Evaluation of circulating plasma miR-9, miR-29a, miR-192, and miR-375 as potential biomarkers for predicting prediabetes and type 2 diabetes in Nepali adult population.

Circulating plasma miRNAs have emerged as potential early predictors of glucometabolic disorders. However, their biomarker potential remains unvalidated in populations with diverse genetic backgrounds, races, and ethnicities. This study aims to validate the biomarker potential of plasma miR-9, miR-29a, miR-192, and miR-375 for early detection of prediabetes and type 2 diabetes mellitus (T2DM) in Nepali populations that represent distinct genetic backgrounds, races, and ethnicities. A total of 46 adults, categorized into healthy controls (n = 25), prediabetes (n = 9), and T2DM (n = 12) groups, were enrolled. Baseline sociodemographic, anthropometric, and clinical characteristics were collected. Fold change in plasma expression of all four miRNAs was quantified using RT-qPCR against the RNU6B reference gene. Their biomarker potential was determined by receiver operating characteristic (ROC) curve analysis. Multivariate discriminant function and hierarchical cluster analyses were used to evaluate the effectiveness of the miRNA panel in reclassifying study participants who were initially categorized according to their glucose tolerance status. Plasma expression of all four miRNAs was significantly upregulated in T2DM patients compared to normoglycemic controls. Furthermore, the expression of only miR-29a and miR-375 was upregulated in T2DM patients than in prediabetic individuals. Notably, only miR-192 expression was significantly upregulated in prediabetic individuals than in the normoglycemic controls. The miRNA expression profiles had the potential of reclassifying the participants into three original groups with an accuracy of 69.6 %. ROC curve analysis identified miR-192 as the predictor for both prediabetes and T2DM, while miR-9, miR-29a, miR-192, and miR-375 were predictive only for T2DM. The specific set of miRNA combinations significantly improved their predictive accuracy. This study validates the early predictive biomarker potential of plasma miR-9, miR-29a, miR-192, and miR-375 also in the Nepali population and paves the way for future translational studies to validate their utility in clinical laboratories.

An uncommon encounter: crossed fused renal ectopia with singular ureter: a case report.

BACKGROUND: Crossed fused renal ectopia (CFRE) is a common congenital anomaly where one kidney is positioned abnormally on the opposite side of the midline, often fused with the other kidney. However, single ureter draining crossed fused renal ectopia is a rare occurrence. CASE REPORT: Here, we report a case of crossed fused renal ectopia with a single ureter in a 46-year-old Nepali male who presented with history of lithuria. Computed tomography revealed that the left kidney was situated on the right side and fused with the right kidney. The renal pelvises of both kidneys were fused, and a single ureter, located on the right side, was draining both kidneys into the bladder. The patient was advised to have regular follow-ups. CONCLUSION: Crossed fused renal ectopia with a single ureter represents a rare renal anomaly. Asymptomatic patients can typically be managed conservatively. Regular follow-up is recommended to monitor renal function, calculus formation, infections, and malignant changes.

Zenker's diverticulum: A case study of dysphagia in an elderly gentleman.

Zenker's diverticulum (ZD) is an acquired, false, and pulsion diverticulum formed by the protrusion of mucosa and submucosa through Killian's dehiscence. The index case is a 91-year-old Nepali patient with a known history of diabetes mellitus, hypertension, rheumatic heart disease, and stage 4 chronic kidney disease, who has been experiencing dysphagia, halitosis, and chronic cough for 25 years. A computed tomography (CT) scan of the chest revealed an outpouching filled with air, fluid, and some solid contents, arising at the level of the cricoid cartilage and extending posteriorly to the esophagus, compressing it. A barium swallow test was performed for confirmation and revealed similar findings. The patient was counseled for surgery but declined due to old age and comorbidities. ZD is commonly seen in the geriatric population and patients with neuromuscular discordance. Barium swallow and CT chest scans can diagnose ZD, and surgery is the mainstay of treatment.

Trans-abdominal fetal reduction in higher order multiple pregnancies: a pioneer cohort retrospective study in Nepal.

