A rare case report of patent vitellointestinal duct presenting as a periumbilical pain in an adult.

The vitellointestinal duct (VID) is an embryological remnant of the vitelline duct, a structure that connects the developing fetus to the yolk sac and is responsible for the nutritional support of the fetus during the early embryological days. The VID usually gets obliterated by the fifth to ninth week of gestational age after the establishment of placental nutrition. The patent VIDellointestinal duct is a relatively rare congenital condition that occurs in approximately 2% of the general population, with the most common presentation being Meckel's diverticulum. Complete patency is rarer, occurring in 0.1% of the general population. The complete persistence of the VID results in enterocutaneous fistula, and the presentation may vary, ranging from cutaneous manifestations like skin lesions, granulomas, abscesses, or umbilical discharge to abdominal symptoms including acute abdominal pain and hematochezia. Some patients are even asymptomatic and are detected incidentally. We present a rare case of complete patency of the VID in a 30-year-old adult male presenting with acute periumbilical pain. Imaging findings guided the diagnosis, and surgical resection with histopathological examination further confirmed the condition.

Transient aphonia following spinal anesthesia during emergency cesarean section: Case report and review of literature.

Subarachnoid block with local anesthetic agents is a well-established anesthesia technique among pregnant females for labor analgesia and cesarian delivery. Although it is considered a reliable and safe technique for both mothers and fetuses, unexpected high or low levels of block may occur due to accidental injection of these agents into different meningeal spaces other than intended. Hypotension, bradycardia, headache, and failed anesthesia are common complications of spinal anesthesia. Though rare, neurological complications like aphonia, dysphagia, and tingling sensation have also been reported. The article reports a case of a 22-year-old primigravida who sustained transient aphonia following intrathecal administration of bupivacaine for an emergency cesarian section for meconium-stained liquor with fetal distress. There were no other neurological manifestations or features suggestive of high spinal block. The sensory level of the block was fixed to T6 with hemodynamic stability throughout aphasia with an episode of hypotension preceding aphonia. Aphonia commenced 9 min after the spinal anesthesia continued for a total duration of 15 min. Neurological examination, relevant investigations, and consultations were done to make a diagnosis. Thus, it is important to be aware of the possible neurological complications associated with spinal anesthesia.

Intralobar pulmonary sequestration in 2 extremes of ages: A Case report.

Pulmonary sequestration is a relatively rare phenomenon characterized by nonfunctional lung tissue supplied by one or more systemic arteries without direct connection to the tracheobronchial tree. Intra-lobar pulmonary sequestration comprises 75% of the total pulmonary sequestrations. Most patients with pulmonary sequestrations are often diagnosed with a childhood chest infection, so pulmonary sequestration is considered a childhood disease. However, few cases are found in adults and the elderly, with or without symptoms, and imaging findings on computed tomography (CT) or magnetic resonance imaging (MRI) are variable due to infection and inflammation. Failure to diagnose and treat this condition may lead to recurrent pneumonia and fatal hemoptysis. In this case report, we present cases of pulmonary sequestration at extremes of ages, one at 12 and the other at 65.

Congenital pulmonary airway malformation (CPAM): A case report and review of the literature.

Congenital pulmonary airway malformation (CPAM) is a rare congenital dysplastic malformation characterized by failure of bronchial development and localized glandular overgrowth. Previously known as Congenital Cystic Adenoid Malformation (CCAM), CPAM is classified into 5 types, from type 0 to type IV, depending upon the origin of pulmonary areas of the lung, cyst size, and cyst appearance. CPAM is a rare congenital anomaly typically diagnosed prenatally in ultrasound. However, few cases are diagnosed in childhood and even fewer in adulthood. CPAM can be differentiated from pulmonary sequestration based on the origin of the arterial supply; the former has its arterial supply from the pulmonary artery, whereas pulmonary sequestration has its arterial supply from the systemic circulation. Another differential diagnosis of CPAM includes congenital bronchogenic cyst, congenital lobar emphysema, pleuropulmonary blastoma, congenital cystic bronchiectasis, and congenital diaphragmatic hernia. The most common presentation is recurrent chest infection and chest pain, whereas other presentation includes pneumothorax and hemoptysis. Here, we present a case of a 6-year-old child with recurrent episodes of fever and cough diagnosed as a type II CPAM based on computed tomography findings.

