Diagnostic and prognostic role of elafin in skin acute graft versus host disease: a systematic review

BACKGROUND AND OBJECTIVE

Graft versus host disease (GVHD) is the common complication seen after allogeneic hematopoietic stem cell transplantation (HSCT) and a pleomorphic syndrome that resembles autoimmune and other immunologic disorders, leading to profound immune dysregulation and organ dysfunction. The most common targets of GVHD are skin, gastrointestinal tract and liver. GVHD is classified as acute graft versus host disease (aGvHD) if it occurs within the first 100 days after HSCT and chronic graft versus host disease(cGVHD) if it occurs after day 100. The skin is most frequently and earliest affected by aGvHD, followed by the gastrointestinal tract and liver. An ideal biomarker would predict the onset and severity of clinical acute GVHD and help to direct management, and this is an area of active research regarding the use of biomarkers for diagnosis and prognosis of acute GVHD. Recently, elafin has been identified as a potential plasma biomarker for aGVHD.

METHOD

We searched the databases PubMed, Cochrane library, and medRxiv for all studies investigating the Diagnostic or prognostic role of elafin in GVHD. We set the search strategy incorporating the search terms, 'elafin', 'graft versus host', and 'GVHD', and operated using the Boolean operators 'AND', and 'OR'. Thus, retrieved articles were then exported on an Excel® sheet, and duplicates were removed. The systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. After selecting the study based on inclusion criteria, data on study characteristics and biomarker description was extracted on a pre-determined data extraction table on the Microsoft Excel version. The quality assessment of the included studies was determined using the QUIPS tool.

RESULT

The search revealed 547 studies and 6 studies that met the eligibility criteria of this review have been included. The major finding of our study is the significant elevation of elafin in skin aGVHD.

CONCLUSION

Elafin is a significant biomarker for diagnosis and prognosis of skin aGVHD and should be assessed within 2 weeks of the onset of the disease.

Association of copeptin levels with patient prognosis and survival in sepsis syndromes: a meta-analysis

BACKGROUND

Sepsis syndromes are a major burden in the ICU with very high mortality. Vasopressin and copeptin are released in response to hypovolemia and have shown potential significance in diagnosing sepsis.

OBJECTIVE

To investigate the levels of copeptin in patients with sepsis syndromes and evaluate its relation with patient prognosis and mortality.

METHODS

Four databases were searched for literature published from inception to the 8th of November 2022. Original research articles where copeptin was measured in sepsis patients and compared with controls were included. Data extraction and synthesis: study characteristics, levels of copeptin in the participants, and copeptin assay description were extracted. Levels of copeptin in patients were pooled and compared with controls in terms of the standard mean difference (SMD) generated using a random-effects model.

RESULTS

Fifteen studies met the selection criteria. Copeptin levels were significantly higher in patients with sepsis, severe sepsis, and septic shock as compared to controls [(SMD: 1.49, 95% CI: 0.81-2.16, P<0.0001), (SMD: 1.94, 95% CI: 0.34-3.54, P=0.02), and (SMD: 2.17, 95% CI: 0.68-3.66, P=0.004), respectively]. The highest copeptin levels were noted in septic shock patients. The admission copeptin levels were significantly lower in survivors as compared to nonsurvivors (SMD: -1.73; 95% CI: -2.41 to -1.06, P<0.001).

CONCLUSION AND RELEVANCE

Copeptin was significantly elevated in sepsis, severe sepsis, and septic shock. Survivors had a significantly lower copeptin during admission. Copeptin offered an excellent predictability to predict 1-month mortality. Measuring the copeptin in sepsis patients can aid treating physicians to foresee patients' prognosis.

Biomarker role of maternal soluble human leukocyte antigen G in pre-eclampsia: A meta-analysis

INTRODUCTION

Human leukocyte antigen-G (HLA-G) is a non-classical class I HLA molecule shown to regulate the immunomodulation of maternal immune cells to prevent fetal tissue destruction. Low levels of freely circulating maternal soluble HLA-G (sHLA-G) have been observed in pre-eclampsia, however, no pooled evidence exists. This meta-analysis aimed to generate pooled findings on the association of sHLA-G levels with pre-eclampsia and is the first study to perform a trimester-wise comparison of the levels of sHLA-G in preeclamptic cases and normal pregnant controls.

METHODS

The databases PubMed, Emba, Web of Science, and Google Scholar through May 31, 2023. Preeclamptic women were defined as cases and normal pregnancies as controls. Data on the level of sHLA-G in cases and controls was extracted and subjected to a meta-analysis using a random-effects model. The pooled effect was expressed in terms of standardized mean difference (SMD). Sensitivity analysis was performed to investigate the effect of the exclusion of each study on the pooled results. Publication bias was assessed statistically.

RESULTS

Nine studies with altogether 567 PE cases and 1132 normal pregnancy controls were included in the meta-analysis. The first and third trimester levels of sHLA-G in PE cases were significantly lower than that of normal pregnant controls: (SMD: -0.84 [-1.29; -0.38]; p = .003; I2 = 54%) and (SMD: -0.39 [-0.71; -0.06]; p = .02; I2 = 79%) respectively. Sensitivity analysis revealed significant fluctuations in the pooled findings when few studies were excluded, raising questions on the consistency of results among studies.

CONCLUSION

Although we found that first and third-trimester sHLA-G levels in pre-eclampsia are significantly lower, taking into consideration the inconsistent results from the sensitivity analysis, our findings advocate the demand for more studies with larger sample sizes to generate solid ground pooled evidence on the predictive role of sHLA-G in pre-eclampsia.

