Guillain-Barré syndrome associated with resistant cytomegalovirus infection after face transplantation.

A 39-year-old male, who received a facial allograft (cytomegalovirus [CMV] donor-seropositive, recipient-seronegative), developed multidrug-resistant CMV infection despite valganciclovir prophylaxis (900 mg/day) 6 months post transplantation. Lower extremity weakness with upper and lower extremity paresthesias developed progressively 11 months post transplantation, coinciding with immune control of CMV. An axonal form of Guillain-Barré syndrome was diagnosed, based on electrophysiological evidence of a generalized, non-length-dependent, sensorimotor axonal polyneuropathy. Treatment with intravenous immunoglobulin led to complete recovery without recurrence after 6 months.

Association of Previous Smoking Habit and Perceived Social Discrimination with the Risk of Multi-Drug Resistant Tuberculosis in Central Nepal.

BACKGROUND: Multidrug-resistant tuberculosis (MDR TB) caused by Mycobacterium tuberculosis resistant to both Isoniazid and Rifampicin with or without resistant to other drug, is among the most alarming pandemic problem. The objectives of this study was to assess the risk factors of MDR TB in Central Nepal. METHODS: A matched case control study was conducted among 186 cases of MDR TB and 372 non-MDR TB controls from central region of Nepal. Pretested questionnaires containing socio-economic, cultural & behavioral; environmental, biological and health service factors were used. Variables significant in bivariate analysis were entered in multiple regression models for further analysis. RESULTS: After adjusting for confounders, previous smoking habit (aOR= 4.5,(95%CI(1.24-16.2)) (p=0.04), and perceived social discrimination (aOR=5.83,95%CI (1.77-19.71)) (P=0.021) independently predicted greater MDR TB risk. CONCLUSIONS: Encouraging MDR TB cases for smoking cessation through awareness activities should be a priority. Stigma reduction programs should include the empowerment of patients and communities while promoting TBrelated research for further exploration into the risk factors of TB and associated stigma.

Successful treatment of giant condyloma acuminatum with combination retinoid and interferon-γ therapy.

Giant condyloma acuminatum, or Buschke-Löwenstein tumour, is a unique variant of anogenital warts. It is characterized by locally aggressive behaviour but rarely metastasizes. Many treatment strategies such as radical surgery, radiation and chemotherapy have been used to treat it but their efficacy is often poor and the recurrence rates are high. We report a case of 16-year-old girl who was treated with oral retinoid combined with intramuscular interferon-γ. All lesions cleared within three months. During a follow-up period of more than two years, no recurrence has developed. This relatively painless, non-scarring treatment may represent a novel therapeutic option.

Effectiveness of intra-operative and post-operative use of 5-fluorouracil in trabeculectomy--a randomized clinical trial.

INTRODUCTION: The success rate of trabeculectomy is limited by postoperative scarring. OBJECTIVE: To evaluate the effectiveness of intra-operative and post-operative use of 5-Fluorouracil (5-FU) in trabeculectomy. MATERIALS AND METHODS: Thirty consecutive eyes undergoing trabeculectomy were randomized systematically into 3 groups of ten patients each. Group A served as a control; in Group B intraoperative 5-FU was used, whereas Group C received post-operative sub-conjunctival 5-FU. The variables studied were pre- and post-operative intraocular pressure, post-operative bleb characteristics and complications. STATISTICS: Data were evaluated using the SPSS ver 10.0 program. ANOVA, paired t test and chi2 tests were performed. RESULTS: The means of age in years of patients in group A, B and C were 49 +/- 9.23, 56.50 +/- 8.39 and 52.10 +/- 8.96 respectively (p = 0.222). The means of pre-operative IOP in groups A, B and C were 37.80 +/- 10 mmHg, 42.00 +/- 11.22 mmHg and 29.40 +/- 12.82 mmHg respectively. The medians of pre-operative anterior chamber depth (ACD) in groups B and C were 3 and 2 in group A according to van Herrick's grading. The mean values of final IOP were 11.90 +/- 3.50, 11.70 +/- 4.24, 11.00 +/- 2.83 mmHg (p = 0.841). The median post-operative anterior chamber depth in all the groups was similar compared to the pre-operative anterior chamber depth (p = 0.510). The final bleb scores in all the groups were similar (p = 0.873). CONCLUSION: The intra-operative and post-operative use of 5-FU in trabeculectomy is almost equally effective in terms of IOP control and bleb characteristics.

