Obturator hernia: a persisting clinical diagnostic challenge - a case report.

Introduction: The presentation of a strangulated obturator hernia is rare, with it accounting for less than 0.04% of all hernias. Delay in presentation and diagnosis results in complications like bowel ischemia, necrosis, perforation, and peritonitis, thereby increasing morbidity and mortality. Case presentation: The authors report the case of an 85-year-old multiparous woman who presented with a 3-day history of abdominal pain and vomiting. Upon examination, she exhibited hypotension, altered sensorium, and a distended abdomen with visible peristalsis. An abdominal pelvic computed tomography scan confirmed the diagnosis of 'intestinal obstruction secondary to an incarcerated obturator hernia'. Subsequently, a lower midline laparotomy was performed, successfully reducing the bowel and repairing the hernial orifice. The patient was discharged on the fourth postoperative day, and there has been no hernia recurrence as of her 3-month follow-up. Discussion: The presentation of a strangulated obturator hernia can be elusive. During clinical examination, both the Howship-Romberg sign and the Hannington-Kiffs sign tests may be negative. Laparoscopic obturator hernia repair has been shown to reduce hospital stay and morbidity. A midline laparotomy has the advantage of easy manual reduction, minimizing bowel trauma, accurately accessing the bowel, and facilitating bowel resection. Conclusion: Obturator hernias constitute rare subtypes of abdominal hernias. They typically occur in older women, and patients often present with poor functional status and multiple comorbidities. The clinical diagnostic tests are uncertain, even in patients with a high index of suspicion. Timely diagnosis and appropriate surgical management are crucial for a favorable outcome.

Paediatric Moyamoya disease: acute presentation with fever and confusion in an 8-year-old: a case report.

Introduction and importance: Moyamoya is a chronic vaso-occlusive cerebrovascular disorder which involves internal carotid artery and its proximal branches, forming compensatory Moyamoya vessels. It may manifest with diverse symptoms, but early detection is crucial for a favourable prognosis. Case presentation: The authors present a case of an 8-year-old child who presented to the emergency with acute onset fever and confusion in speech. Although the symptoms were vague, she was advised for a thorough investigation. MRI of the brain revealed an infarct on the brain that raised suspicion of a vaso-occlussive disorder. Subsequent magnetic resonance angiography and digital subtraction angiography revealed underlying Moyamoya disease. Clinical discussion: Although the initial diagnosis of Moyamoya disease can be challenging, prompt diagnosis and simple medical measures like single antiplatelet regimens are useful for secondary ischaemic prevention. Conclusion: This case highlights the essence of considering Moyamoya disease as one of the differentials while dealing with children presenting with subtle cerebrovascular symptoms.

Diagnosis of systemic sarcoidosis in a patient with bilateral granulomatous pan-uveitis: a case report.

Introduction and importance: Sarcoidosis is a systemic disease usually presenting with features of hilar lymphadenopathy like persistent cough, dyspnoea, cough, night sweats. However, its first and only manifestation can be ocular symptoms consistent with uveitis. Case presentation: The authors present such association in a 53-year-old female who had ocular symptoms on and off, designated as uveitis. Despite medications, her symptoms rather flared up. On diagnostic assesement done years later, chest X-ray showed bilateral hilar lymphadenopathy, serum angiotensin-converting enzyme levels were also raised, and the diagnosis of systemic sarcoidosis was confirmed. Clinical discussion: Eye involvement can occur way before the systemic presence of the disease is detected and can be present clinically as an isolated entity which makes diagnosis of underlying sarcoidosis a challenge. Conclusion: Consideringsarcoidosis as one of the differential diagnosis when attending patients with non-resolving uveitis remains the mainstay of this report.

Longitudinally extensive transverse myelitis, a disabling disorder with a good prognosis: a case series from Nepal.

