Chylous ascites following retroperitoneal lymphadenectomy in a patient with recurrent dysgerminoma of ovary: A case report.

Chylous ascites is an uncommon condition of accumulation of milky fluid rich in lymph and chylomicrons in the peritoneal cavity. Post-surgical complications following dissection near the base of the mesentery, retroperitoneum, or near the cisterna chyli, malignancies (e.g., pancreatic adenocarcinomas, lymphoma, gastric carcinoma), cirrhosis, and trauma are the prime causes of chylous ascites. Here we report a rare case of chylous ascites following clearance of isolated paraaortic nodal recurrence in a 28-year-old female with dysgerminoma of ovary. The patient developed chylous ascites on the fifth day following surgery, which was confirmed by an increased drain fluid triglyceride level. She was managed conservatively with dietary modification including a high-protein and carbohydrate but low-fat-based diet mainly containing medium-chain fatty acids. Subsequently, she recovered from chylous ascites on the sixteenth day, completed second line chemotherapy, and is now doing well.

Multimodality treatment of a primary vulvar melanoma in a low resource setting: A case report.

Primary vulvar melanoma is a rare but highly aggressive malignant neoplasm accounting for 1-2 % of all malignant melanoma and 5-10 % of all vulvar cancers in females. Here we report a case of 32 years old female diagnosed with primary vulvar melanoma during the evaluation of a two cm growth in the inner labia minora on the right side. She underwent wide local excision with excision of the distal one cm of the urethra and bilateral groin node dissection. The final histopathology was vulvar malignant melanoma with 1 out of 15 groin nodes involved but all resected margins were free of tumor. The final surgical stage was T4bN1aM0 (8th AJCC TNM) and IIIC (FIGO). She received adjuvant radiotherapy followed by 17 cycles of Pembrolizumab. To date, she is both clinically and radiologically disease free with a progression-free survival of 9 months.

A thalamic epidermoid cyst presenting with memory disturbances: a case report.

Epidermoid cysts are benign, slow-growing tumors. They account for 0.2-1.8% of all intracranial tumors and rarely appear as intraparenchymal masses. The most prevalent symptom in people of middle age is an insidious-onset headache. Case presentation: We present a 20-year-old college student who presented with memory disturbances. The imaging revealed a left thalamic mass. The tumor was excised and diagnosed histopathologically as an epidermoid cyst. Clinical discussion: Epidermoid cysts resemble epidermal skin cells in histology. The lesion of the thalamus involving the ventrolateral and anterior regions is involved with memory and language. Of note, to our knowledge, no cases of memory issues associated with thalamic epidermoid cysts have been reported in the literature. Conclusion: The ideal treatment is cystic component removal with complete capsule excision. Sometimes, in cases of incomplete excision, radiotherapy can be another option.

Clinical profile and dynamic magnetic resonance imaging in Hirayama disease: a single-centered cross-sectional study in Nepal.

Hirayama disease (HD) is juvenile monomelic amyotrophy of the distal upper limb first described by Hirayama in 1959 AD. HD is a benign condition with chronic microcirculatory changes. The hallmark of HD is necrosis of the anterior horns of the distal cervical spine. Materials and Methods: Eighteen patients were assessed for clinical and radiological Hirayama disease. Clinical criteria included insidious onset nonprogressive chronic upper limb weakness and atrophy in teens or early twenties without sensory deficits and coarse tremors. MRI was done in a neutral position followed by neck flexion to evaluate cord atrophy and flattening, abnormal cervical curvature, loss of attachment between the posterior dural sac and subjacent lamina, anterior shifting of the posterior wall of the cervical dural canal, posterior epidural flow voids, and an enhancing epidural component with its dorsal extension. Results: The mean age was 20.33 years, and the majority, 17 (94.4%), were male. Neutral-position MRI revealed loss of cervical lordosis in 5 (27.8%) patients, cord flattening in all patients with asymmetry in 10 (55.5%), and cord atrophy was observed in 13 (72.2%) patients with localized cervical cord atrophy in only 2 (11.1%) and extension of atrophy to dorsal cord in 11 (61.1%) patients. Intramedullary cord signal change was seen in 7 (38.9%) patients. Loss of attachment of posterior dura and subjacent lamina and anterior displacement of dorsal dura was seen in all patients. A crescent-shaped epidural intense enhancement was noted along the posterior aspect of the distal cervical canal in all patients, with dorsal level extension in 16 (88.89%) patients. The mean thickness of this epidural space was 4.38±2.26 (mean±2SD), and the mean extension was 5.5±4.6 vertebral levels (mean±2SD). Conclusion: The high degree of clinical suspicion can guide additional contrast studies in flexion as a set MRI protocol for early detection and avoiding false negative diagnoses of HD.