Bacteriology of endotracheal tube biofilms and antibiotic resistance: a systematic review

Bacteria commonly adhere to surfaces and produce polymeric material to encase the attached cells to form communities called biofilms. Within these biofilms, bacteria can appear to be many times more resistant to antibiotics or disinfectants. This systematic review explores the prevalence and microbial profile associated with biofilm production of bacteria isolated from endotracheal tubes and its associations with antimicrobial resistance. A comprehensive search was performed on databases PubMed, Embase, and Google Scholar for relevant articles published between 1st January 2000 and 31st December 2022. The relevant articles were exported to Mendeley Desktop 1.19.8 and screened by title and abstract, followed by full text screening based on the eligibility criteria of the study. Quality assessment of the studies was performed using the Newcastle-Ottawa Scale (NOS) customized for cross-sectional studies. Furthermore, the prevalence of antimicrobial resistance in biofilm-producers isolated from endotracheal tube specimens was investigated. Twenty studies encompassing 981 endotracheal tubes met the eligibility criteria. Pseudomonas spp. and Acinetobacter spp. were predominant isolates among the biofilm producers. These biofilms provided strong resistance against commonly used antibiotics. The highest resistance rate observed in Pseudomonas spp. was against fluoroquinolones whereas the least resistance was seen against piperacillin-tazobactam. A similar trend of susceptibility was observed in Acinetobacter spp. with a very high resistance rate against fluoroquinolones, third-generation cephalosporins and carbapenems. In conclusion, endotracheal tubes were associated with colonization by biofilm forming bacteria with varying levels of antimicrobial resistance. Biofilms may promote the occurrence of recalcitrant infections in endotracheal tubes which need to be managed with appropriate protocols and antimicrobial stewardship. Research focus should shift towards meticulous exploration of biofilm-associated infections to improve detection and management.

Socio-demographic determinants of the knowledge of Monkeypox Virus among the general public: a cross-sectional study in a Tertiary Care Center in Nepal

BACKGROUND AND OBJECTIVE

Monkeypox virus (MPXV) is the causative agent of monkeypox's zoonotic infection and was declared a global emergency by the World Health Organization (WHO). Studies from different countries have shown insufficient knowledge among the general public on MPXV. This study aimed to assess the knowledge of the general public of Nepal on MPXV.

METHODS

Three hundred people were interviewed in person in October 2022, and 282 complete responses were recorded. The questionnaire related to the knowledge of MPXV was derived from a previous study conducted among the general population of Saudi Arabia. Twenty-two questions were included that assessed the knowledge and attitude of Nepalese toward monkeypox. Statistical comparison between high and low knowledge was performed using Pearson's Chi-square test. Logistic regression models were deployed to establish the relationship between participants' knowledge and socio-demographic characteristics.

RESULTS

Among the total respondents, 53.8% demonstrated high knowledge of monkeypox. People aged 18-25 years, unmarried people, and those living in urban areas had significantly higher levels of knowledge. Most respondents believed that MPXV is not a conspiracy or bioterrorism (63.1%) and agreed that it is likely to affect people's social and economic life as COVID-19 did (67.0%). The history of COVID-19 vaccination (aOR: 2.980; 95%CI: 1.227, 7.236) and the younger age (aOR: 2.975; 95%CI: 1.097, 8.069) were found to be significant determinants of the knowledge of the participants on monkeypox.

CONCLUSION

We observed that most Nepalese populations had a high knowledge of monkeypox and that social media was the most valuable source of information.

Does Caplacizumab for the management of thrombotic thrombocytopenic purpura increase the risk of relapse, exacerbation, and bleeding? An updated systematic review and meta-analysis based on revised criteria by the International Working Group for thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening condition marked by abnormal blood clotting and organ damage. Caplacizumab is a potential treatment for the TTP management. This systematic review and meta-analysis aimed to assess Caplacizumab's effectiveness and safety in the TTP management. A comprehensive database search identified nine studies, including randomized controlled trials and observational studies. Primary outcomes included TTP exacerbation, relapse, and major bleeding. Major bleeding risk was evaluated using updated definitions recommended by the International TTP Working Group in 2021. Revised criteria proposed by the IWG for TTP recurrence were employed for a comprehensive assessment of Caplacizumab's impact on relapse and exacerbation. Analysis revealed Caplacizumab significantly reduced all-cause mortality in TTP patients. Some studies raised concerns about bleeding risk, but overall, it did not significantly differ from standard treatment. Likewise, there was no significant difference in TTP relapse rates between Caplacizumab and standard care. This study supports Caplacizumab as a potential adjunct therapy for TTP. However, careful consideration of its advantages and risks is crucial in clinical practice. Further research is needed to address concerns related to adverse effects like bleeding risk and relapse rates associated with Caplacizumab in the TTP management. The findings emphasize the importance of weighing potential benefits and risks when considering Caplacizumab as an adjunct therapy for TTP.

Helicobacter pylori infection and risk of multiple sclerosis: an updated meta-analysis

Numerous studies have proposed that Helicobacter pylori infection may possess a protective effect in terms of future risk of multiple sclerosis (MS), however is poorly evidenced. We performed a systematic review and meta-analysis to obtain the pooled results regarding the prevalence of H. pylori infection in persons with multiple sclerosis (pwMS) and healthy controls. A comprehensive database search was performed in PubMed, Embase, and medRxiv for all relevant literature published from the inception of the databases until the August 1, 2022. The retrieved articles were first screened by title and abstract, followed by full-text screening based on the pre-established eligibility criteria. The risk of bias was assessed using the ROBINS-I tool. Data on the seroprevalence of H. pylori in pwMS and healthy controls was extracted, and a meta-analysis was performed in Review Manager Version 5.4.1. Sub-group analysis was performed in accordance with the geographical distribution (Eastern and Western countries) and the method of detection of H. pylori infection enzyme-linked-immunoassay (ELISA), Immunofluorescence, Immunochromatography). Furthermore, sensitivity analyses and publication bias were determined. The preliminary database search retrieved a total of 822 studies. Seventeen case-control studies with a total of 2721 pwMS and 2245 controls were included as a final sample size for the meta-analysis. The overall risk of bias was moderate. Overall, the rate of H. pylori infection in pwMS was not significantly different than in healthy controls (OR: 0.79 (95% CI = 0.58-1.08); I2 = 79%, p = 0.14). Subgroup analysis revealed that the rate of H. pylori infection among PwMS was not significant in both Eastern and Western countries (OR: 0.75 (95% CI = 0.52-1.08); I2 = 81%, p = 0.12). In contrast, data revealed that the prevalence of H. pylori infection in pwMS was significantly lower than that of control based on studies utilizing ELISA assays detection (OR: 0.71 (95% CI = 0.50-1.00); I2 = 81%, p = 0.05), while no significant difference was seen on studies using other assays than ELISA (OR: 1.19 (95% CI = 0.81-1.77); I2 = 0%, p = 0.38). Our findings of statistically indifferent prevalence of H. pylori infection as compared between pwMS and healthy controls suggested the absence of protective effect for risk of MS following H. pylori infection.

