Peutz-Jeghers syndrome: A case series.

INTRODUCTION: Peutz-Jeghers syndrome (PJS) is a rare hereditary disorder characterized by gastrointestinal hamartomatous polyps, due to mutation of the STK11/LKB1 gene located on chromosome 19p. The polyps are most commonly found in the small bowel followed by colon. CASE PRESENTATION: Our case series includes 4 patients, three being male and one female. Each of them either presented with abdominal pain and other associated symptoms. Oral cavity and lip melanin pigmentation were common. CT abdomen revealed multiple large jejunal, ileal, gastric and colon polyps. Cancer was found in one patient. Different surgical approaches were adopted. All recovered well. DISCUSSION: PJS is an autosomal dominant disorder with an estimated incidence of 1:50,000 to 1:200,000 cases with a significant family history. Mostly found in small bowel followed by colon, it can also occur in a rare organ like gall bladder as evident in our case. PJS carries a substantial risk for gastrointestinal cancer. The treatment modality depends on the site of polyp, mode of presentation and availability of the expertise. CONCLUSION: PJS is a common disease in our part which is usually observed in teen age groups male. They have a varied presentation, from intestinal obstruction (due to intussusception) to GI bleeding. Colonic malignancy at young age may be the first presentation of the disease. Observation of melanin pigmentations on lips helps diagnose the disease; and one should always look at this findings in a young patient with pain abdomen or in intestinal obstruction to confirm/exclude the disease.

Tophaceous gout.

Hyperuricemic patients (≥7.8 mg/dL) can develop polyarticular tophaceous gout from intermittent arthritis if untreated. Acute flares and tophi development can be avoided by lowering blood urate levels with xanthine oxidase inhibitors.

Outcomes of stereotactic thalamotomy in patients of essential tremor: A systematic review.

BACKGROUND: Essential tremor is a neurological condition associated with movement disorder with more prevalence among adult group of population. The burden of essential tremor is peaking globally but with the advancement in the area of functional neurosurgery such as stereotactic thalamotomy, the quality of life of such patients can be improved drastically. METHODS: This systemic review was conducted in accordance to the guidance of preferred Reporting items for Systematic Review and Meta-Analysis(PRISMA). Databases of "PubMed", "Embase", "Web of Science", "Cinhal Plus", and "Scopus" from inception till 2023 was undertaken. A combination of keywords, Medical Subject Headings (MeSH), and search terms such as Search strategy for PubMed search was as follows: "stereotactic thalamotomy" AND "essential tremor". RESULTS: This systematic review analyzed 9 studies with a total of 274 patients of essential tremor patients. Unilateral thalamotomy was carried out among 268 patients and bilateral thalamotomy in rest of the patients. Vim and Vom nucleus were the site of thalamotmy with ventral intermedius nucleus being the major one. Ten different types of clinical tremor rating scales were used to assess pre operative and post operative improvement in the tremor scales of the individual patients. Dysarthria and limb weakness was noted post operative complication in majority of the cases. CONCLUSION: Our study revealed that stereotactic thalamotomy provided good functional outcome in patients of essential tremor who underwent unilateral thalamotomy compared to bilateral thalamotomy. The positive outcome outweighs the complications in such functional surgery.

Continuous versus interrupted anastomotic technique for the hepaticojejunostomy: a prospective cohort study.

