 2023. Patients were randomly assigned (1:1) to traditional colonoscopy or real-time CADe. Blinded pathologists analyzed histopathologic findings. The primary outcome was ADR (the percentage of patients with at least 1 histologically proven adenoma or carcinoma). Secondary outcomes were adenomas detected per colonoscopy (APC), sessile-serrated lesion detection rate, and non-neoplastic resection rate.

RESULTS

The median age was 55.5 years (interquartile range, 50-62 years), 61% were female, 72.7% were of Hispanic ethnicity, and 9.1% had inadequate bowel preparation. The ADR for the CADe group was significantly higher than the traditional colonoscopy group (42.5% vs 34.4%; P = .005). The mean APC was significantly higher in the CADe group compared with the traditional colonoscopy group (0.89 ± 1.46 vs 0.60 ± 1.12; P < .001). The improvement in adenoma detection was driven by increased detection of <5 mm adenomas. CADe had a higher sessile-serrated lesion detection rate than traditional colonoscopy (4.7% vs 2.0%; P = .01). The improvement in ADR with CADe was significantly higher in the first half of the study (47.2% vs 33.7%; P = .002) compared with the second half (38.7% vs 34.9%; P = .33).

CONCLUSIONS

In a single-center pragmatic RCT, real-time CADe modestly improved ADR and APC in average-detector community endoscopists. (ClinicalTrials.gov number, NCT05963724).

Unveiling the Chameleon: A Case Report on Acute Intermittent Porphyria

Acute intermittent porphyria (AIP) is a rare autosomal dominant metabolic disorder with low penetrance, often presenting with a broad spectrum of clinical manifestations. Acute neurovisceral attacks commonly occur in young women, mimicking signs and symptoms of other medical and psychiatric conditions, thus delaying the diagnosis. We present the case of an 18-year-old female college student with recurrent hospitalizations for intractable abdominal pain, now again with pain and new subjective hematuria. The patient had previously undergone an endoscopy/colonoscopy with negative biopsies and serologies for acute pathology, including celiac disease. Celiac studies were repeated, given the possibility of inadvertent gluten exposure before the onset of the latest symptoms, but were negative. Basic labs and repeat imaging, including contrast-enhanced CT, MRI, and magnetic resonance (MR) enterography of the abdomen, continued to be unremarkable, and the patient's symptoms were felt to be functional in etiology. The patient's urinalysis was normal, and pregnancy was also ruled out. The patient continued to have pain despite receiving opiate analgesics, thus prompting a psychiatry consultation. She was diagnosed with acute adjustment disorder with anxiety and was started on hydroxyzine. Due to persistent symptoms, serum and urine samples were sent, revealing low levels of porphobilinogen deaminase (PBGD) and hydroxymethylbilane synthase (HMBS) gene mutation, confirming the diagnosis of AIP. She was treated with oral glucose and outpatient IV hemin infusions with the resolution of symptoms. AIP presents a nonspecific and highly variable clinical picture, often making it a challenging diagnosis due to such a broad differential. While our patient was thought to have acute adjustment disorder due to an unremarkable initial workup, further testing revealed otherwise. This case demonstrates how clinicians must have a high suspicion of AIP when caring for young females, manifesting with neurovisceral and psychiatric signs and symptoms. Timely diagnosis improves a patient's quality of life and can decrease overutilization of healthcare resources.

Helicobacter pylori Infection and Complications of Cirrhosis

INTRODUCTION

Helicobacter pylori is a significant contributor to conditions such as peptic ulcer disease, gastric cancer, gastric mucosa-associated lymphoid tissue lymphoma, and colorectal cancer. Recent studies have suggested a potential link between H. pylori and cirrhosis. However, the impact of H. pylori on cirrhosis-related mortality, inpatient outcomes, and decompensating events remains unclear. Considering the widespread availability of H. pylori testing and effective treatment options, there is a potential rationale for eradicating H. pylori in cirrhotic patients to mitigate the morbidity and mortality associated with cirrhosis. This study aims to investigate the association between H. pylori and inpatient outcomes and complications related to cirrhosis.

METHODS

The National Inpatient Sample (NIS) database, a part of the Healthcare Cost & Utilization Project, was utilized for this study. Inpatient data from the years 2016 through 2019 were extracted for patients with a primary discharge diagnosis of cirrhosis and a concurrent diagnosis of H. pylori infection. The primary outcomes included inpatient mortality, length of stay, and cost of care. Secondary outcomes involved cirrhosis-related complications during hospitalization, such as gastrointestinal bleeding, hepatic encephalopathy, and hepatorenal syndrome.

RESULTS

Over the years 2016 to 2019, 416,410 patients received a primary discharge diagnosis of cirrhosis. Among them, 990 patients (0.2%) had a secondary diagnosis of H. pylori infection. Those with both cirrhosis and H. pylori tended to be younger on average (mean age 54.25 vs. 57.18 years, p=0.01) and more frequently fell within the age range of 18-49 (33.84% vs. 24.71%, P=0.01). H. pylori-infected patients were also more likely to be male (70.71% vs. 63.11%, P<0.028), of Hispanic race (36.4% vs. 18.6%, p< 0.1), and of Black race (20.2% vs. 8.1%, p< 0.1). While H. pylori-exposed patients had lower in-hospital mortality (0.51% vs. 4.44%, p=0.007), their mean length of stay was higher (6.97 days vs. 5.75, p=0.002). The overall cost of care was comparable between the H. pylori-exposed and non-exposed groups (mean USD18,106.18 vs. $16,543.49, P=0.160). H. pylori-exposed patients had a higher overall rate of cirrhosis-related complications (84.85% vs. 67.59%, p< 0.001), gastrointestinal bleeding (48.48% vs. 27.34%, p< 0.001), and hepatorenal syndrome (70.71% vs. 46.99%, p< 0.001), and these differences persisted in multivariable analysis. Initially, rates of hepatic encephalopathy were higher in H. pylori non-exposed patients (21.57% vs. 15.66%, p=0.04), but this discrepancy was corrected after adjusting for potential confounders.