Danazol for the Treatment of Myelodysplastic Syndromes: A Systematic Review

Purpose To study the potential utility of danazol for treating patients with myelodysplastic syndromes, with a focus on efficacy and adverse effects (AEs). Methods MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus were searched for relevant publications from inception June 1, 1950, until June 28, 2022. The studies were screened by title and abstract, followed by full-text screening. The quality of the included studies was assessed via a prespecified set of questionnaires. Data on the efficacy measures and adverse outcomes were extracted and included in a descriptive summary. Results Nine studies consisting of 246 participants were included in our review. The overall quality of the included studies was fair. The age of the participants ranged from 61 to 78 years. In all 9 studies, more male patients had been enrolled than female patients. Overall, a proportion of patients in all the studies reported a desired major response to a danazol dose of 400 to 800 mg/day. Few studies did not observe any improvement in the platelet count. Elevated liver enzyme levels, weight gain, headache, dermatitis, and weakness were the most common AEs observed. One study reported a fatal intracerebral hemorrhage in 1 participant. Conclusions Danazol has been effective in increasing platelet count and hemoglobin level. Despite a few AEs, danazol is a safe drug for the treatment of patients with myelodysplastic syndromes.

Opportunities and Challenges for a Histology-Agnostic Utilization of Trastuzumab Deruxtecan

PURPOSE OF REVIEW

This review delves into the prospects and challenges offered by a potential pan-histological utilization of trastuzumab deruxtecan (T-DXd) in patients with advanced solid tumors.

RECENT FINDINGS

The HER2-targeted antibody-drug conjugate (ADC) T-DXd has shown broad activity across cancer types, with current indications for patients with biomarker-selected breast, gastric, and non-small-cell lung cancer and relevant activity observed in multiple histology-specific trials. Moreover, two recently reported phase 2 trials (DESTINY-Pantumor02 and HERALD) have supported the potential for a pan-cancer utilization of this ADC in patients with advanced cancers expressing HER2 or with HER2 amplifications. By improving the delivery of cytotoxic chemotherapy, ADCs have allowed for meaningful clinical advantages in broad populations of cancer patients, often leading to survival advantages over conventional chemotherapy. Notably, the broad spectrum of activity of certain ADCs has led to the hypothesis of a histology-agnostic utilization based on detecting specific biomarkers, similar to what is already established for certain targeted treatments and immunotherapy. To date, T-DXd has shown the broadest activity across cancer types, with current approvals in breast, gastric, and lung cancer, and relevant antitumor activity observed in a multiplicity of additional cancer types. The optimization of the drug dose, identification of predictive biomarkers, and clarification of mechanisms of resistance will be critical steps in view of a pan-histological expansion in the use of T-DXd.

The association of multiple sclerosis with thyroid disease: A meta-analysis

BACKGROUND

Multiple Sclerosis (MS) is an autoimmune disease with T-cell-mediated inflammation showing different clinical and pathological phenotypes. The relationship between MS and thyroid diseases has been debated, with varying research outcomes. This meta-analysis aims to clarify the association between different thyroid diseases and MS.

METHODS

Databases PubMed, Google Scholar, ScienceDirect, and Web of Science were searched electronically for the studies investigating the association of thyroid disorders in MS. Studies were selected based on the eligibility criteria and meta-analysis was performed on Review Manager Version 5.4 using a random-effects model. Subgroup analyses were performed based on the clinical subtypes of thyroid disorders and forest plots were generated to interpret the findings. Publication bias was assessed using Egger's and Begg's tests and interpreted into funnel plots. Sensitivity analysis was performed to investigate the effect of the exclusion of each study on the pooled odds ratio.

RESULTS

Inclusive of thirteen studies comprising 13,012 MS cases and 56,850 controls, our analysis unveiled notable findings. pwMS displayed a significantly elevated prevalence of both hypothyroidism (Odds Ratio [OR]: 2.29, 95 % Confidence Interval [CI]: 1.16-4.49, pvalue: 0.02, I2 = 27 %) and autoimmune thyroid disorder (OR: 1.70, 95 % CI: 1.02-2.85, pvalue: 0.04, I2 = 79 %). The collective prevalence of all thyroid diseases among pwMS was markedly higher (OR: 1.60, 95 % CI: 1.20-2.11, p-value: 0.001, I2 = 61 %). Furthermore, gender-specific analyses revealed that females with MS experienced a significantly increased prevalence of thyroid disorders compared to their male counterparts. (pooled odds ratio 2.38,95 % CI 1.11-5.10, p-value: 0.03, I2 = 28 %) CONCLUSION: This comprehensive meta-analysis establishes a significant association between thyroid diseases and MS, substantiating the increased risk of thyroid disorders in pwMS. Moreover, the gender-based analysis implicates a potentially significant interaction between gender and the observed association. These findings collectively contribute to a better understanding of the complex interplay between MS and thyroid diseases, offering crucial insights for both clinical management and future research endeavors.