Objective: To share the initial experience of trans-abdominal multifetal pregnancy reduction (MFPR) in Nepal. Method: The procedure was performed in 108 patients in a private hospital over a period of 3 years. Under ultrasound guidance, intracardiac injection of 0.2-3.0 ml of 15% w/v (2 mEq/ml) potassium chloride (KCl) was administered via trans-abdominal route. Results: A total of 108 fetal reduction procedures were carried out at the seventh to fifteenth weeks of gestation, a maximum of 44 (40.7%) of which were done at the ninth to tenth weeks of gestation. A total of 123 fetuses were reduced. Out of total 108 multifetal pregnancies, 96 (88.8%) were due to in-vitro fertilization (IVF). Eighty-five pregnancies (78.7%) underwent reduction from triplet to twin. The second-time reduction was needed in five cases. Two attempts (in the same sitting) were required in three cases. The inadvertent demise of the second fetus was noted in three cases of dichorionic tri-amniotic triplet pregnancy. Conclusion: Ultrasound-guided trans-abdominal fetal reduction performed between the seventh and twelfth weeks of gestation is safe and effective.

A pea in a peculiar place: Unusual case of left upper lobe bronchial foreign body.

Key Clinical Message: Foreign body aspiration is common in old age, sometimes lodged in unusual locations like the left upper lobe bronchus when aspiration happens in a recumbent position. Computed tomography is the preferred diagnostic tool, while flexible bronchoscopy is effective for removing the foreign body. Abstract: Tracheo-bronchial foreign body aspiration (FBA) is common in children and elderly, but often goes unnoticed due to vague symptoms and atypical imaging findings. We present a case of aspiration of pea in elderly presenting with acute symptoms. Computed tomography (CT) reveled an atypical site of foreign body (FB), that is left upper lobe bronchus and immediate removal of the FB was done using a flexible bronchoscope. The symptoms subsided after removal of the FB. Missed FBs can lead to chronic issues like pneumonia and airway obstruction. Advanced age, psychiatric illness, stroke, seizure disorder, and neuromuscular disease increase the risk of aspiration in older adults. Commonly, FBs get lodged in the right middle and lower lobes after aspiration due to vertical orientation of the airways. CT is a helpful tool for diagnosis of FBA and flexible bronchoscopy is effective in removal of the FB in elderly.

Magnetic resonance imaging findings in central nervous system tuberculosis: A pictorial review.

Central nervous system (CNS) tuberculosis is a post-primary form of tuberculosis. It has high mortality and morbidity rates despite early diagnosis and treatment. CNS tuberculosis can manifest as subacute/chronic meningitis, parenchymal tuberculous lesions, and spinal tuberculosis. Hematogenous spread of tuberculous bacilli to the brain results in the development of so called "rich foci" on the pial surface, ependyma, and grey-white matter junction. Rupture of these "rich foci" into the subarachnoid space triggers an intense granulomatous inflammatory reaction. Tuberculous meningitis can manifest as leptomeningitis or pachymeningitis. Intracranial parenchymal tuberculous lesions may present as tuberculoma, tuberculous abscess, cerebritis, rhombencephalitis, and encephalopathy, with atypical presentations not uncommon. Complications of CNS tuberculosis encompass hydrocephalus, syrinx formation, vasculitis, infarcts, neuritis, and enduring neurological deficits. Post-contrast 3D fluid-attenuated inversion recovery (FLAIR) and post-contrast T1 spin-echo sequences excel in detecting tuberculous meningitis compared to other conventional magnetic resonance imaging (MRI) sequences. In proton magnetic resonance spectroscopy (PMRS), the presence of a lipid peak at 1.3 ppm is indicative of tuberculous lesions. Magnetization transfer (MT) imaging enhances the detection of tuberculous lesions, as the magnetization transfer ratio (MTR) of tuberculous pathologies, owing to their high lipid content, is lower than that in bacterial or fungal pathologies and higher than that in viral pathologies. This review article delves into the various typical and atypical imaging presentations of CNS tuberculosis in MRI, along with recent advances in imaging techniques.

Evaluation of variations of optic nerve course in relation to posterior paranasal sinuses in MDCT in a tertiary care center of Nepal: a retrospective cross-section study.

