Predicting response to neoadjuvant chemotherapy for colorectal liver metastasis using deep learning on prechemotherapy cross-sectional imaging.

BACKGROUND AND OBJECTIVES: Deep learning models (DLMs) are applied across domains of health sciences to generate meaningful predictions. DLMs make use of neural networks to generate predictions from discrete data inputs. This study employs DLM on prechemotherapy cross-sectional imaging to predict patients' response to neoadjuvant chemotherapy. METHODS: Adult patients with colorectal liver metastasis who underwent surgery after neoadjuvant chemotherapy were included. A DLM was trained on computed tomography images using attention-based multiple-instance learning. A logistic regression model incorporating clinical parameters of the Fong clinical risk score was used for comparison. Both model performances were benchmarked against the Response Evaluation Criteria in Solid Tumors criteria. A receiver operating curve was created and resulting area under the curve (AUC) was determined. RESULTS: Ninety-five patients were included, with 33,619 images available for study inclusion. Ninety-five percent of patients underwent 5-fluorouracil-based chemotherapy with oxaliplatin and/or irinotecan. Sixty percent of the patients were categorized as chemotherapy responders (30% reduction in tumor diameter). The DLM had an AUC of 0.77. The AUC for the clinical model was 0.41. CONCLUSIONS: Image-based DLM for prediction of response to neoadjuvant chemotherapy in patients with colorectal cancer liver metastases was superior to a clinical-based model. These results demonstrate potential to identify nonresponders to chemotherapy and guide select patients toward earlier curative resection.

Insights into ocular syphilis in Nepal.

PURPOSE: This study aims to elucidate the demographic characteristics, clinical features, diagnostic approaches, and medical management of patients with ocular syphilis, known as 'the great masquerader,' at a tertiary eye care center in Nepal. METHODS: We conducted a retrospective review involving 15 eyes from ten patients with ocular syphilis treated at a uveitis referral center between 2020 and 2022. Lumbar puncture was performed if neurosyphilis was suspected. Treatment success was defined as the absence of ocular inflammation in both eyes and a decrease in Veneral disease research laboratory (VDRL) titres after completing therapy. RESULTS: A total of 15 eyes of 10 patients were diagnosed with syphilitic uveitis based on positive treponemal and non-treponemal serological tests. The mean age of the patient was 39.9 years (range 22-54 years) with an equal distribution between males and females. HIV coinfection was not found in any of the patients. Syphilitic uveitis was the primary presentation in nine patients (90%), while one patient presented with recurrent nodular scleritis. Ocular involvement was bilateral in 50% (5 patients). The mean duration between the initial symptom and the first presentation was 8.7 weeks (range: 4 days to 24 weeks). The most common ocular findings was panuveitis (6 eyes). Eight patients with early syphilis received weekly intramuscular injections of benzathine penicillin G for 3 weeks whereas 2 patients with neurosyphilis were treated with intravenous ceftriaxone 1 gm twice a day for 14 days. Signs and symptoms of majority of patients improved with systemic therapy for syphilis. CONCLUSIONS: Syphilitic uveitis should be included in the differential diagnosis of any form of ocular inflammation.

Comparative study of the effects of laser peripheral iridotomy and cataract surgery on anterior chamber angle parameters in primary angle closure suspect patients.

INTRODUCTION: Prophylactic laser peripheral iridotomy (LPI) and cataract surgery are considered the primary treatments for primary angle closure suspect (PACS) as they have proven effectiveness in widening the iridocorneal angle and addressing the underlying anatomical issues associated with this condition. The objective of this study is to compare the impact of LPI and cataract surgery on anterior chamber angle parameters, aiming to fill the existing research gap. METHODOLOGY: A prospective comparative study was conducted, involving 76 eyes of 61 patients. The study focused on patients diagnosed with PACSs and early cataract. The patients received treatment either through LPI or cataract surgery. Comprehensive eye examination was performed, including gonioscopy and anterior segment parameters were measured using anterior segment ocular coherence tomography (ASOCT). Follow-up examinations were conducted at 1 week and 1 month after the procedures, which included ASOCT and gonioscopy performed during the 1-month follow-up. RESULTS: All anterior chamber angle parameters increased significantly after treatment in both groups, including trabecular iris angle (TIA), angle opening distance at 250, 500 and 750 µm (AOD 250, AOD500, AOD750), trabecular iris surface area at 500 and 750 µm (TISA500, TISA750) and angle recess area at 500 and 750 µm from scleral spur (ARA500, ARA750) (p<0.05 for all). Moreover, all these parameters were greater after cataract surgery than after LPI (p<0.05 for all). CONCLUSION: Compared with LPI, cataract extraction resulted in a wider anterior chamber angle. Moreover, no residual angle closure was observed after cataract extraction, which could morphologically prevent the progress of angle closure. Thus, cataract extraction is superior to LPI in PACSs with early cataract in widening the anterior chamber angle.