CONCLUSION

While patients in this study were diagnosed with both H. pylori and cirrhosis by discharge, it cannot be definitively concluded that H. pylori was the direct cause of cirrhosis complications. Recognizing this uncertainty, further studies are needed better to understand the associations between cirrhosis and H. pylori complications. Distinguishing the causes of cirrhosis and its relationship with H. pylori may offer deeper insights into whether H. pylori is a causative factor or merely correlated in its effects on patients with cirrhosis.

Symptomatic Meckel's Diverticulum Presenting As Recurrent Gastrointestinal Bleeding in an Adult

A 51-year-old male presented to the hospital with recurrent gastrointestinal bleeding. Prior work up with an esophagogastroduodenoscopy (EGD), colonoscopy, and video capsule endoscopy failed to reveal a bleeding source. Given a history of a terminal ileum diverticulum noted on previous colonoscopy and persistence of hematochezia, a Meckel's scan was performed, which revealed abnormal uptake suspicious for a Meckel's diverticulum containing ectopic gastric mucosa. After surgical resection, pathology confirmed a Meckel's diverticulum with gastric heterotopia. This case highlights the importance of considering Meckel's diverticulum for instances of recurrent gastrointestinal bleeding, especially in patients who are still symptomatic despite an extensive workup. Moreover, it is important to note that a Meckel's diverticulum can be missed on video capsule endoscopy.

Ultrasonography guided erector spinae block in spinal surgery for pain management with enhanced recovery: A comparative study

Background

Improved and efficient management of pain can certainly aid enhanced recovery after spinal surgery. Our aim is to evaluate the effect of ESPB in thoracic and lumbar surgeries where we have evaluated VAS for pain, cumulative analgesics consumptions, length of hospital stay and post-operative complications.

Methods

A cross-sectional comparative study done in HAMS among the erector spinae block group and control group. The analysis of different variable was done according to standard statistical analysis. For quantitative data, univariate and multivariate analysis was performed to determine statistically significant differences using student's t-test for continuous variables.

Results

60 patients were analyzed, 30 got spinae block and 30 in control group.The mean pain score for spinae block group were 1.90 ± 0.712 and 3.27 ± 1.230 for control group (p < 0.001). Cumulative mean analgesic consumption values for spinae block vs. control groups were 0.030 ± 0.042 mg vs. 0.091 ± 0.891 mg (p = 0.001) for fentanyl; 1.06E4 ± 2833.300 mg vs. 1.53E4 ± 2848.349 mg (p < 0.001) for paracetamol; 213 ± 64.656 mg vs. 494 ± 58.816 mg (p < 0.001) for ketorol; 5440.00 ± 2060.064 mg vs. 8667.50 ± 2275.006 mg (p < 0.001) for ibuprofen and 121.67 ± 31.303 mg vs. 185.00 ± 51.108 mg (p < 0.001) for tramadol.

Conclusions

The ESPB technique shows early discharge from hospital and lower cumulative analgesics consumption which indicates enhanced recovery after spine surgery than control group. Improvement of pain using VAS shows immediate post-operative period recovery in those who receives spinae block.

Alcoholic Hepatitis Mimicking Iron Overload Disorders With Hyperferritinemia and Severely Elevated Transferrin Saturation: A Case Report

Iron overload disorders can present as non-specific symptoms and develop gradually but, if untreated, can be very fatal. The common causes include multiple blood transfusions for chronic anemia and increased iron absorption, including hereditary hemochromatosis (HH). HH is one of the common causes of iron overload disorders and usually presents with liver cirrhosis in a setting of significantly elevated ferritin and elevated transferrin saturation. Alcoholic hepatitis is a clinical syndrome of progressive inflammatory liver injury associated with long-term heavy intake of ethanol. However, in patients with alcohol abuse, excessive alcohol consumption can disrupt iron metabolism releasing large amounts of iron into circulation. This can cause severely elevated ferritin due to disruption of iron metabolism, simulating iron overload disorders such as HH, especially if the patient also has liver cirrhosis. Even though a high transferrin saturation of greater than 45% is recommended as a cutoff transferrin value as high sensitivity for detecting iron overload disorders, it has a low specificity and positive predictive value and often identifies people with other causes of acutely elevated ferritin levels such as alcohol liver disease and hepatitis. Recognizing this feature and timely management can spare the patient from unnecessary phlebotomies and prompt treatment for alcoholic hepatitis. We present an interesting case of severe alcoholic hepatitis mimicking HH with severely elevated ferritin levels and transferrin saturation with underlying liver cirrhosis.

Rhabdomyolysis Secondary to Severe Hypothyroidism Due to Hashimoto's Thyroiditis: A Case Report

Hashimoto's thyroiditis, a chronic autoimmune inflammation of the thyroid glands, is the most common cause of hypothyroidism in iodine-sufficient areas, which can have varied clinical manifestations. It is more common in females and usually has an insidious course. Most patients present with mild clinical symptoms, such as constipation, fatigue, and weakness. Symptoms are associated with a slight increase in thyroid-stimulating hormone (TSH) levels and the presence of thyroid antibodies. However, overt hypothyroidism is uncommon. We hereby present an interesting case of rhabdomyolysis secondary to severe hypothyroidism due to Hashimoto's thyroiditis.

