Severe recurrent hyponatremia in a 72-year-old patient with undiagnosed partially empty Sella syndrome-a case report.

Hyponatremia is one of the most common electrolyte abnormalities encountered in medical practice and is caused by multiple conditions. SIADH is the most common cause of hyponatremia, however, careful workup must be performed on all patients as mere supplementation may cause recurrent hyponatremia and serious side effects. Adrenal insufficiency is a principal culprit that mimics the clinical picture of SIADH and tends to worsen when treated in the line of SIADH. In addition, individuals may have various comorbidities, such as hypothyroidism in our case, which can also cause hyponatremia, making it difficult to determine precise etiology. We present a case of a 72-year-old man with recurrent hyponatremia, who was subsequently diagnosed as partially empty sella syndrome. Given the temporal relationship between the use of corticosteroids and the improvement of his symptoms, low cortisol and ACTH levels, adrenal insufficiency was most likely the cause of the hyponatremia in our patient.

Giant Gallstone With Gallbladder Perforation and Hepatic Abscess in an Asian Patient.

Giant gallstone with a secondary hepatic abscess is a very rare phenomenon. We recently treated a patient with a giant gallbladder (GB) stone of size 11.5 cm with a hepatic abscess who presented with features of an acute abdomen. This was subsequently managed with an open subtotal cholecystectomy and concomitant hepatic abscess drainage. To the best of our knowledge and after a thorough literature search, this is one of the largest reported gall bladder (GB) stones with wall perforation and hepatic abscess in the Asian subcontinent.

Incidental Intraoperative Diagnosis of Term Conjoined Twins: A Case Series.

Conjoined twins (Siamese twins) represent the rarest form of twin pregnancy. Reported here are two rare cases of conjoined term twins presented to the department of Obstetrics and Gynaecology within 3 months. The first case, 32 years of gravida 6 parity 5 referred from periphery after full trial of labour following multi-organ dysfunction and term intrauterine dead twins. Intraoperatively it was dead conjoined thoraco-omphalopagus females. The patient died after 3 days following multiorgan dysfunction syndrome and disseminated intravascular coagulation. The second case, 22 years gravida 2 parity 1 also referred from periphery in second stage of labour with diagnosis of 39 weeks intrauterine dead twins with obstructed labour, delivered by caesarean with intraoperative conjoined dead females of thoracophagus type. Twins are high-risk pregnancy. This rare diagnosis with complications could have been prevented by regular antenatal checkups, ultrasonography performed by radiologists and early referral antenatally in labour along with multidisciplinary approach. Keywords: conjoined; monozygotic twinning; siamese twins; twins.

The nematicidal potential of novel fungus, Trichoderma asperellum FbMi6 against Meloidogyne incognita.

One of the most damaging pests in vegetable crops is the root-knot nematode (Meloidogyne incognita) worldwide. The continuous use of nematicide is costly and has unintended consequences for human and environmental health. To minimize nematicides, eco-friendly integrated nematode management is required. Trichoderma, an antagonistic fungus has been explored to control root-knot nematode. The fungal bio-control strain FbMi6 was identified as Trichoderma asperellum (accession no. MT529846.1). T. asperellum FbMi6 showed substantial nematicidal activity in the laboratory, with egg hatch suppression (96.6%) and juvenile mortality (90.3%) of M. incognita. T. asperellum FbMi6 was examined under pot and field  conditions (after neem cake enrichment), both alone and in combination, and compared with controls. Application of T. asperellum FbMi6 enriched neem cake (1-ton ha-1) increased (28.3%) the okra yield and decreased (57.1%) nematode population as compared with control. T. asperellum FbMi6 enriched neem cake had higher polyphenol content (resistance enhancer) in okra compared with inoculated check.

Genic-intergenic polymorphisms of CYP1A genes and their clinical impact.

