Surgical challenges of giant parathyroid adenomas weighing 10 g or more.

PURPOSE: An average parathyroid adenoma (PA) weighs < 1 g. This study aimed to characterise giant PAs ≥ 10 g (GPAs) to facilitate surgical management of primary hyperparathyroidism (PHPT). METHODS: All patients with a GPA confirmed on histology were recruited from the Monash University Endocrine Surgery Unit database. Clinical and demographic data were collected and compared to a group of non-GPA patients. RESULTS: A total of 14 GPAs were identified between 2007 and 2018 out of 863 patients (1.6%) with a single PA excised for PHPT. The GPA patients were compared to a control group of 849 non-GPA patients in the same period with similar mean age (62 ± 16 vs 63 ± 14, P = 0.66) and gender distribution (64% vs 75% female, P = 0.35). Pre-operative calcium (Ca) and parathyroid hormone (PTH) levels were significantly higher in GPA patients (P < 0.001). A higher percentage of GPA patients (79%) had concordant localisation studies (ultrasound and sestamibi) than control patients (59%), (P = 0.13), but they were significantly less likely to undergo MIP (55% vs 82%, P = 0.02). The median GPA weighed 12.5 g (IQR 10.5-24.3). Median serum Ca normalised by day 1 post-operatively, while PTH remained elevated. Both serum Ca and PTH levels were in the normal range at 3 months. All GPA lesions were benign on histopathology. CONCLUSION: GPAs are rare and display severe clinical and biochemical abnormalities. Despite their large size, concordant pre-operative imaging was not always achieved, and a few patients were suitable for MIP.

Comparison of dosimetric accuracy of acuros XB and analytical anisotropic algorithm against Monte Carlo technique.

This study reports the comparison between two dose calculation algorithms, Acuros XB 13.5 (AXB) and Analytical Anisotropic Algorithm (AAA) against Monte Carlo (MC) simulations for 3D-Conformal Radiation Therapy (3D-CRT) using a female pelvic rando phantom. 3D-CRT treatment plans were generated on the CT images of rando phantom using AXB and AAA with Source to Axis Distance (SAD) technique. Doses obtained using two algorithms and MC results were compared using MATLAB based software CERR. In house MATLAB code was developed to calculate the gamma dose distribution comparison in terms of dose difference (DD) and distance to agreement distribution (DTA). The results showed that the Dmean in the PTV TOTAL (PTV) volume for AXB and AAA was equal to the mean dose calculated by MC simulations. The gamma passing rates for AXB were more accurate in comparison to AAA with reference to MC for PTV, Bladder and Femoral Heads region. After analysing the dose comparison specially for the PTV, femoral heads, also the analysis of dose volume histogram (DVH) and gamma dose distribution comparison for PTV, femoral heads and bladder, it can be concluded that AXB is more accurate in comparison to AAA. It can be said that AXB is well suited for dose calculation in clinical setup when compared to MC calculations.

Estimation of Backscatter from Internal Shielding in Electron Beam Radiotherapy Using Monte Carlo Simulations (EGSnrc) and Gafchromic Film Measurements.

PURPOSE: The purpose of the study was to estimate the backscatter electron dose in internal shielding during electron beam therapy using Monte Carlo (MC) simulations and Gafchromic film measurements. MATERIALS AND METHODS: About 6 and 9 MeV electron beams from a Varian 2100C linac were simulated using BEAMnrc MC code. Various clinical situations of internal shielding were simulated by modeling water phantoms with 2 mm lead sheets placed at different depths. Electron backscatter factors (EBF), a ratio of dose at tissue-shielding interface to the dose at the same point without the shielding, were estimated. The role of 2 mm aluminum in reduction of backscatter was investigated. The measurements were also performed using Gafchromic films and results were compared with MC simulations. RESULTS: For particular beam energy, the EBF value initially increased with depth in the buildup region and then decreased rapidly. The highest value of EBF for both the energies is nearly same though at different depths. Decreased EBF was observed for 9 MeV beam in comparison to the 6 MeV beam for the same depth of shielding placement. Two millimeter aluminum reduced the backscatter by nearly 25% at maximum backscatter condition for both the energies, though the effectiveness slightly decreased at higher energy. The range of backscatter electrons was varying from 5 to 12 mm in the upstream direction from the interface. The Gafchromic film-measured EBF and MC-simulated EBF were matching well within the clinically acceptable limits except in close vicinity of tissue-lead interface. CONCLUSIONS: This study provides an important clinical data to design internal shielding at the local clinical setup and confirms applicability of MC simulations in backscatter dose calculations at interfaces where physical measurements are difficult to perform.

