Diffuse Alveolar Haemorrhage as Initial Presentation of Systemic Lupus Erythematosus: A Case Report.

Diffuse alveolar hemorrhage results from accumulation of red blood cells in the alveolar space originating from alveolar capillaries. Alveolar hemorrhage in Systemic Lupus Erythematosus is rare but catastrophic and can rapidly progress to respiratory failure. We report a 22-year old lady who presented with dyspnoea on exertion, hemoptysis, bilateral leg swelling and oliguria. Diffuse alveolar hemorrhage was confirmed by bronchoalveolar lavage fluid analysis. Serologic tests and renal biopsy confirmed lupus nephritis. She was treated with systemic immunosuppressive therapy and plasma exchange, to which she had a favourable response. Lupus presenting as alveolar hemorrhage is rare which warrants prompt diagnosis and treatment to prevent complications. Keywords: Bronchoalveolar lavage; Case report; Diffuse alveolar hemorrhage; Systemic lupus erythematosus.

Socioeconomic status and lung cancer risk in Nepal.

BACKGROUND: Lung cancer is the most common cancer among men and the third most common cancer among women in Nepal. Socioeconomic disparities in lung cancer have not been studied in the Nepalese population. METHODS: We conducted a lung cancer case-control study, including 209 cases and 313 controls at the main cancer hospital in Nepal, the B.P. Koirala Memorial Cancer Hospital (BPKMCH). RESULTS: We observed differences in lung cancer risk by ethnicity; the Rai, Limbu and Magar groups had a higher risk of lung cancer than Brahmin (OR=3.11, 95%CI=1.55-6.23). An inverse association was observed between education and lung cancer risk (p for trend=0.0008). We also observed greater lung cancer risk among unmarried individuals (OR=2.25, 95%CI=1.12-4.53), and lower risk in individuals who lived in the Central region compared to the West (OR=0.47, 95%CI=0.26-0.85). There were greater proportions of late stage cancers among women compared to men, in the Rai/Limbu/Magar ethnic groups, in individuals with lower education and in older age groups. CONCLUSIONS: Disparities in lung cancer risk were observed by race/ethnicity, education, marital status, and by region of residence. Further research on socioeconomic influence on lung cancer in Nepal is warranted to develop better prevention efforts against the disease.

Human papilloma virus vaccination in Nepal: an initial experience in Nepal.

Cervical cancer is the most common cancer among women in Nepal. Human papilloma virus (HPV) infection, a recognized cause of cervical cancer, is very common in sexually active women and HPV vaccination has been recommended as a prophylactic therapy. If HPV infection is prevented by the HPV vaccination to the adolescent girls, cervical cancer is also prevented. We received 3,300 vials of quadrivalent human papilloma virus (types 6, 11, 16, 18) recombinant vaccine (Gardasil; Merck and Co.) as a gift from the Australian Cervical Cancer Foundation (ACCF) which has a mission to provide life-saving HPV cervical cancer vaccines for women in developing countries, who cannot otherwise afford vaccination. HPV vaccine was offered to 1,096 of 10 to 26 year aged girls attending 17 secondary schools. In total, 1,091 (99.5%) received the second dose and 1,089 (99.3%) received the third dose of the vaccine. The remaining 5 girls at second dose and 2 girls at third dose remained unvaccinated. No serious vaccine related adverse events were reported except mild pain at the injection site in 7.8% of the vaccine recipients. High cost and low public awareness are the key barriers for successful implementation of the vaccination program in resource limited developing countries. In conclusion, HPV vaccine is safe with high acceptability in Nepalese school girls. However a large population study for longer follow up is warranted to validate the findings of this vaccination program.

Multi-institution hospital-based cancer incidence data for Nepal: an initial report.

While comprehensive cancer registration data are available for some locations in India and Pakistan, the situation regarding other countries in South Asia is less clear. Only one publication with cancer incidence data is available in the literature for Nepal, for one hospital in the Western provinces. The present study was conducted to assess burden across a greater proportion of country with data from 7 major hospitals where cancer is diagnosed and treated. Data from each were transferred to the BP Koirala Memorial Cancer Hospital in Bharatput, the National Cancer Center of Nepal, for compilation. Overall the most common site in males was the lung, followed by the oral cavity and stomach, while the first three in females were cervix uteri, breast and lung. Shifts in the the main cancers were noted with different ages, with leukemias and lymphomas in young individuals replaced by lung, oral and stomach in middle age and lung, stomach and larynx in the oldest category of males. In females the shift was to breast in young women, then cervix in middle age followed by lung in the very aged. There was also variation between hospitals, but this appeared largely due to the differences in the therapeutic modalities available in different institutions.

