Isolated visceral manifestation of Buerger's disease presenting as intestinal obstruction: a case report.

Introduction and importance: Buerger's disease is an uncommon segmental nonatherosclerotic vasculitis essentially affecting small to medium-sized arteries and veins of upper and lower extremities and can lead to limb amputation. Visceral vessel involvement is quite rare accounting for 2% of cases presenting with acute abdomen due to mesenteric ischemia. Moreover, isolated visceral involvement is even rare. Case presentation: A 42-year-old gentleman, a chronic smoker, presented with abdominal pain associated with nausea and vomiting and loose stool of 2 months duration. Magnetic resonance enterography revealed segmental circumferential wall thickening with stricture in the mid part of the jejunum with lymphadenopathy features of possible inflammatory bowel disease (Crohn's disease). Furthermore, intraoperative surgical findings were also suggestive of Crohn's disease. However, histologic findings were consistent with thromboangiitis obliterans. Discussion: Thromboangiitis obliterans can present with inflammatory vascular lesions without necrosis in the early stage to varying degrees of recanalisation, gangrene, and amputation in the late stage. It rarely involves the brain, heart, and abdominal viscera. The visceral involvement may be in the form of intestinal obstruction or mesenteric ischemia or can mimic Crohn's in a background of smoking. Conclusion: This case report will help to learn more about the rarer intestinal presentation of intestinal Buerger's disease. It can present with features of bowel ischemia, obstruction or Crohn's. So, histology would play a pivotal role in differentiating the diagnostic dilemma.

Introduction of enhanced weekend physiotherapy for patients with hip fracture is associated with improved early mobility outcomes.

OBJECTIVE: To assess whether enhanced daily weekend physiotherapy (EWP) for patients with hip fracture was associated with improved clinical outcomes. METHODS: We retrospectively analysed all previously ambulatory adults admitted with hip fracture to our tertiary hospital, comparing 'usual' ('control') care (09/19-03/20) to EWP (09/20-03/21). Outcomes included Day-7 mobility ≥20 m (primary), additional mobility measures, specified postoperative complications, new residential facility placement, acute length-of-stay (LOS) and 30-day death. RESULTS: Amongst 235 eligible patients (128 control, 107 EWP), 66% were female, mean age was 80.4 years (SD 10.5), 20% from residential care and 49% (114/235) were mobilising without aid at baseline (no between-group differences; all p ≥ .20). Median acute LOS was 10 days (IQR 6-15), total hospital LOS was 21 days (IQR 12-37) and 3% (n = 6) died by Day 30. Median Day-7 distance mobilised was 25 m (IQR 7-50) with EWP versus 10 m (3-40) (p = .06). No EWP patients developed pressure injury (0 vs. 6, p = .02); other outcomes were similar between groups. Adjusting for age, residence, baseline cognitive impairment, American Society of Anesthesiologist score and preadmission mobilisation without aids, EWP was independently associated with increased likelihood of mobilising ≥20 m at Day 7 (aOR 1.83, 95% CI 1.04-3.23, p = .03). CONCLUSIONS: Enhanced daily weekend physiotherapy was associated with improvement in early mobility, but not other outcomes assessed. These data would be strengthened by randomised controlled trial data exploring more intense physiotherapy, cost-benefit analysis and patient experience measures.

Correlation of Imaging Findings with Molecular Subtypes of Breast Cancer.

BACKGROUND: Ultrasound and Mammography are first-line imaging in breast cancer. The management of malignant breast lesions depends on molecular biomarkers in the tumor cells. This study aims to correlate different imaging findings in breast carcinoma with immune-histology subtypes. METHODS: The study was a retrospective study conducted between 2018 January to 2021 December. Patients with malignant breast lesions who underwent USG-guided biopsy of breast lesions were included in the study. Ultrasound and mammographic findings of these patients were retrieved in PACS and analyzed. Malignant breast lesions were classified according to molecular markers into Luminal A, Luminal B, Her- 2 enriched, and triple-negative breast cancers. The correlation between imaging findings and molecular subtypes of breast cancer was analyzed. RESULTS: A total of 42 patients were included in the study. The mean age of the patients in our study was 52.24+/-13.54 years with median of 51 years (IQ range-19.5 years). The most common IHC subtype was Luminal type B (22, 52.4%), followed by triple negative (15, 35.7%), luminal type A (4, 9.5%) and least common was Her-2 enriched (1, 2.4%). Mammogram was non-diagnostic in 9.5% of case. Oval shape and well marginated margin in ultrasound were more frequently associated with triple negative breast cancer than other subtypes (P<0.05). Rest of the characteristics of triple negative and other malignancies were not significantly difference in our study. No significant difference is noted between mammographic findings between various subtypes. CONCLUSIONS: Triple negative breast cancer was more common in our population than in the west. Triple-negative breast cancers are more frequently well-defined and oval in shape mimicking benign lesions.

