Burnout among resident doctors: An observational study.

Background: Burnout is a syndrome of emotional exhaustion and depersonalization that reduces efficiency at work. No studies have been reported focusing only on residency burnout and risk factors from our country until now. This study aimed to find out the impact and the association of specific demographic and practice characteristics with burnout among resident doctors. Methods: A prospective cross-sectional survey of all resident doctors under training at that point of time in 2019 in the National Academy of Medical Sciences, Nepal in different specialties was done. We evaluated demographic variables, practice characteristics, and assessed burnout through validated Maslach burnout inventory (MBI) tools, and data were analyzed. Results: A total 347 among 410 resident doctors (227 male) responded to the survey. Median age was 30 years (range 25-44). Overall, 147 (42.4%) of responding residents were burned out with high emotional exhaustion in 58 (16.6%), high depersonalization in 55 (15.9%), and low personal achievement in 34 (9.8). In regression analysis, out of independent variables gender, marital status, having children, specialty, hours of work per week and year of residency, specialties (general surgery odds ratio [OR]; 12.595, confidence interval [CI],[ 1.037-152.9], P; 0.047), obstetrics, and gynecology (odds ratio [OR]; 13.977, confidence interval [CI]; [1.324-147.5], P; 0.028), and anesthesiology (odds ratio [OR]; 11.54, confidence interval [CI]; [1.014-131.4], P; 0.049)) and hours of work per week (≥80 h) (odds ratio [OR]; 2.511, confidence interval [CI]; [1.128-5.589], P; 0.024), were significantly associated with high burnout. Conclusions: Burnout is common among trainee resident doctors which is possibly preventable. Thus, the concern should be to prepare strategies to identify and minimize burnout from the individual, institutional, and societal sides. It is essential to preserve and promote the mental health of trainee residents to prevent serious consequences in the personal lives of resident doctors and as well as on patient outcomes.

Foreign body esophagus: Six years of silence.

Foreign body esophagus remains one of the common medical emergencies which may lead to significant morbidity and mortality. Sharp objects, batteries, and elderly with foreign body esophagus should be treated with emergent removal owing to the complications that might ensue. Endoscopic removal is the preferred choice of treatment but for large foreign body, sharp foreign body, and so on, rigid esophagoscopic removal might be more preferable. Foreign body esophagus though an obvious situation might at times be missed. It is important to make an early definitive diagnosis. We report a unique case of missed foreign body (denture) esophagus despite the obvious signs and symptoms. Definitive diagnosis was made only after 6 years due to the lack of definitive diagnostic procedures and expertise. The foreign body was impacted in the mucosal wall of the esophagus requiring Gastric resection and anastomosis (with McKeown procedure). With this we have tried to highlight the pitfalls in the diagnosis and management of foreign body esophagus. We report a case of a 55-year-old female who presented to the Emergency Room with history of progressive dysphagia and odynophagia for 6 years which was aggravated for the past 6 months. A radiological diagnosis was made. It was followed by a failed attempt of endoscopic removal which warranted the surgical removal of the foreign body.

A rare coexistence of papillary carcinoma and anaplastic carcinoma of thyroid in multinodular goitre: Case report and literature review.

INTRODUCTION: Multinodular goiter is defined as multiple discrete nodules in the thyroid gland. The incidence of Papillary carcinoma thyroid was found to be highest out of total Multinodular Goiter cases while that of Anaplastic carcinoma was the least. We report a rare coexistence of Papillary carcinoma and Anaplastic carcinoma in adult patient with a long-standing Multinodular Goiter. CASE PRESENTATION: Here we present a case of 54 years male with huge anterior neck swelling for 20 years with a gradual increase in size. Computerized tomography of neck revealed solidocystic mass lesion without any significant lymphadenopathy, features suggesting Multinodular goiter with differential diagnosis of Carcinoma Thyroid. Cytological examination showed Papillary thyroid Carcinoma. He underwent total thyroidectomy with central neck dissection. Postoperative period was uneventful. Histopathological report revealed features suggestive of mixed tumor of Papillary thyroid Carcinoma and Anaplastic Carcinoma thyroid TNM Staging T3 N0 M0, Stage IVA. After the final reports patient was sent for adjuvant therapy three weeks later where he received megavoltage external beam radiation and he was followed up till 12th week. He was assessed radiologically which showed no signs of physical progression of the disease. However, he was lost to follow up after that visit. DISCUSSION: Long-standing benign conditions of thyroid can transform into malignant forms in the undefined duration of time. CONCLUSION: Regular follow up and early management of multinodular goiter at the right time can save a patient from undue stress and complication like the conversion into malignancy.

