Impact of Early Blood Pressure Lowering in Patients Presenting with Acute Ischemic Stroke.

PURPOSE OF REVIEW: In this review article we will discuss the acute hypertensive response in the context of acute ischemic stroke and present the latest evidence-based concepts of the significance and management of the hemodynamic response in acute ischemic stroke. RECENT FINDINGS: Acute hypertensive response is considered a common hemodynamic physiologic response in the early setting of an acute ischemic stroke. The significance of the acute hypertensive response is not entirely well understood. However, in certain types of acute ischemic strokes, the systemic elevation of the blood pressure helps to maintain the collateral blood flow in the penumbral ischemic tissue. The magnitude of the elevation of the systemic blood pressure that contributes to the maintenance of the collateral flow is not well established. The overcorrection of this physiologic hemodynamic response before an effective vessel recanalization takes place can carry a negative impact in the final clinical outcome. The significance of the persistence of the acute hypertensive response after an effective vessel recanalization is poorly understood, and it may negatively affect the final outcome due to reperfusion injury. Acute hypertensive response is considered a common hemodynamic reaction of the cardiovascular system in the context of an acute ischemic stroke. The reaction is particularly common in acute brain embolic occlusion of large intracranial vessels. Its early management before, during, and immediately after arterial reperfusion has a repercussion in the final fate of the ischemic tissue and the clinical outcome.

Solution-processed MoS2 quantum dot/GaAs vertical heterostructure based self-powered photodetectors with superior detectivity.

The characteristics of a novel 0D/3D heterojunction photodetector fabricated using solution-processed colloidal MoS2 quantum dots (QDs) on GaAs is presented. MoS2 QDs with a dimension of ∼2 nm, synthesized by a standard sono-chemical exfoliation process with 2D layers have been used for the purpose. The microscopic and spectroscopic studies confirmed the formation of semiconducting (2H phase) MoS2 QDs. The photodetectors were fabricated using n-GaAs substrates with two different doping concentrations resulting in n-n heterojunctions between n-type 0D MoS2 QDs and bulk n-GaAs. The devices fabricated using GaAs with a higher doping concentration, showed an increase in the reverse current of the order of ∼102 upon illumination, while the same with a lower doping concentration showed an increase of the order of ∼103. All the heterojunction photodetector devices show a broadband operation over the visible wavelength range of 400-950 nm, with a peak responsivity of the devices being observed at 500 nm. The peak responsivity and detectivity are found to be ∼400 mA W-1 and ∼4 × 1012 Jones, respectively, even without any external applied bias, which are useful for self-powered photodetection. The results indicate that colloidal MoS2/GaAs based hybrid heterostructures provide a platform for fabricating broadband photodetectors by using highly absorbing MoS2 QDs, which may show the pathway towards next-generation optoelectronic devices with superior detection properties.

Transradial Access Results in Faster Skin Puncture to Reperfusion Time than Transfemoral Access in Posterior Circulation Mechanical Thrombectomy.

BACKGROUND: Successful mechanical embolectomy for acute embolic arterial occlusion in the posterior cerebral circulation can potentially result in less neurologic disability and mortality. The transradial approach can potentially offer more direct navigation into the posterior circulation than the transfemoral approach and can result in faster recanalization time. OBJECTIVE: To compare procedural metrics and the technical and clinical outcomes of transradial versus transfemoral access for mechanical embolectomy in the posterior cerebral circulation. MATERIAL AND METHODS: Single-center retrospective review of a prospectively maintained neurointerventional database from a large volume neurointerventional service in a tertiary academic center. Patients presenting with acute disabling symptoms due to embolic occlusion of a large intracranial artery in the posterior that underwent to endovascular treatment in our institution from January 2017 to January 2019 were included in the present study. RESULTS: Between January 2018 and January 2019 a total of 10 subjects underwent a mechanical embolectomy for acute embolic occlusion on the posterior circulation via transradial access; and between January 2017 and January 2018 a total of 10 subjects underwent a mechanical embolectomy for acute embolic occlusion on the posterior circulation via transfemoral access. Subjects in the transradial access group had a shorter skin puncture to recanalization time compared to the transfemoral group (29.2 ± 17.6 in the transradial group vs. 63.9 ± 56.7 in the transfemoral group respectively). CONCLUSIONS: This is the first study comparing transradial versus transfemoral access for mechanical embolectomy in patients with acute embolic occlusion in the posterior cerebral circulation. Transradial access resulted in a safe, effective, and faster endovascular route for recanalization in the acute embolic occlusion of the posterior circulation.

