Neuritic Leprosy; An Intriguing Re-visit to a Forbidden Ailment.

Leprosy is a chronic infectious disease that presents with varied manifestations. Pure neuritic leprosy is one of the rarest forms of the disease which is characterized by nerve involvement without the characteristic cutaneous stigmata. Eleven year old, healthy male presented with progressively increasing painful swelling at the medial aspect of the arm near to the right elbow joint with difficulty in extending right ring and little fingers at interphalangeal joint and numbness in the same region for last 1 year with no cutaneous abnormalities. Physical examination revealed 6x3 cm firm, tender lesion 3 cm proximal to the right elbow joint with positive tinel's sign, without signs of inflammation, along with characteristic claw hand deformity of right hand and atrophy of hypothenar and interossei muscle. Electro-diagnostic testing revealed findings consistent with a right ulnar axonal neuropathy above the elbow. Magnetic resonance imaging revealed well defined heterogeneously hyper intense linear lesion along the course of thickened ulnar nerve in the distal arm extending posterior to the medial condyle. It also showed an oval shaped lesion (2.1x1.0 cm) arising from the same segment of the nerve, without any bony or muscular involvement of that area. The patient underwent surgical exploration and ulnar nerve decompression with biopsy. Pathology revealed necrotizing granulomatous inflammatory acid fast bacilli stain negative lesion, which was histologically consistent with caseous abscess caused by tuberculoid leprosy, pathognomonic for Hansen's disease. He has been started on antibiotic therapy and is referred to leprosy center for further course of management. Pure neuritic leprosy, though rare, should be considered as differential diagnosis in cases presenting with peripheral neuropathy at leprosy-endemic areas. Prompt diagnosis and treatment is imperative to prevent permanent neurological injury.

Postoperative Complications of Transsphenoidal Pituitary Adenectomy: A Single Institution Based Experience.

Background Inside a cranium, pituitary gland seats in an area of complex anatomical construct. Further it holds a very important physiological role to maintain all bodily function. Pituitary adenoma being one of the commonest tumors of that intricate area is preferably tackled with transsphenoidal approach. However, as in any surgery, it is also not without postoperative complications. Objective To examine and categorize all the postoperative complications that we have encountered in our center after pituitary surgery. Method A retrospective study of patients who had undergone transsphenoidal pituitary adenectomy in past five years was conducted at a tertiary level neurosurgical center and various postoperative complications during hospital stay were noted and analyzed. Result In our series of 53 patients, we met different postoperative complications, out of which diabetes insipidus (DI) was the commonest. Other electrolyte abnormalities excluding diabetes insipidus was the second most common followed by Cerebrospinal fluid leak. Post-operative hematoma requiring re-exploration, panhypopituitarism, seizure and meningitis were among the rare complications. No statistically significant association was noted between tumor size, patient age and sex with surgical complications. Conclusion Postoperative complications should be anticipated in transsphenoidal pituitary surgery even though it is considered to be a relatively safe undertaking. Knowing about these complications is the first step in preventing them.

Abnormal Venous Dilatation other than Typical Varicose Vein, Rare Encounters.

Varicose vein, one of the common vascular illnesses is usually a disease in lower limb. This is due to reflux of blood from deep venous system to superficial venous system. Rarely, this disease can also happen in veins in different location. Four such rare encounters are mentioned in this case series.

Optimal Starting Dose of Warfarin for Treatment of Deep Vein Thrombosis in Nepalese Context, A Retrospective- Prospective Institutional Review.

Background Deep vein thrombosis (DVT) requires an early establishment of effective anticoagulation in order to reduce harms and cost of concomitant treatments. Selection of the right warfarin dose at the start of treatment is important. Objective To know ideal starting dose of warfarin in adult with Deep Vein Thrombosis of our population. Method This is a retrospective-prospective single institution based analytical study including Deep Vein Thrombosis in adults from January 2015 to November 2017. On the first half (January 1, 2015 to July 31, 2016) of the study period, the cases were given 3mg of warfarin as initial dose (Group 1); while in the second half (August 1, 2016 to November 31, 2017) cases were given 5mg as the initial dose (Group 2). Two sequential International Normalisation Ratio (INR) within therapeutic range is considered as target attained. Result There were total of 63 patients (M:F=1:1.03) of which 85.7% (n=54) cases were acute deep vein thrombosis and 14.3% were chronic cases. Mean final dose of warfarin was 6.03 mg; where it was 6.50 mg in group 1 and 5.63 mg in group 2, p=0.11. Difference between final dose and starting dose it was found to be 3.5 mg in Group 1 while that was only 0.63 mg in Group 2 (p<0.01). Conclusion Lesser change in dose of warfarin from its initial starting dose (5 mg) was noticed in group 2. Warfarin 6 mg as ideal starting dose can be recommended but larger, multicentric and follow up studies are essential to substantiate the findings.