Verrucous Carcinoma in a Giant Cutaneous Horn: A Case Report and Literature Review.

BACKGROUND: A cutaneous horn is a common clinical entity which usually presents as a cutaneous lesion. Because of its subtle nature, patients usually tend to present late unless the lesion is big or complications develop. Because of its resemblance to animal horn, it has been given the term "horn." Cutaneous horn seems to have a remarkable history. Though cutaneous horn is benign most of the times, chances of malignancy (20-25%) should be kept in mind. Old age, giant cutaneous horn carries more chances of transformation into malignancy like in our case. Thus, early diagnosis and treatment is required in all cases. Case Presentation. We report a case of a 74-year-old farmer with a cutaneous projection measuring ∼8 × 5 × 3 cm3 over the medial surface of the right pinna for 1 year. It started as a small projection which was progressively enlarging. The primary reason behind him presenting to us was cosmetic reason since it resembled an animal horn. The projection was not associated with pain or similar lesions anywhere else in body. Understanding the malignancy risks and the cosmetic benefits, he was planned for excision biopsy of the horn. He had no systemic signs of malignancy. Histopathological reports were consistent with malignancy. CONCLUSIONS: Cutaneous horns are usually benign lesions and mostly found in the head and neck region. Because of the chances of malignancy, cutaneous horns should undergo surgical removal and biopsy for early and definitive diagnosis and management.

Simultaneous Hydatid Cyst of the Liver and Left Iliac Fossa: An Unusual Case Report.

Hydatid disease is a significant health problem in many livestock-rearing areas especially in the developing world, mainly caused by Echinococcus granulosus. The liver and lung are the most common affected sites. However, hydatid disease can occur anywhere in the body. Simultaneous involvement of two organs or sites is very unusual, mainly for organs other than the lung and liver. We thus report a very unusual combination of hepatic and left iliac fossa with hydatid disease in an adult patient. A 37-year-old farmer from a village presented with intermittent right upper quadrant and left iliac fossa pain associated with distention of abdomen for one month. Abdominal radiological investigations reported hydatid cyst disease; one cyst was found in the right lobe of the liver and another in the left iliac fossa. Positive IgG antibody by the ELISA test also confirmed the diagnosis. Pericystectomy and excision of hydatid cyst without spillage of content for the liver and left iliac fossa were done, respectively. Patient was discharged on the 10th postoperative day with an uneventful postoperative course. There was no recurrence of the lesion during one-year follow-up period. A combination of hydatid disease in the liver and iliac fossa is very unusual, so clinician should have thoughts regarding this rare entity as an important differential diagnosis.

Colonic Volvulus: An Experience at Tertiary Care Hospital in Nepal.