Genomic profiling for non-small cell lung cancer: Clinical relevance in staging and prognosis

Lung cancer is one of the most common cancers prevalent and around 80% of all cases are non-small cell lung cancer (NSCLC). Due to high recurrence rates, the mortality of NSCLC is high. Conventional staging systems allowed risk classification of patients in order to simplify the patient selection for adjuvant chemotherapy. Gene expression analysis has been shown to possess advantage over conventional staging systems in NSCLC in terms of patients risk classification. This article reviews the evidences on the genomic profiling of NSCLC patients into high and low-risk groups based on the expression of genes involved in various proliferative pathways.

Association of vaccination status with the clinicobiochemical profile, hospital stay, and mortality in COVID-19: A case-control study

Background and Aims

The effectiveness of coronavirus disease 2019 (COVID-19) vaccines in reducing symptoms, disease advancement, complications, and mortality in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been well-established. This case-control study aimed to compare different blood parameters, and prognostic and survival outcomes of COVID-19 patients based on vaccination status.

Methods

We performed a case-control study that included hospitalized patients with COVID-19 at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Individuals who received vaccination were designated as cases and unvaccinated individuals as controls. Demographics, co-morbidity, clinical data, laboratory data, and disease outcomes were recorded for both groups. Multivariate, Cox, and linear regression were used for analysing blood parameters, hospital admission, survival, and hospital stay, respectively, between cases and controls.

Results

Out of 100 participants enrolled, 46 were vaccinated, and 54 weren't. At admission, ferritin and erythrocyte sedimentation rate (ESR) were significantly lower in cases. At discharge, cases showed a higher monocyte than controls. Ferritin, ESR, and d-imer showed excellent performance in determining the severity of symptoms. Significant correlation and regression of ferritin and ESR with the length of hospital stay was observed. Length of hospital stay was significantly lower in cases than in controls. No significant differences between cases and controls were observed in mortality.

Conclusion

COVID-19 vaccines effectively reduced hospitalization duration. Ferritin and ESR were significantly lower in vaccinated individuals and showed the best utility in monitoring the disease.

Socio-demographic determinants of the knowledge and attitude of Nepalese healthcare workers toward human monkeypox: a cross-sectional study

Human monkeypox is an infectious zoonotic disease and since May 2022, there has been a spike in cases worldwide. In this regard, a global health emergency has been declared by the World Health Organization (WHO) on July 23rd, 2022. Although there have been no confirmed human monkeypox cases in Nepal yet, the nation is undeniably at risk of an outbreak. Despite all preventive efforts and preparedness for monkeypox, there still remain several challenges including the literacy and knowledge of our healthcare workers regarding monkeypox. The aim of this study was to assess the level of knowledge and attitude of Nepalese healthcare workers regarding monkeypox. A cross-sectional study was performed on different healthcare workers at Tribhuvan University Teaching Hospital on the month of October 2022 using a set of validated questionnaires used previously in a Saudi Arabian study. An in-person survey was conducted where a total of 220 questionnaires were distributed. The response rate was 93%. Knowledge was categorized into high or low based on the mean knowledge score. The attitude was assessed using a 3-point Likert scale. The association of the knowledge and attitude of the respondents in accordance with their socio-demographics was statistically evaluated using Pearson's Chi-square test. The mean knowledge score was 13. A larger proportion of the respondents (60.4%) demonstrated a high knowledge and 51.1% demonstrated a positive attitude. Studying monkeypox during medical education possessed a significant difference in the attitude (p = 0.025). Knowledge did not vary based on socio-demographic characteristics. Despite almost half a year into the monkeypox outbreak, Nepalese healthcare workers still have an unsatisfying degree of knowledge and a negative attitude regarding its control which shows the need for education and awareness.

Intraglandular Foreign Body - Unusual Aetiology of Submandibular Gland Sialadenitis

Obstructive sialadenitis of submandibular gland is commonly due to sialoliths and strictures in the Wharton's duct. Other endogenous pathologies include mucous plugs and polyps. Foreign bodies of Wharton's duct and submandibular gland are rare. Retrograde migration of foreign bodies via ductal orifice, traversing the ductal system to its final intraglandular location is an even rare entity. These often present with painful swelling of the gland and at times with a purulent sialitis. Diagnostic modalities include plain radiography, ultrasonography, sialography, as well as computed tomography and magnetic resonance imaging. Treatment includes antibiotics, incision and drainage of abscess, and removal of foreign body either surgically (intra-oral approach or sialadenectomy) or more recently via sialoendoscopy. This is a case report of 30 years male with accidental cannulation of Wharton's duct with grass that eventually got lodged in the deep lobe of the gland, and was managed with sialadenectomy.

A Study of Trauma Patients in the Emergency Department of a Tertiary Care Hospital in Nepal during Lockdown in COVID-19 Pandemic

Background The nationwide lockdown was imposed upon by the Government of Nepal with regards to the COVID-19 pandemic. Even during times of limited mobility and travel, trauma cases were presenting to the hospital. Objective To asses trauma patterns among patients presented to the Emergency department in Dhulikhel hospital during the lockdown period. The assessment of the burden of trauma during the pandemic could aid in planning allocation of resources and improving trauma care. Method A retrospective cross-sectional study design was used to assess all patients with a history of trauma during the period of lockdown announced by the Government of Nepal for COVID-19 from March 24 to June 14, 2020. Result Among 2097 patients that visited the emergency department, 23% were trauma cases. In comparison to the corresponding time-period in 2019, trauma cases reduced by more than half (54.5%). The majority of patients utilized ambulances as a means of transportation; a few patients utilized Dhulikhel emergency medical services. The most common mechanism of injury was fall injury, followed by motor vehicle accident and physical assault. Traumatic brain injury occurred in 30% of patients. Of all patients, 71% were discharged after initial treatment, 26% were admitted to different wards and 3% were referred to other health centres. Conclusion Fall injury is a crucial public health concern followed by motor vehicle accident among trauma patients even during the pandemic condition. Thus, emergency rooms should aid in planning for preparedness, mitigation of trauma during situations like these, in planning the allocation of resources and improving trauma care.