Patterns of Orthopaedic Injuries among Motorbike Accident Admissions Presenting to a Tertiary Care Hospital in Kathmandu.

BACKGROUND: The anecdotal burden of morbidity secondary to motorbike accidents is thought to enormous by personnel involved in trauma care. The objective of the present study is to ascertain patterns and association of injuries and causes of mortality in a cohort of motorbike accident victims. METHODS: A retrospective chart review of 1337 motorbike accident admissions B and B Hospital in Kathmandu between January 2009 and December 2010 was undertaken. RESULTS: Majority of victims were between 20 to 50 years [1230 (92%) males]. Lower extremity injuries comprised on 816 (61% of total admissions). Tibia fractures were the most common injury in isolation, multiple injury, as well as polytrauma, and a vast majority of these were open fractures. Multiple injuries were seen in 82 (6.1%) patients and 33 (2.5% of Total) patients were polytraumatized. An amputation was necessary in 16 (1.2%) patients and emergent fasciotomy for compartment syndrome was necessary in 23 (1.7%) cases of tibia fractures and 39 (2.2%) of foot and ankle injuries. A floating joint injury was present in 24 (1.8%) patients.. A fat embolism syndrome (FES) was diagnosed in 8 (0.6%) patients. The overall mortality was 0.45% (6 patients). CONCLUSIONS: Motorbike accident is an important cause of morbidity and mortality in Kathmandu, and often involves a very productive age group. There is an imminent need to address this public health problem.

Anaesthetic Management of Patients with Takayasu's Arteritis for Open Cholecystectomy.

Takayasu's arteritis is a well known yet rare form of large vessel vasculitis.1 This inflammatory disease often affects the ascending aorta and aortic arch, causing obstruction of the aorta and its major arteries.2 Anaesthetic management for these patients is complicated by severe hypertension, end-organ dysfunction, stenosis of major blood vessles and difficulties in monitoring blood pressure.1 We present two patients who underwent open cholecystectomy under neuraxial anaesthesia. We have discussed about various perioperative issues and their management.

Study of working experience in remote rural areas after medical graduation.

BACKGROUND: Posting of doctors in remote rural areas has always been a priority for Government; however data are scarce in the country about experience of doctors of working in remote areas after medical graduation. OBJECTIVE: A questionnaire survey of doctors was planned to analyze their experience of working after graduation in remote rural areas in various parts of the country. METHOD: The cross-sectional survey was done by convenience sampling method. A one-page questionnaire with one partially closed-end and five open-end type questions was distributed to the doctors who had worked in remote rural areas after graduation under various governments' postings. RESULT: Two-third of participants had their home in urban areas and 89.8% had stayed for 1 to 5 years. About half of the participants had difficulty in getting the posting in the remote areas of their choice. Most participants indicated provision of opportunities for Residential (postgraduate) Training as their reasons of going to remote areas as well as their suggestions to encourage young graduates to go there. Similarly most also suggested appropriate career, salary and incentives to encourage doctors to go to work in remote areas. About 85% of participants pointed out the major problem faced while posted in remote areas as difficulty in handling varied situations with no guidance or seniors available around. CONCLUSION: The notable points indicated by the participants are centered on the opportunity for Residential Training and difficulties faced without such training. Residential Training is a priority to be considered while planning the health policy for optimum health care of people.

Clinical, MRI and arthroscopic correlation in internal derangement of knee.

BACKGROUND: The traumatic or degenerative internal derangement of the knee requires certain investigations for the establishment of diagnosis, in addition to clinical history and a thorough physical examination. The use of arthrography and arthroscopy improves the accuracy of the diagnosis. MRI scanning of the knee joint has often been regarded as the noninvasive alternative to diagnostic arthroscopy. OBJECTIVE: The purpose of the study was to correlate clinical and low field MRI findings with arthroscopy in internal derangement of the knee. METHODS: Forty one patients with suspected internal derangement of the knee were subjected to MR examination followed by arthroscopy. Clinical criteria used were history, mode of injury, Mc Murray, Apley grinding, Thessaly test for meniscal injury. Drawer test was considered to be essential for clinical diagnosis of cruciate ligament injury. MRI of the knee was performed in low field open magnet (0.35T, Magnetom C, Seimens). Arthroscopy was done within two months of MR examination and was considered gold standard for the internal derangement of the knee. RESULTS: The sensitivity, specificity, diagnostic accuracy of clinical examination were 96.1%, 33.3% and 73.1% respectively for medial meniscal tear; 38.4%, 96.4% and 78.1% respectively for lateral meniscal tear. The sensitivity, specificity, diagnostic accuracy of MRI were 92.3%,100% and 95.1% for medial meniscal tear; 84.6%96.4% and 92.6% respectively for lateral meniscal tear. CONCLUSION: Clinical examination showed higher sensitivity for medial meniscal tear compared to MRI, however with low specificity and diagnostic accuracy. Low field MRI showed high sensitivity, specificity, diagnostic accuracy for meniscal and cruciate ligament injury, in addition to associated derangement like articular cartilage damage, synovial thickening.