Mean Intracranial Volume of Brain among Patients with Normal Magnetic Resonance Imaging Referred to the Department of Radiology and Imaging of a Tertiary Care Centre.

Introduction: The measurement of brain volume is an important aspect of the assessment of brain structure and function. However, limited data is available on brain volumetry in the Nepalese population. The study aimed to find the mean intracranial volume of the brain among patients with normal magnetic resonance imaging referred to the Department of Radiology and Imaging of a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among patients with normal magnetic resonance imaging referred to the Department of Radiology and Imaging in a tertiary care centre. All magnetic resonance imaging of the brain during the study period was reviewed by a radiologist. Magnetic resonance imaging with abnormal findings, clinical signs of neurological deficit, dementia and psychiatric symptoms were excluded from the study. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. Results: Among 285 Magnetic Resonance Imaging datasets, the mean intracranial volume was 1286.30±129.88 cc (1271.22-1301.38, 95% of Confidence Interval). The mean cerebral volume was 985.06±106.4 cc, cerebellar volume was 126.99±13.05 cc and brain stem volume was 19.97±2.54 cc. Conclusions: The mean intracranial volume of the brain among patients with normal magnetic resonance imaging was found to be lower than other studies done in similar settings. Keywords: brainstem; cerebellum; cerebrum; magnetic resonance imaging.

Magnetic Resonance Imaging Evaluation of Suspected High-Altitude Cerebral Edema in Patients from High Altitude.

BACKGROUND: Trekkers in high altitude of Himalayas could lead to Acute Mountain Sickness and High Altitude Cerebral Edema. This study was conducted to evaluate magnetic resonance imaging findings among the clinically suspected High Altitude Cerebral Edema patients rescued from high altitudes in Nepal Himalayas. METHODS: 49 patients with clinically suspected High Altitude Cerebral Edema were retrospectively evaluated in this cross-sectional study who were sent for a brain magnetic resonance imaging. They were categorized in 3 groups according to the magnetic resonance imaging features in this study. RESULTS: There was a slight male preponderance. 6 patients (12.25%) had magnetic resonance imaging findings highly suggestive of High Altitude Cerebral Edema. 5 patients had T2 high signal intensity and restricted diffusion in the splenium of corpus callosum of which 3 had features of microhemorrhage. One patient with normal brain morphology and intensity in T1, T2, and FLAIR images showed innumerable variable-sized microhemorrhages in Susceptibility Weighted Imaging. 14 of patients showed various T2 and FLAIR white matter high signal intensity without restricted diffusion. And one patient had features of subacute lacunar infarcts. 28 patients (57.14 %) showed no abnormal signal changes in the magnetic resonance imaging scan. CONCLUSIONS: Typical magnetic resonance imaging features of cytotoxic edema in corpus callosum and microhemorrhage in the patients with High Altitude Cerebral Edema further support the findings in other similar studies. T2 white matter hyperintensities in deep, subcortical or periventricular location and lacunar infarcts could be seen in High Altitude Cerebral Edema. Normal magnetic resonance imaging of the brain is not infrequent.

Massive haemoptysis in a woman with left lower lobe pulmonary artery interruption-A rare clinical presentation.

Proximal interruption of the pulmonary artery (PA) is a rare congenital vascular anomaly with varying presentation. These patients can be asymptomatic or symptomatic with breathlessness, haemoptysis, recurrent chest infections and pulmonary hypertension. Here, we present a patient who presented with massive haemoptysis secondary to interruption of the left lower lobe PA. To the best of our knowledge, massive haemoptysis due to isolated interruption of the left lower lobe PA has been rarely reported in the English medical literature.

