Dermatomyositis with positive anti-TIF1 gamma antibodies in an adult female: A case report.

Dermatomyositis is an uncommon autoimmune disease with only few cases reported from Nepal. Presence of anti TIF-1 gamma antibodies in DM are the strongest predictor of malignancy. Timely screening of malignancies for early detection and management remains the mainstay of this report.

Comorbidities in children with cerebral palsy: a single-centre cross-sectional hospital-based study from India.

OBJECTIVE: To describe the comorbidities in children with cerebral palsy (CP) and determine the characteristics associated with different impairments. DESIGN: Cross-sectional study. SETTING: Tertiary care referral centre in India. PATIENTS: Between April 2018 and May 2022, all children aged 2-18 years with a confirmed diagnosis of CP were enrolled by systematic random sampling. Data on antenatal, birth and postnatal risk factors, clinical evaluation and investigations (neuroimaging and genetic/metabolic workup) were recorded. MAIN OUTCOME MEASURES: Prevalence of the co-occurring impairments was determined using clinical evaluation or investigations as indicated. RESULTS: Of the 436 children screened, 384 participated (spastic CP=214 (55.7%) (spastic hemiplegic=52 (13.5%); spastic diplegia=70 (18.2%); spastic quadriplegia=92 (24%)), dyskinetic CP=58 (15.1%) and mixed CP=110 (28.6%)). A primary antenatal/perinatal/neonatal and postneonatal risk factor was identified in 32 (8.3%), 320 (83.3%) and 26 (6.8%) patients, respectively. Prevalent comorbidities (the test used) included visual impairment (clinical assessment and visual evoked potential)=357/383(93.2%), hearing impairment (brainstem-evoked response audiometry)=113 (30%), no understanding of any communication (MacArthur Communicative Development Inventory)=137 (36%), cognitive impairment (Vineland scale of social maturity)=341 (88.8%), severe gastrointestinal dysfunction (clinical evaluation/interview)=90 (23%), significant pain (non-communicating children's pain checklist)=230 (60%), epilepsy=245 (64%), drug-resistant epilepsy=163 (42.4%), sleep impairment (Children's Sleep Habits Questionnaire)=176/290(60.7%) and behavioural abnormalities (Childhood behaviour checklist)=165 (43%). Overall, hemiparetic and diplegic CP and Gross Motor Function Classification System ≤3 were predictive of lesser co-occurring impairment. CONCLUSION: CP children have a high burden of comorbidities, which increase with increasing functional impairment. This calls for urgent actions to prioritise opportunities to prevent risk factors associated with CP and organise existing resources to identify and manage co-occurring impairments. TRIAL REGISTRATION NUMBER: CTRI/2018/07/014819.

Comparative Study of Perioperative Outcomes Between Modified Blumgart Duct to Mucosa and Dunking Pancreaticojejunostomy.

BACKGROUND: Pancreaticojejunostomy (PJ) is the ''Achilles heel" of pancreaticoduodenectomy (PD) which affects perioperative as well as oncological outcomes. However, there is a lack of information about the superiority of the type of anastomosis in terms of overall morbidity and postoperative pancreatic fistula (POPF) after PD. Here, we compare the outcomes of modified Blumgart PJ with the dunking technique of PJ. METHODOLOGY: A case-control study of a prospectively maintained database of 25 consecutive patients undergoing modified Blumgart PJ (study group) and 25 patients who underwent continuous dunking PJ (control group) between January 2018 to April 2021 was done. Between groups, comparisons were made for the duration of surgery, intraoperative blood loss, original fistula risk score, overall complications as graded by Clavien Dindo (CD), POPF, post pancreatectomy haemorrhage (PPH), delayed gastric emptying (DGE), and 30-day mortality at 95% confidence level. RESULTS: Among 50 patients, 30 (60%) were male. The most common indication for PD was ampullary carcinoma (44% in the study group vs. 60% in the control group). The duration of surgery was approximately 41 minutes longer in the study group compared to the control (p = 0.02), while the intraoperative blood loss was similar between the two groups (496.00 ± 226.35 ml vs 508.00 ± 180.67 ml, p = 0.84). While there was no significant difference in mean fistula risk score between the two groups, the POPF (8% vs 32%, p = 0.03), PPH (0% vs 20%, p =0.02), and overall major complications (CD≥ III) according to CD Grading (12% vs 40%, p = 0.02) were significantly lower in the study group. Similarly, the duration of hospital stay in the study group was 4.64 days shorter than the control group (p = 0.001). However, there was no significant difference in the 30-day mortality between the two groups. CONCLUSIONS: Modified Blumgart pancreaticojejunostomy has better perioperative outcomes in terms of procedure-specific complications like POPF, PPH, overall major postoperative complications, and duration of hospital stay.