Evaluation of AAA and XVMC Algorithms for Dose Calculation in Lung Equivalent Heterogeneity in Photon Fields: A Comparison of Calculated Results with Measurements.

AIMS: The aims of the present work are (1) to evaluate dose calculation accuracy of two commonly used algorithms for 15 MV small photon fields in a medium encompassing heterogeneity and (2) to compare them with measured results obtained from gafchromic film EBT2. MATERIALS AND METHODS: Authors employed kailwood (Pinus Wallichiana) to mimic lung. Briefly, seven Kailwood plates, each measuring 25x25 cm2 of varying thicknesses totaling 13 cm equivalent to the mean thickness of an adult human lung, were sandwiched between 5 cm tissue equivalent material from top and 10 cm below. Physical measurements were performed using Radiochromic film EBT2. The field sizes of 1x1, 2x2, 5x5 and 10x10 cm2 were selected at 100 cm SSD. Simulations were performed using EGSnrc/DOSRZnrc Monte Carlo code. The dose variation inside the inhomogeneity and near the interface was calculated using AAA & XVMC algorithm. RESULTS: Preliminary results show that there is large variation of dose inside inhomogeneity. The maximum variation of dose inside the inhomogeneity for 1x1 cm2 was found 40% by AAA and 4.5% by XVMC compared to measured/simulated results. For the field size of 2x2 cm2, these figures were 27% by AAA & 3.5% by XVMC. For 5x5 cm2 field size, the variation is small which becomes insignificant for larger fields. CONCLUSION: The results presented in this work indicate that for smaller fields, XVMC algorithm gives more realistic prediction, while there is the need for caution on using AAA algorithm for dose calculations involving small area irradiation encompassing heterogeneities and low-density media.

Design, Development and Rationalization of Sarpagandha Ghanvati.

Sarpagandha ghanvati is a classical Ayurvedic formulation widely prescribed for anxiety and insomnia. It contains Sarpagandha (roots of Rauwolfia serpentina L. (Benth.) Ex Kurz; Family: Apocyanaceae), Khurasani ajowan (Hyocyamus niger L.; Family: Solanaceae) seeds, Jatamansi (Nardostachys jatamansi DC. Family: Valerianaceae) roots and Pipplamul (root of Piper longum L.; Family: Piperaceae). The objective of this study was to make a comparative evaluation of Ghanvatis and tablets of this formulation. Two tablet formulations were prepared; one incorporating only powders of all ingredients; the other with ethanol extracts of the first three ingredients and powder of Piper longum root. Similarly, two types of Sarpagandha ghanvati pills were prepared; one as per Ayurvedic Formulary of India; the other with ethanol extracts of the first three ingredients and powder of Piper longum root. Alcohol extracted 0.22% w/w of total alkaloids as against 0.061% w/w extracted by water. Tablets prepared with powders of all the ingredients had friability more than 3.0% where as those prepared with ethanol extract had very low friability. Ghanvatis, prepared as per the Ayurvedic formulary, did not show reserpine although other alkaloids were present. They showed less content uniformity and lower drug release. Ethanol extracted reserpine along with other alkaloids. Ghanvatis made with the alcoholic extracts exhibited better content uniformity and drug release than the traditional formulation. Tablets prepared with powders or extracts of the ingredients exhibited good content uniformity but the release of alkaloids from the tablets of powders was only 80%. Tablets of the extracts had good content uniformity with 90% release of the total alkaloids. Tablets prepared with alcoholic extracts using 1% polyvinylpyrrolidone as binder and 5% dried starch powder as disintegrating agent confirmed to all the requirements. Thus, the study shows tablets made with the extracts are superior to Ghanvatis and powder tablets.