A Type II hybrid effectiveness-implementation study of an integrated CHW intervention to address maternal healthcare in rural Nepal.

Skilled care during pregnancy, childbirth, and postpartum is essential to prevent adverse maternal health outcomes, yet utilization of care remains low in many resource-limited countries, including Nepal. Community health workers (CHWs) can mitigate health system challenges and geographical barriers to achieving universal health coverage. Gaps remain, however, in understanding whether evidence-based interventions delivered by CHWs, closely aligned with WHO recommendations, are effective in Nepal's context. We conducted a type II hybrid effectiveness-implementation, mixed-methods study in two rural districts in Nepal to evaluate the effectiveness and the implementation of an evidence-based integrated maternal and child health intervention delivered by CHWs, using a mobile application. The intervention was implemented stepwise over four years (2014-2018), with 65 CHWs enrolling 30,785 families. We performed a mixed-effects Poisson regression to assess institutional birth rate (IBR) pre-and post-intervention. We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to evaluate the implementation during and after the study completion. There was an average 30% increase in IBR post-intervention, adjusting for confounding variables (p<0.0001). Study enrollment showed 35% of families identified as dalit, janjati, or other castes. About 78-89% of postpartum women received at least one CHW-counseled home visit within 60 days of childbirth. Ten (53% of planned) municipalities adopted the intervention during the study period. Implementation fidelity, measured by median counseled home visits, improved with intervention time. The intervention was institutionalized beyond the study period and expanded to four additional hubs, albeit with adjustments in management and supervision. Mechanisms of intervention impact include increased knowledge, timely referrals, and longitudinal CHW interaction. Full-time, supervised, and trained CHWs delivering evidence-based integrated care appears to be effective in improving maternal healthcare in rural Nepal. This study contributes to the growing body of evidence on the role of community health workers in achieving universal health coverage.

A case report: Lateral medullary syndrome with facial nerve palsy and hemiparesis.

Lateral medullary syndrome (LMS) is the most common and severe neurological syndrome associated with atherothrombotic occlusion of the intracranial vertebral artery, followed by posterior inferior cerebellar artery and medullary artery occlusion. It presents as a typical triad of oculosympathetic palsy (Horner's syndrome), ipsilateral gait ataxia, and hypoalgesia with ipsilateral thermoanesthesia of the face. In LMS, the upper motor neuron facial palsy is caused by the involvement of aberrant supranuclear fibers of the facial nerve. The caudal extension of the infarction to the pyramidal tracts may explain contralateral hemiparesis. Here, we have discussed a 42-year-old non-diabetic, hypertensive male with LMS, hemiparesis, and left UMN-type facial palsy. We reported this case because developing nations, have few tertiary level health facilities for neurological examination, and non-neurologists often miss the diagnosis; therefore, the characteristics must be known and understood.

A rare case report on hypertrophic pachymeningitis: Serum IgG4-related disease.

IgG4-related disease (IgG4-RD) is an immune-mediated inflammatory condition of unknown etiology characterized by invasion of tissue by IgG4-producing plasma cells. It can affect almost any organ system, but central nervous system involvement is a rare occurrence. A careful clinicopathological correlation is required to establish the diagnosis. The condition is highly treatable with glucocorticoids, but it is likely that it is underdiagnosed. Although IgG4-related disease responds quickly to glucocorticoids, if left untreated, can lead to end-stage organ failure and even death. We present a case of a 46-year-old female patient who presented with headache, tingling, numbness, flickering movement in her left lower limb gradually extending to torso and head, and loss of consciousness. After radiological and immunohistochemical studies, the diagnosis of IgG4-related hypertrophic pachymeningtis was confirmed. Corticosteroid therapy was administered, and the patient symptomatically improved. Clinicians should be aware of this rare condition, and the importance of early diagnosis and appropriate corticosteroid therapy should be emphasized.

