A Recurrent Case of Ameloblastic Fibroma in 37-year Old Male

Ameloblastic fibroma (AF) is a benign mixed epithelial and mesenchymal odontogenic tumor. This was previously grouped in odontogenic tumor showing odontogenic epithelium with odontogenic ectomesenchyme, with or without hard tissue formation. This report describes a case of ameloblastic fibroma in a 37-yearold male who came with the complain of swelling in the left side of lower jaw since one year. Enucleation of the mass followed by reconstruction was done six years back. However, after two years of initial treatment; radiographic findings suggested recurrence. Histopathological examination confirmed the diagnosis of ameloblastic fibroma. Patient had no clinical and radiographic evidence of recurrence in three and six months' follow-up. Because of the higher proliferative capacity and malignant degree of the mesenchymal component in the recurrent neoplasm, sarcomatous transformation may occur. Hence, a long term clinical and radiographical follow-up is essential due to its transformation into ameloblastic fibrosarcoma.

Morphometric Analysis of Posterior Fossa and Foramen Magnum among Pediatric Age Group 6 to 16 Years

Background Configuration and size of the foramen magnum and posterior cranial fossa plays an important role in the pathophysiology of various disorders like Chiari malformations, basilar invagination etc. Thus, a fundamental knowledge of normal anatomy of this region is important to the clinician for diagnosis and treatment. However, we couldn't find any anatomical study related to the concerned topic among the pediatric population aged 6 to 16 years in Nepal to the best of our knowledge. Objective To attain the baseline results (volume of bony part of posterior cranial fossa and the surface area of foramen magnum) that will help in the better diagnosis, classification, and treatment of diseases related to posterior fossa and craniovertebral junction and serve as a future reference defining an anatomic range in our region. Method This is a retrospective prospective observational study conducted from 1st February 2021 to 31st January 2022 at Dhulikhel Hospital, Kathmandu University Hospital, Kavrepalanchowk, Nepal. We used convenient sampling technique to fulfil our sample size. We considered 68 patients, who got recruited either from our emergency and OPD departments and were fulfilling our criteria of inclusion. Upon the recruitment, 68 consecutive head CT scan of pediatric patients with normal reports (without any bony or soft-tissue abnormality) were studied. Volume of the posterior fossa was calculated with the help of inbuilt "advanced work station - 3D volume calculator" program in 128 slices - SOMATOM PERSPECTIVE CT Scanner from Siemens, Germany. The area of the foramen magnum was calculated using formula πr2 , where r is average radius calculated from obtained antero-posterior and transverse diameter. Result The age of the patients ranged between 6 and 16 years with the mean age of 10.56 ± 3.38 years with male to female distribution of 1: 1.125. The mean volume of the posterior fossa was 165.61 ± 8.52 mm3 . The mean AP diameter, transverse diameter, and the surface area of foramen magnum were 3.31 ± 0.12 mm, 2.72 ± 0.12 mm, and 28.60 ± 0.09 mm2 respectively. Conclusion Normal ranges of volume of posterior cranial fossa and various dimensions and surface area of foramen magnum of pediatric population were determined using CT scans, which could serve as future reference in Nepal.

Assessment of Sexual Dimorphism in Mandibular Ramus: An Orthopanoramic Study

Background Mandible is the largest and strongest bone of the face, is very durable, and hence remains well preserved than many other bones. In cases of mass disasters where an intact skull is not found, the mandible may play a vital role in sex determination as it is the most dimorphic bone of the skull. Morphometric analysis of mandibular ramus provides highly accurate data to discriminate sex. This can be accomplished by the use of panoramic radiography which is widely available and is used routinely to assess the mandibular structures. Objective To evaluate and compare the various parameters of the mandibular ramus and to determine the usefulness of the mandibular ramus as an aid in sex determination. Method Orthopantomograms of 140 samples (70 males and 70 females) were collected from the archives and traced manually on matte acetate tracing paper. Various parameters of mandibular ramus were measured on the right and left sides. The obtained measurements were subjected to discriminant function analysis. Result Mandibular measurements on the right side were greater than on the left side. However, only the ramus breath (minimum and maximum) and projective height of ramus were statistically significant (p < 0.05). All the measurements were higher for males than females. F-statistic values indicated that the highest sexual dimorphism was seen with the projective height of ramus and least with minimum ramus breath. Conclusion Mandibular ramus measurements can be a useful tool for gender determination and can be an essential tool in forensic science especially when there is damaged or partially preserved mandibles and may be helpful for medico-legal purpose in Nepal.