Fetal Ascites Mimicking Maternal Ovarian Tumor: A Rare Cause of Obstructed Labour.

Fetal ascites has been diagnosed more frequently these days because of routine ultrasound scanning in pregnancy. However as a cause of dystocia in labour, it is very rare. Twenty four years second gravida of 28 weeks 6 days of gestation presented to labour room with preterm obstructed labour. Abdominal examination revealed less readily palpable fetal parts and distantly localized fetal heart sounds. An urgent ultrasound showed huge maternal ovarian cyst. She then underwent emergency cesarean section; delivered a male baby with grossly distended abdomen. However, the ovaries were normal looking. Routine antenatal ultrasounds help in identifying maternal and congenital fetal anomalies. They also guide in planning the most appropriate management. Whenever fetal ascites is diagnosed antenatally, possibility of dystocia in labour should be kept in mind.

Prevalence and factors associated with childhood overweight/obesity of private school children in Nepal.

INTRODUCTION: Childhood overweight/obesity is a global health problem because of adverse health and nutrition consequences worldwide. Currently, there is a paucity of information on childhood overweight/obesity in Nepal. Therefore, the objective of this study was to assess the prevalence of, and the factors associated with, childhood overweight/obesity among primary school children. METHODS: A cross-sectional study was conducted in June-December, 2013. We collected data using the structured self-administered questionnaire with parents of children aged 6-13 years in grades 1-6 studying at private schools of the Lalitpur district of Nepal. Height and weight measurements of 986 children were taken, and the corresponding body mass index (BMI)-for-age was calculated. The prevalence of childhood overweight/obesity was reported in proportion. Factors associated with childhood overweight/obesity were examined using the Chi-square tests followed by multiple logistic regression analyses. RESULTS: Of 986 children, 144 (14.6%) were overweight and 111 (11.3%) were obese. Overall, 255 (25.9%) children were found to be overweight/obese. Children from families, having ≤2 siblings (adjusted odds ratio (aOR)=1.958, 95% confidence interval (CI): 1.163-3.296), upper class family (aOR=3.672; 95% CI: 1.154-11.690), and advantaged ethnic group (aOR=1.561; 95% CI: 1.00-2.437) and children who were of larger birth weight (>4.0kg) had a greater likelihood of being (aOR=2.557, 95% CI: 1.222-5.349) overweight/obese. CONCLUSIONS: A quarter of children were found to be overweight/obese in private primary schools. Preventive interventions should focus on the advantaged ethnic groups, families with fewer siblings, and upper class families. A greater emphasis ought to be placed on formulation and implementation of policies aimed at addressing the newly emerging problems of childhood overweight/obesity in Nepal. New school health programs are to be launched and strengthened including avoidance of high energy junk food, and promoting outdoor activities.

Tobacco use among rural Nepalese women: Cross-sectional community based study.

INTRODUCTION: Tobacco use is responsible for a considerable number of morbidity and mortality in the world. Annually 14,000 deaths are attributed to tobacco use in Nepal. Despite having social acceptability of tobacco in Nepalese society, little has been known about tobacco use among rural women. The aim of this study was to report the prevalence of and examine the factors associated with tobacco consumption among women of reproductive age in a rural community of Dailekh district of Nepal. MATERIALS AND METHODS: It was descriptive, cross-sectional study carried out among women of reproductive age in the rural community of Dailekh district. A random sampling was used to obtain 110 women aged 15-49 years. RESULTS: More than two in five were tobacco user and among them 4 in 5 used smoked form of tobacco. This study showed early initiation of tobacco using habit (mean: 14.96 year) where 92% of participants initiated <19 years. Influencing factors for initiation of tobacco use was peer's pressure (95.8%), and respondents reported that they used tobacco to reduce stress (37.5%). CONCLUSION: Tobacco using pattern was high in reproductive age group women. Knowledge and perceptions on tobacco use were poor. Hence, an effective and appropriate community based awareness programs are required to discourage the use of tobacco.

Basic sciences: an alternative career?

Career selection is a crucial and a complex process which is also true for the medical profession. In the context of our country, due to the limited opportunity and proper guidance, migration of medical graduates to foreign countries is increasing. Though, clinical subjects have a huge attraction, basic science field has failed to impress our medical graduates. In current scenario, basic science field seems to be a dumping site for the incompetent as the candidates who have failed trying their luck elsewhere stumble upon basic science careers though it is not true for all. Moreover, a very few medical graduates are interested in developing their career as a basic scientist. Therefore, to motivate today's young medical graduates, there is a need of a good mentor along with a proper career guidance which can help them to understand the basic science field as an alternative career.