The humancytochrome P450 1A (CYP1A) subfamily genes, CYP1A1 and CYP1A2, encoding monooxygenases are critically involved in biotransformation of key endogenous substrates (estradiol, arachidonic acid, cholesterol) and exogenous compounds (smoke constituents, carcinogens, caffeine, therapeutic drugs). This suggests their significant involvement in multiple biological pathways with a primary role of maintaining endogenous homeostasis and xenobiotic detoxification. Large interindividual variability exist in CYP1A gene expression and/or catalytic activity of the enzyme, which is primarily due to the existence of polymorphic alleles which encode them. These polymorphisms (mainly single nucleotide polymorphisms, SNPs) have been extensively studied as susceptibility factors in a spectrum of clinical phenotypes. An in-depth understanding of the effects of polymorphic CYP1A genes on the differential metabolic activity and the resulting biological pathways is needed to explain the clinical implications of CYP1A polymorphisms. The present review is intended to provide an integrated understanding of CYP1A metabolic activity with unique substrate specificity and their involvement in physiological and pathophysiological roles. The article further emphasizes on the impact of widely studied CYP1A1 and CYP1A2 SNPs and their complex interaction with non-genetic factors like smoking and caffeine intake on multiple clinical phenotypes. Finally, we attempted to discuss the alterations in metabolism/physiology concerning the polymorphic CYP1A genes, which may underlie the reported clinical associations. This knowledge may provide insights into the disease pathogenesis, risk stratification, response to therapy and potential drug targets for individuals with certain CYP1A genotypes.

Macro and microanatomy of some organs of a juvenile male Ganges River dolphin (Platanista gangetica spp. gangetica).

Ganges River dolphins (Platanista gangetica spp. gangetica) are air-breathing, warm-blooded mammals endemic to the Ganges and Karnaphuli rivers of the Indian subcontinent. Nevertheless, very little basic histomorphological research has been conducted on this endangered species. Therefore, this study aimed to describe the morphological features of different organs of P. gangetica. Despite becoming aquatic animals, they showed similarities with terrestrial mammals, such as the pair of lungs and an apical bronchus in the respiratory system, which are pretty standard in ruminants and pigs. However, unlike the terrestrial animal, the tracheobronchial tree was stiffer due to circularly arranged anastomosing plates of the hyaline cartilaginous ring in the trachea, cartilaginous plates in the bronchiole, and thick alveolar septa. The digestive system showed a three-chambered mechanical and glandular stomach similar to the artiodactyles. However, the intestine showed smaller caecum like the monogastric mammal. The urogenital system showed lobulated kidneys, a urinary bladder, a fibroelastic penis with sigmoid flexure, and a long urethral process similar to some terrestrial ruminants. Considering the aquatic environment, all those modifications, unlike terrestrial mammals, are necessary for their adaptation. Thus, this research will broadly help our clinicians and conservationist to take further steps toward disease diagnosis and monitoring of marine health of this endangered species.

Integrated Management of Meloidogyne Incognita and Soilborne Fungi Infecting Cucumber Under Protected Cultivation.

Relative efficacy of various approaches for management of Meloidogyne incognita and the soilborne fungus Fusarium oxysporum f. sp. cucumerinum has been tested in cucumber under protected cultivation conditions for two seasons. Management practices, namely, chemicals (fumigant, nonfumigant, and fungicide), organic amendments (neem cake, leaves, and oil opted as soil and seed treatment), and biocontrol agents (egg-parasitic fungus and Purpureocillium lilacinum), were combined for the management of the disease complex in a randomized block design. Two significant parameters were measured: plant growth parameters (shoot length, dry shoot weight, dry root weight, and yield) and disease parameters (galls per plant, final nematode population, egg masses per plant, and fungal incidence). All treatments significantly improved plant growth parameters and reduced nematode reproduction as compared to untreated check. The integration of formalin and neem oil seed treatment favors the low root galling index compared to all other treatments in both the seasons. Formalin and neem oil seed treatment reduced the nematode population and fungal incidence, and increased the yield of cucumber during both the seasons.

Meckel's diverticulum causing acute intestinal obstruction: A case series.

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract. Most cases are asymptomatic and when symptomatic, preoperative diagnosis of MD is poor. Intestinal obstruction, Malena or hematochezia, and inflammation are major symptoms. We report three cases of 18-month, 2-year, and 9-year old male patients presenting with intestinal obstruction.