Background: The proximity of optic nerves to the posterior paranasal sinuses (PNS) is a critical consideration in preventing optic nerve injuries during functional endoscopic sinus surgery. Methods: A retrospective cross-sectional study was conducted on 367 patients aged 13 years and above. Four radiologists, each with 2-6 years of experience, evaluated computed tomography scans of the PNS and the head of these patients. The optic nerves were classified into four types based on DeLano's classification, and their respective prevalence rates were determined. Additionally, the prevalence of optic nerve dehiscence and pneumatization of the anterior clinoid process was assessed. Results: A total of 734 optic nerves were evaluated and categorized into four groups as per DeLano's classification. The most common type was classified as type 1 optic nerve, representing 65.4% of all optic nerves. Types 2, 3, and 4 optic nerves accounted for 16.9, 8.6, and 9.1%, respectively. The prevalence rates of type 1, type 2, type 3, and type 4 optic nerves were 76.6, 24.5, 12.3, and 14.4%, respectively. Optic nerve dehiscence was observed in 14.3% of cases, with a prevalence of 21.2% in the study. Type 3 optic nerves were most commonly associated with dehiscence, with 49.2% of them showing dehiscence in their course through the ethmoid or sphenoid sinus. The prevalence of pneumatization of the anterior clinoid process in the study population was 28.3%, with type 3 optic nerves being the most frequently associated. Conclusion: An understanding of the relationship between optic nerves and posterior PNS, as well as awareness of optic nerve dehiscence, is essential in preventing injuries during sinus surgeries. Type 1 optic nerve predominates among Nepalese patients visiting our hospital.

Delayed presentation of congenital sigmoid colon stenosis: a rare entity.

Congenital sigmoid colon stenosis is a rare entity that can mimic Hirschsprung disease. Presentation of congenital colon stenosis is usually within first few weeks of life. Our case presented with features of distal bowel obstruction at 2 years of age with the history of chronic constipation and progressive abdominal distention from first week of life and bilious vomiting for the last 1 week. Clinical diagnosis of Hirschsprung disease was made. Contrast enhanced CT abdomen showed bowel obstruction with transition point at the level of proximal sigmoid colon. There was a short segment stenosis at the level of proximal sigmoid colon. Contrast enema showed stenosis at proximal sigmoid colon. The bowel distal to stenosis was normal in calibre. Similar findings were seen during surgery. Mesocolon was present in stenosed segment of the bowel. The resected stenotic segment showed adequate ganglion cells in histopathology.

Hashimoto thyroiditis in a lingual thyroid: An interesting case.

Key Clinical Message: Whenever an enlarging mass is seen in throat, possibility of lingual thyroid should be considered. Thyroid function test should be done whenever ectopic thyroid is detected. Imaging (ultrasonography or Tc-99m scintigraphy) is adequate for diagnosis. Conservative treatment with levothyroxine helps in reducing size of lingual thyroid. Abstract: Hashimoto thyroiditis in lingual thyroid results in enlargement of the thyroid gland and oropharyngeal symptoms. Suppression therapy with levothyroxine results in reduction in size of the gland. We present an interesting case of Hashimoto disease in an adolescent female presenting as oropharyngeal mass.

Pituitary stalk interruption syndrome: A case report.

Pituitary stalk interruption syndrome (PSIS) is a rare congenital abnormality. It comprises the triad of thin or interrupted pituitary stalk, aplasia or hypoplasia of anterior pituitary gland, and absent or ectopic posterior pituitary gland. The patient usually presents with a spectrum of symptoms predominantly secondary to anterior pituitary hormonal deficiency. The etiology of this syndrome is not well-established but the genetic cause is considered to be the most common etiology. Early diagnosis is crucial in preventing and reducing morbidity. The prognosis is good if the condition is diagnosed early and the hormonal therapy is started promptly. The diagnosis of PSIS is primarily based on magnetic resonance imaging (MRI) findings.

Von Hippel Lindau Disease with central nervous system and multiple visceral manifestations: A case report.

Von Hippel-Lindau (VHL) disease is an autosomal-dominant syndrome caused by mutations in the VHL gene, located on the short arm of chromosome 3. Patients with VHL are likely to manifest with a spectrum of multiple benign and malignant tumors involving various organ systems. We present a case of a 28-year-old female without a remarkable family history who presented with complaints of hematuria and abdominal discomfort. Initial laboratory investigations confirmed hematuria. Subsequent abdominal computed tomography scan revealed heterogeneous enhancing solid mass in bilateral kidneys, avidly enhancing mass in the right adrenal gland, bilateral simple renal cortical cysts, and a pancreatic cyst. With a provisional diagnosis of VHL disease, an MRI of the brain and spine was performed, which showed the presence of a cerebellar hemangioblastoma. Her catecholamine and vanillylmandelic acid levels were in the normal range not in line with pheochromocytoma. The patient then underwent bilateral partial renal nephrectomy and right adrenalectomy. Histopathologic examination reported clear renal cell carcinoma and pheochromocytoma of the right adrenal gland mass. Molecular genetic testing confirmed the presence of VHL disease.

