Rare case of combined vascular malformation of the face: a successful surgical management.

Combined vascular malformation affecting the facial region is an extremely rare clinical entity that is debilitating both functionally and emotionally. Treatment warrants a multidisciplinary approach with the aim of removing the vascular anomalies and ameliorating any functional facial disfigurement. Here, we present a case of a 40-year-old female with combined vascular malformation of the face who was treated successfully with surgical intervention accompanying significant resolution of facial disfigurement.

Design, synthesis and biological evaluation of novel antipyrine based α-aminophosphonates as anti-Alzheimer and anti-inflammatory agent.

Herein, a series of novel antipyrine based α-aminophosphonates derivatives were synthesized and characterized. The synthesized derivatives were subjected for in vitro cholinesterase inhibition, enzyme kinetic studies, protein denaturation assay, proteinase inhibitory assay and cell viability assay. For cholinesterase inhibition, the results inferred that the test compounds possess better AChE activity (0.46 to 6.67 µM) than BuChE (2.395 to 12.47 µM). Compound 4j inhibited both AChE and BuChE (IC50 = 0.475 ± 0.12 µM and 2.95 ± 0.16 µM, respectively), implying that it serves as a dual AChE/BuChE inhibitor. Also, kinetic studies revealed that compound 4j exhibits mixed-type inhibition against both AChE and BuChE, with Ki values of 3.003 µM and 5.750 µM, respectively. Further, protein denaturation and proteinase inhibitory assays were used to test in vitro anti-inflammatory potential. It was found that compound 4o exhibited highest activity against protein denaturation (IC50 = 42.64 ± 0.19 µM) and proteinase inhibition (IC50 = 37.57 ± 0.19 µM) when compared to diclofenac. In addition, cell viability assay revealed that active compounds possess no cytotoxicity against N2a cell and RAW 264.7 macrophages. Finally, molecular docking experiments for AChE, BuChE, and COX-2 were conducted to better understand the binding modes of active compounds.Communicated by Ramaswamy H. Sarma.

Fingerprint-based robust medical image watermarking in hybrid transform.

To protect the medical images integrity, digital watermark is embedded into the medical images. A non-blind medical image watermarking scheme based on hybrid transform is propounded. In this paper, fingerprint of the patient is used as watermark for better authentication, identifying the original medical image and privacy of the patients. In this scheme, lifting wavelet transform (LWT) and discrete wavelet transform (DWT) are utilized for amplifying the watermarking algorithm. The scaling and embedding factors are calculated adaptively with the help of Local Binary Pattern values of the host medical image to achieve better imperceptibility and robustness for medical images and fingerprint watermark, respectively. Two-level decomposition is done where for the first level LWT is utilized and for the second level decomposition DWT is utilized. At the extraction side, non-blind recovery of fingerprint watermark is performed which is similar to the embedding process. The propounded design is implemented on various medical images like Chest X-ray, CT scan and so on. The propounded design provides better imperceptibility and robustness with the combination of LWT-DWT. The result analysis proves that the proposed fingerprint watermarking scheme has attained best results in terms of robustness and authentication with different medical image attacks. Peak Signal to Noise Ratio and Normalized Correlation Coefficient metrics are used for evaluating the proposed scheme. Furthermore, superior results are obtained when compared to related medical image watermarking schemes.

Comparative Study between the Use of Pigtail Catheters and Traditional Chest Tube Drain in Cases with Pneumothorax.

Background Pneumothorax is a condition in which air or other gas is present in the pleural cavity. Mainstay of management of pneumothorax is to remove the air from the pleural space usually done by chest tube insertion. There is still uncertainty whether minimal invasive management with pigtail catheter is sufficient for the management of pneumothorax. Objective To find the effectiveness, safety, tolerability, efficacy of pigtail catheters and large bore chest tubes. Method Prospective comparative study was done in Dhulikhel Hospital between August 2019 till August 2021. Chest tube insertion used to be the only available treatment modality till December 2020 (15 months). Following January 2021 after obtaining ethical clearance for use of pigtail insertion for pneumothorax, this treatment modality was done (8 months). Result Among 76 patients, 52(68.4%) underwent a large bore chest tube and 24 (34.6%) pigtail catheter patients. Mean age of the patients was 48 years (SD 18.01). Duration of hospital stay and length of hospital stay was more in large bore catheters and less in pigtail catheters. Eight hours post tube placement of the expansion of the lungs was present in pigtail and was statistically significant. Pain killer used in pigtail catheters was limited to Non-steroidal anti-inflammatory drugs, for large bore catheter opioids were added and were statistically significant. Conclusion Pigtail catheter is nearly effective as compared to traditional wide bore catheters.