Severe Malaria with a Rare Tetrad of Blackwater Fever, Acute Renal Failure, Disseminated Intravascular Coagulopathy, and Acute Acalculous Cholecystitis

Background

Blackwater fever (BWF) is a severe clinical syndrome occurring as a complication of malarial infection characterized by intravascular hemolysis, hemoglobinuria, and acute renal failure in people exposed to Plasmodium falciparum and, to some extent, in people who were exposed to medications like quinine and mefloquine. The exact pathogenesis of classic BWF remains unclear. The mechanism leading to damage to the red blood cells (RBCs) can be immunologic nonimmunologic, leading to massive intravascular hemolysis. Case Presentation. We present a case of classic blackwater fever in a 24-year-old otherwise previously healthy male without any history of antimalarial prophylaxis use, returning from recent travel to Sierra Leone. He was detected to have P. falciparum malaria in the peripheral smear test. He was treated with artemether/lumefantrine combination therapy. Unfortunately, his presentation was complicated by renal failure and was managed with plasmapheresis and renal replacement therapy.

Conclusion

Malaria continues to be a parasitic disease that can have devastating effects and continues to be a challenge globally. Although cases of malaria in the United States are rare and cases of severe malaria, mainly attributed to P. falciparum, are even more uncommon. Care should be taken to retain a high level of suspicion to consider the diagnosis, especially in returning travelers from endemic areas.

Better Social-emotional Behavior in Young Nepali Children is Associated with Household Wealth, Child Age, and Family Participation in a Community Development Intervention

Background Mental health and behavior problems are under-recognized in low- and middleincome countries, especially in young children. Early identification of these problems could encourage governments to address the shortages of child mental health professionals and promote early intervention programs to help children achieve their full developmental potential. Objective Describe the social-emotional development of young rural Nepali children; explore risk factors for poor development. Method The study was embedded in a longitudinal intervention trial comparing control households with those who received training in family nutrition+livestock management (Partial Package) or family nutrition+livestock management+community mobilization (Full Package). At midline, enumerators completed a 145-item household questionnaire, child anthropometry, and Administered the Ages and Stages Questionnaire-Social-Emotional (ASQ-SE) to all enrolled children age 33-47 months (n=310). Bivariate and regression analyses examined the relationship of child and household risk factors to administered the Ages and Stages QuestionnaireSocial-Emotional scores. Result Administered the Ages and Stages Questionnaire-Social-Emotional scores were below age cutoffs in 24% of children, suggesting worse social-emotional development. In bivariate analyses and the adjusted linear regression model, older child age, greater household wealth, and Full Package Intervention status were all associated with better social-emotional development scores. Partial Package Intervention status was associated with worse scores. Conclusion The Administered the Ages and Stages Questionnaire-Social-Emotional is a potential tool to assess child social-emotional development in the context of household and community level interventions. Further work is necessary to validate the administered the Ages and Stages Questionnaire-Social-Emotional and similar tools in Nepal, and to better understand the prevalence of challenges to optimal socialemotional development in young children in order to use this information to design and monitor needed interventions.

Associations between biomass fuel use and child health: a community-based study in Bhaktapur, Nepal

Background

Biomass fuel use for cooking is widespread in low- and middle-income countries. Previous studies have mainly focused on adverse health outcomes in adults or specific diseases. In a cohort among young children living in Bhaktapur, Nepal, we aimed to describe the association between the use of biomass cooking fuels in families with child health using measures of linear growth, cognition and chronic illness.

Methods

Caregivers of 600 marginally stunted children aged 6-11 months were interviewed about their primary source of cooking fuel at enrolment into a randomized controlled trial. Children's body length (n = 572) was measured at age 18-23 months. At the same time, blood samples (n = 497) were taken, and we measured leukocyte telomere length (LTL) as a marker of chronic disease risk. We chose LTL expressed as z-scores as a measure of chronic disease. Cognitive abilities were measured by the Wechsler Preschool and Primary Scale of Intelligence, 4th edition (WPPSI-IV) and NEPSY-II subtests when the children were 4 years old (n = 531). Associations were estimated in multiple regression models.

Results

About 18% of all families used biomass as primary cooking fuel. Children from families using biomass fuel were on average slightly shorter (mean difference 0.14 Z-scores, 95% CI: 0.28, 0.00), had lower IQ scores (mean difference 2.2 (95% CI: 0.5, 3.9), and shorter LTL (mean difference: 0.09 (95% CI: 0.05 to 0.13) compared to those not using biomass fuel. The observed associations were unaltered after adjusting for relevant confounders.

Conclusions

In children from households in poor, urban neighborhoods in Nepal, biomass fuel use for cooking was associated with health indicators for child growth and cognition as well as longevity and chronic illnesses reflected in shortening of telomeres. As this was an observational study, residual confounding cannot be excluded. Our findings support the ongoing effort to reduce exposure to biomass fuel in low-resource settings.

Key messages

A Case Report of Aerococcus urinae Urinary Tract Infection in an Elderly Male with Multimorbidity

Aerococcus urinae is a rare cause of urinary tract infection (UTI) seen in elderly males with multimorbidity. Incidence is estimated between 0.15 and 0.8%. This organism is frequently misidentified for other gram-positive species. Missed or delayed diagnosis of A. urinae UTI can lead to systemic infection with high morbidity and potential mortality. We present a classic case of A. urinae UTI in a 91-year-old male with multiple comorbidities, including heart failure, diabetes mellitus, and metastatic prostate carcinoma. Empiric therapy with nitrofurantoin was unsuccessful, but intravenous ceftriaxone and bladder catheterization resulted in rapid symptomatic improvement. Variable antimicrobial sensitivities and resistance have been reported for A. urinae. Therefore, antimicrobial resistance testing should be performed for all patients with A. urinae infections.