Microcatheter to recanalization (procedure time) predicts outcomes in endovascular treatment in patients with acute ischemic stroke: when do we stop?

BACKGROUND AND PURPOSE: Endovascular treatment for acute ischemic stroke consists of various mechanical and pharmacologic modalities used for recanalization of arterial occlusions. We performed this study to determine the relationship among procedure time, recanalization, and clinical outcomes in patients with acute ischemic stroke undergoing endovascular treatment. MATERIALS AND METHODS: We analyzed data from consecutive patients with acute ischemic stroke who underwent endovascular treatment during a 6-year period. Demographic characteristics, NIHSS score before and 24 hours after the procedure, and discharge mRS score were ascertained. Procedure time was defined by the time interval between microcatheter placement and recanalization or completion of the procedure. We estimated the procedure time after which favorable clinical outcome was unlikely, even after adjustment for age, time from symptom onset, and admission NIHSS scores. RESULTS: We analyzed 209 patients undergoing endovascular treatment (mean age, 65 ± 16 years; 109 [52%] men; mean admission/preprocedural NIHSS score, 15.3 ± 6.8). Complete or partial recanalization was observed in 176 (84.2%) patients, while unfavorable outcome (mRS 3-6) was observed in 138 (66%) patients at discharge. In univariate analysis, patients with procedure time ≤30 minutes had lower rates of unfavorable outcome at discharge compared with patients with procedure time ≥30 minutes (52.3% versus 72.2%, P = .0049). In our analysis, the rates of favorable outcomes in endovascularly treated patients after 60 minutes were lower than rates observed with placebo treatment in the Prourokinase for Acute Ischemic Stroke Trial. In logistic regression analysis, unfavorable outcome was positively associated with age (P = .0012), admission NIHSS strata (P = .0017), and longer procedure times (P = .0379). CONCLUSIONS: Procedure time in patients with acute ischemic stroke appears to be a critical determinant of outcomes following endovascular treatment. This highlights the need for procedure time guidelines for patients being considered for endovascular treatment in acute ischemic stroke.

Requirements for emergent neurosurgical procedures among patients undergoing neuroendovascular procedures in contemporary practice.

BACKGROUND AND PURPOSE: Provisions for an emergent neurosurgical procedure have been a mandatory component of centers that perform neuroendovascular procedures. We sought to determine the need for emergent neurosurgical procedures following neuroendovascular interventions in 2 comprehensive stroke centers in settings with such provisions. MATERIALS AND METHODS: Analysis of retrospectively collected data from procedure logs and patient charts was performed to identify patients who required immediate (before the termination of the intervention) or adjunctive (within 24 hours of the intervention) neurosurgical procedures related to a neuroendovascular intervention complication. The types of neurosurgical procedures and in-hospital outcomes of identified patients are reported as an aggregate and per endovascular procedure-type analyses. RESULTS: We reviewed a total of 933 neuroendovascular procedures performed during 3.5 years (2006-2010). A total of 759 intracranial procedures were performed. There was a need for emergent neurosurgical procedures in 8 patients (0.85% cumulative incidence and 1.05% for major intracranial procedures) (mean age, 46 years; 7 were women); the procedures were categorized as 3 immediate and 5 adjunctive procedures. There were 5 in-hospital deaths (62.5%) among these 8 patients. Neurosurgical procedures performed were external ventricular drainage placement in 6 (6 of 8, 75%) patients, decompressive craniectomy in 1 (12.5%) patient, and both surgical procedures in 1 (12.5%) patient. CONCLUSIONS: The need for emergent neurosurgical procedures is very low among patients undergoing intracranial neuroendovascular procedures. Survival in such patients despite emergent neurosurgical procedures is quite low.

Lambda light chain myeloma with oliguric cast nephropathy and remission with bortezomib, doxorubicin and dexamethasone.