A rare case of persistent lateral marginal vein of Servelle in Klippel Trenaunay Syndrome: A successful surgical management.

INTRODUCTION AND IMPORTANCE: Klippel-Trenaunay Syndrome (KTS) is a rare congenital vascular disorder characterized by capillary malformation, varicosities, and tissue overgrowth. It usually affects the unilateral lower extremities manifesting commonly as pain, localized rise of temperature, and venous tortuosity. However, in severe cases, ulceration, cellulitis, and chronic lymphatic malformation may be present. Management is mostly supportive and involves the use of compression stockings. CASE PRESENTATION: Here, we report a case of KTS with a persistent lateral marginal vein of Servelle managed with radiofrequency ablation along with sclerotherapy of selected perforators. On a two-year follow-up, the symptoms had resolved and Doppler ultrasonography revealed resolution of the defective vein along with the absence of incompetent perforators. CLINICAL DISCUSSION: In cases with venous malformation with the persistence of embryonic avalvular venous structures, like the lateral marginal vein of Servelle, surgical intervention is warranted especially at a younger age to reduce the risk of future thromboembolic events and recurrence. CONCLUSION: Varicosities of the lateral marginal vein of Servelle can be managed successfully by radiofrequency ablation and adjunct sclerotherapy in selected cases.

The Cut-off Value of Great Saphenous Vein Diameter at the Level of Femoral Condyle to Predict the Sapheno-Femoral Junction Incompetence.

Background Varicose vein is one of the commonest problems that patients visit to a vascular out patient services (OPD). It causes a great deal of morbidity in today's population. Objective To see the correlation between the size of great saphenous and Saphenofemoral junction incompetence. Method From January 2019 till January 2020, 396 patients with symptomatic or clinically diagnosed varicose veins were screened for Saphenofemoral junction reflux. The diameter of the saphenous vein was measured with B-mode imaging, and reflux was quantified based on valve closure time using Doppler spectral measurements. Best saphenous vein diameter cutoff for predicting reflux was determined using receiver operating characteristics curve analysis. Result Out of 792 limbs, the Great Saphenous Venous System was involved in 452 limbs, the Short Saphenous Venous System was involved in 151 limbs and significant perforators were present in 240 limbs. Mean great Saphenous Vein diameter of diseased limb (Reflux Positive) was 5.68 mm and 4.0 mm in control group (Reflux Negative). Mean Saphenofemoral junction diameter was 8.23 mm in diseased limbs and 6.16 mm in control limbs. Receiver operating characteristics curve showed great saphenous vein diameter at femoral condyle of 4.5 mm as best cut-off value for diagnosis of sapheno femoral junction reflux. Conclusion Great Saphenous Vein diameter at femoral condyle of 4.5 mm is the best cut-off value for diagnosis Saphenofemoral junction reflux. The Sensitivity and specificity of this cut off value is 81.8% and 71% respectively.

Solving the Mystery of Giant Intrathoracic Mass.

Intrathoracic schwannoma are highly vascular nerve sheath benign tumors arising from neural crest derived schwann cells of the intercostal nerves. Common clinical presentation is palpable mass but in our case patient presented with shortness of breath which is rare presentation in Schwannoma. Imaging studies of the patient showed the lesion in left lung, however surgical finding showed mass to arise from chest wall and it was confirmed to be schwannoma by histopathological examination.

Synthesis of carbazole based α-aminophosphonate derivatives: design, molecular docking and in vitro cholinesterase activity.