Endothelium, Platelets, and Coagulation Factors as the Three Vital Components for Diagnosing Bleeding Disorders: A Simplified Perspective with Clinical Relevance

Bleeding disorders are a major group of hematological disorders, which are highly prevalent in the world. Excessive bleeding can result in serious consequences including hypoperfusion and cardiac arrest. The body has its selfmechanism to control excessive bleeding which is termed hemostasis. Hemostasis is achieved in two major steps, the formation of the primary and secondary hemostatic plugs. Endothelium, platelets, and coagulation factors are three components involved in hemostasis. Endothelium and platelets have a major role in forming the primary hemostatic plug. Consequently, the first step in investigating a bleeding disorder is platelet count. Despite normal platelet count, abnormality in the primary hemostatic plug may arise due to functional defects of the platelets including adhesion, activation, and aggregation. Von Willebrand disease (VWD) is an endothelial defect and the most prevalent inherited defect in coagulation. Abnormalities in the secondary hemostatic plug are largely due to coagulation factor deficiencies, and, to a lesser extent, the presence of inhibitors. Techniques involving viscoelastics have been aiding in rapid diagnosis and are useful in point-of-care testing. This article discusses the investigation of bleeding disorders from the perspective of the endothelium, platelet, and coagulation factor physiology. These three components should be properly investigated to achieve the definitive diagnosis of bleeding disorders.

Toothbrush, an Unusual Foreign Body

Accidental consumption of foreign body is a common presenting complain among patients especially in young age group. Majority of patients can be discharged safely after reassurance while a fraction of patient requires observation and further management. Here we report a case of a 35-year-old gentleman who presented to the out-patient department of our hospital in June 2021 for accidental ingestion of toothbrush. After detailed history and physical examination upper gastrointestinal endoscopy was planned for the patient. Failed endoscopic removal was considered the indication for surgery. A supraumbilical midline incision was used to remove the toothbrush. Following the surgical removal, he was managed conservatively and was discharged without significant complications. We describe this case in detail in addition to reviewing the pertinent literature.

Clinical Profile and Diagnosis of Obstructive Sleep Apnea Syndrome using Overnight Polysomnography in a Tertiary Care Hospital

Background Obstructive sleep apnea is a highly prevalent yet largely under-diagnosed disease that poses a significant burden on the healthcare system. Objective To determine the role of predictors for Obstructive sleep apnea syndrome and its severity in Nepalese population. Method Prospective and analytical study conducted in the Department of Otorhinolaryngology and Head and Neck surgery at Kathmandu University Hospital between March 2018 and June 2020. A total of 85 adult patients with Obstructive sleep apnea with an Epworth sleepiness score greater than 10 were included. Overnight polysomnography was done and scoring of sleep associated events were done according to the American Academy of Sleep Medicine criteria. Participants were classified as simple snoring and mild, moderate or severe Obstructive sleep apnea syndrome groups depending on the Apnea Hypopnea Index values. Relationship of Apnea hypopnea index was analyzed with age, neck circumference, body mass index and Epworth Sleepiness score. Result Simple snoring was seen in 18(21.17%) patients, 14(16.47%) had mild Obstructive sleep apnea, 13(15.29%) had moderate Obstructive sleep apnea, whereas the severe group consisted of 40(47.05%) patients. The minimum Epworth Sleepiness Score was 10 and the maximum was 25. The Apnea hypopnea index correlated positively with Body mass index (p=.010) and Epworth sleepiness score (p <.001). However, Apnea hypopnea index had no association with age (p=.437) and neck circumference (p=.118). Conclusion Health professionals need to be extremely vigilant while examining patients presenting with Obstructive Sleep Apnea. Polysomnography is the investigation of choice in the early identification of this treatable disease.

Comparison of Two Entry Methods for Laparoscopic Port Entry

Background The first step in laparoscopic surgery is to establish the pneumoperitoneum for which many approaches have been introduced to minimize the complications. Although controversies exist regarding the most efficient technique, till now the best entry technique is still unsettled. Objective To compare the safety, operating time and outcome of Direct Trocar Insertion with a well-established and widely practised Open Access Technique. Method This is a prospective study at Nobel Medical College Teaching Hospital from November 2019 to February 2021. Patients were grouped into either of the two groups, Group 1 for Direct Trocar Insertion and Group 2 for Open Access Technique. They were later analysed for major and minor complications of the technique and a comparison of either method was done at the end of the study period. Result A total of 823 patients were enrolled in the study. Among the study population, 411 patients had Direct Trocar Insertion while 412 patients had Open Access Technique. The majority of the operation that was done during the study period was laparoscopic cholecystectomy. Patients in the Open Access Technique group experienced more complications compared to Direct Trocar Insertion group. Conclusion Despite the fear of adopting the Direct Trocar Insertion, this is a safe, better and quick technique for laparoscopic port entry. However, any surgeon practising laparoscopic surgery should be competent to adopt either technique to overcome failure in either process during port entry.

Pilonidal sinus of the cheek: an extremely rare clinical entity-case report and brief review of the literature

Background

Pilonidal sinus is commonly seen at the sacrococcygeal region and few other sites, usually located at the midline, at areas where hairs collect or near protuberances or some adjacent rubbing surfaces. Its presence elsewhere is uncommon. We share an interesting case of a recurrent discharging sinus from the cheek bulge of a male which turned out to be a pilonidal sinus containing tuft of hairs on exploration and wide excision.