Initial experience in a cancer hospital in Nepal with sentinel lymph node mapping and biopsy for evaluation of axillary lymph node status in palpable invasive breast cancer.

To evaluate the performance and feasibility of sentinel lymph node biopsy in early breast cancer patients using patent blue dye. From March 2004, we are consecutively enrolling breast cancer patients with tumor size less than 5 cm with no clinically palpable axillary lymph nodes in this feasibility study. So far, 21 patients underwent sentinel lymph node biopsy using 1.0% patent blue dye injection around the tumor followed by axillary dissection. Sentinel lymph node biopsy was compared with axillary dissection for its ability to accurately reflect the final pathological status of the axillary nodes. Age of patients ranged form 32-67 years old with mean age of 46.72 years. Fifty seven percent of patients were postmenopausal. Patients with T1 lesions were 8 and T2 were 13. The sentinel lymph node/s were successfully identified in 20 out of 21 patients (95.0%). The number of sentinel lymph nodes ranged from 1 to 5 (average 2.0) and non-sentinel nodes ranged from 5-22 (average 12.0). Infiltrating ductal carcinoma was diagnosed in 15 patients, DCIS with early invasion in 4 patients, invasive lobular carcinoma in 1 and medullary carcinoma in 1 patient. Of the 20 patients in whom sentinel lymph nodes were successfully identified, nodes were positive in 35.0% (7/20) of patients. All the positive nodes were detected in group with T2 lesions. SLNs were the only positive nodes in 2 patients. There were no false negative patients, yielding an accuracy of 100.0%. Lymphatic mapping using patent blue dye alone is technically feasible for patients with small (T1 or T2) palpable breast tumors. The sentinel node can be reliably identified in the majority of these patients, and its histology reflects that of the axilla with a high degree of accuracy. This method is very useful in economically backward countries as it involves less expensive material.

Retrospective study of chest wall tumors at a cancer hospital in Nepal.

Primary and metastatic tumors of both soft tissues and bony skeleton, and primary tumors of adjacent organs invading the chest wall constitute chest wall tumors. A retrospective review of all the patients with chest wall tumors was done at BP Koirala Memorial Cancer Hospital (BPKMCH). Primary tumors of breast were excluded. Surgical treatment consisted of wide local excision (WLE). Chest wall reconstruction, if needed, was achieved by a muscular flap +/- prolene mesh +/- omental transposition. Thirty one patients were treated in the period from October 1999 to October 2003. Age of the patients varied from 3 years to 72 years (mean age--38 years). Presenting complaint was mass in 96.8% and pain in 48.4% cases. The mass was 5 cm or less in 34.4%, from 5 to 10 cm in 32.3%, and more than 10 cm in 32.3% cases. The lesions were located in sternal region, anterior, lateral, posterior, and vertebral chest wall in 6.5%, 32.3%, 41.9%, 16.1% and 3.2% respectively. WLE was done in 29 cases. Chest wall reconstruction using both muscular flaps and prolene mesh (15x15 cm) was done in 8 cases. In three of them, where concomitant wedge resection of the lung was done, omental transposition was added. In rest of the cases, primary closure, muscular/myocutaneous flap or skin grafting was done. Minor complications were observed in 31.0% cases, which were managed conservatively. Two patients received adjuvant radiotherapy and four patients--adjuvant chemotherapy. There were no postoperative deaths. The rate of malignancy was 48.4%.

Treatment of vitreoretinal disorders in the developing world: indications and outcomes of vitreoretinal surgery in Nepal.

PURPOSE: To examine the outcomes of vitreoretinal surgery for retinal disorders at Tilganga Eye Centre in Kathmandu, Nepal. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Records of 255 patients undergoing vitreoretinal surgery from December 2000 to January 2003 were reviewed. METHODS: Demographics, diagnoses, duration of symptoms, vision, and examination findings were noted before and after vitreoretinal surgery. MAIN OUTCOME MEASURES: Postoperative data were categorized by surgery type and analyzed by anatomic success, symptoms, and visual acuity (VA). RESULTS: Sixteen percent of patients had >6/60 vision preoperatively, and the mean duration of vision loss before presentation was 4.9 months. Major indications for surgery were retinal detachment (RD) (75%) and vitreous hemorrhage (19%). Anatomic success was achieved in 74.5% of patients. Postoperatively, 39% of patients experienced improved VA, with 33% obtaining >6/60 vision. CONCLUSIONS: Despite prolonged duration of vision loss at presentation, vitreoretinal surgery in the developing world can restore useful vision in many patients with RD and vitreous hemorrhage.