Acquired Constricting Band Syndrome

The superstitious beliefs of gaining a good fortune led to wearing rubber bands around the hand leading to the development of the constricting band syndrome. Acute compartment syndrome is a limb-threatening condition characterized by elevated interstitial pressure in a confined fascial compartment and if left untreated, it results in tissue necrosis, irreversible nerve and muscle injury and permanent functional impairment. We report a 46 years old male with history of wearing rubber hand on all his fingers, who presented late with gangrene and autoamputation.

Predictors of CKD and rate of decline in eGFR in the elderly: A case-cohort study

We wanted to examine the predictors of annual estimated glomerular filtration rate (eGFR) decline during a five-year follow-up in elderly individuals with pre-existing chronic kidney disease (CKD) stage 3 or greater (defined as baseline eGFR of less than 60 ml/min per 1.73 m2 or a urinary albumin-to-creatinine ratio > 30 mg/g), and to examine the difference in risk factors when compared to a co-hort without CKD. Our research team identified 599 patients who were 65 years of age or older with and without CKD stage 3 or greater at baseline. Data regarding various predictors such as age, sex, race, proteinuria, medication use, contrast exposure, acute kidney injury episodes, coronary artery disease, congestive heart failure, dyslipidemia, gout etc. were obtained. Semi-partial correlations were used to determine the fac-tors providing the largest unique contribution to the overall variability in eGFR. Semi-partial correlations identified age, proteinuria, and intravenous contrast ex-posure as the most significant predictors of eGFR decline in this population. Overall, patients in the pre-existing CKD cohort were more likely to be older, Af-rican American and with co-morbidities like diabetes, hypertension, etc. In this group, the unadjusted rate of decline in eGFR varied from 0.5% to 8.3% per year. This study identifies important risk factors for eGFR decline in the population aged > 65 years. It also concludes that each episode of acute kidney injury, wheth-er related to contrast or other nephrotoxins, increases the risk for CKD progression and eGFR decline in the elderly.

Development of slow sponge sand filter (SpSF) as a post-treatment of UASB-DHS reactor effluent treating municipal wastewater

In this study, conventional slow sand filter (SSF) and modified slow sponge sand filter (SpSF) were investigated for the post-treatment of up-flow anaerobic sludge blanket (UASB)-down-flow hanging sponge (DHS) reactor effluent. The seasonal variation did not show significant differences in removal efficiencies of both filters. However in summer, both filters were able to achieve high total suspended solids and total biochemical oxygen demand removal averaging 97% and 99%, respectively. Contrary to organic removal, total nitrogen removal efficiency was satisfactory, showing increased removal efficiencies averaging 58% and 62% for SSF and SpSF in summer. On the other hand, average total coliform removal of SSF and SpSF was 4.2 logs and 4.4 logs and corresponding Escherichia coli removal was 4.0 logs and 4.1 logs, respectively. From our observation, it could be concluded that the relative performance of SpSF for nutrients and coliforms was better than SSF due to the effectiveness of sponge media over fine sands. Moreover, microbial community analysis revealed that the members of phylum Proteobacteria were predominant in the biofilms of both filters, which could have contributed to pollutant removal. Therefore, SpSF could be concluded to be a suitable post-treatment of UASB-DHS system in warmer conditions.