Antibiotics Use among Geriatric Patients Admitted in the Department of Medicine in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Ageing predisposes to increased risk of infections which make these population vulnerable to high risk of various chronic co-morbidities, organ dysfunction and mortality. Increased frequency of infections has led to an increasing proportion of geriatric patient admission to hospitals, and antibiotics therapy has long been recognized as a cornerstone in the treatment of infections. The aim of this study was to find out the prevalence of antibiotic use among geriatric patients admitted to the Department of Medicine in a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among geriatric patients admitted to Department of Medicine in a tertiary care centre from 1 May 2022 to 31 August 2022. Ethical approval was obtained from the Institutional Review Committee (Reference number: 17/22). Patients with the age of ≥60 years, admitted to the Department of Medicine who stayed for at least 24 hours was included as the study population. Convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated. Results: Among 520 geriatric patients, antibiotics was used in 252 (48.46%) (44.16-52.76, 95% Confidence Interval) patients. Ceftriaxone was the most common antibiotic used in 165 (65.48%) patients, followed by oral azithromycin in 72 (28.57%). The mean antibiotics used per patient was 1.59±0.73. Conclusions: The prevalence of antibiotic use in the geriatric population was found to be lower than in the other studies done in similar settings. Keywords: aged; antibiotics; drug utilization.

"Augmenting the referral pathway for retinal services among diabetic patients at Reiyukai Eiko Masunaga Eye Hospital, Nepal: a non-randomized, pre-post intervention study".

BACKGROUND: Diabetic Retinopathy (DR) is an important public health issue in Nepal. Despite the availability of retinal services, people may not access them because of the lack of knowledge about DR and poor referral systems. DR screening uptake was low at Reiyukai Eiko Masunaga Eye Hospital(REMEH) since retina services were started. Scheer Memorial Hospital is a multispeciality hospital near to REMEH. It has no eye department but has been running a regular diabetic clinic. This was a site for referring diabetic patients for DR screening. Improving DR awareness among general physicians has the potential to address these challenges. METHODS: The aim of our study was to investigate the effectiveness of providing health education to selected health personnel and establish a referral pathway on the attendance of diabetic patients for retinal screening at REMEH. This was a non-randomized, pre-post intervention study design. Total of three health education sessions were provided to the health care professionals of Scheer on diabetic retinopathy using Power Point presentations, posters, pamphlets and videos. The study period was 16 months (2020 June -2021 September) and divided into 8 months pre-intervention(baseline data collection) and 8 months post intervention period. The proportional increase in number of diabetes attendance pre and post intervention was calculated by Z test. The change in knowledge of health care personnels pre and post intervention was scored and evaluated through a questionnaire and calculated by paired- t test. Data was analyzed using Excel and Epi Info 7.The Protocol was published on August 21, 2021, in JMIR Publications. RESULTS: The proportional increase in number of referrals of diabetes attendance post intervention increased from 50 to 95% and was statistically significant (p < 0.001, 95% CI: 0.214-0.688). The mean score of knowledge gained by physicians on DR awareness was more at post intervention (8.8 ± 1.32) than pre intervention (6.4 ± 1.51). It was statistically significant (p < 0.001). CONCLUSION: This study shows that a well-planned health education intervention changes the knowledge in physicians about DR. There is an increase in the number of referrals and attendance of patients for DR screening with the change in knowledge and referral mechanism. TRIAL REGISTRATION: Clinical Trials.gov NCT04829084; https://clinicaltrials.gov/ct2/show/NCT04829084 :02/04/2021.