Pulmonary embolism at CT pulmonary angiography in patients with COVID-19 at a tertiary care center in Nepal: a cross-sectional study.

Coronavirus disease 2019 (COVID-19) began to spread in December 2019 and was declared a pandemic by WHO on 11 March 2020. Pulmonary embolism (PE) is a known sequel to COVID-19 infection. Many patients showed worsened symptoms of thrombotic events of pulmonary arteries during the second week of the disease for which computed tomography pulmonary angiography (CTPA) is recommended. The most frequent complications in critically ill patients are prothrombotic coagulation abnormalities and thromboembolism. So, this study aimed to assess the prevalence of PE in patients with COVID-19 infection and to evaluate the relation to disease severity on CTPA findings. Methods: This cross-sectional study was performed to evaluate the patients who tested positive for COVID-19 and underwent CTPA. COVID-19 infection in participants was confirmed by a PCR of nasopharyngeal or oropharyngeal swab samples. Frequencies of computed tomography severity scores and CTPA were calculated and compared with clinical and laboratory findings. Results: The study included 92 patients with COVID-19 infection. Positive PE was found in 18.5% of the patients. The mean age of the patients was 59.83±13.58 years with an age range of 30-86 years. Among the total participants, 27.2% underwent ventilation, 19.6% died during treatment, and 80.4% of them got discharged. PE was developed in patients who did not receive prophylactic anticoagulation, which is statistically significant (P≤0.001). There was also a significant relationship between mechanical ventilation and CTPA findings. Conclusions: The authors conclude from their study that PE is one of the complications of COVID-19 infection. Rising D-dimer during the second week of disease alerts clinicians to do CTPA to exclude or confirm PE. This will help in the early diagnosis and treatment of PE.

Incidental finding of tuberous sclerosis complex in a woman with hematuria: A case report of renal angiomyolipoma and review of the literature.

Tuberous sclerosis complex (TSC) is a rare genetic multisystem disorder that was first described by Von Recklinghausen. We describe a case of a female, who initially presented with hematuria and was later found to have multiple manifestations of the disease. The report emphasizes the value of investigations on suspected cases.

Postpartum Symphysis Pubis Diastasis: A Case Report.

The pubic symphysis is a midline, non-synovial joint connecting the right and left superior pubic rami. The joint allows very limited movement of approximately 0.5-1 mm. Under hormonal stimulation during pregnancy, the widening of the symphysis pubis and sacroiliac joints occurs. Pubic symphysis diastasis is defined as the widening of the pubic joint of >10 mm. It is a rare complication of vaginal childbirth for which no gold standard treatment has been defined. Most cases are treated conservatively. A case of pubic diastasis in a 24-year-old G5P2A2L1 following vaginal delivery is reported. Management consisted of simple conservative treatment, which was sufficient in achieving symptomatic relief. Keywords: case reports; pelvic pain; pubic symphysis diastasis.

Diagnostic value of pleural cholesterol in differentiating exudative and transudative pleural effusion.