Slip pulse and resonance of the Kathmandu basin during the 2015 Gorkha earthquake, Nepal

Detailed geodetic imaging of earthquake ruptures enhances our understanding of earthquake physics and associated ground shaking. The 25 April 2015 moment magnitude 7.8 earthquake in Gorkha, Nepal was the first large continental megathrust rupture to have occurred beneath a high-rate (5-hertz) Global Positioning System (GPS) network. We used GPS and interferometric synthetic aperture radar data to model the earthquake rupture as a slip pulse ~20 kilometers in width, ~6 seconds in duration, and with a peak sliding velocity of 1.1 meters per second, which propagated toward the Kathmandu basin at ~3.3 kilometers per second over ~140 kilometers. The smooth slip onset, indicating a large (~5-meter) slip-weakening distance, caused moderate ground shaking at high frequencies (>1 hertz; peak ground acceleration, ~16% of Earth's gravity) and minimized damage to vernacular dwellings. Whole-basin resonance at a period of 4 to 5 seconds caused the collapse of tall structures, including cultural artifacts.

Carcinoma of the appendix – A diagnostic challenge

INTRODUCTION Primary tumors of the appendix are rare. They are usually diagnosed after pathologic inspection of the appendix removed for suspected appendicitis. The main presentation is that of an acute appendicitis or as a palpable mass, mainly in the right lower quadrant. It mimics ovarian pathology in female because of close proximity to its anatomical structures. CASE PRESENTATION We report a case of 52 years female who presented to us in casualty with complains of pain abdomen and other findings suggestive of acute appendicitis. In spite of extensive preoperative investigations, the diagnosis was confirmed only after opening the abdomen as giant mucocele of appendix demanding right hemicolectomy as a treatment modality. CONCLUSION Although primary tumors of appendix is rare identity in the arena of surgery, it should be in the corner of thought as a possible diagnosis which require extensive surgery when compared to simple Appendicectomy.DOI: http://dx.doi.org/10.3126/jcmsn.v10i2.12953 Journal of College of Medical Sciences-Nepal, 2014, Vol.10(2); 36-40

Diagnosis and successful surgical management of posterior nutcracker syndrome in a patient with loin pain hematuria

The syndrome of loin pain hematuria in the absence of stones is poorly understood but must be considered in the differential diagnosis for patients with clinical manifestations resembling nephrolithiasis. A 22-year-old white female with a 4-year history of left flank pain and hematuria underwent an extensive workup with normal renal ultrasound and cystourethroscopies. CT scan and MRI revealed a retro-aortic left renal vein. Posterior nutcracker syndrome was considered the most likely diagnosis. The patient underwent a left laparoscopic nephrectomy with auto-transplantation in the right iliac fossa. She developed azotemia shortly after, which resolved and since then has become asymptomatic.

Prevalence, risk factors and awareness of diabetic retinopathy among admitted diabetic patients at a tertiary level hospital in Kathmandu

INTRODUCTION

Diabetic retinopathy (DR) is one of the commonest causes of visual impairment and blindness in Nepal.

OBJECTIVES

The study aims to explore the prevalence, risk factors and awareness of DR among admitted diabetic patients.

MATERIALS AND METHODS

A non-interventional case series study was conducted among the inpatient diabetic cases referred for ophthalmic consultation. The patients' detailed demographics, awareness on DR, concurrent systemic problems, and glycemic control status were recorded. DR was graded using the Early Treatment Diabetic Retinopathy Study Criteria.

MAIN OUTCOME MEASURES

The prevalence, risk factors and awareness of diabetic retinopathy among the study participants was analyzed.

RESULTS

A total of 277 diabetic patients were enrolled in the study. The mean age was 62.25 ± 13.26 years. Only one-third (34.6 %) of the cases were admitted for sugar control and newly diagnosed cases comprised of 19.49 %. Nearly half of the cases (46.6 %) were not aware of diabetic retinopathy and dilated fundus evaluation was done for the first time in 44.4 %. DR was found in 38.26 % of the cases and was diagnosed in 13 % of the new cases. Almost four-fifths (78 %) of the diabetics had had the disease for a duration of 16 to 20 years. Clinically significant macular edema was found in 5.78 % and proliferative DR in 2.52 %. DR was significantly associated with the duration of diabetes (P value = 0.001) and concurrent hypertension (P value = 0.004).