Paget-Schroetter Syndrome: A Rare Case of Upper Extremity Deep Vein Thrombosis in a Young Swimmer

Paget-Schroetter syndrome (PSS) is a rare form of spontaneous upper extremity deep vein thrombosis associated with vigorous activity of the upper extremities. We present a rare case of a young swimmer who presented with a painful right upper extremity swelling, with compression ultrasound (CUS) revealing extensive venous clots in the basilic, axillary, and subclavian veins. Venous duplex revealed extrinsic compression of the subclavian vein, and catheter-based contrast venography confirmed our diagnosis of PSS. The patient was started on a therapeutic dose of subcutaneous enoxaparin and referred to a higher center for further intervention.

Assessment of Modified Trans-umbilical Port Placement in Laparoscopy

BACKGROUND

Primary port placement is a critical step in any laparoscopic procedure. Although the safety and efficacy of open versus closed technique has been much debated, no particular technique is considered as the best. Therefore, over the period of time different methods have been developed and applied in order to perform laparoscopy procedures, Midat hospital has been using a version of modified trans-umbilical open technique for primary port entry from 2 decades and this study is being carried out to evaluate the technique.

METHODS

Retrospective review was conducted. The patients who underwent laparoscopy surgery by modified trans-umbilical port placement at Midat hospital from June 2019- April 2020 were included in this study.

RESULTS

A total of 100 cases were studied. Cholelithiasis was the main indication of surgery. The mean time recorded to establish pneumoperitoneum was 3.4±1.3 minutes. The rate of umbilical swab culture growth was 1%, pre-peritoneal port placements was 2%. Post-operative primary port site infection rate was 4%. No intra-abdominal injury was noted during the entry of primary port and there was no port site hematoma or recorded hernia over the period of one year.

CONCLUSION

This technique of modified trans-umbilical primary port placement is one of the safest, fastest and easiest techniques to enter the peritoneal cavity.

A Rare Case of Leptomeningeal Carcinomatosis Secondary to Metastatic Non-Small Cell Lung Carcinoma

Leptomeningeal carcinomatosis is a rare complication of metastatic systemic malignancy, with lung cancer being the most common cause. We present a case of a 75-year-old man with a past medical history of right non-small cell lung carcinoma and ischemic stroke who presented with a persistent headache and swallowing difficulties. On evaluation, the patient was initially diagnosed with a subacute infarct of the right posterior frontal lobe following magnetic resonance imaging (MRI). The patient’s headache and dysphagia worsened, increasing the possibility of brain metastasis. The patient underwent cerebrospinal fluid analysis including cytology and multiple MRI studies with no obvious explanation for the symptoms. The patient eventually developed multiple cranial nerve palsies, and a diagnosis of leptomeningeal carcinomatosis was made with neuroradiology consultation for the MRI.

Flower colour and size signals differ depending on geographical location and altitude region

Bees are major pollinators of angiosperms and have phylogenetically conserved colour vision but differ in how various key species use achromatic information that is vital for both flower detection and size processing. We modelled green contrast and colour contrast signals from flowers of different countries where there are well established differences in availability of model bee species along altitudinal gradients. We tested for consistency in visual signals as expected from generalization in pollination principles using phylogenetically informed linear models. Patterns of chromatic contrast, achromatic green contrast and flower size differed among the three floras we examined. In Nepal there is a significant positive correlation between flower size and colour contrast in the subalpine region, but a negative correlation at the lower altitudes. At high elevations in Norway, where pollinators other than bees are common, flower size was positively correlated with colour contrast. At low and medium altitudes in Norway and in Australia, we did not observe a significant relationship between size and colour contrast. We thus find that the relationship between size, green and colour contrast cannot be generalized across communities, thus suggesting that flower visual signal adaptations to local pollinators are not limited to chromatic contrast.

Modeling seasonal water yield for landscape management: Applications in Peru and Myanmar

A common objective of watershed management programs is to secure water supply, especially during the dry season. To develop such programs in contexts of low data and resource availability, program managers need tools to understand the effect of landscape management on the seasonal water balance. However, the performance of simple, parsimonious models is poorly understood. Here, we examine the behavior of a geospatial tool, developed to map monthly water budgets and baseflow contributions and forming part of the InVEST (integrated valuation of ecosystem services and trade-offs) software suite. The model uses monthly climate, topography, and land-use data to compute spatial indices of groundwater recharge, baseflow, and quickflow. We illustrate the model application in two large basins in Peru and Myanmar, where we compare results with observed data and alternative hydrologic models. We show that the spatial distribution of baseflow contributions correlated well with an established model in the Peruvian basin (r² = 0.81 at the parcel scale). In Myanmar, the model shows an overall satisfactory performance for representing month to month variation (Nash-Sutcliffe-Efficiency 0.6-0.8); however, errors are scale dependent highlighting limitations in representing processes in large basins. Our study highlights modeling challenges, in particular trade-offs between model complexity and accuracy, and illustrates the role that parsimonious models can play to support watershed management programs.

Rewardlessness in orchids: how frequent and how rewardless?