INTRODUCTION: Colonic volvulus is not an uncommon cause of large bowel obstruction. Limited research has been done about colonic volvulus in our part of the world which has been regarded as "volvulus belt." The aim of this study is to evaluate the clinical features, management, and factors affecting perioperative outcomes in patients with colonic volvulus. METHODS: A retrospective review of medical records of all patients managed for colonic volvulus in Universal College of Medical Sciences, Bhairahawa from January 2012 to December 2016 was done. Data on patient demographics, clinical course, methods of treatment, and outcomes were analyzed. RESULTS: A total of 62 patients (46 males) were studied. Mean age was 57.9 ± 10.4 years. The most common site involved was sigmoid (85.5%). The diagnosis was made by abdominal x-rays in 39 patients (62.2%), CT scan in 13 patients (21%), and laparotomy in 10 patients (16.1%). Fifty-eight patients (93.5%) were treated surgically. Resection and ostomy was the commonest operation performed in 30 patients (48.7%) followed by resection with anastomosis in 24 patients (38.7%). The overall complication was 38.7%. There were 9.7% of deaths. In multivariate analysis, age ( ≥ 60 years) (odds ratio (OR); 27.0, confidence interval (CI); (1.92-403), P; 0.01), preoperative hypotension (systolic blood pressure <90 mmHg) (OR; 7.82, CI; (1.19-51.2), P; 0.03), and gangrenous bowel (OR; 76.7, CI (3.60-1632), P; 0.005) were significant predictors of postoperative complications . CONCLUSIONS: Volvulus of the colon is common in males and constipation is being commonest risk factors for volvulus. Surgeons should have a high index of suspicion and should be aware of these problems to make the early diagnosis with prompt treatment and to ensure better patient outcomes in volvulus endemic areas like ours.

Volvulus of sigmoid colon in a challenged adolescent: An unusual case report.

Sigmoid volvulus is very uncommon cause of intestinal obstruction in pediatrics population withhigh rate of mortality. To date, few cases of sigmoid volvulus in children and association with several condition has been reported in literature, of them very few cases are with mental disability. We report a challenged (mentally disabled) 14-year old adolescent boy presented asan emergency with feature of complete bowel obstruction. Abdominal X-rays shows dilated loop of large bowel with inverted U shaped. Volvulus of sigmoid colon was found during laparotomy and successfully managed with resection of a redundant colon with colocolic end to end anastomosis. Sigmoid volvulus is relatively uncommon in children as compared to adults. Surgeons should be attentive of this rare entity, cause of large bowel obstruction to allow for early diagnosis and to enable better patient outcomes by reducing the morbidity and mortality.

Buccal oncocytoma: Report of a case and literature review.

INTRODUCTION: More common in major salivary glands, oncocytomas are very rare tumors. They commonly occur in the parotid gland and are painless slow growing predominantly benign tumors. The term "oncocytoma" was introduced by Jaffe to designate those tumors of the salivary glands that consist predominantly of oncocytic cells lining the salivary ducts (1) Similalry, Meza- Chavez had proposed the name "oxyphilic granular cell adenoma. (2) Oncocytomas are extremely rare, benign and slow growing in nature. Here we present a rare case of buccal oncocytoma which is to our knowledge the 19th case of intraoral minor salivary gland tumor and the 7th reported case of buccal oncocytoma. CASE PRESENTATION: Here we present an exceedingly rare case of buccal oncocytoma in a 14 years boy who presented to the department of ENT with right buccal swelling for 6 months. He was posed the diagnosis of buccal cyst after cytological examination supported by CT scan. He then underwent an excisional biopsy where the final diagnosis was made as Buccal Oncocytoma. CONCLUSIONS: Though very rare in the picture, conditions like salivary gland oncocytomas still are reported on and off in the literature. The treatment of which is complete surgical excision.

Rare giant maxillay mucocele: A rare case report and literature review.

INTRODUCTION: Mucocele is a slow growing, benign but locally aggressive cystic structure lined by true epithelium. It often results due to obstructed sinus outflow or obstruction of gland-like mucous retention cyst. It can cause bony destruction and might result in orbital symptoms like diplopia, orbital displacement, visual disturbances. Other clinical features are facial numbness, dental problems, etc. Radiological evaluation is the preferred diagnostic modality. Surgical removal is the treatment of choice both endoscopic and open (could well luc) approach or combined approach are preferred. Here we report a very typical case of maxillary mucocele who presented with subtle symptoms of nasal obstruction. The study was done in compliance with SCARE guidelines.[1]. CASE PRESENTATION: We present a very unique case of 24 years man with complaints of nasal obstruction and swelling over the right cheek for 2 years. He had a history of facial trauma two years back. Diagnosis was made on the basis of radiological examination CT (Computed Tomography) scan. He underwent enucleation via Cold well Luc's approach with good postoperative results. CONCLUSION: Maxillary mucoceles are slow growing benign lesions. However, they are locally aggressive and cause bony destruction resulting into orbital and dental symptoms. Thus early recognistion with regular folllowr up and planning for surgical intervention can help avoid complications.