Prevalence of Left Ventricular Diastolic Dysfunction in Patients with Essential Hypertension.

BACKGROUND: Left Ventricular Diastolic Dysfunction is considered a critical link between hypertension and heart failure, particularly in individuals with heart failure and preserved ejection fraction. The aim of this study is to assess the prevalence and factors associated with clinical parameters of left ventricular diastolic dysfunction in patients with essential hypertension. METHODS: A hospital-based cross-sectional study was done among 68 newly diagnosed and known hypertensive patients visiting out patientdepartmentat Bir hospital. Patients who meet the inclusion criteria were chosen alternatively by referring OPD register. Patients with hypertension had undergone echocardiography to see whether left ventricular diastolic dysfunction was present and was compared to other clinical parameters like age, sex, body mass index, and dyslipidemia using the student t-test/chi-square test. RESULTS: The prevalence of left ventricular diastolic dysfunction in essential hypertensive patients was 33.8%. About 25% patients had grade 1; 7.4% and 1.5% of patients had grade 2 and grade 3 diastolic dysfunction respectively. Patients who had a duration of hypertension of more than five years were more than nine times (OR 9.14; 2.89-28.87) more likely to have Left ventricular diastolic dysfunction. Age and Body Mass Index were found statistically significant with diastolic dysfunction (P<0.05). CONCLUSIONS: Left ventricular diastolic dysfunction was found prevalent in hypertensive patients.  Age, Body mass index, Dyslipidemia and Duration of hypertension were found to be statistically significant with diastolic dysfunction  Keywords: Diastolic dysfunction; hypertension; Nepal; prevalence.

Early Outcomes of Extended Hepatectomy: An Experience from the University Hospital of Nepal.

Background Extended hepatectomy (≥ 5 liver segments resection) may be required to have a complete surgical resection and provide the best chance of cure of hepatobiliary tumors. It is associated with high morbidity and mortality but with good perioperative care, its outcomes can be improved. This study was conducted to evaluate the early outcomes of extended hepatectomy at a university hospital in Nepal. Methods For this study, prospectively collected data from all patients who underwent extended hepatectomy from October 2012 to April 2022 were reviewed and analyzed retrospectively. Demographic data, liver volume augmentation methods used, intraoperative variables, and postoperative complications were analyzed. Results Seventeen patients underwent extended hepatectomy from October 2012 to April 2022. Among them 11 (64.7%) were female and the mean age was 53.9 ±16.3 years (18-72 years). Right extended hepatectomy was the most commonly performed procedure (n = 15, 88.2%), and left extended hepatectomy was performed in the remaining (n = 2, 11.8%). Six patients underwent liver volume augmentation procedures (35.3%) with portal vein embolization (PVE) in three, portal vein ligation (PVL) in one, and partial associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in two patients. Overall complications were 70% with major complications (Clavien Dindo ≥ IIIa) constituting 35.3%. The most common hepatectomy-specific complication was post-hepatectomy liver failure (PHLF) in six cases. The 30-day mortality was 17.6% (three patients). Conclusion Extended hepatectomy can be performed with acceptable major complications and mortality rates in selected patients.

Behavioral, cognitive, emotional and social engagement in mathematics learning during COVID-19 pandemic.

A meaningful engagement of learners is critical in the quality teaching and learning of mathematics at school level. Learner engagement has been an ongoing issue in mathematics classrooms in Nepal and elsewhere. In this context, this study aimed to examine the level of engagement (behavioral, social, emotional, and cognitive activities) and their association with learning mathematics through the virtual mode of instruction during the pandemic. The cross-sectional online survey design was employed among 402 secondary-level mathematics teachers in Nepal. Descriptive statistics, correlation, and structural equation modeling were the major statistical techniques used in research. The findings indicate that the level of behavioral, social, emotional, and cognitive engagement of students was found to be high in the online mode of instruction. Additionally, cognitive engagement has significant highest impact on social, behavior, and emotional engagement.

Hepatic mass caused by Fasciola hepatica: A case report.