About one-third of orchid species are thought to offer no floral reward and therefore attract pollinators through deception. Statements of this idea are common in the botanical literature, but the empirical basis of the estimate is rarely mentioned. We traced citation pathways for the one-third estimate in a sample of the literature and found that the paths lead to empirical foundations that are surprisingly narrow. Moreover, recent measurements have detected minute quantities of sugar available to insect visitors in some orchids thought to be rewardless, raising the possibility of a pollination strategy that is largely deceitful but different to absolute rewardlessness. The orchids are a well-studied group and there is no doubt that rewardlessness is common in the family. However, greater empirical effort is needed to verify rewardlessness in orchids and to explore geographic and environmental variation in the proportion of rewardless species.

In Hospital Complications of Atrial Septal Defect Device Closure at Shahid Gangalal National Heart Centre, Kathmandu, Nepal

BACKGROUND

Atrial deptal defect device closure has become the preferred method in the treatment of atrial septal defect. We aim to study the in-hospital complications of atrial septal defect device closure procedure.

METHODS

It was a single center, retrospective study conducted from Febuary 2016 to January 2019. Cardiac catheterization laboratory records of all consecutive patients who underwent atrial septal defect device closure was included and the in-hospital complications were been retrospectively reviewed.

RESULTS

During the study period, a total of 566 patients were attempted for device closure. In 557 (98.4%) of cases device was implanted. Among the 557 patient in which device was implanted 401(71.9%) were female. Age ranged from 5 years to 72 years with the mean of 30.9 years. Transient ST segment elevation 15 (2.6 %)was the commonest complication followed by pericardial tamponade 4 (0.7%), and cardiac arrhythmias 3 (0.5%).

CONCLUSIONS

Atrial deptal defect device closure can be done safely with a high success rate and a low complication rate.

Comparison of Knowledge and Attitude Towards Orthodontic Treatment Among High School Students

Introduction: Adolescence is the time when a person attains awareness including the self-awareness about his/her health. Hence if proper knowledge is instilled during this time, it will be effective and good oral health behavior can last lifetime. The aim of this study was to assess knowledge and attitude towards orthodontic treatment among the students of public and private schools and compare between them. Materials & Method: A descriptive cross-sectional questionnaire-based study was performed among 700 students (350 from private and 350 from government schools around Kathmandu valley) of grade 8-10. Questionnaire consisted of 14 questions about knowledge and 10 questions about attitude relating to orthodontic treatment. Each response as “yes” was given score ‘1’ and responses “no” and “don’t know” were given score ‘0’. Total score was calculated, followed by mean and compared between that of private and government schools and between genders. Result: No significant difference was found in the knowledge between the students of private and government schools. The difference in attitude score was found to be statistically significant (p=0.00). 54.29% of participants had never heard of an orthodontists, 48.57% never thought that crooked teeth have ill effects, and around 50% of participants were not aware that orthodontic treatment would improve the facial appearance. 47% of participants would not undergo treatment if it took 1-2 years, 53% would not agree for extractions and 42% were not willing to wear retainers. Conclusion: The knowledge and attitude level on orthodontics can be improved by incorporating the basic aspects of oral health in the syllabus of school education.

Colour evolution within orchids depends on whether the pollinator is a bee or a fly

Orchids are a classic angiosperm model for understanding biotic pollination. We studied orchid species within two species-rich herbaceous communities that are known to have either hymenopteran or dipteran insects as the dominant pollinators, in order to understand how flower colour relates to pollinator visual systems. We analysed features of the floral reflectance spectra that are significant to pollinator visual systems and used models of dipteran and hymenopteran colour vision to characterise the chromatic signals used by fly-pollinated and bee-pollinated orchid species. In contrast to bee-pollinated flowers, fly-pollinated flowers had distinctive points of rapid reflectance change at long wavelengths and a complete absence of such spectral features at short wavelengths. Fly-pollinated flowers also had significantly more restricted loci than bee-pollinated flowers in colour space models of fly and bee vision alike. Globally, bee-pollinated flowers are known to have distinctive, consistent colour signals. Our findings of different signals for fly pollination is consistent with pollinator-mediated selection on orchid species that results from the distinctive features of fly visual systems.

Device closure of ventricular septal defect: Initial experience in Nepal

Background: Device closure is an attractive alternative in the management of Ventricular Septal defect (VSD). Aims and Objective: The aim of the study was to access the safety and early outcome of VSD device closure at Shahid Gangalal National Heart Centre, Nepal. Materials and Methods: The study was single center, retrospective study. All the VSD cases who were attempted for VSD device closure during December 2016 to February 2019 were included. Catheterization laboratory records for VSD type and size, Device type and size were retrospectively reviewed. Hospital records were reviewed for in-hospital complications.    Results: Sixty-one VSD cases were attempted for device closure. VSD was successfully closed in 55 (90.1%) patients. The mean age of the patient was 11.1 years. Twenty-nine (52.7%) were female and 26 (47.3%) were male. Perimembranous VSD in 49 (89 %) and muscular VSD in 6 (11 %) patients. The size of VSD ranged between 2 and 12mm (Mean 5.4mm). The VSD was closed with Amplatzer duct occluder I, Amplatzer duct occluder II, Amplatzer muscular VSD occluder and Memopart PDA device in 24 (43.7%), 26 (47.3%), 4 (7.2 %) and one patient (1.8%) patients respectively. The postoperative complications were insignicant residual leak across device in 2 (3.6%) patients, mild pericardial effusion in one (1.8%) patient. None of the patient had new onset tricuspid regurgitation, aortic regurgitation and complete heart block. One patient developed Right bundle branch block, one developed Left bundle branch block, one developed Junctional rhythm. There was no mortality. Conclusion: VSD device closure can be safe and effective if patients are selected properly.