Case presentation

A 37 years old hirsute male presents to us with a non-healing discharging sinus at the bulge of the cheek. Exploration after a course of antibiotics showed 2 subcutaneous cavities with tuft of hairs. The area was excised along with a margin, thorough irrigation and curettage was done and the wound was closed primarily; a Z-plasty was incorporated in the central part to break the resultant suture line. Histopathological examination was done to confirm the diagnosis and rule out an off-midline dermoid cyst or an underlying/coexisting malignancy. Post-operative course was uneventful. The patient has been recurrence free for 1.5 years and is satisfied with the nature of the scar.

Conclusions

Pilonidal sinus of the cheek bulge is an extremely rare entity. Complete excision and clinical suspicion are important for cure of this nagging ailment, especially at unexpected areas.

Thresholds for Spinal Anaesthesia-induced Hypotension During Caesarean Section

Background Spinal anaesthesia is the current standard for caesarean section. Hypotension, a common complication, potentially results in adverse foetal and maternal outcomes. However, hypotension-defining criteria are varied. Objective To identify the blood pressure thresholds for spinal anaesthesia-induced hypotension during caesarean section. Method This is a retrospective cohort study of spinal anaesthesia-induced hypotension that occurred till baby-delivery during caesarean section. Reports on intraoperative hypotension, collected previously from January to December 2019, were reviewed to identify the hypotension-defining thresholds. The thresholds were categorized into systolic blood pressure (SBP) of 80, 90 or 100 mmHg, mean arterial pressure (MAP) of 60, 65 or 70 mmHg, combinations, and others. Parturient and anaesthesia characteristics, and associated hypotensive symptoms were also recorded for descriptive analysis. Result Spinal anaesthesia-induced hypotension was identified in 129 (11.5%) cases among 1116 caesarean sections. Altogether, 12 hypotension-defining thresholds were employed. Thresholds of SBP 90, MAP 60, and SBP 80 mmHg were used in 53 (41%), 28 (21.7%), and 21 (16.2%) cases respectively. Mean maternal age was 28 (±4.22) years and 87 (67.4%) cases underwent emergency surgery. Median sensory blockade level was T4. Nausea-vomiting, bradycardia, and tachycardia were associated during five (3.8%), six (4.6%), and 15 (11.6%) hypotensive incidents respectively. Two cases had unrecordable blood pressure but there was no maternal mortality. Conclusion Systolic blood pressure of 90 mmHg and mean arterial pressure of 60 mmHg included the most common thresholds for spinal anaesthesia-induced hypotension during caesarean section. Identifying the safe and clinically relevant hypotension-defining criteria needs further investigation.

Higher rates of early initiation of breastfeeding associated with health facility delivery in Nepal

Background

Initiation of breastfeeding within one hour from birth is one of the five key essential newborn care messages, implemented along with birth preparedness package since 2008. This study aimed to determine the trend of early initiation of breastfeeding (EIBF) and to assess the effect of health facility delivery on EIBF in Nepal.

Methods

We analyzed the data from the last four nationally representative Nepal Demographic and Health Surveys (NDHS) conducted in 2001,2006,2011 and 2016. Data on the early initiation of breastfeeding was obtained from the mothers of infants born within 24 months prior to the survey. The explanatory variable was the place of delivery, dichotomized as either the health facility, or home delivery. Survey year had a significant interaction with the place of delivery. Multivariable logistic regression was conducted separately on pooled samples before (NDHS 2001 and 2006) and after (NDHS 2011 and 2016) the program implementation. Adjusted odds ratio (AOR) with 95% confidence interval (CI) for EIBF was calculated after adjusting for predetermined covariates.

Results

The rate of EIBF increased by 26.5% points (from 32.8% in 2001 to 59.3% in 2016) among infants delivered in a health facility, compared to an increase by 17.1% points (from 29.9% to 47.0%) among home born infants. EIBF increased by 32.5% points before, compared to 49.7% points after BPP. Delivery in a health facility was associated with a higher odd of EIBF in later years (AOR2.3, 95% CI 2.0,2.8), but not in earlier years (AOR1.3, 95% CI 0.9,2.0). Delivery by caesarean section, first-born infant, and lack of maternal education were associated with a lower rate of EIBF in both periods.

Conclusions

Higher EIBF was associated with health facility delivery in Nepal, only after programmatic emphasis on essential newborn care messages. This implies the need for explicit focus on EIBF at birth, particularly when mother is less educated, primiparous or undergoing operative delivery.

Key messages

The rate of initiation of breastfeeding within an hour from birth is increasing in Nepal, with higher rates in health facility delivery, as shown by the recent four nationally representative surveys. Programmatic focus on essential newborn care messages may have contributed to significant association of higher rates of early initiation of breastfeeding when delivered in health facility.

Child abuse and all-cause mortality in the Canadian population

Background

A history of child abuse is common and is associated with the later occurrence of risky health behaviors, mental disorders, and chronic conditions, strongly suggesting that child abuse may be associated with elevated mortality. However, most of the literature on child abuse has studied psychosocial/behavioral or medical outcomes and have not addressed mortality directly.

Methods

Data from the 2012 Canadian Community Health Survey, linked to the Canadian Vital Statistics Database, were used in the analysis. The CCHS-2012 interview (n = 19,830) retrospectively assessed childhood physical abuse, sexual abuse, and witnessing intimate partner violence before the age of 16. Each type of abuse was analyzed separately using Cox proportional hazards models for all-cause mortality. Hazard ratios (HR) and associated 95% confidence intervals (CI) were estimated with and without adjustment for covariates.