Prevalence of methicillin resistant Staphylococcus aureus in school children of Pokhara.

Present study was carried out to find out the prevalence of methicillin resistant Staphylococcus aureus (MRSA) in school children of Pokhara city in western, Nepal. A total of 184 randomly selected children younger than 15 years were included in the study. Nasal swabs collected were subjected to standard bacteriological culture. S. aureus isolates were identified by mannitol fermentation, coagulase positivity and DNase positivity. Antimicrobial susceptibility test was performed on muller-hinton agar (MHA) by modified Kirby-Bauer disc diffusion method. Out of total 184 nasal swabs, S. aureus was isolated in 31.0% (n=57). Among the isolates, 35.1% (n=20) were from male children whereas 64.9% (n=37) were from female. There was no significant sex difference in colonization of S. aureus. Out of 57 isolates, 56.1% (n=32) were MRSA. MRSA isolates indicated relatively high rate of resistance to antibiotic cloxacillin (68.7%) followed by ofloxacin (40.6%), tetracycline (15.6%), erythromycin (9.4%), ciprofloxacin (6.2%) and vancomycin (3.1%).This study showed a high prevalence of MRSA carriage in school children indicating the spread of MRSA in the community.

Two faces of major lower limb amputations.

OBJECTIVES: To review the indications for major lower limb amputations in adults and children in our patient population and to compare our experience in prosthetic rehabilitation with that of other published information. MATERIAL AND METHODS: We retrospectively reviewed charts of patients who underwent amputation between 1997 to 2004 at the Orthopaedic Department of B& B Hospital (BBH), Gwarko and Hospital and Rehabilitation center for Disabled Children ( HRDC), Banepa. There were 113 patients at BBH & 89 patients at HRDC. Major amputation was defined as any amputation at or proximal to wrist and ankle. RESULTS: Major lower limb amputations constituted 73.58%(39/53) of all major amputations at BBH and 97.77% (44/45) at HRDC. Road traffic accident was found to be number one cause for major lower limb amputations (74.29%) in adult population. In children postburn contracture was the leading cause for amputation (29.54%) followed by Congenital limb conditions (22.72%), Spina bifida with trophic ulcers ( 20.45%), Tumor (13.63%), Chronic Osteomyelitis (6.81%), Trauma (4.54%) and Arthrogryposis (2.27%). Prosthetic fitting and rehabilitation is as yet far from satisfactory in the adult population but all the children who had amputation at HRDC were fitted with prosthesis. CONCLUSION: Main causes of major lower limb amputation in both population is largely preventable by instituting safety measures and conducting awareness program. There is a need for an effective prosthetic fitting center for adults.

Tibial plateau fractures: four years review at B & B Hospital.

BACKGROUND: Tibial plateau fractures involve the articular surface of the tibia resulting from a combination of axial loading with varus or valgus stress. Inadequate and inappropriate treatment may result in significant functional loss. OBJECTIVE: The purpose of this study was to determine the outcome of our treatment modalities and to compare with the results of comparable studies. METHODS: The results of treatment of 81 knees were reviewed over the period of five years (1997 to 2002). There were 62 men and 18 women, with an average age of 37 years (15 years to 75 years) at the time of initial evaluation. One patient had bilateral involvement. Fractures were classified according to Schatzker. Seven patients were treated conservatively. Sixteen patients (17 knees, one had bilateral involvement) were operated with closed reduction and percutaneous cannulated screws fixation. Thirty one patients' required open reduction and internal fixation with cannulated screws. Fifteen fractures were plated, and in eleven cases, external fixators were used. Follow up period ranged from six months to three years. RESULTS: Results were graded as excellent, good, fair and poor on the basis of functional outcome. Forty three (54%) patients (44 knees) had excellent, twenty two (26%) had good, five (6%) had fair and ten (14%) had poor results. Poor results were associated with high energy fractures, late presentation, and inadequate physiotherapy follow up. Eight patients (10%) had complications. One had common peroneal nerve palsy, six had wound infection and one patient demonstrated early arthritic changes. CONCLUSION: Tibial plateau fracture is a challenging fracture to manage. Restoration of articular congruity and early range of motion should be the primary goal. Proper and adequate preoperative planning is mandatory. Well maintained articular congruity with stable fixation helps early mobilization and better functional outcome.