Heart failure due to peripartum cardiomyopathy presenting in the first week of puerperium-A case series from Nepal.

Key Clinical Message: Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure associated with pregnancy without any other known cause. With a prognosis that can vary from the complete recovery of left ventricular function to maternal mortality as well as recurrence with subsequent pregnancies, early diagnosis and treatment of PPCM is important in management. Bromocriptine treatment is beneficial effects on LVEF and mortality in women with severe acute PPCM in addition to standard heart failure therapy. However, further study is required to establish its effect in PPCM. Abstract: Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure associated with pregnancy without any other known cause. Most of the clinical presentation is similar to symptoms of advanced pregnancy making the diagnosis difficult. Reported are three patients who developed dyspnea, orthopnea, and dry cough during the first week of puerperium. On examination, bilateral lower limb edema and bilateral basal lung crepitation were present in all patients. Chest radiograph showed pulmonary edema in cases two and three, and pleural effusion in case one. All patients had reduced left ventricular ejection fraction and raised N-terminal pro-b-type natriuretic peptide (NT-proBNP) levels. Case two developed PPCM in the background of left pyelonephritis. Case three was complicated by acute kidney injury. All patients were managed with bromocriptine, diuretics, beta-blockers, ACE inhibitors, and fluid restriction. Hence, PPCM though rare should be considered as a differential in women presenting with features of heart failure in later months of pregnancy or within 5 months of delivery.

Acute calcific periarthritis of acromioclavicular joint: A case report.

Key Clinical Message: It is of utmost importance to be aware of acute calcific periarthritis, as it may confuse the clinicians leading to misdiagnosis. Furthermore, patients may be subjected to various diagnostic and invasive procedures due to a lack of familiarity with this condition. Abstract: Deposition of hydroxyapatite crystals in the para-articular soft tissues is a well-known condition, often involving the shoulder joint. However, the deposition of calcium salts in the para-articular soft tissue of acromioclavicular joint has rarely been described. We report a case of a 55-year-old otherwise healthy man, presented with acute onset of pain and restriction of movement of left shoulder, who was diagnosed based on radiographic findings with calcific periarthritis of the acromioclavicular joint. As suggested by the literatures, he was managed conservatively, and no reoccurrence was reported after the episode.

Misty mesentery, ascites, and bowel wall thickening in a child: Diagnostic clue for intestinal lymphangiectasia.

Primary intestinal lymphangiectasia (PIL) is a rare congenital disorder characterized by lymphatic system obstruction, resulting in the leakage of lymph into the bowel lumen. We present the case of a 6-year-old boy with recurrent diarrhea and weight loss. On examination, bilateral pitting edema in the lower limbs was observed. Laboratory investigations revealed hypoalbuminemia and lymphopenia. Contrast-enhanced CT of the abdomen showed thickening of the jejunum, echogenic fat islands, and enlarged lymph nodes in the mesentery. The diagnosis was confirmed by endoscopic biopsy. The patient was managed with a high-protein diet and replacement of the long-chain triglycerides with medium-chain triglycerides. Gradual improvement in symptoms was observed with regular follow-up. PIL is a protein-losing enteropathy that causes hypoproteinemia, hypolymphopenia, and hypoglobulinemia. PIL usually presents with peripheral edema, weight loss, abdominal pain, and chronic diarrhea. Diagnosis is based on characteristic endoscopic and histopathologic findings. Management involves a multidisciplinary approach, including nutritional modifications, medical therapy, and, in rare cases, surgical resection. PIL remains a challenging diagnosis due to its nonspecific clinical presentation. Clinicians should maintain awareness of this disorder for prompt identification and management.

Not every twist is ovarian torsion: a case report of isolated torsion of the fallopian tube in a child.

Isolated fallopian tube torsion is a rare condition presenting with abdomen pain. The diagnosis is challenging because the clinical findings mimic several other conditions. In this article, we present a case of an adolescent girl who was diagnosed with the condition during laparoscopy. Presentation of the case: A 15-year-old girl presented with complaints of sudden onset left lower quadrant pain, nausea, and vomiting. There was tenderness in the left iliac fossa. Ultrasonography revealed inconclusive findings and contrast-enhanced computed tomography of the abdomen and pelvis suggested possible left adnexal torsion. Hence, she underwent a diagnostic laparoscopy which revealed a twisted, edematous, and congested left fallopian tube. The diagnosis of isolated left fallopian tube torsion was made and she was managed with unilateral salpingectomy. Discussion: Women of the reproductive age group are usually affected by this condition. The common presentations are abdominal pain, nausea, and vomiting. The physical examination may reveal abdominal and cervical motion tenderness. Per abdominal ultrasound is the first go-to modality in children. Magnetic resonance imaging, if available, is advised in children if the ultrasound is inconclusive because of the absence of radiation. However, it may require sedation. Therefore, contrast-enhanced computed tomography abdomen gives an added advantage in such scenarios as in our case. This condition is managed by surgery with salpingectomy or tube detorsion with preservation of the tube, depending on the intraoperative findings. Conclusion: Clinicians should be aware of the condition given the rarity and challenges in the diagnosis of isolated fallopian tube torsion.

Perforated marginal ulcer following Whipple procedure: A case report.

Marginal ulcers are rare complications of pancreatoduodenectomy. Patient can present with varying symptoms such as epigastric discomfort, pain, dysphagia, or can present in emergency department with complications like bleeding and perforation.

Comparative assessment of safety with leadless pacemakers compared to transvenous pacemakers: a systemic review and meta-analysis.

