Inguinal hernia repair in an elderly patient with moderate aortic stenosis under sole epidural anesthesia: A case report.

Key Clinical Message: In resource limited settings, epidural anesthesia can be a safe option for elderly patients with aortic stenosis for lower abdominal surgeries as the hemodynamic changes are known to be less as compared to spinal or general anesthesia. Abstract: Spinal or general anesthesia in an elderly patient with aortic stenosis is always a challenge for anesthesiologists. It is even more challenging in a resource limited setting. The marked hemodynamic changes associated with either spinal or general anesthesia increase the morbidity and mortality. We present a case of right inguinal hernia in a 71-year-old patient with hypertension, bradycardia, and moderate aortic stenosis planned for open mesh repair under sole epidural anesthesia.

Multisystem inflammatory syndrome in a neonate secondary to COVID-19: a case report.

Introduction and importance: Multisystem inflammatory syndrome in children secondary to coronavirus disease 2019 (COVID-19) (MIS-C) is very common and may present with clinical features similar to Kawasaki disease but is rarely reported in neonates (MIS-N). Any history of maternal upper respiratory tract infection should raise suspicion of MIS-N secondary to COVID-19 in critically ill neonates. Case presentation: The authors present a term neonate with gradually progressive respiratory distress requiring mechanical ventilation with marked improvement after starting immunoglobulin and steroids after blood investigations revealed high IgG COVID-19 antibody titers. Clinical findings and investigation: Admitted to the Neonatal Intensive Care Unit as he received bag and mask ventilation for 30 s following delivery, he was kept under oxygen via nasal prongs; but he still had nasal flaring, subcostal retraction, and tachypnea. All the blood investigations were within normal limits except for elevated C-reactive protein. Intervention and outcome: With no improvement despite oxygen via nasal prongs, he was kept under bubble continuous positive airway pressure with positive end-expiratory pressure of 5 cm of H2O. With no improvement even after 24 h of noninvasive ventilation, he was kept under mechanical ventilation in assisted pressure-controlled mode with a peak inspiratory pressure of 22 cm H2O and respiratory rate of 40 breaths/minute. As the mother gave a history of on-and-off cough for almost a month, samples were sent for COVID-19 antibodies which came out to be positive with very high titers of IgG antibodies. Intravenous steroids, immunoglobulin, and subcutaneous low molecular weight heparin were started and marked improvement was noted. The peak inspiratory pressure and FiO2 were gradually tapered off, and he was extubated on the 10th day of mechanical ventilation. Conclusion: Multisystem inflammatory syndrome in neonates is rare but should always be considered in neonates with multisystem involvement and a history of maternal upper respiratory tract infection after excluding all other causes.

Recurrent pancreatitis secondary to hypertriglyceridemia: A case report and case review.

Key Clinical Message: Managing acute pancreatitis secondary to hypertriglyceridemia in pregnancy is challenging. The use of intravenous insulin along with lipid lowering drugs can be an option in settings where plasmapharesis and gene therapy are unavailable. Abstract: Acute pancreatitis secondary to hypertriglyceridemia is rare but various studies have highlighted it as the third most common cause following gallstones and alcohol consumption. Managing acute pancreatitis is always challenging; even more challenging during pregnancy. We present a case of a 31-year- old female with a history of recurrent pancreatitis secondary to hypertriglyceridemia with a current episode of acute pancreatitis at 21 weeks of gestation.

Spontaneous fundal rupture in an unscarred uterus in a female with twin pregnancy after in-vitro fertilization: a case report.

Spontaneous uterine rupture in an unscarred uterus is very rare. It is found to be rarer after in-vitro fertilization. It is associated with significant morbidity and mortality if not diagnosed and treated promptly. Case presentation: Thirty three years female with twin pregnancy following in-vitro fertilization after 11 years of marriage presented to emergency department with lower abdominal pain at 36 weeks 3 days of gestation and was planned for emergency caesarean section for precious twin pregnancy in labour. Clinical findings and investigation: She was vitally stable and on palpation of abdomen, there was generalized tenderness along with guarding. All the investigations were within normal limits. Intervention and outcome: Emergency caesarean section was performed under subarachnoid block which revealed a 6×2 cm fundal uterine rupture with no active bleeding which was repaired in layers. The babies were extracted with a lower uterine segment incision. First twin cried immediately after birth while the second one needed resuscitation and mechanical ventilation due to perinatal asphyxia. Conclusion: Even though rare in a previously unscarred uterus, uterine rupture can present in different forms and thus, requires vigilant evaluation of the patient and prompt intervention to avoid significant maternal or foetal morbidity and mortality.

Ultrasound-guided femoral and sciatic nerve block as an option for below-knee amputation in an elderly patient: A case report.

Peripheral nerve blocks can be a very safe option in elderlypatients with multiple comorbidities where spinal or general anesthesia may be associated with increased risks. We present a 67 years male taking antiplatelet drugs with deranged coagulation profile with bilateral pneumonia with diabetic foot with wet gangrene planned for emergency below knee amputation under ultrasound guided femoral and sciatic nerve block.

Regional anesthesia as a safe option in patient with limb girdle muscular dystrophy undergoing total abdominal hysterectomy: A case report and case review.

Regional anesthesia can be a very safe option in patients with limb girdle muscular dystrophy undergoing lower abdominal surgeries as general anesthesia and volatile anesthetic agents are associated with increased risk of malignant hyperthermia and rhabdomyolysis.