Adenocarcinoma among Patients Diagnosed with Lung Cancer in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Lung cancer is the leading cause of cancer deaths all over the world and adenocarcinoma is the most common type. Diagnosis is made usually at an advanced stage of lung cancer in patients, making it nearly impossible to cure. The aim of this study is to find out prevalence of adenocarcinoma among patients diagnosed with lung cancer in a tertiary care centre. Methods: A descriptive cross-sectional study was carried out in the Department of Pulmonary Medicine of a tertiary care centre among 69 patients from October, 2018 to September, 2019. Ethical approval was taken from the Institutional Review Committee of a tertiary care hospital (Reference number: 54/2018). A convenience sampling technique was used. Data were entered and analysed using the Statistical Package for the Social Sciences version 21.0. Point estimate at 90% Confidence Interval and descriptive statistics were interpreted as frequency, percentage, or as mean and standard deviations. Results: Among 69 lung cancer patients, adenocarcinoma was seen in 27 (39.13%) (29.47-48.79 at 90% Confidence Interval). Out of 27, 10 (37.04%) were male and 17 (62.96%) were female. Chronic obstructive pulmonary disease was the major comorbidity seen among 17 (62.96%) patients. Conclusions: The prevalence of adenocarcinoma was similar to other studies done in similar settings. Keywords: adenocarcinoma; lung cancer; Nepal; smoking.

Zinner Syndrome: A Case Report of Rare Urogenital Anomaly.

Zinner Syndrome is a rare urogenital tract anomaly with unilateral renal agenesis, ipsilateral seminal vesicle cyst, and ipsilateral ejaculatory duct obstruction. The syndrome occurs due to an insult to the development of the paramesonephric duct during embryogenesis. Patients may present late due to dysejaculation as a result of obstruction of the ejaculatory duct or commonly remain asymptomatic. Here, we present such a case presenting with dysejaculation which was diagnosed with Zinner syndrome on ultrasound.

Comparison and outcomes of emergency department presentations with respiratory disorders among Australian indigenous and non-indigenous patients.

BACKGROUND: There is sparse evidence in the literature assessing emergency department presentation with respiratory disorders among Indigenous patients. The objective of this study was to evaluate the clinical characteristics and outcomes for Indigenous Australians in comparison to non-Indigenous patients presenting to Emergency Department (ED) with respiratory disorders. METHODS: In this study, two non-contiguous one-month study periods during wet (January) and dry (August) season were reported on, and differences in demographics, respiratory diagnosis, hospital admission, length of hospital stay, re-presentation to hospital after discharge and mortality between Australian Indigenous and non-Indigenous patients was assessed. RESULTS: There were a total of 528 respiratory ED presentations, 258 (49%) during wet and 270 (51%) in dry season, from 477 patients (52% female and 40% Indigenous). The majority of ED presentations (84%) were self-initiated, with a difference between Indigenous (80%) and non-Indigenous (88%) presentations. Indigenous presentations recorded a greater proportion of transfers from another healthcare facility compared to non-Indigenous presentations (11% vs. 1%). Less than half of presentations (42%) resulted in admission to the ward with no difference by Indigenous status. Lower respiratory tract infections were the most common cause of presentation (41%), followed by airway exacerbation (31%) which was more commonly seen among Indigenous (34%) than non-Indigenous (28%) presentations. Almost 20% of Indigenous patients reported multiple presentations to ED compared to 1% of non-Indigenous patients, though mortality on follow up did not differ (22% for both). CONCLUSIONS: The results of this study may be an avenue to explore possibilities of implementing programs that may be helpful to reduce preventable ED presentation and recurrent hospitalisations among Indigenous population.

Gender Differences in the Clinical and Polysomnographic Characteristics Among Australian Aboriginal Patients with Obstructive Sleep Apnea.