Clinical profile and surgical outcome of pars plana vitrectomy in non-diabetic vitreous hemorrhage.

Background: Spontaneous vitreous hemorrhage is one of the common causes of ocular emergency. There are very few prospective studies on the clinical profile and surgical outcomes for patients with dense vitreous hemorrhage caused by non-diabetic and non-traumatic till date to our knowledge. Objectives: This study was conducted to better understand the etiologies, clinical profile, surgical outcome, and visual prognosis following pars plana vitrectomy for dense vitreous hemorrhage in adults with non-traumatic and non-diabetic retinopathy. Design: This was a prospective interventional study. Methods: This study was conducted in Mechi Eye Hospital (Birtamod, Nepal) from October 2018 to September 2019. All consecutive cases, 46 eyes of 46 patients, with vitreous hemorrhage that underwent vitrectomy were included in our study. There were 14 (30.4%) female and 32 (69.6%) male patients, and the average age at presentation was 43.74 ± 16.19 (17-84) years. The success rate of surgery in terms of visual outcome was evaluated. Results: The most common cause of vitreous hemorrhage was retinal vasculitis with fibrovascular changes and vascular sheathing 19 (41%). The indication of vitrectomy on patient demand was 20 (43.5%). Success rate of surgery in terms of visual outcome (functional outcome) was defined as final visual acuity of >6/60 which was 86.9%. Conclusion: The most common cause of spontaneous vitreous hemorrhage in our study was retinal vasculitis with fibrovascular changes and vascular sheathing. Vitrectomy has a good surgical outcome for spontaneous vitreous hemorrhage in terms of visual outcome (functional outcome) unless guarded by other factors like chorioretinal atrophy followed by optic atrophy and epiretinal membrane.

Self-medication in Primary Dysmenorrhea among Undergraduate Students in a Medical College: A Descriptive Cross-sectional Study.

Introduction: Primary dysmenorrhea is painful menstruation in women with normal pelvic anatomy, usually beginning during adolescence, primarily associated with a normal ovulatory cycle. There is an increased likelihood of self-medication among medical students. The aim of this study is to find out the prevalence of self-medication in primary dysmenorrhea among undergraduate students in a medical college. Methods: A descriptive cross-sectional study was conducted in a medical college among undergraduate female students with primary dysmenorrhea from 1 February 2022 to 31 May 2022. Ethical approval was obtained from the Institutional Review Committee of the same institute (Reference number: 254/2021). Convenience sampling was done. Data were collected through a self-administered questionnaire. Point estimate and 95% Confidence Interval were calculated. Results: Among 213 students with primary dysmenorrhea, self-medication was found to be in 78 (36.62%) (30.15-43.09, 95% Confidence Interval)). Among all the self-medications used, mefenamic acid was most common, used by 45 (57.69%) students, followed by paracetamol 11 (14.10%). Conclusions: The prevalence of self-medication practice in primary dysmenorrhea among undergraduate students was lower when compared to similar studies done in similar settings. Keywords: dysmenorrhea; menstruation; prevalence; self medication.

Augmenting the Referral Pathway for Retinal Services Among Patients With Diabetes Mellitus at Reiyukai Eiko Masunaga Eye Hospital, Nepal: Protocol for a Nonrandomized, Pre-Post Intervention Study.