ASD device closure in elderly adults

Background: Closure of ASDs in elderly patients caused significant clinical and hemodynamic improvement after device closure. Aims and Objective: We aim to share our experience of ASD device closure in elderly adults. Materials and Methods: It was a prospective single center study done at Shahid Gangalal National Heart Centre. All elderly patients (>50years) who underwent ASD device closure fromFeb 2016 to July 2018 and completed three months of device closure were prospectively follow up for the symptoms, RA and RV dimension, Tricuspid Regurgitation and Tricuspid Regurgitation pressure gradient (TRPG). Results: During the study period 48 elderly adults underwent successful ASD device closure. Except one patient we could follow up all patients. Among the patient’s 33 were female, Age ranged from 50years to 72years with the mean age of 55 years. Shortness of breath was the most common symptom during presentation. ASD size ranged from 10mm to 33mm with the mean of 23mm. Device size ranged from 14mm to 40mm with the mean of 29mm. Amplatzer septal occluder was used in 47 patients. RA and RV were dilated in all patients. Mild TR was present in 26 patients, Moderate TR in 17 patients, Severe TR in 5 patients. Mean follow-up time was 12 months. Symptoms reduced in all patients expect one. RA and RV size reduced in all patients. Tricuspid regurgitation pressure gradient reduced from mean of 56 mmHg to Mean of 16 mmHg. During the follow up level of tricuspid regurgitation reduced, 11 patients had mild TR, Trace TR in 15 patients. Conclusion: ASD device closure can result in improvement in clinical and hemodynamic in elderly adults.

Coccygectomy can be a option for coccydynia which is refractory to medical treatment

The aim of this study was to evaluate the clinical outcome of coccygectomy those who were refractory to conservative treatment. Twenty patients (5 males, 15 females) underwent total coccygectomy when coccygodynia did not responding to medical treatment July 2013 to September 2018. All the patients timely attended with non-traumatic (n = 12) and traumatic (n = 8) cause with mean follow-up visits of 24 months (range 18-28 months). The outcome pain intensity was evaluated by visual analogue scale (VAS) in sitting position and during daily activities. Three patients had infection which improved after antibiotic therapy. The VAS improved from 6.4 ± 0.9 to 2.1 ± 0.9 for sitting and from 5.8 ± 0.9 to 1.6 ± 0.6 for daily activities. Improvement in pain and daily activities were significant at the final follow-up. Ninety percent patients were satisfied with the operation.

Integrated assessment of the climate and landuse change impact on hydrology and water quality in the Songkhram River Basin, Thailand

The livelihoods of people in the Songkhram River Basin (SRB) rely heavily on river water, especially those involved in the fisheries. Extensive landuse changes in SRB have raised concerns regarding its impacts in water quality in addition to the looming climate change effects. More importantly there is lack of detailed studies on landuse and climate change impact on river water quality for the sustainable water management. Therefore, this study aimed at quantifying the individual and integrated impact of climate and landuse change in streamflows and nitrate nitrogen loadings in the Songkhram River. Future streamflow was simulated using Soil and Water Assessment Tool (SWAT) whereas future climate projections were derived from three Regional Climate Models (RCMs) under two Representative Concentration Pathways (RCPs). A dynamic, spatially explicit, land use change model (Dyna-CLUE) was used to generate two future land use change scenarios namely economic and conservation scenarios. The results show that in future climate change is to be responsible for a 19.5 and 24% decrease in streamflow and 11.25 and 15.25% decrease in nitrate nitrogen loading as projected under RCP 4.5 and 8.5 scenarios, respectively. Whereas landuse change is found to be responsible for a 5.30 and 6.35% increase in streamflow and an 11 and 11.60% decrease in nitrate nitrogen loading under economic and conservation scenarios, respectively in future. Thus, in conjunction, these two agents are seen to play against each other, creating a net effect of decreased future streamflow (16% on average); whereas, in the case of nitrate nitrogen loading, the two work in tandem, leading to an amplified reduction (24.50% on average). Although landuse change is found to be the less afflicting agent, its role should not be overlooked-it may very well further exacerbate the situation if there is a greater unfavourable climatic variation than projected.

Profile of Fetal Echocardiography in a Tertiary Cardiac Centre of Nepal

Aims: To analyze the fetal echocardiographic diagnosis.Methods: A descriptive study of fetal echocardiographic diagnosis at Shahid Gangalal National Heart Centre between October 2016 to September 2017.  Results: Total of 615 fetal echocardiography was performed in 607 pregnancies. Intrauterine heart disease noted in 79 cases. Echogenic intracardiac foci was the most common abnormality (6%) followed by VSD (1.3%), fetal arrhythmia (1.1%), pericardial effusion (1.6%), cardiomyopathy (0.3%), hypoplastic left ventricle (0.6%), DORV (0.3%) and tricuspid atresia (0.4%).  Similarly the most common referral for fetal echocardiography was for maternal disorder mostly diabetes mellitus.Conclusion: Fetal echocardiography is an important tool for the antenatal diagnosis of congenital heart defects. Appropriate timing and judicious use increases the sensitivity and improves the perinatal outcome of newborns with congenital heart disease

Spectrum of Infections in Living Donor Kidney Transplant Recipients: An Experience From a Tertiary Center in Nepal

BACKGROUND

Kidney transplant recipients are always at risk of infections because they are on lifelong immunosuppressive medications. The spectrum of infections in this special population is not the same as in the general population. Post-transplant infections are extensively studied in the developed world. Publications about post-transplant infections from Nepal are scarce. This study was carried out to study the spectrum of infections, the trends in treatment, and the incidence of tuberculosis in kidney transplant recipients.