Association between pregnancy-induced hypertensive fundus changes and fetal outcomes.

BACKGROUND: Ocular involvement in pregnancy-induced hypertension (PIH) is common. OBJECTIVE: To study the association between pregnancy-induced hypertensive fundus changes and fetal outcomes. SUBJECTS AND METHODS: A prospective cohort study was carried out including 153 subjects with the diagnosis of PIH. The subjects were evaluated for hypertensive fundus changes. Fetal outcomes were assessed in terms of gestational age, birth weight, 1 minute Apgar score, stillbirth and neonatal death. STATISTICS: The chi2 test was used to evaluate the association between the various fundus changes and fetal outcomes using SPSS version 10 software program. RESULTS: Fundus changes were found in 13.7% of the subjects. The means of systolic and diastolic BP of the subjects with hypertensive fundus changes were 182.86 +/- 33.64 and 125.24 +/- 21.36 respectively, whereas those values without fundus changes were 150.72 +/- 12.86 and 100.07 +/- 9.51.Vitreous hemorrhage, serous retinal detachment and macular star were not found in this study. Fetal outcomes in PIH patients with vascular changes alone were similar to those with no fundus changes. Retinal and optic nerve head changes were found to be associated (p = 0.016) with low birth weight (< 2.5 kg). Choroidal changes and optic nerve head changes were associated with low Apgar score. CONCLUSION: Retinal and optic nerve head changes are associated with low birth weight. Choroidal changes and optic nerve head changes are associated with low Apgar score. Fundus evaluation in patients with PIH is an important procedure to predict adverse fetal outcomes.

Orbital rhabdomyosarcoma in an adult.

INTRODUCTION: Rhabdomyosarcoma is the most common primary orbital malignant tumor in children. Orbital lesions represent about 10 % of all the cases of rhabdomyosarcoma. Rhabdomyosarcoma is a rare cause of proptosis in adults. OBJECTIVE: To report a case of primary orbital rhabdomyosarcoma in a 45-year-old female. DESIGN: Interventional case report. The main outcome measures are a rare cause ofproptosis in an adult, discussion on treatment options and prognosis ofrhabdomyosarcoma. RESULT: The patient underwent total orbital exenteration and was referred for radiotherapy and chemotherapy. CONCLUSION: Rhabdomyosarcoma is a rare cause of proptosis in adults. It should be suspected in a case of rapidly-progressive proptosis in adults.

Changing tuberculosis trends in Nepal in the period 2001-2008.

To assess the trends on indicators of TB control in Nepal over a period from 2001-2008. Retrospective analysis of information from Annual Reports of NTP, Nepal from 2001-2008. The incidence of New Smear Positive (NSP) TB declined from 58.9 in 2001 to 53.4 in 2006 per 100000 populations then reversed in the period 2006-2008. This TB incidence decreased in males and the age group <45 years (except 0-14 years). The notification rate of all cases of TB declined by 3 % overall over the entire period from 2001 to 2008. Mortality among smear negative and extra pulmonary declined significantly. The failure rate and defaulter rate were declined significantly and the case detection rate (CDR) was increased significantly within the study period. Increasing trend in CDR, Treatment success rate and decreasing trend in failure rate, defaulter rate are the evidence of progress of NTP, in Nepal. Since there is reversal of incidence of NSP from 2006, a detailed analysis of existing TB control measures is required. If the success is continued and quality care is provided as per International Standard of TB Care, the Millennium Development Goals will be an achievable target.

First national tuberculin survey in Nepal.