Background: Interrupted sutures is the gold standard technique of hepaticojejunostomy (HJ) for bilioenteric anastomosis. This study compares the safety and early complications of continuous and interrupted suture HJ. Methods: A prospective study involving all elective HJ between September 2019 and June 2021 was conducted. Patients with type IV or V biliary strictures, duct diameter less than 8 mm and/or associated vascular injury, and bilateral HJ were excluded. The study patients were divided into two random groups; interrupted and continuous anastomotic technique. Patient demographics, preoperative parameters including pathology (benign vs. malignant), HJ leak, suture time, and postoperative morbidity were recorded. Results: Total 34 patients were enroled. Eighteen (52.9%) were into interrupted and 16 (47.1%) patients into the continuous group. Both the groups were comparable with regards to demographics, haemoglobin, serum albumin, preoperative cholangitis and biliary stenting. Total three (8.8%) patients in the entire study developed bile leak; interrupted-2 and continuous-1, which was not significant statistically (P=1.0). Similarly, total number of sutures used and the mean operating time to complete anastomosis in the continuous group was significantly lesser than the interrupted group (2.3±0.5 versus 9.6±1.6, P<0.001) and (16.2±3.1 versus 38.6±9.2 min, P<0.001), respectively. There were three (18.8%) re-exploration in the continuous anastomotic technique. Among them, only one re-operation was due to HJ anastomosis failure without mortality, remaining had re-exploration for bleeding (non-HJ). Conclusions: Both the techniques is safe with comparable morbidity. Further, continuous has an added advantage of decreased anastomotic time and cost.

Subclavian steal syndrome.

Early recognition and diagnosis of subclavian steal syndrome are vital to avoid unnecessary investigations and ensure appropriate management. This case highlights the significance of comprehensive evaluation, including bilateral blood pressure measurement, in patients with unilateral symptoms.

Antibiotics use among residents in Eastern Nepal: a community-based mixed method study.

Introduction: According to the WHO, more than two-thirds of all antibiotics are used in the community, of which about 30% are used inappropriately. The antimicrobial resistance (AMR) problem is a growing threat to Nepal because of indiscriminate and inappropriate use. However, exact data on the extent of inappropriate use of antibiotics in the community is scarce in Nepal. Objectives: To know the extent of inappropriate use of antibiotics among the community and their knowledge and practice towards the usage of antibiotics. Methods: A community-based cross-sectional study was conducted from 20 December 2017 to 20 March 2018 using a purposive sampling technique. A semi-structured questionnaire was used while conducting face-to-face interviews with 336 respondents to find out the knowledge and practice regarding antibiotic use. Investigators took different antibiotics (in all dosage forms) with them to show participants whether they knew and/or used the antibiotics in the last year. Results: The mean age of respondents with standard deviation was 39.87±13.67 years ranging from 18 to 84 years. Around 35.42% of respondents were farmers and 34.52% were homemakers. 28.87% of respondents were illiterate, 32.44% had primary education and 33.33% had secondary education. Almost half of them (48.51%) think that antibiotics are safe and can be commonly used. So, 43.15% of them preferred taking antibiotics when they had a common cold. The majority of the participants (81.84%) did not have any idea about antibiotic resistance. 94.6% of the respondents used antibiotics inappropriately. Conclusion: The results of the present study revealed that inappropriate use of antibiotics is high and associated with low earning wages in both males and females in the age group 18-39 years.

Malignant rectal GIST managed with chemotherapy (Imatinib Mesylate): A case report and a comprehensive review.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors involving the gastrointestinal tract, arising from the interstitial cells of Cajal. GIST comprises about 1% of all GI tumors. Rectal GISTs are rare and comprise of approximately 5% of all GISTs and only 0.1% of rectal tumors are found to be GISTs. Rectal GISTs may be diagnosed incidentally or present with symptoms, including defecation problems, bleeding, and/or pain. We report a case of a 46-year-old male with rectal GIST metastasized to the liver and bilateral lung parenchyma managed by Imatinib Mesylate (IM) regimen. Rectal GIST although being rare, must be considered as a differential diagnosis in a patient presenting with defecatory problems with bleeding.

Critical View of Safety Dissection and Rouviere's Sulcus for Safe Laparoscopic Cholecystectomy: A Descriptive Study.