Analysis of patient specific dosimetry quality assurance measurements in intensity modulated radiotherapy: a multi centre study.

AIM OF THE STUDY: Statistical analysis of pre-treatment dose verification of intensity-modulated radiotherapy (IMRT) fields to assess the quality of the IMRT practice at different radiotherapy centers. MATERIALS AND METHODS: The dose verification data acquired by the institutional physicist of 10 different hospitals for various types of patients were collected and analyzed for mean, median, standard deviation (SD), range, minimum and maximum % deviation. The percentage of cases having positive and negative dose differences as well dose differences within ± 3% were also determined. RESULTS: The mean values of percentage variation in difference between treatment planning systems calculated dose and difference between measured dose (D(TPS) and D(Meas)) are found to be from -1.79 to 1.48 and median from -1.79 to 1.51. The SDs are found to be from 0.76 to 3.70. The range of variation at these centers varies from 3.99 to 16.45 while minimum and maximum values of percentage variation in difference between D(TPS) and D(Meas) ranges from -10.33 to 13.38. The percentage of cases having positive dose difference ranges from 8 to 94 and cases having negative dose difference ranges from 6 to 92. The percentage of cases having dose difference within ± 3% varies from 57 to 100. CONCLUSION: IMRT centers are having random and biased (skewed towards over or under dose) distribution of the percentage variation in difference between measured and planned doses. The analysis of results of the IMRT pre-treatment dose verification reveals that there are systematic errors in the chain of IMRT treatment process at a few centers. The dosimetry quality audit prior to commissioning of IMRT may play an important role in avoiding such discrepancies.

Doppler ultrasound: a good and reliable predictor of ovarian malignancy.

AIMS: The aim of the present study was to prove the efficiency of Color Doppler and Spectral Doppler in evaluation and characterization of the ovarian neoplasm. MATERIALS AND METHODS: In total, 104 patients with adnexal masses were examined sonographically to evaluate for morphologic characteristics, as well as pulsatility indices (PI), and resistance indices (RI) over a period of 2 years, of which 20 were excluded as the masses were not finally proven to be adnexal, and thus 84 patients with ovarian neoplasm were retained as the study subjects. The final diagnosis was based on histopathologic confirmation. RESULT: Out of 84 cases, 44 were benign and 40 were malignant. Color Doppler showed vascularity in 97.5 % of malignant tumors in contrast to only 68.1 % of benign tumors. The present study showed that, 87.5 % of malignant tumors had PI less than 0.8 in contrast to only 4.54 % of benign tumors. Similarly, 82.5 % of malignant tumors had RI less than 0.6 in contrast to only 6.81 % of benign tumors. CONCLUSION: Multiparameter analysis utilizing B-mode USG along with Color Doppler and Spectral Doppler is the mainstay in diagnosis of patients with ovarian tumors. A good specificity (84.1 %) and sensitivity (97.5 %) with PI and RI values of <1.0 and <0.6, respectively, was achieved with the present study which is highly significant in differentiating between malignant and benign ovarian tumours.

Variation in the insertion of the latissimus dorsi & its clinical importance.