CONCLUSION

The prevalence of DR was 38 % among the admitted diabetic cases and the DR was significantly associated with the duration of diabetes and systemic hypertension. Almost half of the cases had been unaware of DR before referral. This emphasizes the importance of the collaboration of the physician and the ophthalmologist for an early DR detection.

Clinical profile, management and early outcome of gall bladder cancer

Objective To evaluate the clinical profile, management and early outcome of patients with gallbladder cancer.Methods This is a single institution based retrospective study of patients with gallbladder cancer who presented at College of Medical Sciences and Teaching Hospital, Bharatpur, Chitwan, Nepal. Patients presenting during one year period from August 2012 to July 2013 were reviewed. Results Twelve cases of Gall Bladder Cancer were reviewed in this series. Out of 12 patients, 9 were females (75%) and 3 were males (25%), showing female preponderance. Most of the patients (75%) were in age group of 51-70 years. Only one patient (8%) was below 50 years of age. Main symptom was pain associated with anorexia, nausea & vomiting. Major signs were palpable mass, hepatomegaly and jaundice. All the cases had association with gall bladder stone. Of the total population, 50%(n=6) underwent extended cholecystectomy and rest of 6 cases were inoperable. Histopathological reports of all the operated cases were adenocarcinoma.Conclusion Prevalence of gall bladder cancer is higher in females in our series. Most of the patients were in fifth to seventh decade of life. Non specific symptoms like abdominal pain nausea and vomiting were the predominant symptoms. Only 50% of the cases were operable. So we have to do early screening by USG abdomen and CT scan to diagnose the disease earlier.   Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-3, 12-16  

Clinical Profile and Management of Gall Bladder Cancer: Our Early Experience

Objective: To evaluate the clinical profile of patients with gallbladder cancer. Methodology: This is a single institution based retrospective study of patients with gallbladder cancer who presented at College of Medical Sciences and Teaching Hospital, Bharatpur, Chitwan, Nepal. Patients presenting during the two years period from August 2011 to July 2013 were reviewed. Result: Out of 12 patients, 9 were females (75%) and 3 were males (25%), showing female preponderance. Most of the patients (75%) were in age group of 51-70 years. Only one patient (8%) was below 50 years of age. Main symptom was pain associated with anorexia, nausea & vomiting. Major signs were palpable mass, hepatomegaly and jaundice. All the histopathological reports were adenocarcinoma. 8 patients (66.66%) presented with advanced disease and were managed with extended cholecystectomy followed by systemic chemotherapy. Conclusions: Prevalence of gall bladder cancer is higher in females in our series. Most of the patients were in fifth to seventh decade of life and presented in advanced stage. Gallbladder cancer showed association with gallstones. DOI: http://dx.doi.org/10.3126/jonmc.v3i1.10050 Journal of Nobel Medical College Vol.3(1) 2014; 27-30

Surgical outcome and clinical profile of emergency versus elective cases of colorectal cancer in College of Medical Sciences, Nepal