Duodenal gastrointestinal stromal tumor: A case report.

Introduction: Gastrointestinal tumor (GIT) is an uncommon gastrointestinal tumor most commonly arising in the stomach. Duodenum is an uncommon site accounting for only about 3-5% of cases. Case presentation: In this case report, we present a case of high-risk duodenal GIST and review its management strategies. Discussion: An abdominal mass and gastrointestinal (GI) bleeding are its usual presentation, however it may be lost among the long list of differentials of an abdominal mass and GI bleeding, if a high index of suspicion is not maintained. Surgery, with or without tyrosine kinase inhibitors like imatinib mesylate, has been the cornerstone in management of GIST. Conclusion: This case underlined the importance of duodenal GIST as a cause of GI bleed and abdominal mass as well as shone light upon historical developments, current updates and managements of GISTs.

A case report on atypical spindle cell lipomatous tumor: A rare entity.

Introduction: Atypical spindle cell lipomatous tumor (ASPLT), a separate entity for the group of benign/low grade adipocytic neoplasm that is characterized by adipocyte adequacy and the presence of lipoblast-like cells and spindle cells at varying degrees. Case presentation: Here, we report a rare case of 60 years old male with atypical spindle cell lipomatous tumor in the anterior abdominal wall. Discussion: Histopathology is the gold standard for establishing the diagnosis and grade of soft tissue tumor and consistent radiology-pathology correlation is essential to avoid any diagnostic pitfalls [1]. Ultrasound is preferred as an initial investigation for superficially located lesions. Conclusion: ASPLT show a wide variety of microscopic features, and differential diagnosis is important and difficult. Recognition of morphologic clues and immunohistochemistry/molecular tests to confirm the diagnosis.

Mesenteric inflammatory myofibroblastic tumor mimicking acute appendicitis: A case report.

Introduction: An Inflammatory myofibroblastic tumor, a neoplasm of intermediate biological potential, of the small bowel mesentery, is a rare tumor, most commonly reported in but not confined to the pediatric age group. Case presentation: This case report underlines a case of a (small bowel) mesentery IMT in an adult female presenting with recurrent symptoms similar to acute appendicitis. Discussion: It can present with symptoms similar to acute appendicitis necessitating a high index of suspicion for its prompt diagnosis. Treatment primarily includes surgical resection with recent advances in targeted therapy with tyrosine kinase inhibitors showing promising results. Conclusion: IMTs can present as clinical as well as histopathological mimickers of a variety of diseases especially in the abdomen. Prompt diagnosis requires both imaging and histopathological examination.

Human genetic factors associated with pneumonia risk, a cue for COVID-19 susceptibility.

Pneumonia, an acute respiratory tract infection, is one of the major causes of mortality worldwide. Depending on the site of acquisition, pneumonia can be community acquired pneumonia (CAP) or nosocomial pneumonia (NP). The risk of pneumonia, is partially driven by host genetics. CYP1A1 is a widely studied pulmonary CYP family gene primarily expressed in peripheral airway epithelium. The CYP1A1 genetic variants, included in this study, alter the gene activity and are known to contribute in lung inflammation, which may cause pneumonia pathogenesis. In this study, we performed a meta-analysis to establish the possible contribution of CYP1A1 gene, and its three variants (rs2606345, rs1048943 and rs4646903) towards the genetic etiology of pneumonia risk. Using PRISMA guidelines, we systematically reviewed and meta-analysed case-control studies, evaluating risk of pneumonia in patients carrying the risk alleles of CYP1A1 variants. Heterogeneity across the studies was evaluated using I2 statistics. Based on heterogeneity, a random-effect (using maximum likelihood) or fixed-effect (using inverse variance) model was applied to estimate the effect size. Pooled odds ratio (OR) was calculated to estimate the overall effect of the risk allele association with pneumonia susceptibility. Egger's regression test and funnel plot were used to assess publication bias. Subgroup analysis was performed based on pneumonia type (CAP and NP), population, as well as age group. A total of ten articles were identified as eligible studies, which included 3049 cases and 2249 healthy controls. The meta-analysis findings revealed CYP1A1 variants, rs2606345 [T vs G; OR = 1.12 (0.75-1.50); p = 0.02; I2 = 84.89%], and rs1048943 [G vs T; OR = 1.19 (0.76-1.61); p = 0.02; I2 = 0.00%] as risk markers whereas rs4646903 showed no statistical significance for susceptibility to pneumonia. On subgroup analysis, both the genetic variants showed significant association with CAP but not with NP. We additionally performed a spatial analysis to identify the key factors possibly explaining the variability across countries in the prevalence of the coronavirus disease 2019 (COVID-19), a viral pneumonia. We observed a significant association between the risk allele of rs2606345 and rs1048943, with a higher COVID-19 prevalence worldwide, providing us important links in understanding the variability in COVID-19 prevalence.