Introduction: Longitudinally extensive transverse myelitis (LETM) is a rare spinal cord disorder with variable etiologies and presentations. It can present solely or as an association with other neurological disorders. Methodology: It was a series of cases of LETM in a tertiary care hospital. Clinical presentation and outcomes: The initial three cases presented with bilateral lower extremity weakness and were diagnosed as transverse myelitis while, the fourth case, already diagnosed as LETM presented with seizure followed by loss of consciousness. All four cases had a good prognosis to date with continued physiotherapy. Conclusion: The early diagnosis of the disease helps to guide the optimal management and decide the potential need for physiotherapy.

Esophageal squamous carcinoma in a 25-year-old female, changing trend in epidemiology: A case report.

Timely diagnosis, comprehensive assessment, and a multidisciplinary treatment approach are essential for young patients with esophageal squamous cell carcinoma, even when conventional risk factors are absent. This report emphasizes the need for increased clinical awareness and improved patient outcomes in an evolving epidemiological landscape.

Dermatomyositis with positive anti-TIF1 gamma antibodies in an adult female: A case report.

Dermatomyositis is an uncommon autoimmune disease with only few cases reported from Nepal. Presence of anti TIF-1 gamma antibodies in DM are the strongest predictor of malignancy. Timely screening of malignancies for early detection and management remains the mainstay of this report.

Endovenous laser ablation versus conventional surgery (ligation and stripping) for primary great saphenous varicose vein: a systematic review and meta-analysis.

Background: The great saphenous varicose vein was managed with high ligation and stripping conventionally, but with the development of minimally invasive surgical techniques like endovascular laser ablation (EVLA), they have become popular. This systematic review and meta-analysis of randomized controlled trials aim to compare the short-term and long-term outcomes of these two modalities on headings like procedural time, technical success, recovery time, recurrences, cost-effectiveness, and complications. Materials and methods: The protocol followed in this study was registered prospectively in the Registry of Systematic Reviews/Meta-analyses. Electronic databases were searched with appropriate search terms for relevant studies, and after their screening, data was extracted. The odds ratio was used for dichotomous data, and the mean difference or standardized mean difference was used for continuous variables. Results: This study identified 18 publications (10 randomized controlled trials) with a total of 1936 patients. There was no difference in procedural time, recovery time, recurrences at 1, 2, and 5 years, or clinical severity score. The surgery group had 4.35 times higher statistically significant odds of being technically successful at 2 years, while pooling data on bruising, hematoma, sensory disturbance, infection, and phlebitis showed that the EVLA group was less likely to develop postoperative complications. Conclusion: Technical failures were more common in the EVLA, whereas postoperative complications were more common in the surgery group. Both have comparable clinical effectiveness, and neither modality has clear superiority over the other. Parameters like cost-effectiveness must be assessed at the hospital level before choosing the right procedure for the patients.

Anesthetic challenges in difficult airway in a patient with maxillary carcinoma: A case report.

Airway management in patients with maxillary carcinoma presents unique challenges. To ensure safety, a tailored and collaborative approach is essential. This is a case where anesthetic plan of awake fiberoptic oral endotracheal intubation was chosen.

Fahr's disease presenting as Parkinson's disease along with dysphagia and dysarthria: A case report.

Fahr's disease, a rare motor and neurocognitive condition, is characterized by idiopathic calcification of basal ganglia. This article presents such case of 61-year-old female, exhibiting movement, speech, and swallowing difficulties with multiple calcifications in brain in NCCT. Early and supportive management can lead to improved outcomes and prevent unnecessary interventions.

Spectrum of congenital heart disease in Nepal from 2002-2022: A systematic review and meta-analysis.