Results

An effect on mortality was observed among men for witnessing interpersonal violence (age-adjusted HR 2.47, 95% CI 1.48-4.12), and severe physical abuse (age-adjusted HR 2.3, 95% CI 1.21-4.36). In each case, the association was not significant for women; the age-adjusted HRs being 0.93 (95% CI: 0.51-1.70) and 0.59 (95%CI: 0.64-2.60) respectively. The association was seen only among those reporting frequent abuse ( &gt; =10 times) and weakened (became not significant) with adjustment for covariates that may mediate the association such as smoking and chronic conditions.

Conclusions

As predicted by a broader literature on childhood adversity, child abuse increases the risk of mortality. The effect was significant for severe physical abuse in men, but imprecision due to a limited number of deaths may have rendered other associations non-significant. The study provides some degree of confirmation that child abuse contributes to later life mortality. Hence public health strategies that prevent child abuse and mitigate the harms of the mediators might prevent mortality.

Key messages

Witnessing intimate partner violence is just as harmful as actually experiencing physical abuse. Preventing children's exposure to violence in family is valuable in preventing mortality in adulthood. Enhancing child abuse prevention programs and mitigating the harmful effects of the mediators such as smoking, substance use, and chronic conditions is important in reducing mortality in adult life.

Solid Variant of Alveolar Rhabdomyosarcoma of Nasal Cavity

Rhabdomyosarcoma comprises about half of the soft tissue tumors. Approximately 40% of the alveolar subtype occur in the head and neck region. Patients present with unilateral nasal mass with/without lymphadenopathy and with/without orbital manifestations. Diagnosis is aided radiologically by CT scan, MRI along with biopsy and is confirmed by immunohistochemistry. Treatment involves surgical resection, chemotherapy, radiotherapy or a combination of these. In spite of treatments, however, the outcome is poor. This is a case report of 14-year-old male who presented with unilateral nasal mass with proptosis of right eye who was eventually diagnosed as a case of alveolar rhabdomyosarcoma of solid variant.

Obligate Myiasis: A Case Series From Nepal

Although maggots are unanonymously linked to carcass or dead tissues, there are reports of its infestation into living tissues as well. Myiasis denotes maggot infestation in living tissue. There are two forms of myiasis namely obligate and facultative. Obligate myiasis denotes maggots feeding on living tissue whereas facultative myiasis represents the opportunistic behaviour of the fly taking advantage of wound or necrotic tissue, laying by eggs which hatch into maggots. Decreased physical activity and poor hygiene leads to maggot infestation. Maggot invasion of living tissues is undesirable occurrence which can best be avoided by improving hygiene. People with low living standards in the developing nations are the occasional victims for maggot infestations. We present cases of obligate myiasis for their uniqueness and rarity.

Galvanic Skin Response as a Simple Physiology Lab Teaching Tool- An Alternative Indicator of Sympathetic Arousal

Background Sympathetic arousal response due to rewarding emotion may not be considered threat to the well-being but such arousal response evoked by fear or punishment can be stressful. When such changes are recorded in lab as biological signals, induced with appropriate stimulus, the observed response may serve as a good indicator of homeostatic alteration. In this study, skin conductance was utilized to record sympathetic response for cognitive load, by application of simple subtraction task. Objective To detect sympathetic arousal by utilization of galvanic skin response during mental arithmetic task. Method Total of eighty two subjects, forty two female and forty male participated in the study. Twenty two subjects were provided mental task to record skin conductance. In sixty subjects, galvanic skin response, pulse rate, respiratory rate and temperature were recorded by appropriate transducers to obtain baseline and task response to detect differential recordings. Subjects performed the mental exercise of arithmetic task (MAT) with transducer placed in upper limbs. Mean of averages for respective variables were statistically calculated from obtained recordings. Result For measured galvanic skin response, 57 subjects showed increased skin conductance (rise in amplitude) whereas, 25 subjects had no rise in amplitude ("A peak") while performing the mental arithmetic task, when compared to control recording. However, in 20 subjects, pulse rate and respiratory rate showed significant rise though, the change in the skin conductance was not significant. Conclusion Galvanic skin response is useful for demonstration of sympathetic activation induced by simple mental subtraction task, and can be utilized along with vital parameters mentioned in this study to discuss in vivo variation that exist as differential for core and superficial sympathetic outflow among individuals.

Imaging localized electric fields with nanometer precision through tip-enhanced Raman scattering

Tip-enhanced Raman scattering may be used to image various aspects of plasmon-enhanced local electric fields with extremely high spatial resolution.

Management of cysto-biliary communication in hydatid cyst of liver

Introduction: Biliary communication of hepatic hydatosis is one of the important complications. It may be minor or major communication. Minor communication is usually diagnosed during operation by the presence of bile stained hydatid fluid on aspiration or bile leak during surgery. However, in major communication, patients present with obstructive jaundice, abdominal pain and cholangitis. Surgical management of major communication is difficult and is associated with high morbidity and mortality.Methods: This is a retrospective study at Tribhuvan University Teaching Hospital, Kathmandu, Nepal over a period of two year (April 15th 2012 to April 15th 2014) and analyzed the medical records of 30 patients admitted and treated for hydatid cyst of liver in surgical ward during that period. Demography, clinical features, management and outcome were analyzed.Results: Of 30 patients with hepatic hydatid cyst operated over a period of two years, thirteen patients had cystobiliary communication. Amongst them, five minor communications were diagnosed during operation and managed with suture plication and omentopexy. Out of the eight major communications, seven were diagnosed preoperatively and all had cholangitis, and one had hydatid cyst of gallbladder and was diagnosed intraoperatively. Among six cases of major communication, five cases required CBD exploration and bile duct reconstruction while partial cholecystectomy was done for hydatid cyst of gall bladder and one case was managed by ERCP sphincterotomy, evacuation of cyst content and stenting. one case was managed with pigtail drain as the patient had infected hydatid cyst and not fit for surgery.Conclusion: Cystobiliary communication is a common complication of hydatid cyst of liver. Therapeutic options are related to size and location of the cyst and size of communication.Journal of Society of Surgeons of Nepal Vol.17(1) 2014: 31-34