Effectiveness of Clinical Presentation (CP) Curriculum in teaching clinical medicine to undergraduate medical students: A cross-sectional study.

Introduction: The Clinical Presentation (CP) curriculum was first formulated in 1990 at the University of Calgary, Canada. Since then, it has been adopted at various medical schools, including Patan Academy of Health Sciences (PAHS), a state-funded medical school in a low-income country (LIC), Nepal. This study aims to evaluate the perceived effectiveness of the CP curriculum by students and faculty at PAHS, and test knowledge retention through a surprise non-routine exam administered to students.  Method: This is a cross-sectional study to evaluate the efficacy of the CP curriculum in teaching clinical medicine to the first batch of MBBS students of PAHS School of Medicine. Ethical approval was obtained from the Institutional Review Committee (IRC)-PAHS (Ref no std1505911069). Perceived effectiveness was evaluated using a set of questionnaires for faculty and students. A total of 33 students and 34 faculty filled the perception questionnaires. Subsequently, a questionnaire consisting of 50 Multiple Choice Questions (MCQs) from different clinical medicine disciplines was administered to test students' knowledge retention. Out of 49 students, 38 participated in the surprise non-routine exam.   Result: A significantly higher number of faculty preferred the CP curriculum compared to the traditional system of teaching clinical medicine (16 vs 11, Kruskal Wallis: 0.023, ie. P-value < 0.05). A significantly higher number of the students liked and recommended CP curriculum in the clinical year of medical education (20 vs. 13 with p-value < 0.05). In the non-routine surprise exam, two thirds of the students scored 60% or above.  Conclusion: Both faculty and students perceive that the CP curriculum system is an effective teaching and learning method in medical education, irrespective of their different demographic and positional characteristics. The students' overall performance was good in surprise, non-routine exams taken without scheduling or reminders.

Effectiveness of low-dose radiation therapy in COVID-19 patients globally: A systematic review.

Background: Novel Corona Virus Disease 2019 (COVID-19) can affect multiple organs, including the lungs, resulting in pneumonia. Apart from steroids, other anti-COVID drugs that have been studied appear to have little or no effect on COVID-19 pneumonia. There is a well-known history of inflammatory disease, including pneumonia, treated with low-dose radiation therapy (LDRT). It reduces the production of proinflammatory cytokines, Interleukin-1a (IL-1a), and leukocyte recruitment.   Methods: A comprehensive literature search was conducted using PubMed, Scopus, Embase, CINAHL, and Google Scholar, with keywords such as "radiotherapy," "low-dose radiation therapy," "low-dose irradiation," "covid-19 pneumonia," "SARS-CoV-2 pneumonia," and "covid pneumonia." with additional filters for human studies and customized articles in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We reviewed randomized controlled trials, quasi-experimental studies, cohort, case-control, and cross-sectional studies with a clearly defined intervention, including low-dose radiotherapy alone or in combination with any therapy to treat COVID-19 pneumonia from December 2019 to May 2021. Patients receiving standard or high-dose radiotherapy, including for other diseases, were excluded. Zotero software was used to collect and organize research from various databases, remove duplicates, extract relevant data, and record decisions. Participants' demographics and baseline status were obtained from the full-text articles along with the intervention's outcome/effect on patient status.  Results: Four studies with 61 participants that met the inclusion criteria were included. One was a double-blind randomized controlled trial, one a non-randomized trial, while the other two were single-arm clinical trials. Low-dose radiation therapy did not show any significant improvement in COVID-19 patients.  Conclusion: Only two studies included in this review demonstrated an improvement in inflammatory markers; however, patients were also given steroids or other drugs. Therefore, the confounding effects must be considered before drawing conclusions. This systematic review does not support mortality benefit, clinical course improvement, or imaging changes with LDRT.