Objective: To determine the importance of a critical view of safety (CVS) techniques and Rouviere's sulcus (RS) in laparoscopic cholecystectomy (LC) and its relation to biliary duct injuries (BDIs) and to determine the frequency and the type of RS. Design, Setting, and Participants: A descriptive study was carried out among 76 patients presenting to the surgery department of a tertiary care center in Nepal. The study population included all patients in the age group 16-80 years undergoing LC. Outcome Measures: The main outcome of interest was to calculate the percentage of BDIs along with the frequency and the type of RS. Results: A total of 76 patients were enrolled in the study, out of which 57(75%) were female patients with a male-to-female ratio of 1:3 and a mean age of 45.87 ± 15.33 years. Seventy-one (93.4%) patients were diagnosed with symptomatic gallstone disease. The CVS was achieved in 75 (98.7%) of the cases, whereas in 1 case, the CVS could not be achieved, and in the same patient routine LC was converted into open cholecystectomy owing to the difficult laparoscopic procedure. In 56 (73.7%) cases, RS was first visible to the operating surgeons after port installation, alignment, and adequate traction of the gallbladder; in 20 (26.3%) cases, RS was not originally apparent. Conclusion: According to the findings of this study and the literature's critical assessment of safety, this method will soon become a gold standard for dissecting gall bladder components. The technique needs to be extended further, especially for training purposes. Major difficulties can be avoided by identifying RS before cutting the cystic artery or duct during LC.

Median nerve schwannoma with a diagnostic delay of 8 years: a case report.

Introduction: Schwannomas are benign tumors of the peripheral nerve sheath, and the median nerve is the most commonly involved nerve. These benign tumors of the peripheral nerve sheath are very rare; they are clinically and radiologically similar to most other benign swellings of the hand; thus, they are often misdiagnosed. Case Presentation: A 41-year-old lady presented with an 8-year-long history of swelling over the distal forearm. The tumor measured 3.5×3.5×3.5 mm and was located over the flexor aspect of the distal part of her right forearm. Schwannoma was suspected from the clinical presentation and imaging, but the final diagnosis was established only after the surgery and histopathological analysis. At the follow-up after 1 year, the patient is doing well and her symptoms have not recurred. Conclusion: Imaging characteristics of schwannoma can be misinterpreted as some other condition, making the preoperative diagnosis very difficult and important. Thus, clinicians should be aware of such swellings, especially those that have been unnoticed or misdiagnosed, and provide optimal diagnoses to confer good outcomes.

Role of radiological corroboration in a locally aggressive inverted papilloma: a case report.

Introduction and importance: Sinonasal inverted papilloma is a rare benign tumor of the nasal cavity and paranasal sinuses (PNS). Radiological evaluation is the key to management. Case presentation: A 46-year-old male presented with complaints of right nasal congestion and occasional bleeding for 4 months. During anterior rhinoscopy, a pinkish fleshy mass occupying the right nasal cavity was seen. X-ray and computed tomography (CT) PNS view showed opacification in the right nasal cavity and maxillary sinus. An MRI of the nose and PNS revealed a peculiar convoluted striated/cerebriform pattern. Histopathology report described the features of an inverted papilloma. The patient underwent endoscopic removal of the mass under general anesthesia. Surgical resection of the tumor was performed along with adjacent normal mucosal tissues. The patient recovered well and was followed-up for recurrence. Clinical discussion: Sinonasal inverted papilloma is commonly found in males in their fifth to sixth decade of life. A CT scan is the initial modality of choice to evaluate the extent of the disease. MRI is superior to CT in distinguishing tumors from other conditions as well as to evaluate soft tissue extensions. Involvement of the frontal sinus is a risk factor for recurrence. The first option for treating an inverted papilloma is complete surgical removal with the adjacent uninvolved mucosa. Conclusion: In a biopsy-proven case, radiological assessments like CT and MRI play a pivotal role in studying the typical morphology, delineating the extension, and detecting recurrence.

Left segmental hypoplasia of liver with concomitant gallbladder agenesis.

Key Clinical Message Congenital liver anomalies are rarely reported. To the best of our knowledge and literature review, associated gallbladder agenesis with left hepatic lobe agenesis is extremely rare. The rarity of this condition and its uncertain radiological features often leads to misdiagnosis and unwarranted surgical treatments.

Spontaneous idiopathic omental bleeding: a case report of rare cause of acute abdomen.