The latissimus dorsi is the larger, flat, dorso-lateral muscle on the trunk, posterior to the arm, and partly covered by the trapezius on its median dorsal region. Origin of the latissimus dorsi is from spinous processes of thoracic T7-T12, thoracolumbar fascia, iliac crest and inferior 3 or 4 ribs, inferior angle of scapula and insertion on floor of intertubercular groove of the humerus. We have studied 50 cadavers in the different medical colleges in which we found 2% case of anterior and posterior slip of the muscle fibers with their extension up to the pectoralis major and teres major respectively. Usually, latissimus dorsi involve in extension, adduction, transverse extension also known as horizontal abduction, flexion from an extended position, and internal rotation of the shoulder joint. It also has a synergistic role in extension and lateral flexion of the lumbar spine. The latissimus dorsi may be used for the tendon graft surgeries. Tight latissimus dorsi has been shown to be one cause of chronic shoulder pain and chronic back pain. Because the latissimus dorsi connects the spine to the humerus, tightness in this muscle can manifest as either sub-optimal glenohumeral joint function (which leads to chronic shoulder pain) or tendinitis in the tendinous fasciae connecting the latissimus dorsi to the thoracic and lumbar spine. Latissimus dorsi used for pedicle transplant rotator cuff repair reconstruction of breast, face, scalp and cranium defect. The extra slip of the latissimus dorsi may puzzle any transplant operations. We as anatomist discuss the clinical implication of the extra slip of latissimus dorsi.

Occupational radiation exposure in health care facilities.

BACKGROUND: Radiation, which is used extensively to diagnose and treat human diseases, poses an occupational health risk for the concerned health workers. Personal dosimetry is an important tool to monitor occupational radiation exposures. OBJECTIVE: This study was conducted to reveal and to describe the situation of occupational radiation exposure monitoring among staffs in different health care facilities in Nepal. METHODS: A cross-sectional study was performed among the 35 Health Care Facilities. Information about types and number of X-ray procedures performed, types and number of personnel involved, workload and the availability of personal dosimetry service were collected. RESULTS: Six Health Care Facilities had personal dosimetry service available for a total of 149 personnel. Of a total of nearly one million X-ray procedures performed in the 35 Health Care Facilities in 2007, 76 percent was performed by non-monitored personnel. The majority of the facilities performing high dose procedures, like catheterisation, angiography and intestinal barium procedures did not offer personal dosimetry for the involved personnel. CONCLUSION: There are a limited number of personnel being monitored with personal dosimetry. There are no regulatory dose limits for occupationally exposed staff. Thus, there is an urgent need to establish a national radiation protection authority to regulate the use of radiation in Nepal.

Antimicrobial susceptibility patterns of Salmonella typhi and Salmonella paratyphi A in a tertiary care hospital.

BACKGROUND: Enteric fever is still an important public health problem in developing countries including Nepal. A changing antibiotic susceptibility pattern of Salmonella typhi and Salmonella paratyphi A and emergence of multi drug resistance has increased to a great concern. Aim of the study was to investigate the antibiotic susceptibility pattern of Salmonella typhi and Salmonella paratyphi A. METHODS: Study was carried out at the department of microbiology in Kathmandu Medical College. Blood culture samples were collected from suspected enteric fever patient and tested microbiologically by standard procedure. Antibiotic susceptibility test was performed by Kirby-Bauer disc diffusion method and results were interpreted by National Committee for Clinical Laboratory (NCCLS) guideline. RESULTS: Of total 78 (2.0%) Salmonella serotype isolated from 3,980 blood culture samples, in which 47 (60.3%) were S. typhi and 31 (39.7%) were S. paratyphi A. Isolates were from all age group median age being the 25 years. Among the tested antibiotics S. typhi was susceptible towards Ciprofloxacin (100%) followed by Gentamicin (97.9%), Ofloxacine (95.7%), Ceftriaxone (95.7%) and Chloramphenicol (93.6%). In case of S. paratyphi A most of the tested antibiotics showed high percentage of susceptibility and least susceptible antibiotic for S. paratyphi A was Ampicillin (25.8%). Three isolates of S. typhi showed multidrug resistance. CONCLUSIONS: A considerable variation was observed in the antimicrobial susceptibility pattern of S.typhi and S. paratyphi A. Hence antibiotic susceptibility test must be sought before instituting appropriate therapy to prevent from further emergence of drug resistance.

Microbiological analysis of isolates in Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal.