BACKGROUND: In this study, we assessed the clinical and polysomnographic (PSG) characteristics according to gender among Australian Aboriginal men and woman diagnosed to have obstructive sleep apnea (OSA). METHODS: In this retrospective study, all adult Aboriginal patients over 18 years of age diagnosed to have OSA with an apnea hypopnea index (AHI) > 5/hour over a 5 year period were included. RESULTS: Of the 337 patients (168 females and 169 males), who underwent a diagnostic PSG, 297 (88%) were diagnosed to have OSA (AHI) >5/hour), 154/297 males (52%) and 143/297 females (48%). Amongst male and female patients with OSA, 63% and 37% were in the severe spectrum (AHI>30/hour). The male cohort had higher stage N1 NREM sleep (P<0.001), reduced N3 NREM sleep (P<0.001), higher AHI severity (P<0.001), higher NREM AHI (P<0.001), and high arousal index (P<0.005). REM sleep-related AHI was higher among female patients with all severity of OSA, along with severe oxygen desaturation during REM sleep. Among patients with severe OSA, the female cohort were younger (age 46 years vs 49 years, P=0.030) and had higher BMI with all severity of OSA, while males had larger neck circumference compared to females. Hypertension increased the odds of severe OSA versus the combined odds of mild and moderate OSA for both genders. CONCLUSION: This study highlights some important differences in the way sleep apnea manifests in Australian Aboriginal males and females and further studies are warranted to explore avenues to look for a physiological basis for these observations and targeted interventions.

Current Imaging Trends in COVID-19 Pneumonia.

COVID-19 has rapidly emerged as a pandemic threatening lives and healthcare systems worldwide. With the emergence of the disease in Nepal, all faculties of medicine need to be well prepared to face the challenge. Fortunately, now plenty of research is available to facilitate our preparedness in the war against COVID-19. The reverse transcriptase-polymerase chain reaction is the current gold standard diagnostic test and chest Computed Tomography scan for screening the disease is considered inappropriate by most society recommendations. The Nepal Radiologists' Association has proposed its guidelines which have been endorsed by the Nepal Medical Council. This article aims to summarize the role of imaging focusing on chest X-ray and Computed Tomography scan including the indications, specific findings, and important differentials. Imaging needs to be done taking necessary precautions, to minimize disease transmission, protect health care personnel, and preserve health care system functioning.

Clinical Profile and Outcome of Adult Patients with Scrub Typhus in a Tertiary Care Centre of Eastern Nepal.

INTRODUCTION: Scrub typhus is an under-diagnosed and undertreated zoonotic human infection. There are no data related to profile of adult patients in Nepal. We conducted this study to report socio-demographic, clinical profile and complications of scrub typhus in our scenario. METHODS: This was a descriptive cross-sectional study carried out in Nobel Medical College Teaching Hospital, eastern Nepal. The sample enrollment process was consecutively who were admitted under medical ward and intensive care unit. Diagnosis was established serologically with positive test of IgM antibodies against scrub typhus using immuno-chromatography. Operational definitions for organ system dysfunction were based upon simple available clinic laboratory profiles and imaging. Collected data were entered in Microsoft Excel 2007 and converted it into Statistical Package for Social Science 11.5 Version for statistical analysis. RESULTS: A total of 47 patients were analyzed during this study. Diagnosis of scrub typhus was more common 17 (36.17%) in age group of (40-60 years) with female predominance 32 (68.08%). Most patients (70.15%) were of above 40 years. Fever 47 (100%), asthenia 40 (85.10%), generalized body-ache 41 (87.23%), anorexia 46 (97.87%) and headache 39 (82.97%) were present in most of our patients at sometime during their illness. Respiratory dysfunction was the commonest 37 (78.72%) system dysfunction followed by renal 30 (63.82%) and hepatic 20 (42.55%) impairment. Fortunately no deaths occurred. CONCLUSIONS: Scrub typhus occurred more commonly in elderly female patients. Early empirical treatment may prevent mortality. Large studies involving whole country is needed to see real scenario of disease in this setting.

Scenario of Sepsis in Intensive Care Unit in a Tertiary Care Hospital.