Hypersensitivity reaction to intravenous ondansetron: A case report.

Ondansteron is widely used as prophylaxis for postoperative nausea and vomiting and is associated with various side effects. We present a case of hypersensitivity reaction in the form of itching and rashes in a 6-year-old female patient with a single dose of intravenous ondansetron.

Fall Injuries in Nepal: A Countrywide Population-based Survey.

BACKGROUND: An estimated 424,000 fatal falls occur globally each year, making falls the second leading cause of unintentional injury-related deaths after road traffic injuries. More than 80% of fall-related fatalities occur in low- and middle-income countries. Data from low-income South Asian countries like Nepal are lacking, particularly at the population level. The aim of this study was to provide an estimate of fall-injury prevalence and the number of fall injury-related deaths countrywide in Nepal and to describe the epidemiology of fall injuries in Nepal at the community level. METHODS: A countrywide cross-sectional study was performed in 15 of the 75 districts in Nepal using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey tool. The SOSAS survey gathers data in 2 sections: demographic data, including the household's access to health care and recent deaths in the household, and assessment of a representative spectrum of surgical conditions, including injuries. Data was collected regarding an individuals' experience of injury including road traffic injuries, falls, penetrating trauma, and burns. Data included anatomic location, timing of injury, and whether health care was sought. If health care was not sought, the reason for barrier to care was included. Descriptive statistics were used to analyze the data. RESULTS: Of 2695 individuals from 1350 households interviewed, 141 reported injuries secondary to falls (5.2%; 95% confidence interval [CI], 4.4%-6.1%), with a mean age of 30.7 years; 58% were male. Falls represented 37.2% of total injuries (n = 379) reported (95% CI, 32.3%-42.3%). Twelve individuals who suffered from a fall injury were unable to access surgical care (8.5%; 95% CI, 4.5%-14.4%). Reasons for barrier to care included no money for health care (n = 3), facility/personnel not available (n = 7), and fear/no trust (n = 2). Of the 80 recent deaths reported, 7 were due to fall injury (8.8%; 95% CI, 3.6%-17.2%), and patients had a mean age of 46 years (SD 22.8). Surgical care was not delivered to those who died for the following reasons: no time (n = 4), facility/personnel not available (n = 1), fear/no trust (n = 1), and no need (n = 1). CONCLUSION: The Nepal SOSAS study provides countrywide, population-based data on fall-injury prevalence in Nepal and has identified falls as a crucial public health concern. These data highlight persistent barriers to access to care for the injured and the need to improve trauma care systems in developing countries such as Nepal.

Unmet surgical needs in children: a household survey in Nepal.

PURPOSE: While an estimated two billion people lack access to surgical care, little data are available on surgical conditions for pediatric populations in low- and middle-income countries. Our study aims to assess pediatric surgical needs in Nepal. METHODS: A countrywide cross-sectional study was performed in 15 randomly chosen districts; 3 clusters (2 rural; 1 urban) per district were selected. The prevalence of surgical conditions, unmet surgical needs, and barriers to care were analyzed among children (0-18 years of age). RESULTS: Overall, 1,350 households and 2,695 individuals were surveyed (response rate: 97 %); 800 respondents (29.7 %, 95 % CI 27.9-31.4 %) were pediatric; 59.8 % (95 % CI 56.3-63.2 %) were male; median age was 10 years (IQR 5-15). Of them, 84 (10.5 %, 95 % CI 8.5-12.8 %) had a surgical condition; 48 (6.0 %, 95 % CI 4.5-7.9 %) reported an unmet need for surgical care. Based on this, we estimate that 706,076 (95 % CI 529,557-929,666) children live with untreated surgical conditions. Barriers to care included limited availability of services (31.3 %), funds (22.9 %), time (4.2 %), and fear/mistrust of medical services (16.7 %). CONCLUSION: Close to 700,000 children in Nepal are estimated to need surgical consultation. Programs to address this should be developed alongside efforts by policy makers and donors to rectify the lack of care, bolster limited funds, and strengthen healthcare systems.

Psychiatric Comorbidities in Patients with Deliberate Self-Harm in a Tertiary Care Center.

INTRODUCTION: Deliberate self-harm (DSH) is one of the common psychiatric emergencies in medical practice. It has become a global health problem with rates increasing over time. Very few studies have been conducted on this important health issue in Nepal. We conducted a hospital based study to evaluate the cause, mode and psychiatric comorbidities present in patients of DSH. METHODS: This cross sectional study was performed on 200 cases of deliberate self-harm in a tertiary referral centre in Eastern Nepal from April 2012 to July 2012 by the data collected from the medical records of these patients. Various sociodemographic data and psychiatric comorbidities prevalent in them were studied. RESULTS: Most of the patients (77%) were below the age of 35. The female-to-male ratio was 1.35:1. 76% of the patients had received formal education. Majority (73.5%) were married. By occupation, 38% were housewives and 25.5% were students. 72.5% of cases had consumed organophosphates/-chlorides. Interpersonal conflict (72%) was the major cause for DSH. Psychiatric disorders according to ICD-10 criteria were found in 37% of cases and premorbid personality problems were found in 20% of cases. The most prevalent psychiatric disorder was adjustment disorder (13.5%) followed by mood disorder (11%). CONCLUSION: Majority of DSH cases were of younger generation. Psychiatric disorders and comorbid personality problems were commonly seen in DSH patients. This has significance for proper evaluation and management.