BACKGROUND: Diabetic retinopathy (DR) is an important public health issue in Nepal with a huge social and economic impact. Despite the availability of retinal services, people may not access them because of the lack of knowledge about DR and poor referral systems. Published studies on referral pathways in Nepal are scarce. Improving DR awareness among general physicians has the potential to address these challenges. OBJECTIVE: The aim of this study is to evaluate the effect of a health education intervention on health personnel, establish a referral pathway, and assess the impact of the intervention on the attendance of patients with diabetes mellitus for retinal screening at Reiyukai Eiko Masunaga Eye Hospital in Nepal. METHODS: This is a nonrandomized, pre- and postintervention study. Health education on DR will be provided to selected health personnel of the intervention hospital (Scheer Memorial) using information education and communication (IEC) materials in the form of PowerPoint presentations, posters, pamphlets, videos, and pre- and postevaluation questionnaires along with referral slip. Pre- and postevaluation will be undertaken during the study period. Data will be analyzed using MS Excel and Epi Info 7. RESULTS: The ethical approval for this study has been obtained from the Ethical Review Board of the Nepal Health Research Council (ERB Protocol Registration Number # 582/2020P). The study is expected to be completed in 18 months from the start of the project. The baseline data collection was from June to January 2020 for a period of 8 months. The postintervention data collection was from February to September 2021 for a period of 8 months. The last 2 months are planned for data analysis and report writing. CONCLUSIONS: Health education intervention could be a low-cost solution to improve the awareness, access, and utilization of retinal health care services; this is an understudied topic in Nepal. Working closely with the stakeholders, this study will evaluate the role of health education interventions (which are already validated in other low-income settings) to strengthen referral and reduce the burden of DR in Nepal. TRIAL REGISTRATION: ClinicalTrials.gov NCT04829084; https://clinicaltrials.gov/ct2/show/NCT04829084. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/33116.

Drug Prescription in the Department of Medicine of a Tertiary Care Hospital according to the World Health Organization/International Network for Rational Use of Drugs Core Indicators: A Descriptive Cross-sectional Survey.

INTRODUCTION: To establish appropriate health care services in developing countries, rationalization of drug use holds utmost importance. Drug use patterns can be found out using Core Indicators of the World Health Organisation in collaboration with the International Network of Rational Use of Drugs. With the help of the indicators, this study aimed to find out the way the drugs were prescribed in the Medicine out-patient department of a tertiary care hospital. METHODS: A descriptive cross-sectional survey was conducted from October 2019 to March 2020 in a tertiary care hospital. The ethical approval was taken from the Institutional Review Committee of the Dhulikhel hospital (reference number 198/19). Convenient sampling was done. After taking consent from the patient, data was collected from prescriptions written on the patient's card. The data were analysed using Statistical Package for the Social Sciences Version 25. Descriptive statistics were applied and the results were expressed as frequency and percentage, mean and standard deviation. RESULTS: A total of 559 prescriptions were analysed, of which a total of 1427 medicines were found to be prescribed with an average number of medicines per the prescription of 2.55±1.388. Drugs prescribed by generic name were 820 (57.5%), antibiotics were 138 (9.7%) and injections were 8 (0.6%). Drugs prescribed from the Essential Drug List of Nepal was 939 (65.8%). CONCLUSIONS: Our study revealed that despite some results being up to the mark, there is a requisite for the proper regulation of prescribing and dispensing drugs in order to promote rationalisation.

Branch Retinal Vein Occlusion in a Case of Sarcoidosis.

BACKGROUND: Sarcoidosis is a chronic inflammatory disorder characterized by non-caseation granuloma. It is an inflammatory disorder of unknown etiology. Sarcoidosis has variable ocular presentations from anterior uveitis to rare venous occlusions. CASE: We present a rare case of sarcoidosis with bilateral hilar lymphadenopathy and a compatible uveitis. Positive findings of mutton fat keratic precipitates, Koeppes nodule, posterior synechiae, trabecular meshwork nodules, Candle wax dripping sign, Branch retinal vein occlusion and choroidal granuloma in one eye supported the diagnosis of sarcoidosis. Elevated serum acetylcholine esterase and bilateral hilar lymphadenopathy also confirmed the diagnosis of sarcoidosis. OBSERVATION: The patient responded well to oral steroids and laser photocoagulation of the vein occlusion area. The patient developed complications of steroid like Herpes Zooster of abdomen and avascular necrosis of femur. CONCLUSION: Branch Retinal Vein Occlusion is a rare vascular complication in ocular sarcoidosis. Systemic steroids and laser for vein occlusion is mainstay of treatment. Physician must be aware of serious complications of steroid therapy, as seen in this case. Keyword: Sarcoidosis, Branch retinal vein occlusion, Steroids.

Subretinal Cysticercosis in a Challenging Case: A Case Report.