BACKGROUND: Sepsis has been defined as life-threatening organ dysfunction caused by dysregulated host response to infection. Sepsis is an important cause of mortality in intensive care unit worldwide. The study aims to identify the outcome of sepsis patient admitted at tertiary care hospital. METHODS: This is a descriptive cross-sectional hospital based study on 76 adult patients admitted at intensive care unit of Nobel Medical College with diagnosis of sepsis with an objective of estimating mortality of sepsis and identifying associated symptoms with it. Baseline demographics, clinical and laboratory data were collected and analyzed. RESULTS: Out of 76 patients with sepsis, mean age of the patients was 50.07±18.15 years. Majority of patients 31.6% with sepsis were above age groups >60 years. The most common symptoms among the patients were fever, which was seen in 69 (90.8%) patients. The most common source of infection in those patients was found to be unknown, which was seen in 36.8% of patients. While analyzing the outcome, it was noted that 25 patients with sepsis (32.9%) died during treatment. CONCLUSIONS: Sepsis is related with high mortality. Elderly patients are at more risk. Fever is the commonest presentation and source is not identified in majority of cases.

Clinical Profile and Outcome of Adult Patients with Scrub Typhus in a Tertiary Care Centre of Eastern Nepal: A Descriptive Cross-sectional Study.

INTRODUCTION: Scrub typhus is an under-diagnosed and undertreated zoonotic human infection. There are no data related to profile of adult patients in Nepal. We conducted this study to report socio-demographic, clinical profile and complications of scrub typhus in our scenario. METHODS: This was a descriptive cross-sectional study carried out in Nobel Medical College Teaching Hospital, eastern Nepal. The sample enrollment process was consecutively who were admitted under medical ward and intensive care unit. Diagnosis was established serologically with positive test of IgM antibodies against scrub typhus using immuno-chromatography. Operational definitions for organ system dysfunction were based upon simple available clinic laboratory profiles and imaging. Collected data were entered in Microsoft Excel 2007 and converted it into Statistical Package for Social Science 11.5 Version for statistical analysis. RESULTS: A total of 47 patients were analyzed during this study. Diagnosis of scrub typhus was more common 17 (36.17%) in age group of (40-60 years) with female predominance 32 (68.08%). Most patients (70.15%) were of above 40 years. Fever 47 (100%), asthenia 40 (85.10%), generalized body-ache 41 (87.23%), anorexia 46 (97.87%) and headache 39 (82.97%) were present in most of our patients at sometime during their illness. Respiratory dysfunction was the commonest 37 (78.72%) system dysfunction followed by renal 30 (63.82%) and hepatic 20 (42.55%) impairment. Fortunately no deaths occurred. CONCLUSIONS: Scrub typhus occurred more commonly in elderly female patients. Early empirical treatment may prevent mortality. Large studies involving whole country is needed to see real scenario of disease in this setting.

Anatomical Variations in Circle of Willis in Patients Undergoing CT Cerebral Angiography in a Tertiary Hospital in Nepal: A Descriptive Cross-sectional Study.

INTRODUCTION: Variation in Circle of Willis is a commonly encountered entity in patients undergoing computed tomography angiography, identification of which is crucial in the management of patients with vascular pathologies. The aim of the study was to find out the anatomical variations in the Circle of Willis in patients undergoing Computed Tomography cerebral angiography in a tertiary hospital in Nepal. METHODS: This is a descriptive cross-sectional study involving 95 patients using convenient sampling techniques who were sent to the Department of Radiology and Imaging, Tribhuvan University Teaching hospital, for further evaluation of suspected vascular pathologies in the brain from April 2017 to September 2017. Ethical approval was taken from the Institutional Review Committee of the Institute of Medicine with reference number 326 (6-11-E). CT angiographic images of these patients were evaluated for the presence of variations in Circle of Willis, aneurysms, and other vascular pathologies. Data were analyzed using SPSS. RESULTS: Among 95 subjects included in the study, the anatomical variations in the arteries of Circle of Willis was seen in 52 (54.7%) patients, hypoplastic posterior communicating artery being the most common variation 33 (34.7%). The aneurysm was seen in 22 (23.2%) of cases. CONCLUSIONS: CT Angiography is a commonly performed imaging modality for suspected cases of cerebral aneurysms and various other vascular pathologies. Multidetector computed tomography can effectively detect variations in arteries of Circle of Willis, recognition of which is crucial in operative management of vascular pathologies.