Cast nephropathy is one of the major causes of renal failure in patients with multiple myeloma resulting from precipitation of free light chains inside the tubules. Timely diagnosis and treatment confers a better prognosis though around 10% of patients with cast nephropathy remain dialysis dependent in spite of treatment. We report the clinical course and outcome of a patient presenting with acute kidney injury and oliguria, preceded by acute gastroenteritis and intake of Chinese medications and dialysis dependent state for eight weeks. Kidney biopsy revealed cast nephropathy with lambda light chain restriction and severe tubular injury. Serum protein electrophoresis was normal with no "M spike" but serum free light chain ratio was altered with very high lambda and normal kappa light chain levels. Bone marrow biopsy showed >85% atypical plasma cells. Haemodialysis was continued and chemotherapy with bortezomib, doxorubicin and dexamethasone was started. Kidney function gradually improved with discontinuation of dialysis after 1 month and complete remission of acute kidney injury and myeloma in 4 months of chemotherapy.

Genetic predisposition to parthenium dermatitis in an Indian cohort due to lower-producing genotypes of interleukin-10 (-) 1082 G>A and (-) 819 C>T loci but no association with interferon-γ (+) 874 A>T locus.

BACKGROUND: Parthenium dermatitis is an activated T cell-mediated type IV hypersensitivity. Its pathogenesis is well characterized, with interindividually varying serum levels of pro- and anti-inflammatory and regulatory T-cell cytokines and coherently perturbed cross-regulation between them. The functional single nucleotide polymorphisms (SNPs) in these cytokine genes might function as risk/susceptibility factors for the disease. OBJECTIVES: We analysed the serum levels of interferon (IFN)-γ and interleukin (IL)-10 cytokines in cases vs. controls and investigated whether IFN-γ (+) 874 A>T and IL-10 (-) 1082 G > A and (-) 819 C>T are associated with serum levels and genetically predispose to the disease. METHODS: The study included 60 patch test-confirmed patients and 60 age- and sex-matched controls. The serum levels of cytokines were estimated by high-sensitivity enzyme-linked immunosorbent assay kits. SNP genotyping was performed by amplification refractory mutational system-polymerase chain reaction. RESULTS: In patients, the serum level of IFN-γ was significantly increased and that of IL-10 was significantly decreased, with no difference in IgE concentration. Genetically no IFN-γ (+) 874 A>T alleles/genotypes were associated with the disease, but a strong predisposition was found due to lower-producing genotypes of IL-10 (-) 1082 G>A and (-) 819 C>T SNPs, with 2·1 and 3·5 times more risk, respectively, while intermediate IL-10-producing genotypes provided resistance. CONCLUSIONS: High serum IFN-γ might play a role in disease pathogenesis, but this is genetically not endowed by the IFN-γ SNP studied. In contrast, low serum IL-10 was very much connected, with the genetics of both studied IL-10 loci. These might be key managing factors concerning pathogenesis/susceptibility.

Allergic fungal rhinosinusitis in chronic rhinosinusitis.

BACKGROUND: Rhinosinusitis is the inflammation of nasal and paranasal sinus mucosa and is associated with mucosal alteration ranging from inflammatory thickening or gross nasal polyp formation.The main objective of this study is to determine the prevalence of allergic fungal rhino sinusitis among the patients having chronic rhino sinusitis with or without polyps who under goes functional endoscopic sinus surgery. METHODS: The patient with chronic rhinosinusitis with or without polyp who FESS were studied. Surgical specimens were sent for mycology and histopathological analysis for identification of fungus. RESULTS: Headache 41(82%) and nasal block 45(90%) were the commonest clinical presentation. Out of 50 patients, fungal elements were detected by KOH in 8(16%) of cases and histopathological examination in 11(22%) of cases. CONCLUSIONS: Allergic Fungal Rhinosinusitisis a common disorder in patients with chronic rhinosinusitis, it need different specific tests for the diagnosis, a more specific diagnostic tests are fungus culture, and IgE to fungal antigen and skin test are needed for definite diagnosis.

Knowledge, behavior and attitude towards sexually transmitted infections and acquired immunodeficiency syndrome of adolescent students.

BACKGROUND: Adolescence is a period of great physical, mental and emotional turmoil within teenagers. The objective of the study was to assess the knowledge of, attitude to and behaviour towards STI and AIDS among adolescence. METHODS: Four randomly selected higher secondary school from students of class XI and XII were included after taking their verbal consent. A pre-designed and pre-tested questionnaire was given to all the participants of the school. In order to get correct answers, specific questions were explained to the students with the help of their class teachers. RESULTS: The results were encouraging with the majority (94.16%) have heard about STIs and HIV/AIDS. Teachers (100%), Newspaper/magazine (90%) and Television (78.33%) were the main informational source about disease. Respondents correctly identified that unsafe sexual contact (86.66%) as major mode of transmission of AIDS and more than 90% of students regarded the use of condoms as the true preventive method for the disease. Among those respondents 6% were sexually active and their partners were either sex worker (71%) or friends (29%). CONCLUSIONS: The student's attitude towards disease was positive and most of the adolescent wished inclusion of sex education in their text book from secondary level school's curriculum.