Background: Pleural effusions are most commonly classified as transudative or exudative based on Light's criteria which has shown misclassification in 10%-20% of cases. Studies have demonstrated lesser misclassification with pleural fluid cholesterol criteria. Thus, this study aimed to find the diagnostic properties of pleural fluid cholesterol in differentiating the type of effusion. Materials and methods: This cross-sectional study involving 72 patients was undertaken in a tertiary center in Nepal for a duration of 2 years. On the basis of Light's, Heffner's, etiological, and pleural fluid cholesterol criteria, pleural effusion was classified as exudative or transudative. The findings were then evaluated to determine the diagnostic value of each approach in identifying the effusion type and comparing them on the basis of sensitivity, specificity, positive predictive value and negative predictive value. Result: Pleural fluid cholesterol detected effusion as exudative with sensitivity of 91.94% and specificity of 80.00% against Light's criteria; with a sensitivity of 98.28% and specificity of 85.71% against the etiological diagnosis. Additionally, against the etiological diagnosis, sensitivity of both Light's and Heffner's criteria was 100%; however, specificity was 71.43% and 64.29% respectively, which is far less than that of pleural fluid cholesterol (85.71%). Furthermore, pleural fluid cholesterol was also found to have better results than protein ratio, LDH ratio and pleural fluid protein ratio in determining the type of effusion. Conclusion: When considering the avoidance of confusing outcomes in equivocal instances and cost effectiveness in developing nations, pleural fluid cholesterol can be one of the most useful alternative diagnostic methods for differentiating between exudative or transudative effusions.

Stress among Resident Doctors Working in Different Hospitals of Nepal in the Face of COVID-19 Pandemic: A Descriptive Cross-sectional Study.

INTRODUCTION: The emergence and propagation of COVID-19 pandemic has subjected resident doctors to greater workload and consequent psychological implications. Many studies have illustrated various degrees of mental health issues among health care workers in general; however very limited ones have focused primarily on the resident doctors. Therefore, this study aimed to find out the prevalence of stress among the resident doctors of Nepal. METHODS: A descriptive cross-sectional study was carried out in all the teaching hospitals of Nepal with ethical clearance from the Institutional Review Committee (Reference number-245). An online self-designed structured questionnaire developed using Google forms along with questions from stress subscale of Depression, Anxiety and Stress Scale - 21 was disseminated to the residents via social media platforms using Convenience sampling technique. Responses generated were analyzed with Statistical Package for the Social Sciences.Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS: The prevalence of stress among resident doctors was found to be 16 (8.2%) (4.3-12.1 at 95% Confidence Interval). Greater prevalence of stress was seen among residents working outside Kathmandu valley, those in the frontline and those who were unmarried. Loss of collaborative study/ professional and academic growth experiences was responsible for causing extremely severe stress among 60 (30.9%) residents, followed by stress due to uncertainty regarding COVID-19 58 (29.9%) and unavailability/lack of quality control of personal protective equipment 58 (29.9%). CONCLUSIONS: This study has shed light upon the prevalence of stress and its precipitating factors in Nepalese resident doctors due to COVID-19 pandemic. Our findings could help address these issues for their mitigation promptly.

Pneumomediastinum in COVID-19 Patients with Acute Respiratory Distress Syndrome.

BACKGROUND: Pneumomediastinum, an uncommon entity, has been on the rise with increasing cases of COVID-Acute respiratory distress syndrome. It has been unclear whether this entity represents an indicator of poor clinical outcome or not. The aims of this study were to find out the incidence of pneumomediastinum in COVID-Acute respiratory distress syndrome patients, describe their clinical characteristics and try to explain its plausible mechanisms.. METHODS: A descriptive, cross-sectional study was carried out in the ICU of our hospital among 280 patients admitted with COVID-Acute respiratory distress syndrome over a period of 6 months. Demographics along with various clinical, laboratory, and radiological parameters were analyzed. Relevant statistical analyses were done to summarize our findings. RESULTS: The incidence of pneumomediastinum in COVID-ARDS patients was 2.8%. All patients were male, none had pulmonary co-morbidities and six of them (60%) were on invasive mechanical ventilation. All intubated patients were on lung protective mechanical ventilation. The median PEEP, peak airway pressure and plateau pressure were 10 (IQR: 4), 29 (IQR: 8) and 28 (IQR: 4) respectively. The mean CT severity score was 22.7 (SD: 1.64). Five patients died after 6.8 days (SD: 4.8) of diagnosis. The average hospital stay was of 34 days. CONCLUSIONS: Pneumomediastinum is a possible complication of COVID-Acute respiratory distress syndrome which could signify the disease severity and vice versa. Furthermore, it could be an indicator of relatively poor prognosis and therefore requires larger studies to establish the association.