BACKGROUND: Urinary tract infections (UTIs) are the common cause of bacterial infection. Recently UTI become more complicated and difficult to treat because of appearance of pathogen with increasing resistance to antimicrobial agents. OBJECTIVE: To determine the etiology of the urinary tract infections and their susceptibility to antimicrobial agents. METHODS: This study was carried out in Kathmandu Medical College, at department of microbiology. Total 3,460 urine samples were tested microbiologically by standard procedure. Antibiotic susceptibility test was performed for all the isolates by Kirby Bauer disc diffusion method and result was interpreted according to National Committee for Clinical Laboratory Standards (NCCLS) guide line. RESULTS: Out of 3,460 urine samples 680 (19.7%) showed the significant bacteriuria. The most common pathogens isolated were Escherichia coli 75.7% followed by Klebsiella pneumoniae 10.7%, Acinetobacter spp 5.5%, Proteus spp 3.5% and Pseudomonas aeruginosa 1.2%. Most susceptible antibiotic was Amikacin, Ceftriaxone and Ciprofloxacin for most of the isolates. E. coli which was the main isolate was found to be most susceptible to Amikacin 96.1%, Nitrofurantoin 91.3% and Gentamicin 77.7% followed by Ceftriaxone 65.8% and Ciprofloxacin 64.1%. CONCLUSION: Regular surveillance of the resistance rate among uro-pathogens is needed to ensure the appropriate therapy of UTI.

Prediction of cancer cases for a hospital in Nepal: a statistical modelling.

OBJECTIVE: The aim of this study was to predict the number and trends of cancer cases for radiotherapy up to the year 2015 in Manipal Teaching Hospital, Pokhara, Nepal. METHODS: A retrospective study was carried out on data retrieved from the radiotherapy treatment records of patients treated at Manipal Teaching Hospital between 28 September 2000 and 31 December 2008. Different statistical programmes were used for statistical modelling and prediction. Using curve-fitting methods, Linear, Logarithmic, Inverse, Quadratic, Cubic, Compound, Power, Exponential, and Growth models were tested. RESULTS: Including constant term, none of the models were best fitted. However, excluding the constant term, the cubic model was best fitted; R2=0. 95, p=0.001 for total cancer cases, R2=0. 94, p=0.001 for female cancer cases and R2=0. 95, p=0.001 for male cancer cases. The cancer cases estimated using cubic model showed a steady increase in the total frequency of cancers (including male and female cancer cases) following the year 2010. The three most common cancers reported were head and neck 24.2% (CI 21.6 - 27.0), lung 20.9% (CI 18.4 -23.6), cervix 15.9% (CI 13.7-18.3) respectively. CONCLUSION: The cancer cases in need of radiotherapy will increase in future years. The curve fitting method could be an effective exploratory modelling technique for predicting cancer frequency and trends over the years.

Drug resistant cases of tuberculosis in directly observed treatment short course.

BACKGROUND: Resistance of Mycobacterium tuberculosis to antituberculous drugs has emerged as a major public health threat. The objective of this study was to determine Multi Drug Resistance cases of tuberculosis in Directly Observed Treatment Short Course program of Nepal. METHODS: The sputum samples collected and culture on Lowenstein Jensen media followed by biochemical test. All the isolates antibiotic sensitivity test performed on medium by proportion method. RESULTS: Tuberculosis was most commonly found in economically active age group (21-50 years). All the isolates of pulmonary tuberculosis were found to be M. tuberculosis. A Multi-drug resistant case of tuberculosis primary and acquired in Directly Observed Treatment Short Course Program of Nepal was found (3.6%). Out of 460 untreated cases, 9 (1.9%) cases were found to be MDR and among 90 previously treated cases 11 (12.2%) were found to be MDR. Multi drug resistant cases of tuberculosis were found most commonly in productive age group (21-30). The incidence of tuberculosis was found higher in male than in female. But multi drug resistant M. tuberculosis cases equally affected both the gender. Majority of the MDR cases found higher number of M. tuberculosis in their sputum. CONCLUSIONS: The above study showed that drug resistant cases of tuberculosis in DOTS program of Nepal was found higher. To reduce the drug resistance, before starting chemotherapy antibiotic sensitivity test should be performed.