Ocular cysticercosis occurs rarely and may involve various parts of the eye including subretinal space. We report a case of a 42 years-old female with diminution of vision in the right eye for one month and no vision in the left eye for 10 years. Best corrected visual acuity in the right eye was 5/60. Fundus examination showed whitish round elevated cystic mass temporal to the macula. It was confirmed as a subretinal cyst by Brightness scan and Magnetic Resonance Imaging. The subretinal cyst was removed in toto by pars plana vitrectomy followed by histopathological examination of the cyst which confirmed the diagnosis of cysticercosis. This case report highlights the importance of early diagnosis of subretinal cysticercosis which could threaten the vision in a one-eyed patient. Pars plana vitrectomy could be an effective method for subretinal cyst removal in toto even in a challenging case.

Outcome of intravitreal bevacizumab injection without pre and postoperative antibiotics.

BACKGOUND: Intravitreal injections are the most common treatment modality for several retinal pathologies. Despite endophthalmitis being the most feared complication, antibioprophylaxis remains controversial in intravitreal injections. METHODS: This was a retrospective study done for a period of 2 years from 1st January 2017 to 31st December 2018 in B. P Koirala Lions Centre for Ophthalmic Studies (BPKLCOS) among patients receiving intravitreal bevacizumab. The intravitreal injection was given by a single surgeon. It included 503 eyes which received intravitreal bevacizumab over a period of 2 years without pre and postoperative antibiotics. RESULTS: Out of 503 eyes studied over a period of 2 years without antibiotic prophylaxis the rate of endophthalmitis was 0.0019% which is very low compared to the other studies with rate of endophthalmitis between 0.019-0.09%. CONCLUSION: The risk of endophthalmitis was low even without pre/post-operative antibiotics. Intravitreal injection can be given safely without pre-operative and post-operative antibiotics. Trial Registration not applicable as it is a retrospective study.

Combined Intravitreal Bevacizumab And Dexamethasone In Bilateral Lupus Retinopathy.

This paper reports and discusses a case of bilateral lupus retinopathy with macular edema in a patient diagnosed with systemic lupus retinopathy and treated with combined intravitreal bevacizumab (0.025 mL/0.625 mg) and intravitreal dexamethasone (0.05 mL/0.2 mg). The patient was a 25-year-old female with a history of diminution of vision in both eyes. Best corrected visual acuity (BCVA) of the right eye was 2/60 and of the left eye was 1/60. Fundus examination revealed bilateral swelling of the optic disc nasally, cotton wool spots, and multiple flame shaped, dot and blot hemorrhages in the disc and macula. Optical coherence tomography (OCT) revealed macular edema in both eyes. Despite being treated with immunosuppressive the visual acuity did not improve. Two doses of combined intravitreal bevacizumab (0.025 mL/0.625 mg) and dexamethasone (0.05 mL/0.2 mg) were given to the patient in both eyes at an interval of one week. Two weeks after the last intravitreal injection the BCVA was 6/24 and N8 in both eyes. Fundus examination revealed a decrease in the number and size of hemorrhages, and resolution of the blurred disc margin, cotton wool spots, and hard exudates. OCT of the macula 2 weeks after the last intravitreal injection showed a significant decrease in macular edema. The intraocular pressure was not elevated for a period of 6 months. This case would be a unique case of lupus retinopathy with macular edema receiving a combined half dose of intravitreal injection bevacizumab and dexamethasone with promising results. This could be beneficial in a set up where the patients cannot afford intraocular steroid implants.

Disseminated neurocysticercosis with bilateral papilledema: a case report.

BACKGROUND: Ocular cysticercosis is a disease which rarely involves cutaneous skin and the optic nerve. Patients with clinical presentation of subcutaneous nodules and papilledema should always be evaluated for cysticercosis. CASE PRESENTATION: We report a rare case of ocular cysticercosis with multiple disseminated subcutaneous nodules and papilledema in both eyes. A 22-year-old Brahmin man presented with complaints of gradual loss of vision in both eyes and multiple small masses all over his body. On clinical evaluation, multiple subcutaneous nodules were seen on his face, mandibular area, elbow, arm, and abdomen. A fundus evaluation showed bilateral blurred disc margin. The case was managed with steroids and anti-parasitic drugs. CONCLUSION: This case report highlights the importance of ruling out neurocysticercosis in cases with multiple disseminated subcutaneous nodules and papilledema.