BACKGROUND: Leadless pacemakers (LP) and transvenous pacemakers (TVP) are two stable pacing platforms currently available in clinical practice. Observational data show mixed results with regards to their comparative safety. This meta-analysis was aimed to evaluate the comparative safety of LP over TVP. METHODS: The study protocol was registered in PROSPERO registry (CRD42022325376). Six databases were searched for published literature from inception to April 12, 2022. RevMan 5.4.1 was used for statistical analysis. Odds ratio (OR) and mean difference were used to estimate the outcome with a 95% confidence interval (CI). RESULTS: A total of 879 studies were imported from the databases. Among these, 41 papers were screened for full text and 17 meet the inclusion criteria. Among them, pooled results showed 42% lower odds of occurrence of complications in the LP group (OR 0.58, CI 0.42-0.80) compared to TVP group. Notably, 70% lower odds of device dislodgment (OR 0.30, CI 0.21-0.43), 46% lower odds of re-intervention (OR 0.54, CI 0.45-0.64), 87% lower odds of pneumothorax (OR 0.13, CI 0.03-0.57), albeit, 2.65 times higher odds of pericardial effusion (OR 2.65, CI 1.49-4.70) were observed in the LP group. CONCLUSIONS: This meta-analysis showed LP to be a significantly safer modality compared to TVP, in terms of re-intervention, device dislodgment, pneumothoraxes, and overall complications. However, there were higher rates of pericardial effusion in the LP group. There was a diverse number of patients included, and all studies were observational. Randomized trials are needed to validate our findings.

Duplication of urethra: A case report from Nepal.

Urethral duplication is uncommon with few cases reported in the literature. We report a case in which a patient presented with discharge from proximal part of penis since childhood and recent history of infection. The diagnosis of pre-pubic sinus was made and complete excision of the sinus tract was done.

Protein S Deficiency with Recurrent Deep Vein Thrombosis and Post Thrombotic Syndrome: A Case Report.

Protein S is a vitamin K-dependent protein that acts as a break in secondary hemostasis by inactivating activated factor V and activated factor VIII. We report a case of a 40 years old male who had the first episode of deep vein thrombosis of the left lower limb 10 years back, which despite treatment, reoccurred 3 months later in the bilateral lower limb. Thrombophilic screening showed severe protein S deficiency. The patient then developed deep vein thrombosis of both upper limbs. The patient was advised to place an inferior vena cava filter, which he denied. The patient is now presenting with multiple episodes of post-thrombotic syndrome. Such attacks are treated with elastic compression stockings, rivaroxaban, and morphine. However, despite medication, the pain has not yet subsided. Hence, even though protein S deficiency is the rare cause of deep vein thrombosis when recurrent should be considered despite its rare occurrence. Keywords: deep vein thrombosis; protein S deficiency; rivaroxaban.

Safety and efficacy of human serum albumin treatment in patients with cirrhotic ascites undergoing paracentesis: A systematic review and meta-analysis.

Ascites is the most common presentation of decompensated liver cirrhosis. It is treated with therapeutic paracentesis which is associated with several complications. The role of human albumin in patients with cirrhotic ascites remains elusive and has been extensively studied with conflicting results. Thus, in order to fully appraise the available data we sought to perform this systematic review and meta-analysis. Herein we included studies comparing the efficacy and safety of human albumin comparing with other volume expanders and vasoactive agents in patients undergoing paracentesis in cirrhotic ascites. Odds ratio (OR) and mean difference (MD) were used to estimate the outcome with a 95% confidence interval (CI). Albumin use reduced the odds of paracentesis induced circulatory dysfunction (PICD) by 60% (OR 0.40, 95% CI 0.27-0.58). While performing subgroup analysis, albumin use lowered the odds of PICD significantly (OR 0.34, 95% CI 0.22-0.52) in comparison to other colloid volume expanders, but did not lower the odds of PICD in comparison to vasoconstrictor therapy (OR 0.93, 95% CI 0.35-2.45). Albumin was associated with a statistically significant lower incidence of hyponatremia (OR 0.59, 95% CI 0.39-0.88). Albumin did not reduce the overall mortality, readmission rate, recurrence of ascites, mean arterial pressure, incidence of renal impairment, hepatic encephalopathy, and gastrointestinal (GI) bleeding. Thus, treatment with albumin in cirrhotic ascites reduced PICD and hyponatremia although there was no benefit in terms of mortality, readmission rate, recurrence of ascites, hepatic encephalopathy, and GI bleeding.

Prevalence of Anxiety, Depression, and Perceived Stigma in Healthcare Workers in Nepal During Later Phase of First Wave of COVID-19 Pandemic: A Web-Based Cross-Sectional Survey.

Introduction The COVID-19 pandemic has caused discrimination and social stigma among healthcare workers (HCW) causing psychological problems due to prolonged work shifts, uncertain pay, lack of personal protective equipment (PPE), added fear of infection to self or family, and so on. This online survey is directed towards the determination of anxiety, depression, and stigma among healthcare providers in Nepal during the later phase of the first wave of the COVID-19 pandemic. Materials and methods Anxiety and depression were assessed using standard Generalized Anxiety Disorder-7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9), respectively. Data for the survey were collected from January 10, 2021, to February 6, 2021, and analyzed using Stata 15 (College Station, TX: StataCorp LLC). Results A total of 213 participants were enrolled in the study from different parts of Nepal and their mean age was 29.90±6.43 years. The prevalence of anxiety and depression among healthcare workers was 46.95% and 41.31%, respectively. A bidirectional relationship was present between GAD-7 and PHQ-9 score interpretation. About 57% of HCW experienced some form of perceived stigmatization due to COVID-19. Frontline HCW were six times more likely to be stigmatized compared to non-front line HCWs and diagnosis of COVID-19 was associated with three times higher odds of facing perceived stigmatization. Conclusion A significant number of HCW experienced symptoms of anxiety and depression during the later phase of the COVID-19 pandemic. Frontline HCW who were infected experienced a higher level of stigma.