Background: Congenital heart diseases are recognized as public health concerns worldwide and Nepal is no exception. This study aims to study congenital heart disease in Nepal on grounds of burden, commonest type, common presentations, and associated noncardiac anomalies so that its spectrum can be known for prompt diagnosis and adoption of screening protocols. Methods: Relevant articles were searched in electronic databases using appropriate search terms and Boolean operators. Data were extracted in Excel and analyzed in Comprehensive Meta-Analysis Software. The proportion was used as an effect measure and a fixed or random-effect model was used as per the heterogeneity. Forest plots were used to give visual feedback. Results: A total of nine studies were included in the qualitative and quantitative synthesis after a rigorous screening of imported studies. The prevalence of congenital heart disease was 0.7% (Proportion: 0.007; CI: 0.001-0.035; I2: 99.263%). The burden of atrial septal defect was 32.1%, ventricular septal defect was 31.1%, patent ductus arteriosus was 12.6% and Tetralogy of Fallot was 7.3%. The most common presentations were respiratory tract infection (54.7%), developmental delay (49.8%), difficulty in breathing (44.5%), failure to thrive (17.1%), and cyanosis (15.9%). Conclusions: The prevalence of congenital heart disease in Nepal was 0.7% and the frequency of male patients was higher. The atrial septal defect was the commonest on the whole, while, Tetralogy of Fallot was the commonest among cyanotic variety. Respiratory tract infection was frequently seen at presentation and the most commonly associated noncardiac anomaly was the cleft palate.

Post-Coronavirus disease syndrome (post-COVID-19) syndrome: A case report.

Post-COVID syndrome, a cluster of symptoms that develops or persists even after the recovery from COVID-19 or viral clearance, can have multi-system manifestations. This entity should be considered in patients who recently tested positive for COVID-19 after ruling out other possible obvious causes. Its management should involve a multidisciplinary approach.

Prevalence of migraine and tension-type headache among undergraduate medical students of Kathmandu Valley: A cross-sectional study.

Background: Headache is the most prevalent neurological symptom which can be of a serious condition, as in brain tumor, but mostly it is a benign condition that includes primary headache such as migraine or tension-type headache (TTH). Migraine reoccurs frequently and is more severe but owing to the high prevalence of TTH, however, impaired quality of life due to TTH is greater than that of migraine at the population level. Medical students are constantly subjected to stress and in such a condition, it was necessary to find out the burden of headache among medical students. This cross-sectional study done among medical students aims to generate some data and literature which will change the outlook of stakeholders towards headache disorders among medical students. Methods: This cross-sectional study is based upon Headache Screening Questionnaire-English Version questionnaire based upon the ICHD-3 beta criteria. Medical students of Kathmandu valley were sampled by using convenient sampling and data were collected. Data were refined in Microsoft Excel and imported to SPSS 20 for analysis. Results: A total of 352 individuals were part of this study, out of which 229 (65.1%) were males and 123 (34.9%) were females with a mean age of 21.72 ± 1.601 years (mean ± SD). Prevalence of migraine and TTH was found to be 15.3% (95% confidence interval [CI]: 11.7%-19.3%) and 40.3% (95% CI: 34.9-45.2), respectively. Through multivariate binomial regression, it was observed that the odds of being diagnosed with migraine increased with age (adjusted odds ratio [AOR] = 1.266 [1.013-1.583], p = 0.038), females had twice the odds of experiencing migraine headaches compared to males (AOR = 2.119 [1.074-4.180], p = 0.03), and medical students who stayed at the hostel were at lesser odds of experiencing migraine headache (AOR = 2.772 [1.501-5.118], p = 0.01). Conclusion: Prevalence of migraine and TTH among undergraduate medical students was found to be 15.3% and 40.3%, respectively.

Hansen's disease masquerading as rheumatoid arthritis: A case report.

Hansen's disease, a chronic granulomatous disease, classically has cutaneous and neurological manifestations. Musculoskeletal manifestation of the disease is underappreciated. This case report conveys that musculoskeletal manifestation of the disease should not be missed, as sometimes it is the only presenting symptom, to avoid delay in correct diagnosis and treatment.

Carbamazepine induced toxic epidermal necrolysis and Stevens-Johnson syndrome overlapping during pregnancy in a South-East Asian patient: A case report.