Knowledge, Attitude and Practice on Antibiotics Use and its Resistance Among Medical Students in A Tertiary Care Hospital.

INTRODUCTION: Antimicrobial resistance is an urgent and serious global health problem, demanding considerable attention from health care professionals worldwide. The unavoidable consequence of the widespread use of these agents has been the reason for emergence of antibiotic resistant pathogens, leading to increase in need for new drugs. This study aims to assess knowledge, attitude and practice towards antibiotics use and its resistance in undergraduate medical students. METHODS: A descriptive, cross-sectional study was conducted among 228 undergraduate medical students studying in tertiary care hospital in February, 2018. Data was collected through self administered questionnaire and was entered in Statistical Package for Social Sciences 2016. Descriptive statistical analysis was carried out to find out knowledge, attitude and practice on antibiotics use and its resistance on medical students. RESULTS: The mean knowledge, attitude and practice score towards antibiotics use among students was 7.44±1.26, 3.35±1.12 and 5.06±1.45 respectively. Out of total students, only 39 (17.1%) had good knowledge and practice whereas 114 (50%) had good attitude towards antibiotics use. Approximately, all 224 (98.2%) students were aware that antibiotics are useful for bacterial infection. Fifty two (22.8%) students said that antibiotics are safe drugs, therefore, can be used commonly. CONCLUSIONS: Although half of the students had good attitude, majority had moderate knowledge and practice towards antibiotics use. Adequate educational training should be provided to future doctors regarding proper prescribing, dispensing and usage of antibiotics.

Lens induced glaucoma in a tertiary eye care centre in Western Nepal.

INTRODUCTION: Lens induced glaucoma due to hypermature cataracts is an important cause of secondary glaucoma in the developing world. The most common etiology of lens induced glaucoma is phacomorphic glaucoma from untreated senile cataract. OBJECTIVES: To study the demographics, clinical presentations and surgical outcome of lens induced glaucoma (LIG). MATERIALS AND METHODS: It is the prospective case series of fifty three patients eyes with LIG over a 6 months period from June 2015 to November 2015. All cases of lens induced glaucoma underwent cataract surgery. Data including demographics, clinical presentations, surgical outcome were analysed using Statistical Package for Social Studies 20.0. RESULTS: The mean age was 61.5 years (Standard deviation 8.9) with predominantly women (30, 56.6%) were affected. Phacomorphic glaucoma (38, 71.7%) was the main cause of lens induced glaucoma, followed by phacolytic glaucoma (15, 28.3%). The main clinical symptoms were reduced vision (100%), eye pain (96.2%) and redness of eyes (62.3%). All patients (100%) presented with visual acuity of <3/60 or worse and intraocular pressure (IOP) more than 40 mm Hg (34, 64.2%). All 53(100%) patients underwent cataract surgery and all of them had tremendously reduced intraocular pressure with a mean 13.9 mmHg and vision had improved from >6/18 as noted in 16(30.2%) cases. CONCLUSIONS: The main clinical presentations of LIG are triad of acute reduced vision, eye pain and redness. The better final BCVA is found when there is an early presentation and less IOP at the time of presentation Public awareness, early detection and early intervention aids in good visual recovery and control of intraocular pressure in LIG.

Initial Treatment of Unresectable Neuroendocrine Tumor Liver Metastases with Transarterial Chemoembolization using Streptozotocin: A 20-Year Experience.