Vestibular Schwanomma: An Experience in a Developing World.

BACKGROUND: Tumors related to the acoustic nerves represent 90% of cerebellopontine angle diseases and have been in the picture for at least 200 years. Famous as acoustic neuromas and vestibular neuromas, these are usually benign, slow-growing tumors of Schwann cells of the myelin sheath. Surgery is the treatment of choice though some authors have suggested "wait and watch" policy. The aims of our study were to study the clinical presentation and management of the tumors, and to evaluate the perioperative outcomes of the surgery. METHODS: A retrospective review of the datasheet of 33 patients diagnosed with vestibular schwanomma who had undergone surgery from January 2014 to January 2017 was performed in National Academy of Medical Sciences, Bir Hospital, Kathmandu, Nepal. Analysis of the demographic data and perioperative outcomes was performed. RESULTS: Hearing loss was the main presenting symptom in 72% cases followed by tinnitus, dizziness, facial numbness and sudden sensorineural hearing loss. Mean tumur size was 39.7 ± 3 mm. The mean age of the patients was 46 ± 3 years with a female preponderance (1.2:1). In particular, the retrosigmoid route was preferred in all the cases since it was the most employed approach at our center and 63% of the tumors presented to us were grade 5. The surgical techniques allowed safe preservation of the facial function which was 93%. The hearing loss did not improve after the surgery in 94% while it worsened in 6% of cases. We did not find any significant relation between outcome and size, age, gender or laterality of the tumor (P > 0.05). There was no perioperative mortality. CONCLUSIONS: The benign and slow-growing nature of vestibular schwanomma usually poses problems for the early diagnosis and treatment especially in a poor resource setting like ours. Likewise, there are very few studies so far done in the country regarding the incidence and management of the disease. Thus, this study might be helpful in providing insight into the occurrence of the disease in the present scenario and the need for much more studies in the future.

Massive encrustations as a consequence of longterm indwelling urethral catheter: A rare case report.

Longterm indwelling urethral catheter can cause several complications such as lower urinary tract infections, tissue damage, pain, hemorrhage and encrustation of catheter leading to blockage. A 55- year old male presented with suprapubic pain for three months owing to poorly draining Foley catheter. He had undergone surgery for bladder calculi two and half a years back. He had been discharged with Foley catheter. He did not show up at the hospital for two and half years. The catheter was never changed during this period. Plain X-ray abdomen revealed a large encrustation with radiopacity surrounding the foley's bulb. Open suprapubic cystostomy was performed. The intact Foley catheter with encrusted bulb was removed. His postoperative period was uneventful. Surgical removal is the only treatment of choice for unusual massive encrustations in long-term indwelling urethral catheter. Minimally invasive technique is getting popularity, however we performed open cystostomy and removal due to the lack of expertise and instruments in our hospital setting. Catheterization under aseptic condition, frequent catheter change, early treatment of urinary infection and proper patient education on catheter hygiene are few methods that can reduce the complications of longterm indwelling urinary catheter.

A rare case report of patent vitellointestinal duct causing bowel obstruction in an adult.