Normal Anatomy and Variants of Renal Vasculature with Multidetector Computed Tomography in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Preoperative multisection computed tomography evaluation can provide necessary anatomic information in minimally invasive surgeries. This study was done to estimate the preva-lence and pattern of variations of renal vasculature through contrast-enhanced computed tomogra-phy in patients referred to the radiology department of a tertiary care hospital. METHODS: A descriptive cross-sectional study was conducted from 6th April 2016 to 6th April 2017. Ethical approval was taken. The triple-phase contrast-enhanced computed tomography was per-formed on 188 patients enrolled through convenient sampling. The images were evaluated in un-enhanced, arterial, and venous phases for the vascular variants. Data were analyzed based on the anatomical types of variations and descriptive statistics such as frequency and percentage using the Statistical Package for the Social Sciences. RESULTS: Out of the 188 patients, 60 (31.9%) had accessory renal arteries. The most common variant was hilar arteries which comprised 38 cases (20.2%) whereas polar arteries were present in 21 (11.1%)cases and the capsular artery was present in one (0.5%) case. Early bifurcation of the renal artery was noted in 15 (8%) cases with 10 (5.3%) on the right and 5 (2.7%) on the left side. Twelve (6.3%) cases of the double right renal vein were noted whereas retroaortic left renal vein was noted in only 4(2.1%) cases. CONCLUSIONS: Based on our study, almost one in three patients had accessory renal arteries and eighty-five out of a thousand patients had variants of renal veins.

Double Aortic Arch with Coarctation of Aorta in an Adolescent: Unraveling the Vascular Ring.

We report the case of a 12-year-old girl with balanced double aortic arch with coarctation of the aorta presenting with symptoms of respiratory and swallowing difficulty. On investigation, the patient had a double aortic arch with coarctation and clinically nonsignificant disease in the infrarenal aorta. Division of the nondominant aortic arch was done through a left thoracotomy, along with resection of the coarctation segment and placement of an interposition Dacron tube graft.

Role of MR Morphology and Diffusion-Weighted Imaging in the Evaluation of Meningiomas: Radio-Pathologic Correlation.

INTRODUCTION: Preoperative differentiation of benign, atypical and malignant meningiomas would significantly help in surgical planning and treatment. The aim of this study is to look at radio-morphologic behavior of various histopathological types and grades of meningiomas and their diffusion characteristics. METHODS: We performed an analytical cross-sectional study including all patients operated on for meningiomas at our hospital during January 2016 to July 2018. We studied 38 meningiomas in 38 patients aged 14 to 73 years old. All patients underwent MRI prior to surgery, including diffusion-weighted sequences, in a 1.5T scanner. Signal intensity in T2-weighted images, diffusion-weighted images (b=0, 90 and 1,000), and Apparent Diffusion Coefficient maps within the tumors and in the normal parietal white matter as a reference were evaluated. In the histological study, cellularity, proliferation index, histological grade, and cerebral invasion were evaluated. RESULTS: There was female predilection with male:female ratio of 1:2.4. Most meningiomas were supratentorial with most common origin being parafalcine and convexity. Of the 38 meningiomas, 31 were WHO grade I, 6 were WHO grade II (atypical) and one was WHO grade III (anaplastic). Among various tumors' behaviors, incomplete CSF cleft, pial invasion and parenchymal invasion were significantly high in high-grade tumors. Similarly, tumors showing pial invasion, breached tumor-brain interface, no capsular enhancement and parenchyma invasion showed significantly low NADC. Mean ADC value was 0.722±7.7x10-3 mm2/s (normalized ADC 0.9±0.1) in the atypical group and 0.876±24.56x10-3 mm2/s (normalized ADC 1.11±0.31) in the typical group. No statistically significant differences of ADC/NADC were found between histologic subtypes. Two subtypes of typical meningiomas, metaplastic and angiomatous meningioma had the highest values in the ADC maps. CONCLUSIONS: MR morphology like pial invasion, breached tumors brain interface, parenchymal invasion can predict aggressiveness and atypical nature of meningiomas. Meningioma shows moderately restricted diffusion. The signal on the ADC map is associated with tumors cellularity and aggressiveness suggesting its usefulness for predicting the histological grade.