Loss of Consciousness and Cardiac Arrest as an Atypical Presentation of Tubercular Meningitis: A Case Report.

Tubercular meningitis is a devastating presentation of extra pulmonary tuberculosis, with fatality in each case without treatment. A 39 years male, a regular consumer of alcohol and a known case of major depressive disorder, presented with the alleged history of using an electric heater in a closed room, and presented to emergency with unconsciousness and cardiac arrest. As his neurological status didn't improve over 72 hrs, a magnetic resonance imaging brain was done which was non-conclusive. Electroencephalogram revealed diffuse right fronto-parietal seizure activity ceasing with midazolam injection, hence levetiracetam was started. Lumbar puncture revealed increased adenosine deaminase and nil white blood cells. Repeat lumbar puncture showed lymphocytic-predominant pleocytosis, elevated protein and low glucose. The patient was started on anti-tubercular therapy and an injection of dexamethasone was added. Repeat electroencephalogram didn't show any seizure-like activity. It is important to be aware of variety of presentations of tubercular meningitis. Delay in treatment leads to irreversible neurological damage and even death. Keywords: cardiac arrest; case report; tubercular meningitis; unconsciousness.

Performance and preference of problem-based learning (PBL) and lecture-based classes among medical students of Nepal.

Background: PBL (problem based learning) is new active learning educational strategy that has been extensively tested and used in recent years. Patan Academy of Health Sciences (PAHS) is one of medical schools from Nepal, a Low Income Country (LIC) implementing PBL for undergraduate medical education. This study aims to compare PAHS students' understanding and knowledge retention when taught through PBL and lecture-based classes and compare students' perceptions of PBL and lectures in medical education. Methods: This is a cross-sectional study of medical students of a PBL based medical school in Nepal, a non-Western low-income country. Ethical approval was given by the institutional research committee of the Patan Academy of Health Sciences. Understanding and knowledge retention was assessed with 50 vignette-based multiple-choice questions, half of which were taught through PBL sessions, and the remaining half were taught in didactic lectures during basic science years of medical school. A separate pre-validated perception questionnaire was used to assess students' preferences regarding PBL and lectures. Results: Out of 107 students, 99 participated in the understanding and knowledge retention questionnaires and 107 completed perception questionnaires. Understanding and knowledge retention of students was found to be the same for topics taught by PBL and lectures, with median scores of 17 and s16, respectively. PBL were mostly preferred for the physiology (59.81%), pathology (51.40%) and pharmacology (53.27%) concepts, and lectures were mostly preferred for the anatomy (78.50%), biochemistry (45.79%), and microbiology (42.99%) topics. Students wanted the same concepts to be taught through both PBL and lectures, especially for anatomy. Conclusions: Understanding and knowledge retention is the same for topics taught by either PBL or lectures during the basic science years of undergraduate medical education. Students prefer PBL for physiology, pathology, and pharmacology-related concepts, conventional didactic lecture for physiology and microbiology, and a combination of lecture and PBL sessions for anatomy.

Unilateral Facial Palsy at High Altitude: A Case Report.

Poudel Sangeeta, Bibechan Thapa, Saroj Adhikari Yadav, and Brenton Systermans. Unilateral facial palsy at high altitude: a case report. High Alt Med Biol. 22:426-428, 2021.-The facial nerve has a long and tortuous route predisposing it to palsy or paresis. Bell's palsy is the most common cause of facial nerve palsy. Most often Bell's palsy is self-limited but it is very crucial to rule out other causes and provide prompt treatment accordingly. Some causes of facial palsy that are specific to high altitude include hypoxia, cold weather, vitamin D deficiency, and high-altitude cerebral edema. Health facilities and diagnostic tools are compromised in resource-limited settings such as at high altitudes. This leads to a diagnostic dilemma, possibly delaying targeted treatment, and resulting in poorer outcomes. Clinical diagnosis plays an important role in such settings. The immediate descent and initiation of steroids improve the condition in many cases. In this article, we discuss the case of a Sherpa who presented to the Everest emergency clinic during the 2021 climbing season with unilateral facial palsy.