Background: Patients who undergo emergency colorectal cancer surgery has poor outcome compared to elective surgery, both in terms of morbidity and mortality. Approximately 15 to 30% of colorectal cancers present as an emergency, most often as obstruction or perforation. Objective: To compare surgical outcome and clinical profiles of emergency and elective cases for colorectal cancer. Methods: Retrospective analysis of 34 cases who underwent surgery for colorectal cancer between December 2011 to January 2013was carried out and their surgical outcomes, clinical presentation, demographic profile were analyzed. Results: The total numbers of patients included in this study were 34. Out of which 52.94 %( n=18) were emergency cases and 47.05 %( n=16) were elective. Male female ratio was 3:1 in emergency cases and 2.6:1 in elective cases. Per rectal bleeding (56%) and altered bowel habit (31.25%) was predominant clinical presentation in elective cases whereas intestinal obstruction (55.55%) and peritonitis (22.22%) were predominant clinical presentation in emergency cases. In emergency cases most of the tumors were located in left side (77.77%) and in elective cases rectum was common site (37.5%). Left hemicolectomy was the commonest surgery performed (72.22%) in emergency set up. In elective cases, right hemicolectomy, left hemicolectomy, APR and LAR was done in 31.25%, 31.25%, 25% and 25% cases respectively. In the emergency group 11.11% (n=2) developed enterocutaneous fistula and early mortality within 30 days was observed in 5% (n=1) of emergency cases only. Conclusion: In emergency conditions, colorectal cancer presented with intestinal obstruction where as elective cases presented with per rectal bleeding and altered bowel habits. Compared with the elective patients, the emergency patients had higher rate of morbidity and mortality. Because of higher incidence of colorectal cancer in our institution, in all emergency cases who presents with features of intestinal obstruction and peritonitis, we have to rule out colorectal cancer especially if the patients are elderly. Therefore, we should encourage screening programme for early detection of colorectal cancers for better outcome of surgery. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-2, 25-30 DOI: http://dx.doi.org/10.3126/jcmsn.v9i2.9684

Retrorectal tumors: report of two cases

Retrorectal tumor is uncommon identity presenting with nonspecific sign and symptoms making difficulty in diagnosis. Benign tumors are more common than malignant. The lesion may be malignant or progress to malignancy from benign state. Retrorectal masses in young women may continue to grow and result in dystocia. Cystic lesions are also at risk of becoming infected, which renders subsequent excision more difficult and increase the risk of recurrence. Cross-sectional imaging is required to determine the extent of resection and the appropriate surgical approach. Surgical removal leads to favorable outcomes for patients with benign purely cystic retrorectal tumors. We report two such benign rectal lesions. ] Journal of College of Medical Sciences-Nepal, 2012, Vol-8, No-4, 46-50 DOI: http://dx.doi.org/10.3126/jcmsn.v8i4.8701  

Arterio-Venous (AV) Fistula: Surgical outcome in College of Medical Sciences Teaching Hospital, Bharatpur, Chitwan

Aims Arteriovenous fistula is considered as reliable form of vascular access for hemodialysis in Chronic Kidney Disease (CKD) patients. We aim to evaluate prospectively, the outcome and primary failure rate of Arteriovenous fistula in 30 Chronic kidney Disease patients with Glomerular Filtration Rate (GFR) <30ml/min. Materials and methods This prospective study was conducted at the department of cardiothoracic and vascular surgery (CTVS), College of Medical Sciences, Bharatpur from May 2011 to May 2012. Thirty patients ranging from age 25 to 76 years with stage IV and V CKD, i.e. GFR below 30ml/min, were included in this study. Detailed physical examination including arterial pulses i.e. axillary, brachial, radial and ulnar and blood pressure in both upper limbs was recorded. Allens test was performed on every patient and left upper limb was used for AV fistula formation. Brachiocephalic fistula was made in 19 (63.33%), while radiocephalic fistula was made in 11 (36.67%) patients. Patients were evaluated post operatively, on outdoor basis, weekly for 6weeks. All patients were evaluated for the presence or absence of complications i.e. infection, hematoma, thrombosis, aneurysms and steal syndrome. Results The complication was primary failure in two patients. One male patient got secondary infection and one female patient got post operative hematoma leading to 6.66% primary failure of fistula. No other complications were noted. Conclusion Arteriovenous fistula is the gold standard for vascular access for hemodialysis in patients with deteriorating renal function and end-stage renal disease. It is designed to improve the effectiveness of dialysis with fewer risks and complications than other vascular accesses. This study gives the higher success rate of 93.33% and concludes that age should not be a limiting factor when determining candidacy for arteriovenous fistula creation and is the safe procedure. Journal of College of Medical Sciences-Nepal, 2012, Vol-8, No-4, 1-6 DOI: http://dx.doi.org/10.3126/jcmsn.v8i4.8693

Demographics and awareness of diabetic retinopathy among diabetic patients attending the vitreo-retinal service at a tertiary eye care center in Nepal

INTRODUCTION

Diabetic retinopathy (DR) is one of the leading causes of blindness in Nepal.