Idiopathic omental hemorrhage is a rare cause of an acute abdomen, which is potentially life threatening. Here, we report a case of a 34-year-old male who presented to the emergency department with sudden, severe pain abdomen and abdominal distension for 1 day. There was no history of trauma, abdominal surgeries or any significant past medical history. The diagnosis was suspected on contrast computed tomography, which revealed hyperdense areas of blood in the peritoneal cavity with contrast extravasation from the omentum. The patient underwent successful emergency laparotomy, peritoneal lavage and greater omentectomy to achieve hemostasis.

Immunoglobulin A nephropathy in remission: a case report.

Immunoglobulin A nephropathy is the most prevalent form of primary glomerulonephritis. Case presentation: A 33-year-old military male presented with complaints of fever, headache, myalgia, chills, and haematuria for 10 years. His lab results showed elevated serum creatinine levels and proteinuria. A renal biopsy was done which was consistent with a diagnosis of immunoglobulin A nephropathy. He was managed with antihypertensive, including angiotensin-converting enzyme inhibitors, steroids and immunosuppressants, and Omega-3 fatty acids. There was remission of the symptoms and the patient's serum creatinine and sonogram findings returned to baseline. Conclusion: Routine follow-up along with the appropriate use of medications can limit disease complications and progression.

Recurrent pyogenic cholangitis.

The incidence of hepatolithiasis is variable. Globalization has additionally altered disease dynamics globally. A multi-disciplinary team approach is deemed necessary for the timely diagnosis, safe, affordable treatment, and good prognosis.

Advancing Analytics of EEG Signals.

Electro Encephalo Graphy (EEG) is a non-invasive diagnostic tool that is widely used in the field of neurosurgery. The EEG measures the electrical activity of the brain, which provides essential information about brain function and can help diagnose various neurological conditions. In neurosurgery, EEG monitors the brain during surgery to ensure that the patient's brain function remains stable and minimize the risk of neurological complications. EEG is also used in the preoperative evaluation of patients who are being considered for brain surgery. This information is critical in helping the neurosurgeon determine the best surgical approach and to minimize the risk of damaging critical brain structures. Additionally, EEG can be used to monitor the brain's recovery after surgery, which can help predict the patient's prognosis and inform the treatment plan.In recent years, the use of EEG has become increasingly sophisticated and has allowed for more precise and detailed monitoring of brain function during surgery. For example, high-resolution EEG techniques can be used to provide real-time information about the activity of specific brain regions. Additionally, developing wearable and portable devices in the future will allow continuous monitoring of brain function, providing real-time data on a patient's condition. In conclusion, EEG is a critical tool in the field of neurosurgery and has dramatically improved the ability of neurosurgeons to diagnose, treat, and monitor patients with neurological conditions. With continued advances in EEG technology, its use in neurosurgery will likely continue to grow and play an increasingly important role in improving patient outcomes.

Primary adrenocortical carcinoma: a case report.

Adrenal tumors are very common, affecting 3-10% of the human population, and most are small, benign, nonfunctional adrenocortical adenomas. Adrenocortical carcinoma (ACC), in contrast, is a very rare disease. The median age of diagnosis is in the fifth to sixth decade. There is a predilection for the female gender (the ratio of female to male ranges from 1.5 to 2.5 : 1) the adult. Case presentation: A 28-year-old man who had no prior history of systemic hypertension or diabetes mellitus presented with bilateral limb swelling for 2 months and facial puffiness for 1 month. He had an episode of hypertensive emergencies. A radiological and hormonal work-up established the diagnosis of primary ACC. One cycle of chemotherapy was given until he lost follow-up and succumbed to death due to financial constraints. Conclusions: Adrenocortical carcinoma is an extremely uncommon tumor of the adrenal gland, and it is even more uncommon when it manifests without any symptoms. If patients exhibit signs of rapid and multiple adrenocortical hormone excess, such as weakness, hypokalaemia, or hypertension, ACC may be suspected. Recently developed gynecomastia in men may be brought on by an ACC producing too much sex hormone. To accurately diagnose the condition and give the patient a fair prognosis, a multidisciplinary approach involving endocrine surgeons, oncologists, radiologists, and internists is advised. Proper genetic counseling is recommended. It is critical to know whether the adrenal mass is malignant or not, and to get this ascertained by a computed tomography finding and biopsy.