A series of novel carbazole based α-aminophosphonate derivatives were synthesized under solvent-free condition, characterized and evaluated for their cholinesterase inhibition, enzyme kinetic inhibition, in-vitro cell viability using N2a cells, neuroprotective studies against H2O2-induced stress using N2a cells and antioxidant studies using DPPH radical activity. Test compounds displayed better AChE activity (0.475 to 7.781 µM) than BuChE (3.306 to 21.32 µM). Compound 4j was most potent derivative against AChE as well as BuChE with IC50=0.475 ± 0.12 µM and IC50=3.306 ± 0.21 µM respectively. Kinetic inhibition studies indicate that compound 4j exhibits mixed type inhibition against both enzymes which was supported by molecular docking studies. Cell viability studies showed that compounds did not induce any cytotoxic effect against N2a cells using MTT assay. Also, compound 4j, 4 s and 4r were subjected to H2O2-induced stress using N2a cells and were found to be protective in nature. ADME predictions were carried out to understand the pharmacokinetics behaviour.Communicated by Ramaswamy H. Sarma.

Analysis of Lung Cancer Cases Presenting in Outpatient Department of University Hospital of Nepal.

Background Lung cancer is one of the leading cause of cancer related death. Most common histopathology of lung cancer is non-small cell carcinoma of which adenocarcinoma is the most common. There are limited number of studies done in Nepal to know different aspects of lung cancer. Objective To know demographic parameters of patients diagnosed as lung cancer in a university hospital. The study also aims to know the different histopathological diagnosis of lung cancer. Method All the patients presenting to outpatient department (Cardio Thoracic and Vascular unit) of Dhulikhel Hospital, if are diagnosed as cancer of lung/bronchus will be included in the study. The duration of the study was January 2017 to December 2021. The details on age, gender, presenting symptoms, histopathology of lung cancer, operability will be included in database and will be analyzed. Result There were total of 127 patients diagnosed as lung cancer. Male:female ratio was 1.7:1. Overall mean age was 63.23 years (SD 13.5 years, Range 19-89 years). Non small cell carcinoma was the most common type of lung cancer with 83.7%. In non small cell carcinoma, most common type was Squamous cell carcinoma followed by undifferentiated and Adenocarcinoma. Only five (3.93%) cases were in operable stage. Conclusion Despite the fact that lung cancer is one of the most common cancer, patients usually present late and moslty are not in operable stage. This study shows that squamous cell carcinoma is the most common histopathology in lung cancer cases.

Massive Hemoptysis and Pulmonary Thromboembolism in a Patient with Pulmonary Tuberculosis: A Therapeutic Conundrum Managed with Bronchial Artery Embolization.

Hemoptysis is a crucial entity taking into account its morbidity and mortality. Pulmonary tuberculosis is the leading cause for massive hemoptysis in our part of the world, which if left untreated may be life threatening. We present a case of a 37-year-old male patient with pulmonary tuberculosis with concurrent pulmonary thromboembolism presenting with massive hemoptysis, which was successfully managed with Bronchial Artery Embolization. This case represents that this measure can be a viable therapeutic choice for a patient with a severe lifethreatening hemoptysis, particularly when other treatment options are unavailable or ineffective.

Synthesis, characterization, in vitro cholinesterase and hRBCs hemolysis assay and computational evaluation of novel 2,3,4,5-tetrahydrobenzothiazepine appended α-aminophosphonates.

A series of novel 2,3,4,5-tetrahydrobenzothiazepine appended α-aminophosphonate derivatives were synthesized by subjecting 2,3-dihydrobenzothiazepine to Pudovik reaction using diethyl phosphite. Tested derivatives exhibited better AChE inhibition (0.86-12.85 µM) when compared to BuChE (3.13-19.36 µM). Derivative 5f (IC50 = 0.86 ± 0.08 µM), 5g (IC50 = 1.05 ± 0.06 µM) and 5d (IC50 = 1.64 ± 0.06 µM) exhibited higher AChE inhibitory activity as compared to standard drug galantamine (IC50 = 2.15 ± 0.05 µM). Similarly, derivative 5e (IC50 = 3.13 ± 0.11 µM) and 5f (IC50 = 3.64 ± 0.06 µM) demonstrated comparable BuChE inhibitory activity to reference drug galantamine (IC50 = 3.86 ± 0.03 µM). Further, enzyme kinetic studies were carried out for the most active molecule i.e. derivative 5f (for AChE) and derivative 5e (for BuChE) and the results imply that derivatives 5f and 5e show mixed-type inhibition with Ki values of 1.779 µM and 3.851 µM respectively. Enzyme reversibility inhibition studies demonstrated that all the tested derivatives possess reversible inhibitor characteristics. In addition, % hemolysis studies were carried out using human red blood cells (hRBCs) and the results demonstrated that the synthesized derivatives were biocompatible in nature as they impart very less cytotoxicity to hRBCs (CC50 > 1000 µg/mL). Also, cell viability studies for tested derivatives revealed no cytotoxicity in N2a cells. Moreover, molecular docking studies revealed that derivative 5e and 5f bind to the PAS and CAS of the AChE. ADME predictions suggested that synthesized derivatives have high possibility of being drug-like.