METHODS

This is a retrospective analysis of the patient data in Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Follow-up data from the first 100 kidney transplant recipients was recorded in a Microsoft Excel worksheet and descriptive analysis was done.

RESULTS

In the first 100 transplants done until 21 September 2011, 92 patients' data were recorded and 8 patients' data were missing. The mean follow-up period was 61.03 months. The population was 76.09% male (n = 70) and 23.91% female (n = 22). A total of 641 episodes of infections were recorded. Urinary tract infections were the most common type of infection. Escherichia coli was the most common organism isolated (36% of all cultures). There were 17 (2.65%) episodes of viral and 42 (6.6%) episodes of fungal infections. Tuberculosis was diagnosed in 6 (6.5%) patients.

CONCLUSION

Urinary tract infection is the most common type of infection in post-kidney transplant patients. Quinolones were the most common agents used to treat urinary tract infections. The incidence of tuberculosis in kidney transplant recipients is 6.5% in 5 years' follow-up.

Abnormalities in Protocol Graft Kidney Biopsy 6 Months Posttransplantation in a Tertiary Care Center Hospital of Nepal

BACKGROUND

Increasing graft survival is the prime focus of every transplantation program. Detection of subclinical abnormalities with the help of protocol renal graft biopsies performed at predetermined intervals after transplantation has been one of the approaches. The objective was to study the abnormalities in protocol renal graft biopsy specimens at 6 months posttransplantation.

METHODS

This was a hospital-based observational descriptive study. It included the recipients who underwent kidney transplantation between October 2014 and September 2015. The recipients were followed up postoperatively on an outpatient basis, as per the institution protocol. At 6 months posttransplantation, protocol graft biopsy was performed in all patients with normal functioning allograft without proteinuria after obtaining informed written consent.

RESULTS

A total of 57 patients with chronic kidney disease underwent renal transplantation during the study period. Protocol biopsy was performed in 47 recipients. Subclinical rejection was found in 4 (8.5%) recipients. Two recipients had significant tubulitis and interstitial inflammation. One of them showed features of Banff Type IA cellular rejection (t2, i2) and another showed Banff Type IB cellular rejection (t3, i2). Biopsy specimen of 1 recipient showed significant glomerulitis and peritubular capillaritis (g3, ptc1). Another recipient showed significant peritubular capillaritis (ptc2) with C4d positivity. IgA nephropathy was present in 6 (12.8%) recipients. BK virus nephropathy was found in 2 (4.3%) recipients.

CONCLUSION

This study demonstrates that abnormal histologic findings occur in protocol graft biopsy specimens at 6 months post renal transplantation in patients without any clinical or laboratory abnormalities.

Evaluation of result of lumbar laminoplasty for multilevel lumbar canal stenosis

<p class="Abstract">The aim of our study is to evaluate the clinical and functional outcome following lumbar laminoplasty with posterior element reconstruction with mini-plate and screws for multilevel lumbar canal stenosis. This study was done on 40 patients (18 males and 22 females) of degenerative multilevel lumber canal stenosis patients underwent open double door lumbar laminoplasty with posterior element reconstruction with mini-plate and screws from January 2015 to June 2018. Thirty four patients underwent surgery for 2 level involvement and 6 underwent for 3 level involvement of lumbar canal stenosis. The mean post-operative hospital stay was 5.2 ± 1.1 days. Per-operative complication was dural tear in 2 cases. Pre-operative mean VAS score of back pain and leg pain were 7.0 ± 0.7 and 7.2 ± 1.1 which were significantly reduced to 1.0 ± 0.2 and 1.0 ± 0.8 respectively at final follow-up. All patients were followed-up for minimum 1 year. Pre-operative mean Japanese Orthopedic Association score was 8.6 ± 2.2 which was significantly increased to 14.8 ± 0.4 after 12 months of surgery. Pre-operative mean Oswestry Disability Index was 34.4 ± 3.0 which was significantly reduced to 8.5 ± 2.2 after 12 months of surgery. The outcome of lumbar laminoplasty with posterior element reconstruction with mini-plate and screws for multilevel lumbar canal stenosis show good result and can be one of the good option for the treatment for multilevel lumbar canal stenosis.</p>

Preoperative serum uric acid predicts incident acute kidney injury following cardiac surgery

Background

Acute kidney injury (AKI) following cardiac surgery is a frequent complication and several risk factors increasing its incidence have already been characterized. This study evaluates the influence of preoperative increased serum uric acid (SUA) levels in comparison with other known risk factors on the incidence of AKI following cardiac surgery.

Methods

During a period of 5 month, 247 patients underwent elective coronary artery bypass grafting, valve replacement/ repair or combined bypass and valve surgery. Datas were prospectively analyzed. Primary endpoint was the incidence of AKI as defined by the AKI criteria comparing patients with preoperative serum uric acid (SUA) levels below versus above the median. Multivariate logistic regression analysis was used to identify independent predictors of postoperative AKI.

Results

Thirty (12.1%) of the 247 patients developed postoperative AKI, 24 of 30 (80%) had preoperative SUA- levels above the median (≥373 μmol/l) (OR: 4.680, CI 95% 1.840; 11.904, p = 0.001). In the multivariate analysis SUA levels above the median (OR: 5.497, CI 95% 1.772; 17.054, p = 0.003), cardiopulmonary bypass (CPB) time > 90 min (OR: 4.595, CI 95% 1.587; 13.305, p = 0.005), cardiopulmonary bypass (CPB) > 30 kg/m² (OR: 3.208, CI 95% 1.202; 8.562; p = 0.02), and preoperative elevated serum-creatinine levels (OR: 1.015, CI 95% 1.001; 1.029, p = 0.04) were independently associated with postoperative AKI.