Management of root-knot nematode, Meloidogyne incognita and soil borne fungus, Fusarium oxysporum in cucumber using three bioagents under polyhouse conditions.

Complex diseases caused by Meloidogyne incognita and Fusarium fungus in cucumber is the most destructive disease under polyhouses. The experiment was conducted in the polyhouse of the Department of Horticulture, CCS HAU, Hisar, Haryana, India during summer season (2015-16) to evaluate the potential of bacterial and fungal biocontrol agents against Meloidogyne incognita and Fusarium oxysporum f. sp. cucumerinum in cucumber. Bioagents - Trichoderma viride (Tv), Pseudomonas fluorescence (Pf), Purpureocillium lilacinum (Pl) were taken 10 and 20 g kg-1 seed and bioagents liquid formulation, 10- and 15-ml kg-1 seed, were mixed with the potted soil. Chemical as well as untreated check were also maintained. All the treatments significantly improved the plant growth parameter, viz., shoot length (SL), root length (RL), fresh shoot weight (FSW), fresh root weight (FRW), dry shoot weight (DSW) and dry root weight (DRW) as compared to untreated check. However, significant reduction in nematode population and maximum improvement in plant growth parameter was recorded with carbofuran followed by higher dose of bioagents liquid formulation. Among the bioagents, bioagents liquid formulation was most effective in suppressing root knot nematode galling (43 / root system) and final population in soil (131 J2s / 200 cc soil) and fungus wilt incidence (25 %) at 30th day of after germination and significantly improved the plant growth parameters - shoot length (147.3 cm), fresh shoot weight (55.6 g), dry shoot weight (22.51 g) and dry root weight (4.50 g) from other bioagents. Bioagents liquid formulation was effective in suppression of root-knot nematode and fungus complex disease than the powder formulations of bioagents. More studies should be needed in future to evaluate the efficacy of bioagents as seed treatments and soil applications under field conditions.

Retrospective Genotyping and Whole Genome Sequencing of a Canine Parvovirus Outbreak in Bangladesh.

Canine parvovirus 2 (CPV-2) outbreaks in close quarters such as kennels or shelters can cause substantial case fatality. Thirteen dead Labradors from a secluded kennel of security dogs presented with typical clinical signs and gross pathology of parvovirus infection. Whole genome shotgun sequencing from tissue-extracted genomic DNA detected new CPV-2a as the contributing antigenic variant. Further genotyping using polymerase chain reaction coupled with high-resolution melt assays (PCR-HRM) confirmed new CPV-2a infection in all deceased dogs. PCR-HRM of additional thirty-four clinically suspected dogs suggested that this variant is in wider community circulation, at least in the southeastern part of Bangladesh. We present complete genome sequence of the new CPV-2a variant circulating in the domestic canine population of Bangladesh.

Hereditary Vitamin-D Dependent Rickets Type II: A Case Report.

Hereditary vitamin D dependent rickets type II is a rare genetic disorder in children characterized by early onset of rickets and deranged biochemical parameters. Low serum calcium level, high alkaline phosphatase, high parathyroid hormone, and high values of 1,25-dihydroxy vitamin D are characteristic biochemical findings. We are reporting a rare case of Vitamin D Dependent Rickets and subsequent improvement after addition of cinacalcet. This is a case report of a 2.5-year-child with Hereditary Vitamin D Dependent Rickets type II receiving cinacalcet as adjunct to oral calcium and calcitriol. Oral cinacalcet (0.25mg/kg/day) was added to the regimen as an adjunct after treatment failure with high dose of oral calcium and calcitriol. A significant improvement in radiological findings and normal homeostasis of calcium, phosphate and parathyroid hormone was achieved after initiation of cinacalcet.