Modelling potentially suitable lac cultivation zones of Butea monosperma to promote livelihood security in rural India.

The present paper highlights the importance of lac cultivation through Butea monosperma. We have modelled the suitable habitat of major lac host B. monosperma using MAXENT for the current and future climatic scenarios (RCPs 2.6, 4.5, 6.0 and 8.5). The study suggested the dominance of suitable habitats of B. monosperma in central-eastern to eastern and southern parts of the country. Temperature seasonality (Bio_4) was the most significant bioclimatic variable in regulating the distribution of B. monosperma followed by elevation and annual precipitation (Bio_13). The projection for the year 2050 suggested the habitat shift towards the eastern and southern parts. The study indicated the major habitat of B. monosperma continued to exist in the Chotanagpur plateau in eastern India. The model predicted approximately a 9-13% decrease in the overall potential habitat of B. monosperma by 2050, and the distribution of species would be nearly extinct from the northern and western parts. Presently, only the 5% lac host trees are being utilised for lac cultivation, and the study suggested that conservation and promotion of B. monosperma on projected suitable habitats and even by utilising 25% of resources, the lac production may jump manifold catering to global demand, rural economy and employment and shall contribute towards 'Self Reliant India'.

Design, synthesis and evaluation of dihydropyranoindole derivatives as potential cholinesterase inhibitors against Alzheimer's disease.

A series of novel dihydropyranoindole derivatives containing sulphonamide group were designed, synthesized and evaluated for in-vitro anti-cholinesterase activity. The result showed that all the compounds exhibited potent acetylcholinesterase (AChE) activity (IC50 = 0.41-8.79 µM) while demonstrated moderate to good activity for butyrylcholinesterase (BuChE) (IC50 = 1.17-30.17 µM). The tested compounds exhibited selectivity towards AChE over BuChE. Compound 5o was most potent towards both AChE (IC50 = 0.41 µM) and BuChE (IC50 = 1.17 µM) when compared to standard galantamine and rivastigmine. Enzyme kinetics and molecular docking studies revealed that compound 5o shows mixed type inhibition and binds to peripheral anionic site (PAS) and the catalytic sites (CAS) of both the enzymes. Furthermore, cell viability studies were also performed against N2a cells along with neuroprotection studies against H2O2 in the same cell line. Antioxidant studies using DPPH radical and H2O2 were also performed which revealed that all compounds possessed some antioxidant activity. Also, DNA damage protection assay for compound 5o was performed implying that compound 5o was protective in nature. ADME studies were also performed which demonstrated good pharmacokinetics. These findings indicated that dihydropyranoindole derivatives could be possible drug lead in the search for new multifunctional AD drugs.

C-ARM Guided Angiogram/Angioplasty for Selected Failed Arterio Venous Fistula. A Report of a Procedure at University Hospital of Nepal.

End Stage Renal Disease is a last stage of Chronic Kidney Disease which is characterized by Glomerular Filtration rate of less than 15 ml/min/1.73 m2 . Hemodialysis is the most commonly used modality for treatment of Chronic Kidney disease. Among the access for hemodialysis arteriovenous fistula is the most common modality. However most common problems of fistula are significant stenosis of more than 50% which is characterized by limb swelling, pigmentation, tortuous veins, and difficulty maintaining flow during dialysis from AV fistula. These can be managed either by minimal intervention or with surgical intervention. Very few hospitals in Nepal and other countries have an angiographic suite to perform minimal intervention include angiogram with angioplasty. So in this case we try to address the use of C-Arm to perform angiogram or fistulogram and even angioplasty for the management of significant stenosis or complications of arteriovenous fistula.