INTRODUCTION: Toxic Epidermal Necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are rare and severe forms of drug-induced skin reaction. Most frequently involved drugs are noted to be non-steroidal anti-inflammatory agents, antibiotics, and anticonvulsants. These have high morbidity and mortality and counts among dermatological emergencies. CASE PRESENTATION: We report an eventful case of a 22-year-old lady who suffered and recovered from carbamazepine-induced SJS/TEN overlapping during her pregnancy. Our patient had a history of epilepsy for which she was under sodium valproate. Switching to carbamazepine due to its low teratogenicity led our patient to this condition. History of prodromal symptoms and exposure to carbamazepine helped in the diagnosis. Carbamazepine abstinence and a multidisciplinary approach in symptomatic management worked very well for the patient. CLINICAL DISCUSSION: Carbamazepine-induced TES/SJS manifests multisystem effects and requires a multidisciplinary approach for management. The condition itself is life-threatening and in its addition, their sequelae further threaten the life of the patients. Early intervention is the key. Genetically susceptible are thought to be the ones carrying human leukocyte antigen B*15:02 (HLA-B*15:02) allele and it is most prevalent in South-East Asian populations. Screening of this allele before using carbamazepine prevents the incidence of carbamazepine-induced SJS/TEN. CONCLUSION: Prodromal symptoms of carbamazepine-induced SJS/TEN constitute flu-like symptoms that should not be missed. Early intervention and multidisciplinary approach prevent secondary infections and complications. Screening for HLA-B*15:02 variant allele and close monitoring of these adverse reactions along with proper counseling to patients goes a long way in preventing the development of this life-threatening condition.

An Analysis of Single Nucleotide Substitution in Genetic Codons - Probabilities and Outcomes.

BACKGROUND: Single nucleotide substitutions (SNS) in genetic codon are of prime importance due to their ability to alter an amino acid sequence as a result. Given the nature of genetic code, any SNS is expected to change the protein sequence randomly into any of the 64 possible codons. In this paper, we present a theoretical analysis of how single nucleotide substitutions in genetic codon may affect resulting amino acid residue and what is the most likely amino acid that will get selected as a result. METHODS: A probability matrix was developed showing possible changes and routes likely being followed as a result of base substitution mutation causing changes at the translational level for the amino acid being encoded. RESULTS: We observe that in event of single base pair substitution in a given amino acid; a chosen set of amino acids is theoretically more probable to be resulted suggesting a directional rather than a random change. This study also indicates that for a given amino acid coded by a number of synonymous codons, all synonymous codons will result into same list of amino acids in case of all possible SNS at three positions. CONCLUSION: The present work has resulted into development of a theoretical probability matrix which can be used to predict changes in amino acid residues in a protein sequence caused by single base substitutions.

Genetic variation within native populations of endemic silkmoth Antheraea assamensis (Helfer) from Northeast India indicates need for in situ conservation.

A. assamensis is a phytophagous Lepidoptera from Northeast India reared on host trees of Lauraceae family for its characteristic cocoon silk. Source of these cocoons are domesticated farm stocks that crash frequently and/or wild insect populations that provide new cultures. The need to reduce dependence on wild populations for cocoons necessitates assessment of genetic diversity in cultivated and wild populations. Molecular markers based on PCR of Inter-simple sequence repeats (ISSR) and simple sequence repeats (SSR) were used with four populations of wild insects and eleven populations of cultivated insects. Wild populations had high genetic diversity estimates (H(i) = 0.25; H(S) = 0.28; H(E) = 0.42) and at least one population contained private alleles. Both marker systems indicated that genetic variability within populations examined was significantly high. Among cultivated populations, insects of the Upper Assam region (H(i) = 0.19; H(S) = 0.18; H(E) = 0) were genetically distinct (F(ST) = 0.38 with both marker systems) from insects of Lower Assam (H(i) =0.24; H(S) =0.25; H(E) = 0.3). Sequencing of polymorphic amplicons suggested transposition as a mechanism for maintaining genomic diversity. Implications for conservation of native populations in the wild and preserving in-farm diversity are discussed.