BACKGROUND: The majority of patients with neuroendocrine tumor liver metastases (NELM) present with multifocal disease and are not surgical candidates. We present our 20-year experience with transarterial chemoembolization (TACE) using streptozotocin (STZ) in patients with initially unresectable NELM. METHODS: Patients with unresectable NELM treated with TACE using STZ at a single institution from 1995 to 2015 were identified after institutional board approval. Imaging was independently reviewed by a radiologist to evaluate for RECIST 1.1 responses. RESULTS: Ninety-one patients with NELM who underwent 474 TACE treatments during the past 20 years were identified. Median age was 62 years, and 54 % of the patients were females. Median number of TACE treatments per patient was four (range 1-22). TACE treatment with STZ was very well tolerated with 10.3 % of treatments being associated with side effects, predominantly transient, including hyper/hypotension, bradycardia, or postembolization syndrome. Median overall survival from the start of TACE was 44 months (5-year OS from TACE 40.8 % and 5-year PFS 20.3 %), and 54 % of the patients who had carcinoid syndrome reported improved symptoms after TACE treatments. Age, grade, liver tumor burden, and ability to undergo multiple TACE treatments were independent predictors of overall survival in multivariable analysis. Chromogranin A levels >115 ng/ml were associated with worse overall survival (p < 0.001). CONCLUSIONS: In patients with unresectable NELM, TACE with STZ is well tolerated with minimal toxicity and can lead to diminished carcinoid syndrome and long-term survival. This is a novel, conservative approach for the initial treatment of unresectable NELM.

Surgical outcome of pediatric dacryocystorhinostomy in Nepal.

PURPOSE: To report the indications and surgical outcome of dacryocystorhinostomy (DCR) in children treated at a single tertiary eye hospital in Nepal. METHODS: The medical records of consecutive pediatric patients who underwent external DCR with silicon tube intubation after failed nasolacrimal irrigation and probing from January 2010 to June 2011 were retrospectively reviewed. Surgical success was defined as resolution of epiphora, normal tear film height, negative fluorescein dye disappearance test and anatomic patency determined by irrigation of the lacrimal system. RESULTS: The etiology of the nasolacrimal duct obstruction was acquired nasolacrimal duct obstruction (NLDO) in 63%, congenital NLDO in 23%, trauma in 1% and congenital bony abnormality in 1 patient. Of the 38 patients who completed follow-up, 37 (97%) had a successful result. CONCLUSIONS: External DCR effectively treated a variety of pediatric NLDO etiologies, with a low rate of complications.

Prospective evaluation of vascular complications after liver transplantation: comparison of conventional and microbubble contrast-enhanced US.

PURPOSE: To prospectively compare diagnostic performance of conventional Doppler ultrasonography (US) and microbubble contrast material-enhanced US for assessment of vascular complications after liver transplantation, with clinical follow-up or angiography as reference standard. MATERIALS AND METHODS: This study was approved by institutional review board and was HIPAA compliant. Written informed consent was obtained. Seventy-two patients (49 men, 23 women; average age, 52.3 years) were included in this study. Patients who had undergone liver transplantation underwent conventional color Doppler and contrast-enhanced US of the liver. Quality of hepatic artery (HA) and portal vein (PV) visualization, contrast material arrival time, and time for complete evaluation of vasculature were compared for both techniques. McNemar test was used to compare vascular flow visualization scores; Student t test was used to compare mean study times with both techniques. Patients without HA flow at Doppler US underwent angiography; those with flow were followed up clinically. McNemar test was used to compare sensitivity of both techniques. RESULTS: Contrast-enhanced US helped significantly improve flow visualization in hepatic vessels (P < .001). Mean contrast material arrival time was 13.7 seconds +/- 3.8 (standard deviation) in proper HA and 20.7 seconds +/- 6.3 in PV. Mean study time decreased from 27.4 minutes +/- 13.9 to 9.3 minutes +/- 4.5 (P < .01). Doppler US failed to depict HA flow in eight patients; contrast-enhanced US showed flow in six and no flow in two of these patients. Follow-up results confirmed contrast-enhanced US findings. Sensitivity, specificity, and accuracy for Doppler US were 91.3%, 100%, and 91.5%, respectively. Sensitivity, specificity, and accuracy of contrast-enhanced US were all 100%. Sensitivity and accuracy values of the two techniques were significantly different (P < .014); there was no significant difference in specificity (P > .99) CONCLUSION: Contrast-enhanced US helped improve flow visualization in the HA and PV, decrease scanning time, and correctly differentiate between thrombosis and a patent artery in patients without HA flow at conventional Doppler US.