SETTING: The size of the tuberculosis (TB) problem in Nepal is unknown, as no national tuberculin or TB prevalence survey has yet been performed. OBJECTIVE: To assess the prevalence of TB infection and the annual risk of TB infection (ARTI) in primary schoolchildren in the three ecological zones (mountains, hills and terai) and Kathmandu valley. DESIGN: A representative sample of primary schoolchildren were tuberculin skin tested using the Mantoux method. The data were analysed using cut-off levels to define infection and by the mirror method. RESULTS: Of 19577 children registered, 17260 (88.2%) were available for analysis. Seventy-eight per cent had a visible bacille Calmette-Guérin scar. The best estimate of the prevalence of TB infection was 7.0% (95%CI 4.2-9.7), with an ARTI of 0.86% (95%CI 0.49-1.23) using the mirror method, with a mode at 16 mm. Although the ARTI was higher in Kathmandu and the mountains compared to the hills and terai, the difference between the areas was not significant. CONCLUSION: The ARTI in Nepal is lower than previous estimates, indicating a decrease in transmission or overestimation of previous estimates. To obtain information about the trend of the ARTI in Nepal, the survey needs to be repeated in 5 to 7 years.

Leadership, management and technical lessons learnt from a successful public-private partnership for TB control in Nepal.

BACKGROUND: There is considerable interest in involving private practitioners (PPs) in tuberculosis (TB) control, but little experience. OBJECTIVE: To describe and discuss leadership, management and technical lessons learnt from the successful implementation of a public-private partnership (PPP) for TB control in Nepal. METHODS: Description and discussion of implementation of the PPP is based on feedback from the working group charged with developing the PPP, PPs involved in diagnosis and referral, NGOs providing direct observation of treatment and tracing of late patients, and members of the Nepal National TB Programme. FINDINGS: The process of building the partnership was slow and demoralising, yet with perseverance partners gradually increased their involvement and commitment to the PPP. Leadership was needed to foster communication and openness between partners. It was not necessary to involve all PPs: many patients bypassed PPs and went directly to the free DOTS centres. CONCLUSION: An understanding of issues that arose during development of the Lalitpur PPP may assist assessment of the feasibility of PPPs in other settings, and increase the likelihood of successful implementation. The wider literature on partnerships may be useful to further inform the development of PPPs for health in developing countries.

Dosages of anti-tuberculosis medications in the national tuberculosis programs of Kenya, Nepal, and Senegal.

SETTING: National tuberculosis programs in Kenya, Nepal, and Senegal. OBJECTIVES: To ascertain adequacy of initial prescriptions of dosages of anti-tuberculosis medications in the three national tuberculosis programs. METHODS: Collection of patient treatment cards in a representative sample of treatment centers in Kenya, Nepal, and Senegal. Calculation of drug dosages in milligram per kilogram body weight of isoniazid, rifampicin, and pyrazinamide and comparison with international recommendations for dosage of these medications. RESULTS: A total of 12,346 patient treatment cards were available. Yet of these only 8640 were analyzed: 5575 (65% of total) from Kenya, 612 (53% of total) from Nepal, and 2453 (95% of total) from Senegal had the patient's weight recorded and were given a nationally recommended treatment regimen. The proportions of patients receiving an internationally recommended isoniazid dosage were 34%, 15%, and 15%, respectively in Kenya, Nepal and Senegal; the corresponding figures for rifampicin were 77%, 77%, and 93% and for pyrazinamide 25%, 3% and 75%, respectively, in the three countries. The majority of errors were over-dosage, but some cases of under-dosage were also identified. CONCLUSIONS: This study shows that over-dosage was a frequent event in all three countries. Two major reasons for this error are inadequate drug combinations in Kenya and Senegal, and in all three countries recommendations for weight brackets that did not ideally fit internationally recommended dosages. It is vital to address these problems to reduce both the risk of unnecessary drug toxicity on one end of the spectrum, and suboptimal drug levels on the other.