INTRODUCTION: Patent vitellointestinal duct occurs in about 2% of the population which unusually leads to small intestinal obstruction associated with high morbidity and mortality. Here we are reporting an unusual case of patent vitellointestinal duct causing small intestinal obstruction in an adult patient. PRESENTATION OF CASE: A 22-year-old male without any medical illness presented as an emergency with a 3day hystory of abdominal pain, multiple episode of vomiting and abdominal distention. Distended abdomen and sign of peritonitis were found on abdominal examination. Abdominal X-rays revealed multiple small intestinal air-fluid levels. A patent vitellointestinal duct extending from distal ileum to the posterior wall of the umbilicus was found causing closed loop ileal obstruction during laparotomy. Resection of a vitellointestinal duct along with gangrenous distal ileum and cecum with ileocolostomy was performed. He was discharged on the 8 th postoperative day. DISCUSSION: Diagnosing and management of cause of intestinal obstruction in patients without history of abdominal surgery is very challenging. Early resuscitation and timely surgical intervention of intestinal obstruction due to a rare patent vitellointestinal duct can be life-saving measure. CONCLUSION: The patent vitellointestinal duct is an uncommon entity in adults and moreover this disorder leading to intestinal obstruction is very rare. Surgeons should be aware of this infrequent cause of small bowel obstruction to allow for early diagnosis and to facilitate better patient outcomes.

Acute Appendicitis in Pregnancy and the Developing World.

BACKGROUND: Acute appendicitis is the commonest nonobstetric surgical emergency during pregnancy. The aim of the study was to compare perioperative outcomes of acute appendicitis in pregnant and nonpregnant patients. METHODS: A retrospective review of medical records of 56 pregnant patients between 2011 and 2016 who were compared with 164 nonpregnant women of reproductive age who underwent open appendectomy between 2014 and 2016 for acute appendicitis. The patient's demographics and perioperative data were analyzed. RESULTS: The median age of pregnant and nonpregnant patients observed was 26 years (range 19-37) and 26 years (range 18-43). There were no significant differences between the groups in negative appendectomy (21.4 and 21.3%, P = 0.52), perforated appendicitis (25 and 23.8%, P = 0.85), postoperative complications (28.6 and 26.8%, P = 0.80), and median length of hospital stay (5 and 4.5 days, P = 0.36). There were 3.6% preterm labour, no maternal mortality, and no fetal loss. In multivariate analysis, WBC >18000/mm3 and long patient time to surgery were independent risk factors for appendicular perforation and postoperative complication (P < 0.05). CONCLUSION: Our results of appendectomy in pregnant patients are comparable with nonpregnant patients. Hence the same perioperative treatment protocol can be followed in pregnant and nonpregnant patients even in resource-poor setting.

Laparoscopic Cholecystectomy in the Elderly: An Experience at a Tertiary Care Hospital in Western Nepal.

BACKGROUND: The incidence of gallstone increases with increasing age. No studies have been reported in the elderly population with laparoscopic cholecystectomy from developing nations. The aim of this study was to compare perioperative outcomes of laparoscopic cholecystectomy between the elderly (≥60 years old) and the young (<60 years old). METHODS: From July 2015 to June 2016, a retrospective review of medical records of 78 elderly patients (≥60 years old) and 164 young patients (<60 years old) who underwent laparoscopic cholecystectomy was done. The patients' demographics and perioperative outcomes were analyzed. RESULTS: Median ages were 65 years (range: 60-80) and 45 years (range: 21-59) for the elderly group and the young group. The majority of patients were female (62.8 and 72%). There were no significant differences in the conversion rate (9 and 7.9%, P = 0.78), postoperative complications (17.9 and 14.6%, P = 0.50), and length of stay in the hospital (4 days for both groups, P = 0.35) between the two groups. There was no mortality in either of the groups. CONCLUSION: Our results of laparoscopic cholecystectomy in elderly patients are comparable with those in young patients. Therefore, laparoscopic cholecystectomy is safe even in the elderly population.

A Child with Severe Malaria Presenting with Acute Surgical Abdomen (Duodenal Perforation).

Plasmodium falciparum, the commonest cause of severe malaria in children, is an important cause of mortality in developing nations like Nepal. Duodenal perforation in a case of complicated malaria, although a rare entity, can occur in children. Early diagnosis, proper medical treatment, and early surgical repair can be a lifesaving measure in such cases. Here, we report a case of a 5-year-old male child with falciparum malaria complicated by a duodenal perforation that was successively managed with appropriate antimalarial drugs and early surgical repair.