Interesting Scenarios during Radiofrequency Ablation of Varicose Veins at University Hospital of Nepal.

A varicose vein is a common venous condition which affects the great saphenous vein and small saphenous vein causing symptoms of pain, edema, itchiness, pigmentation, and ulceration. There are various modalities of the treatment of varicose veins; however, radiofrequency ablation is among the tested and proven treatments for varicose veins. With every case, there can be some unexpected or interesting scenarios which can pose both technical and surgical difficulties. The main objective of this paper is to introduce these scenarios which can occur despite following the standard protocol and methods both preoperatively and intraoperatively. In these scenarios, the surgeon quickly need to decide how to deal with the aberrations. Based on extensive literature and consensus of a team of three vascular surgeons, lists of interesting scenarios were prepared along with their definition. Any occurrences of such scenarios were noted in the operation theatre note. Here, we describe 39 (6.38%) interesting cases among 611 cases of radiofrequency ablation that was performed in Dhulikhel Hospital, Kathmandu University Hospital, from January 2014 until December 2019. Despite following the proper protocol, we can face many unexpected challenges preoperatively, peroperatively, and postoperatively. From this article, we concluded that vigilance of all the factors and proper Doppler ultrasonography can help in identifying most of these scenarios and aid in making proper surgical planning.

Unexpectedly Large Electron Correlation Measured in Auger Spectra of Ferromagnetic Iron Thin Films: Orbital-Selected Coulomb and Exchange Contributions.

A set of electron-correlation energies as large as 10 eV have been measured for a magnetic 2 ML Fe film deposited on Ag(001). By exploiting the spin selectivity in angle-resolved Auger-photoelectron coincidence spectroscopy and the Cini-Sawatzky theory, the core-valence-valence Auger spectrum of a spin-polarized system have been resolved: correlation energies have been determined for each individual combination of the two holes created in the four subbands involved in the decay: majority and minority spin, as well as e_{g} and t_{2g}. The energy difference between final states with parallel and antiparallel spin of the two emitted electrons is ascribed to the spin-flip energy for the final ion state, thus disentangling the contributions of Coulomb and exchange interactions.

Case report of eventration of diaphragm due to an unknown febrile illness causing phrenic nerve palsy and other multiple nerve palsies.

INTRODUCTION: Diaphragmatic eventration can be congenital or acquired. Diagnosis is delayed due to no symptoms or very mild ones and is generally done by imaging modalities. This condition is managed by plication of the affected part of diaphragm by various surgical approaches. PRESENTATION OF CASE: A forty seven years lady presented with one year long history of abdominal pain, bloating and fullness after meals who was being treated in line of peptic acid disorder. She had developed bilateral foot drop after typhoid fever at seventeen years of age. Clinical examination and imaging with chest x-ray, chest ultrasound and computed tomography scan suggested eventration of left hemidiaphragm. Plication of eventration of left hemidiaphragm was done via mini thoracotomy of the left thorax. There were no postoperative complications and she was discharged on the sixth postoperative day. DISCUSSION: Acquired eventration of diaphragm is commonly due to traumatic phrenic nerve palsy but rarely can be associated with a history of infection causing nerve palsies. Thoracic ultrasound is an emerging modality for diagnosis supporting X-rays and CT Scans. Plication of eventration with minimally invasive techniques has less number of hospital stay and less pain compared to open approaches. CONCLUSION: Non-traumatic diaphragmatic eventration due to acquired phrenic nerve palsy following an unknown febrile illness is a rare case to be reported in Nepal. The aim of treatment is expansion of intra-thoracic space which is done by plication of the diaphragm.

Clinico-pathological Profile of Kidney Biopsy Patients in a Tertiary Hospital of Central Nepal.