INTRODUCTION: Fascioliasis is a zoonotic infestation which presents with a wide spectrum of clinical pictures. However, it may often be overlooked, especially in the acute phase, because of uncertain symptoms. Fasciola hepatica can have an initial presentation similar to malignant liver mass or complex hepatic cyst. Here, we report a case of a hepatic mass caused by fasciola hepatica. CASE PRESENTATION: A 48-year-old woman came with chief complaints of epigastric and right hypochondrial discomfort associated with nausea and vomiting. Ultrasonography (USG) showed a heterochronic lesion in the segment VIII of the liver with few cystic lesions. CECT abdomen and pelvic gave impression of ill-defined irregular hypodense lesions in the right lobe of the liver with progressive enhancing peripheral and central cystic areas suggestive parasitic liver infestation likely echinococcus alveolaris. Right hepatectomy was done and the patient was discharged without any complications. DISCUSSION: Fascioliasis is uncommon in developed countries but more commonly seen in developing countries. The identification of fasciola hepatica eggs in the stool is a standard method for the diagnosis of fascioliasis. Fascioliasis may cause a wide variety of clinical signs ranging from asymptomatic infection to severe liver cirrhosis. Surgery for complex hydatid cysts of the liver is potentially burdened by serious complications. Technique of choice for surgical management remains inconclusive. CONCLUSION: Fasciola hepatica infection can mimic a malignant liver mass or a complex hepatic cyst because of its uncertain presentation. The disease can be prevented with public education and environmental precautions.

Comparative genomic analyses of multi-drug resistant Mycobacterium tuberculosis from Nepal and other geographical locations.

Nepal exhibits a tuberculosis (TB) incidence rate that is comparable to neighbouring high TB incidence countries. In addition, it records >500 cases of multi-drug resistant (MDR) TB each year. The objective of this study was to perform whole-genome bioinformatic analysis on MDR-TB isolates from Nepal (n = 19) to identify the specific mutations underlying their phenotypic resistance. In addition, we examined the dominant genotype among the Nepal MDR-TB isolates, the East-Asian Beijing sub-lineage, to determine its relatedness to a panel of 1274 genomes of international strains available from public databases. These analyses provided evidence that the XDR-TB isolates in our collection were not derived from importation of primary XDR-TB to Nepal but were more likely the result of acquisition of second-line drug resistance in Nepal. Resistance to fluoroquinolones was detected among a high proportion of the Nepal isolates. This has implications for the management of TB, including appropriate antimicrobial stewardship and susceptibility testing for fluoroquinolones and other second-line TB drugs, to minimise the development of XDR-TB among Nepal TB cases.

Transduodenal surgical ampullectomy for intra-ampullary papillary tubular neoplasm (IAPN): A case report.

INTRODUCTION AND IMPORTANCE: Intra-ampullary papillary tubular neoplasms (IAPNs) are relatively rare kind of neoplasms occurring in the region of the papilla which exhibit significant malignant transformation. The patient was concerned about his pain and the possibility of malignancy. CASE PRESENTATION: We report a case of a 47-year-old male who presented with persistent upper abdomen pain. Following detail investigations, he was diagnosed as IAPN and managed by transduonal ampullectomy (TDA). CLINICAL DISCUSSION: The insidious onset of IAPN along with its high risk of malignancy makes it mandatory for its proper treatment. Although, endoscopic approach is advantageous for initial therapy, it has some technical difficulties. Hence TDA forms the cornerstone in the management of IAPN with good prognosis. CONCLUSION: Transduodenal ampullectomy is a safe and feasible option for IAPN. It can be the first choice of treatment in selected cases where endoscopic papillectomy is not available.

Assessment of Airway Parameters for Predicting Difficult Laryngoscopy and Intubation in a Tertiary Center in Western Nepal.

BACKGROUND: The screening tests used for pre-operative evaluation of airway to predict difficult laryngoscopy and intubation have variable diagnostic accuracy. The unanticipated poor laryngeal view is gold standard for defining difficult intubation. We aimed to find out the prevalence of difficult laryngoscopy and intubation, which airway parameter better predicts difficult intubation and whether difficult laryngoscopy is associated with difficult intubation or not. METHODS: This analytic cross sectional study was conducted in 665 ASA I/II adult patients, aged 18-65, without obvious airway pathology undergoing elective surgery under general anesthesia. The pre-operative screening tests included mouth opening, modified mallampatti, ratio of height to thyromental distance, sternomentaldistance and upper lip bite test. Cormack-Lehane grade III/ IV was defined as difficult laryngoscopy and potentially difficult intubation. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy and area under curve at 95% confidence interval was calculated for all five screening tests. RESULTS: The prevalence of difficult laryngoscopy and intubation was 6.6% (44 cases). The upper lip bite test because of its highest specificity, positive predictive value, negative predictive value, accuracy and area under curve (99.7%; 93.9%; 99.7%; 95.2%; 85.1% respectively) with moderate level of sensitivity (70.5%) was better predictor of difficult intubation than other tests. The difficult laryngoscopy was associated with difficult intubation (p=0.00). CONCLUSIONS: The prevalence of difficult laryngoscopy and intubation was 6.6%.The upper lip bite test was a better predictor of difficult intubation and there was a significant association of difficult laryngoscopy with difficult intubation.