Cancer treatment by radiotherapy in Western Nepal: a hospital-based study.

OBJECTIVE: The aim of this study was to describe utilization of radiotherapy and treatment compliance in the context of Nepal. METHODS: A retrospective study was carried out on data collected from the radiotherapy treatment records of patients treated at Manipal Teaching Hospital (MTH), Pokhara, between 28 September 2000 and 30 May 2008. RESULTS: In the 944 patients, the gender distribution showed a slight female preponderance (53.7 vs. 46.3%). Curative treatment was given to 62.8% (n= 593) and palliative to the remaining 37.2% (n= 351). Patients older than 50 years were more likely to receive palliative radiotherapy (p= 0.001). The commonest cancers treated were head and neck at 23.7% (n= 224), followed by lung at 21.3% (n= 201) and cervix at 16.1% (n= 152). The majority of patients were between 50-70 years of age (n= 564). Nineteen percent (n= 179) did not complete the prescribed dose of radiation. Unplanned treatment interruptions were found in 35.6% (n= 336) and this was not affected by age (p= 0.1) or gender (p= 0.1). The most frequent treatment interruption compromising optimal effectiveness of cancer treatment was observed for head and neck cancers, constituting 43% (n= 96) of patients in the group. CONCLUSION: Head and neck in both sexes and cervix in females were the most common cancers treated with a curative intent. Lung cancer, the second most common in both genders, was treated with palliative intent in a large number of cases. This indicates the need for early diagnosis for a possible curative treatment.

Removal of sub-mucosal foreign body (metal wire) from the pharynx using image intensifier.

It is well known how difficult it is to localize a foreign body in the sub-mucosal tissues. This is a report of a male who swallowed a metal wire which lodged in the pharyngeal sub-mucosal tissue. The foreign body was localized using an image intensifier and removed successfully.

Spherical foreign bodies in the oesophagus removed by balloon angiographic catheter.

Two children aged three and seven years presented to the department of Otolaryngology with total dysphagia following the accidental swallowing of a steel ball bearing and a plastic ball. These rare spherical foreign bodies were removed successfully by oesophagoscopy under general anaesthesia using an innovative method involving a balloon angiographic catheter.

Angiolymphoid hyperplasia with eosbvophilia-case report.

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a benign condition characterized by subcutaneous lesions in the head-neck region. It is frequently misdiagnosed as a malignant lesion. Knowledge of the existence of the disease and pathological interpretation are requisites for early diagnosis. We present a case report and review of the literature.

Facial nerve schwannoma.

An uncommon case of bilobed facial nerve schwannoma and its management is presented.

Modified sham feeding and Congo red test in determining completeness of vagotomy.

Gastric acid response to modified sham feeding was evaluated in 14 patients with duodenal ulcer prior to vagotomy and in 18 patients after vagotomy. Nine patients in the latter group had recurrent ulcer, suggesting inadequate vagotomy. Based on values in the 32 tests (14 pre and 18 postoperative), cut-off levels of six secretory indices were selected to provide a specificity of 1.00 for the presence of ulcer. When applied separately to the 18 postoperative patients and to the 13 patients who underwent the endoscopic congo red test, observed volume of 75 ml/h and peak volume of 90 ml/h following sham feeding gave specificity, sensitivity and efficiency of 1.00 each in determining inadequate vagotomy. The endoscopic congo red test done in 13 post-vagotomy cases showed a sensitivity of 1.00, and high specificity (0.89) and efficiency (0.92). Measurement of crude gastric juice response to modified sham feeding is a convenient bedside test to confirm inadequate vagotomy. The endoscopic congo red test is also useful, especially as a screening test, and has the added advantage that it can be used intra-operatively.