Background Kidney biopsy is an important diagnostic tool in Nephrology. As of now, we don't have a central kidney biopsy registry in our country and there are many studies showing heterogeneous patterns of pathologies observed in the country. We thought of looking on the clinico-pathological profile of kidney biopsy patients prevailing in our centre. Objective This study was carried out with an objective to know the clinico-pathological profile of kidney biopsy patients prevailing in our centre. Method This was a hospital based, prospective, observational study carried out in a tertiary teaching hospital of Chitwan over a period of 3 years from May 2016 to April 2019. All the consecutive kidney biopsy patients were included in the study. The indication of kidney biopsies were the standard indication based on clinical presentation and investigations. The patient`s demographic profile, indication of kidney biopsy and histological patterns were studied and analysed using appropriate statistical tools. Result A total of 210 kidney biopsies were analysed over a period of three years, that makes around 5-6 biopsies per month. The mean age of the patient was 35.7 ± 14.9 years. Male were 106 (50.5) and females were 104 (49.5) with male to female ratio of 1.01. The average number of glomeruli was 23.4 ± 11.0. The commonest indication of kidney biopsy and histological pattern were nephrotic syndrome 56 (26.7) and IgA nephropathy 51 (24.2) respectively. Among nephrotic syndrome group, the commonest histological pattern was minimal change disease 21 (37.5). Non-diabetic kidney diseases in diabetes were seen in eight (53.4) diabetic patients making it a significant problem in diabetes and the commonest histological pattern in them were minimal change disease and idiopathic cresentic glomerulonephritis two (13.3) each. Conclusion The commonest indication and histological pattern of the kidney biopsy were nephrotic syndrome 56 (26.7), and IgA Nephropathy 51 (24.2) respectively. Nondiabetic kidney diseases in diabetes were seen in eight (53.4) of the diabetic patient making it a significant problem in diabetes and the commonest histological pattern in them were minimal change disease and idiopathic cresentic glomerulonephritis two (13.3) each.

Clinicodemographic Profile and Outcome of Maintenance Hemodialysis Patients in a Tertiary Hospital of Central Nepal, Chitwan.

Background Maintenance hemodialysis is a popular treatment modality of renal replacement therapy for end stage renal disease patients; however their mortality seemed to be rising in our centre. There were no previous studies regarding the clinicodemographic profile and outcome of maintenance hemodialysis patients from this region. Objective This study was carried out with an objective to know the clinicodemographic profile and outcome of maintenance hemodialysis patients in our centre. Method This study was a hospital based prospective observational study carried out over a period of three year, from May 2016 to April 2019, in the hemodialysis unit of the department of nephrology. All the consecutive end stage renal disease patients on maintenance hemodialysis were included in the study. The patient's demographic profile and outcome were studied and analysed using appropriate statistical tools. Result A total of 156 patients were enrolled in the study. Males were 96(61.5%) and females were 60(38.5%). The mean age of the patient was 52.2±15.6 years. The commonest causes of end stage renal disease and reasons for admission were Type 2 diabetes mellitus 68(43.6%) and volume overload with heart failure 101(64.7%) respectively. At the end of three years, 39(25%) were expired, 14(8.9%) were transferred to other centre and four (2.6%) underwent kidney transplantation. The average duration of hemodialysis was 20.3± 17.5 months. Majority of the patients 154(98.7%) had repeat admission ranging from 1 time 21(13.5%) to 10 times two (1.3%). There was a significant association between age ≥ 40 years and diabetes with mortality (p value < 0.003 and < 0.028 respectively). Conclusion The commonest cause of end stage renal disease and the reason of admission were Type 2 diabetes mellitus 68 (43.6%) and volume overload with heart failure 101 (64.7%) respectively. The overall mortality was 39 (25%) and the commonest cause of mortality was sepsis/health care associated pneumonia 30 (76.9%). There was significant association between age ≥ 40 years and diabetes with mortality (p value < 0.003 and < 0.028 respectively).

Atypical Location of an Atrial Myxoma: A Case Report.

Here, we report a case of a right atrial myxoma attached to the lateral wall, which is seen in only 10% cases, impinging upon the tricuspid valve. A 57 year old male normotensive, non-diabetic, nonsmoker patient was presented to us on 5th of August 2018 with the complaints of cough, dyspnea and orthopnea for the last two years. This type of presentation is very rare. After excision of myxoma, there was a significant improvement in the signs and symptoms of the patient. In this report, we emphasize the rarity of myxoma in the Right Atrium, and its difficulty in diagnosis because of its uncommon location and atypical presentation, surgical management has shown to quickly alleviate the majority of symptom and expectant sequeale.