Draft Genome Sequence of an Isolate of Extensively Drug-Resistant Mycobacterium tuberculosis from Nepal.

Extensively drug-resistant (XDR) Mycobacterium tuberculosis has become a challenge to the treatment of tuberculosis (TB) in several countries, including Nepal. Here, we report for the first time the draft genome sequence of an isolate of XDR-TB collected in Nepal and describe single-nucleotide variations associated with its extensively drug-resistant phenotype.

Cesarean Sections under General Anesthesia at a Tertiary Care Center in Western Nepal: A Descriptive Cross-sectional Study.

INTRODUCTION: General anesthesia is feared to have adverse feto-maternal outcomes compared to neuraxial anesthesia. It is recommended to keep rate of caesarean sections under general anesthesia below 5% and 15% for elective and emergency caesarean sections respectively. This study was conducted to find out the prevalence of caesarean sections under general anesthesia at a tertiary care center in western Nepal. METHODS: A descriptive cross-sectional study was conducted among caesarean sections conducted at Manipal Teaching Hospital, Pokhara, Nepal from January 2014 to December 2017. Ethical approval was taken from the Institutional Review Committee with reference number MEMG/IRC/GA/122. All the caesarean sections conducted during this study period were included in the study using whole sampling method. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. Data for each patient was subsequently entered into an Excel spreadsheet and analyzed using Statistical Package for Social Sciences version 20. RESULTS: Among 3613 cases, caesarean sections under general anesthesia was observed in 175 (4.84%) in our center over a period of four years at 95% Confidence Interval (4.13-5.55%). The yearly variations ranges from 2.83% to 8.99%. The rate of general anesthesia was found slightly higher in elective 31 (5.82%) as compared to emergency caesarean section 144 (4.67%). CONCLUSIONS: The four year medical records of our institution showed fluctuating trend of caesarian sections under general anesthesia. The rate of general anesthesia for emergency caesarian section was within the recommended rate while it was slightly higher in elective caesarian section.

Prevention of Shivering during Spinal Anesthesia: Comparison between Tramadol, Ketamine and Ondansetron.

INTRODUCTION: Shivering is an unpleasant experience after spinal anesthesia. We conducted this study to evaluate the efficacy of ondansetron, ketamine and tramadol for prevention of shivering. METHODS: In this randomized controlled study, 120 patients aged 18-65 years of American Society of Anesthesiologist (ASA) physical status I and II undergoing various surgical procedures were included and allocated alternately to one of the 4 groups; Normal saline (Group1), Ondansetron 4mg (Group2), Ketamine 0.25mg/kg (Group3) and Tramadol 0.5mg/kg (Group4). Incidence of shivering, effect on hemodynamics, nausea, vomiting, sedation and emergence reactions were recorded. Data was analyzed using SPSS (The Statistical Package for Social Sciences) version 20.0 software. RESULTS: The patients were comparable in terms of demographic variables, baseline temperature, type of surgery, median level of sensory blockade, duration of surgery and anesthesia. Shivering was present in 17 (56.7%), 5 (16.7%), 3 (10%) and 3 (10%) patients respectively in Group 1, 2, 3 and 4 which was statistically significant when compared to Group 1 (P=0.00) The odds of NS and ondansetron, NS and ketamine, NS and tramadol was 6.53, 11.76 and 11.76 respectively which showed that study drugs were effective in preventing shivering. None of the patients were sedated in Group 1 and 2. Mild to moderate sedation was present in Group 3 and 4 (P=0.00). None of the patients had drug related adverse reactions. CONCLUSIONS: Prophylactic use of ondansetron, low doses of ketamine and tramadol is effective in preventing shivering post spinal anesthesia without untoward effects.