Acute hydrocephalus caused by colloid cyst of third ventricle: A case report.

Colloid cysts (CCs) of third ventricle are rare benign lesions. They present with acute hydrocephalus and its sequalae like brain herniation, infarcts resulting even death in otherwise healthy individual. We present a case of an acute hydrocephalus caused by CC of third ventricle. A middle age male was airlifted from a remote district of Nepal to our hospital with no accompanying doctor. The patient had headache, multiple episodes of vomiting, abnormal body movement, and loss of consciousness for 24 hours. On examination, vitals were stable; the Glasgow Coma Scale (GCS) score was 7. The patient was intubated in emergency and an MRI brain was done. MRI showed an obstructive lesion in third ventricle with features consistent with CC and an active hydrocephalus. There were multifocal infarcts in the bilateral cerebrum, left part of mid brain and pons, left thalamus and left superior cerebellum. We inserted external ventricular drainage in emergency operation theatre within hours and endoscopic excision of the lesion was done on the next day. In histopathology, the lesion was confirmed to be a CC.

Ischemic Portal Venous Gas and Pneumatosis Intestinalis Managed Conservatively in a Patient with Rheumatic Heart Disease and Warfarin Induced Coagulopathy: A Case Report.

Mesenteric ischemia is a surgical emergency. The presence of hepatic portal venous gas and pneumatosis intestinalis is a frequent finding in computed tomography. Not all hepatic portal venous gas and pneumatosis intestinalis are due to mesenteric ischemia. A 70-year-old female, with a known case of diabetes mellitus, rheumatic heart disease and atrial fibrillation under warfarin presented with diffuse abdominal pain, multiple episodes of vomiting and ecchymosis in bilateral flanks. Evaluation of the coagulation profile suggested warfarin-induced coagulopathy. Portal venous gas was detected during an ultrasound examination. Subsequent contrast-enhanced computed tomography abdomen showed hepatic portal venous gas, pneumatosis intestinalis, paucity of branches of the ileocolic artery, and reduced enhancement of caecum and ascending colon. Mild ascites were present in the pelvis. Arterial blood gas analysis revealed compensated metabolic acidosis. The patient was managed conservatively and discharged after nine days of hospital admission. Conservative approach can be considered for suspected mesenteric ischemia in surgically unfit candidates. Keywords: case reports; mesenteric ischemia; portal vein; rheumatic heart disease; warfarin.

Changes in liver morphology in patients with extrahepatic portal venous obstruction: a retrospective magnetic resonance imaging study.

OBJECTIVE: To investigate the liver parenchymal changes on MRI in patients with extrahepatic portal venous obstruction (EHPVO). METHODS: This was a retrospective evaluation of the MRI studies in patients with EHPVO between January 2016 and April 2018. The diagnosis of EHPVO in each case had been established on the basis of clinical and Doppler parameters. Following findings were recorded on MRI: liver size; outline; overall volume redistribution; volume redistribution of caudate, right and left lobes; signal heterogeneity, intrahepatic biliary radicle dilatation, focal liver lesions, gallstones and ascites. RESULTS: A total of 164 MRI studies were evaluated. Median age was 27 years (range, 6-70). There were 90 (54.9%) males and 74 (45.1%) females. The median liver size was 14 cm (range 5-17). The median spleen size was 15.9 cm (range, 6-28). A spleen size ≥12 cm was seen in 136 (82.9%) patients. The liver outline was nodular in 32 (19.5%) patients. Volume redistribution was seen in 63 (38.4%) patients. Caudate lobe hypertrophy was seen in 49 (29.9%) patients. Right lobe atrophy and hypertrophy was seen in 4 (2.4%) and 1 (0.6%) patients respectively. Left lobe atrophy and hypertrophy was seen in 15 (9.1%) and 10 (6.1%) patients respectively. 30 MRI (18.3%) showed heterogeneous signal intensity. Focal lesions were seen in 22 (13.4%) patients. Intrahepatic biliary radicle dilatation, gallstones and ascites were seen in 120 (73.2%), 54 (32.9%) and 26 (15.9%) patients respectively. CONCLUSION: Liver morphological changes are common in EHPVO. ADVANCES IN KNOWLEDGE: The morphological changes in liver in patients with EHPVO have not been described previously. This information will prevent misdiagnosis of this condition as cirrhosis.