The Effect of Vacuum on Venous Drainage: an Experimental Evaluation on Pediatric Venous Cannulas and Tubing Systems

Introduction: To observe how vacuum assisted venous drainage (VAVD) may influence the flow in a cardiopulmonary bypass circuit with different size of venous lines and cannulas. Methods: The experimental circuit was assembled to represent the cardiopulmonary bypass circuit routinely used during cardiac surgery. Wall suction was applied directly, modulated and measured into the venous reservoir. The blood flow was measured with a flow-meter positioned on the venous line. The circuit prime volume was replaced with group O date expired re-suspended red cells and Plasmalyte 148 to a hematocrit of 28% to 30%. Results: In an open circuit with gravity siphon venous drain, angled cannulae drain more than straight ones regardless the amount of suction applied to the venous line (16 Fr straight cannula (S) drains 90 ml/min less than a 16 Fr angled (A) with a siphon gravity). The same flow can be obtained with lower cannula size and higher suction (i.e. 12 A with and -30 mmHg). Tables have been created to list how the flow varies according to the size of the cannulas, the size of the venous tubes, and the amount of suction applied to the system. Conclusions: Vacuum assisted venous drainage allows the use of smaller cannulae and venous lines to maintain a good venous return, which is very useful during minimally invasive approaches. The present study should be considered as a preliminary attempt to create a scientific-based starting point for a uniform the use of VAVD. Keywords: cardio-pulmonary bypass; experimental study; vacuum assisted drainage.

Effect of Vacuum on Venous Drainage: an Experimental Evaluation on Pediatric Venous Cannulas and Tubing Systems

INTRODUCTION

To observe how vacuum assisted venous drainage (VAVD) may influence the flow in a cardiopulmonary bypass circuit with different size of venous lines and cannulas.

METHODS

The experimental circuit was assembled to represent the cardiopulmonary bypass circuit routinely used during cardiac surgery. Wall suction was applied directly, modulated and measured into the venous reservoir. The blood flow was measured with a flow-meter positioned on the venous line. The circuit prime volume was replaced with group O date expired re-suspended red cells and Plasmalyte 148 to a hematocrit of 28% to 30%.

RESULTS

In an open circuit with gravity siphon venous drain, angled cannulae drain more than straight ones regardless the amount of suction applied to the venous line (16 Fr straight cannula (S) drains 90 ml/min less than a 16 Fr angled (A) with a siphon gravity). The same flow can be obtained with lower cannula size and higher suction (i.e. 12 A with and -30 mmHg). Tables have been created to list how the flow varies according to the size of the cannulas, the size of the venous tubes, and the amount of suction applied to the system.

CONCLUSIONS

Vacuum assisted venous drainage allows the use of smaller cannulae and venous lines to maintain a good venous return, which is very useful during minimally invasive approaches. The present study should be considered as a preliminary attempt to create a scientific-based starting point for a uniform the use of VAVD.

Prevalence of depression among elderly people living in old age home in the capital city Kathmandu

Background: There has been a considerable increase in the numbers of older people in the world population of both developed and developing countries. These populations are thought to be at greater risk for depression. Many researches are conducted on physical wellbeing of elderly but studies regarding depression among elderly, especially in old age home is lesser in the developing countries. Objectives: To assess depression among elderly residing in an old age home in Kathmandu and its association with some of the socio-demographic variables. Methods: One hundred fifty elderly people residing in social welfare centre elderly home, Pashupatinath, Gaushala, Kathmandu, Nepal were selected randomly. Geriatric depression scale (GDS) was applied in all the individuals to assess the prevalence and degree of depression. Results: This study showed that, 47.33% of population had depression. Among the depressed population, 70.42% had mild depression and 29.58% had severe depression. There was significant association between the prevalence of depression and history of physical illness. Conclusion: Depressive disorder is highly prevalent among the elderly population residing in the old age home in Kathmandu with history of physical illness. DOI: http://dx.doi.org/10.3126/hren.v11i3.9634 Health Renaissance 2013;11(3):213-218

Bacteriology and antimicrobial susceptibility of adult chronic dacryocystitis

INTRODUCTION

Chronic dacryocystitis results in chronic infection and inflammation of the lacrimal sac.

OBJECTIVE

To identify the aetiology of chronic dacryocystitis and to determine their antimicrobial susceptibility pattern.

MATERIALS AND METHODS

A cross - sectional study was undertaken including 120 lacrimal swab materials collected from patients aged above 15 years suffering from chronic dacryocystitis.

STATISTICS

Data analysis was done by using software "Win pepi'' ver 7.9.

RESULTS

The bacteria of eight different species were isolated from 76.66 % (92/120) culture positive samples. 85.86 % showed a single and 14.13 % showed a mixed growth pattern. Coagulase negative staphylococci were the most common bacteria (P= 0.018) accounting for 33.96 % followed by Staphylococcus aureus (25.46 %), Streptococcus pneumoniae ( 19.81 % ), Streptococci viridans (5.66 %), Escherichia coli (5.66 %), Haemophilus spp ( 4.71 % ), Streptococcus pyogenes (3.77 %) and Bacillus spp (0.94 % ). Staphylococcus aureus were the most predominant bacteria in mixed growth. Rate of infection was higher in males 81.39 % than in females 74.02 %. Infection was higher in the age group of above 31 years. In the antimicrobial susceptibility test, except staphylococcus aureus, all the Gram positive isolates were 100 % sensitive to chloramphenicol and were least sensitive to tobramycin, but Gram negative isolates were equally sensitive to Chloramphenicol and Nalidixic acid.

CONCLUSION

Coagulase negative staphylococci are the most frequently isolated bacteria. Staphylococcus aureus is predominantly found in mixed growth. Chloramphenicol is the most effective drug of choice for chronic dacryocystitis.