Conclusions

Serum uric acid is an independent risk marker for AKI after cardiac surgery. From all evaluated factors it showed the highest odds ratio.

Percutaneous balloon kyphoplasty, a good minimally invasive surgical option for osteoporotic thoracolumbar compression fracture

<p>The aim of this study is to evaluate balloon kyphoplasty as a surgical option for osteoporotic thoracolumbar compression fracture. The study was conducted on 30 patients from January 2014 to December 2017. The anterior vertebral height, kyphotic angle and functional evaluation by Oswestry disability index (ODI) and visual analogue scale (VAS) score were recorded preoperatively, immediate post-operatively at 3, 6, 12 months and yearly then on. All patients showed improvement in mean kyphotic angle from 16.4 ± 3.5 to 5.6 ± 1.7 post-operatively and 8.4 ± 1.6 at final follow-up. There was significant increase in mean anterior vertebral height from 51 ± 7.3% before surgery to 75.5 ± 7.4% at one day after surgery and 71.2 ± 3.2% at the last follow-up. There was significant improvement in mean VAS score from 8.1 ± 0.9 before surgery to 2.2 ± 0.4 at one day, and 2.4 ± 0.3 at final follow-up. The improvement in patients’ ODI score after surgery from 71.4 ± 3.4 to 26.0 ± 4.8 at one day and 21.2 ± 5.5 at final follow-up was noted. The mean operating time was 45.5 ± 15.5 min for each vertebra. Within first day of surgery improvement in pain relief and mobility was experienced by all patients. The orthopedic balloon ruptured in one patient and it was replaced then procedure was continued with no complications. There were no neurological complications in all cases and there was no infections and any occurrence of symptomatic pulmonary embolism. In conclusion, balloon kyphoplasty is a good minimally invasive procedure where along with reduction of pain and disability there is also restoration of sagittal alignment post-operatively.</p>

Rod derotation technique, a good option for correction of Idiopathic kyphoscoliosis

<p class="Abstract">Review of the radiological and clinical outcomes of the correction of idiopathic scoliosis by convex  rod rotation were done in this prospective interventional study. Axial translation technique with pedicle screw-rod was used for correction of scoliosis. 35 patients (10 males, 25 females) were studied on the basis of clinical and radiological outcomes with a mean age of 14.8 years and follow-up a period of 32.5 months. Placement of screws was more on the concavity, around apical region and instrumentation at all level were not mandatory. Radiological evaluation was done pre-operatively and at 1, 3, 6 and 12 months postoperatively by whole spine standing AP, lateral radiographs and yearly thereafter. Spinal balance was noted, measurement of Cobb's angles, SRS questionnaire for clinical evaluation and complications were all documented. The study result shows three-dimensional deformity of spine can be corrected effectively with simple rod rotation with pedicle screw instrumentation by axial translation technique.</p>

Wide local resection of sacral chordoma through posterior midline approach

<p class="Abstract">This study was performed in 21 patients with sacral chordoma from July 2008 to June 2017 and posterior surgical approach was used for resection. Out of 21 patients, 12 had done subtotal sacrectomy and the remaining 9 had done partial sacrectomy. Their follow-up periods were at least five years. Operative time ranged between two to four hours. All patients recovered well from operation and two to five units of blood transfusion were needed for each. After operation, majority of the patients developed some bowel and bladder dysfunction and five patients developed wound infection. During the follow-up, two patients had tumor recurrence and one patient expired two years after operation. The remaining 18 patients were tumor-free at the 5-years follow-up. Wide surgical resection via the posterior midline approach could be a good management plan for the sacral chordoma. However, complete removal with surgical margin varies according to the location of the tumor.</p>

Evaluating the impacts of climate and land-use change on the hydrology and nutrient yield in a transboundary river basin: A case study in the 3S River Basin (Sekong, Sesan, and Srepok)

Assessment of the climate and land-use change impacts on the hydrology and water quality of a river basin is important for the development and management of water resources in the future. The objective of this study was to examine the impact of climate and land-use change on the hydrological regime and nutrient yield from the 3S River Basin (Sekong, Srepok, and Sesan) into the 3S River system in Southeast Asia. The 3S Rivers are important tributaries of the Lower Mekong River, accounting for 16% of its annual flow. This transboundary basin supports the livelihoods of nearly 3.5 million people in the countries of Laos, Vietnam, and Cambodia. To reach a better understanding of the process and fate of pollution (nutrient yield) as well as the hydrological regime, the Soil and Water Assessment Tool (SWAT) was used to simulate water quality and discharge in the 3S River Basin. Future scenarios were developed for three future periods: 2030s (2015-2039), 2060s (2045-2069), and 2090s (2075-2099), using an ensemble of five GCMs (General Circulation Model) simulations: (HadGEM2-AO, CanESM2, IPSL-CM5A-LR, CNRM-CM5, and MPI-ESM-MR), driven by the climate projection for RCPs (Representative Concentration Pathways): RCP4.5 (medium emission) and RCP8.5 (high emission) scenarios, and two land-use change scenarios. The results indicated that the climate in the study area would generally become warmer and wetter under both emission scenarios. Discharge and nutrient yield is predicted to increase in the wet season and decrease in the dry. Overall, the annual discharge and nutrient yield is projected to increase throughout the twenty-first century, suggesting sensitivity in the 3S River Basin to climate and land-use change. The results of this study can assist water resources managers and planners in developing water management strategies for uncertain climate change scenarios in the 3S River Basin.