Histomorphological spetrum of breast lesions.

BACKGROUND: Cancer of the breast is the second most common cause of cancer in women. Mass in the breast, whether benign or malignant is a cause of anxiety to the patients and the family members. All breast lumps are considered to be carcinomas until proved otherwise and are the causes of concern both for the patient and surgeon. METHODS: This is a retrospective study conducted in Kathmandu Model Hospital for a total duration of three years from August 2007 to August 2010. RESULTS: 114 sample of breast tissue sent for histopathology were studied. Peak incidence of benign lesion was in between 21-30 years and malignant lesions in between 31-50 years. No breast lesions were seen in the first decade of life. Cancer of the breast was seen in 12.28% of cases. Fibroadenoma and fibrocystic disease were the commonest benign lesion and infiltrating ductal carcinoma was the commonest malignant lesion. Specimens from 10 male breasts were received. Gynaecomastia was the most common lesion encountered in males. Infiltrating ductal carcinoma was seen in a 70 year old male. CONCLUSIONS: Breast cancer is one of the commonest causes of breast lump particularly in women and is growing public health problem in Nepal.

Triiodothyronin, thyroxine and thyrotropin in vitiligo.

BACKGROUND: Vitiligo is a common pigmentary disorder of the skin, affecting individuals globally. Not only is this ailment psychologically incapacitating, it also has a high incidence of autoimmunity, signifying that its manifestations may be the portrayal of dysfunction of immune system. OBJECTIVE: The aim of this study is to find out the situations of abnormal thyroid function test (TFT) in vitiligo patients. METHODS: A prospective cross sectional study was conducted at the Dhulikhel Hospital, KUTH, Dhulikhel during November 2008 to January 2011 with the objective to assess the thyroid function tests in vitiligo patients. RESULTS: Total 66 vitiligo patients with male 30 (45%) and female 36 (55%). Total 26 (39.39%) vitiligo patients have been found to have abnormal thyroid function test. Among them 10 had abnormal T3, seven had abnormal T4 and 12 had abnormal TSH level. Thyroid function test were normal in other vitiligo patients. Total seven vitiligo had high level of T3 than normal value, four male and three female. Two had higher level of T4 above 2.0 ng/dl and all were male, while five had abnormally low level of T4 with three male and two female. There were seven vitiligo patient with increased T3 level and three with decreased T3 level, among them six were males and four were females, the age group was ranged from seven to 68 years old. The T4 level were found abnormal in seven vitiligo patients among which five were males and two were females with the age group ranging from 7 to 51 years. CONCLUSIONS: There has been significant association of thyroid disorder in the patient with vitiligo. Therefore, patient with vitiligo need to undergo thyroid function test to rule out the thyroid disorder and prevent from long-term complications.

A simple new technique of performing myomectomy for a predominantly subserosal myoma quickly within few minutes.

Removing a degenerated myoma located around the uterine cornu by an innovative technique shelling the myoma a little away from the base by choice of a low placed incision, advantageous in terms of no requirement of blood transfusion because of the reduction in the surgical time is described in a 24 years old lady demanding a fertility conserving surgery.

Management of tracheocutaneous fistula.

We describe a simple technique that utilises local skin flaps of closure of a large tracheocutaneous-fistula with a adequate support to the tracheal wall by double breasting of local flaps, thus avoiding the post-operative respiratory problems that can occur due to a single flap projecting into the tracheal lumen during inspiration.This technique avoids the complications associated with primary closure of fistulae & also the morbidity of waiting for secondary closure to occur. It also precludes the need for a more extensive operation in the form of muscle flap rotation. The fistulous tract does not need to be excised but forms a component of the repair.

Study of Auditory function in Rheumatoid Arthritis.

Rheumatoid Arthritis may affect the auditory function and is a subject of debate. The exact etiopathogenesis is not known. However there is evidence of rt of synovial joints of ossicles. Rheumatoid Arthritis may involve the Aoditory system by producing conductive hearing loss, abnormal otoadmittance and sensorineural hearing loss. Patients with pre-existing ear disease were not included in the study. In the present study, effcet of Rheumatoid Arthritis on auditory function is observed. The Study was carried out on 25 patients of classical or definite Rheumatoid Arthritis and 16 controls at M.Y. Hospital, Indore.