OBJECTIVE

To investigate the demographic characteristics and awareness of diabetic retinopathy among new cases of diabetes mellitus (DM) attending the vitreo-retinal service of a tertiary eye care centre in Nepal.

MATERIALS AND METHODS

A hospital-based, cross-sectional study including all consecutive new cases of DM was carried out. Detailed demographics of the subjects and their awareness of potential ocular problems from diabetes mellitus were noted.

RESULTS

A total of 210 patients with a mean age of 57 +/- 10.4 years were included. Brahmins (34.8 %) and Newars (34.3 %) were the predominant ethnic groups. Housewives (38.6 %) and office workers (18.6 %) were the major groups affected. Two-fifths (37 %) of the cases were unaware of DR and its potential for blindness. Awareness was significantly higher among literate patients (P = 0.006). Fundus evaluation was done for the first time in 48.6 %, although almost four-fifths had a duration of diabetes of five years or more. DR was found in 78 % of the cases, with 16.7 % already at the proliferative stage and about 40 % exhibiting clinically significant diabetic macular edema.

CONCLUSION

A lack of awareness of DR coupled with a high proportion of cases already at a sight-threatening stage of retinopathy at their first presentation reflects the need for improved awareness programs to reduce the burden of blindness from DR in Nepal.

Cardiorenal syndrome: A literature review

The incidence of cardiorenal syndrome is increasing; however, its pathophysiology and effective management are still not well understood. For many years, diuretics have been the mainstay of treatment for cardiorenal syndrome, although a significant proportion of patients develop resistance to diuretics and even deteriorate while on diuretics. Trials on different ways to counteract diuretic resistance and newer treatment modalities, such as nesiritide, arginine vasopressin receptor antagonists, adenosine receptor antagonists and ultrafiltration, have shown promising results.

Optical coherence tomographic assessment of macular thickness and morphological patterns in diabetic macular edema: Prognosis after modified grid photocoagulation

Introduction: The topographic mapping is useful for monitoring patients for the development of macular edema and following the resolution of edema after laser treatment. Objectives: To evaluate the usefulness of optical coherence tomography (OCT) for mapping of macula after laser therapy in clinically significant macular edema (CSME). Materials and methods: A prospective study was carried out enrolling 60 eyes of 35 patients with the diagnosis of CSME. OCT was performed at first visit and every successive follow up visit. The retinal thickness was measured automatically using OCT retinal mapping software. Statistics: Correlation between vision status and central macular thickness (CMT) was done using the Spearman’s correlation test. The analysis of variance (ANOVA) and independent t-test were used for comparison of groups. Results: The OCT revealed sponge like thickening pattern (ST) in 67.4 % followed by cystoid macular edema (CME) in 19.6 %. Best corrected visual acuity (BCVA) improved in 89.1 % after 6 months of treatment. There was high correlation between vision status and CMT (P =<0.001). The mean values of baseline CMT were 301.68 (±134.738), 434.83 (±180.758), 518.67 (±275.184), 327 (±108.393) and 334.85 (±158.91) microns for the OCT patterns of ST, CME, sub-foveal detachment (SFD), vitreo-macular interface abnormality (VMIA) and average CMT respectively (p=0.042). Conclusion: OCT is a useful tool for evaluating CSME. It can show the various morphological variants of CSME while the BCVA and CMT are fairly different. DOI: http://dx.doi.org/10.3126/nepjoph.v4i1.5864 NEPJOPH 2012; 4(1): 128-133