A case report on recurrent area postrema syndrome in AQP4-IgG-positive NMOSD.

Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory condition of the central nervous system caused by severe immune-mediated demyelination and axonal destruction, mainly affecting optic nerves and the spinal cord. We describe a 26-year-old Nepalese woman with recent onset of headache, nausea, vomiting and hiccups indicative of Area Postrema Syndrome (APS). The antibody test for aquaporin-4 was strongly positive. Brain magnetic resonance imaging (MRI) showed a bilateral hyperintense signal in the area postrema (AP). The patient started on methylprednisolone, and then azathioprine was added. However, the patient was readmitted because of tingling in her right upper extremity and sudden onset of tremors. An MRI scan showed an enlarged lesion in AP. Rituximab was started on top of the previous treatment, and a second dose was given after 2 weeks. The patient had been monitored regularly and symptom-free for 5 months. Hence, we emphasize the immediate need for a diagnostic approach for NMOSD management.

Catecholaminergic Polymorphic Ventricular Tachycardia Presented As Generalized Tonic-Clonic Seizure: A Case Report.

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited, highly malignant cardiac channelopathy that causes autopsy-negative sudden deaths and sudden infant deaths. The symptoms of CPVT range from asymptomatic to syncopal. We present a patient who has had sporadic seizures for the last four years and was diagnosed with focal seizures. Genetic testing revealed heterozygosity for a variant of uncertain significance in the cardiac ryanodine receptor (RYR2). Pathogenic variants are known to be associated with CPVT. A subcutaneous implantable cardioverter-defibrillator (ICD) was placed and is being closely followed in the cardiology clinic.

Vulval Aggressive Angiomyxoma in a 19 year teenager: a case report.

BACKGROUND: Aggressive Angiomyxoma is a benign, slowly growing, locally aggressive and recurrent tumour that occurs in the pelvic-perineal region of females in their reproductive years. It presents as a painless, soft, gelatinous mass and metastasizes rarely. Suspicion can be made based on clinical examination and radiological imaging but final diagnosis is confirmed only after histopathology and immunohistochemistry. The choice of treatment is surgical wide local excision. CASE PRESENTATION: We hereby present a case of a 19-year, unmarried lady, with a body mass index of 21 kg/m2, who presented with a chief complaint of painless mass in left vulva which progressively increased in size in the past one year. Clinical examination revealed a large, cauliflower like, exophytic mass of 10 cm × 10 cm size. Radiological imaging confirmed involvement of lymph nodes. Wide local excision with adequate tumour free margin and depth was used as a treatment modality. The diagnosis was confirmed via histopathological examination of the excised specimen. There is no recurrence in the patient up to date. CONCLUSION: Aggressive Angiomyxoma is a rare tumour and it is most often misdiagnosed. This report highlights the importance of considering Aggressive Angiomyxoma as a differential diagnosis of vulval masses and the two-step surgical approach for its treatment in low resource setting.

Clinico-Radiological Profile of Patients With Lateral Medullary Syndrome: A Five Years Observation From a Single-Centered Tertiary Hospital in Nepal.

OBJECTIVE: We aim to correlate the prevalence of symptoms of the lateral medullary syndrome (LMS) based on radiological classification. METHODS: A five-year record of 41 patients diagnosed with LMS and admitted to a tertiary care center in Nepal was reviewed. We used chi-square tests to compare symptoms between rostral and caudal groups and different horizontal subtypes. RESULTS: The subtype prevalence in the horizontal classification of LMS was large (31.7%), lateral (22%), dorsal (19.5%), typical (14.6%), and ventral (12.2%). The most common symptoms in the typical subtype of the horizontal classification were: pain/temperature loss in the contralateral body (7.3%) and dysphagia (7.3%); in the ventral subtype, swaying on the Romberg test (12.2%), dysarthria (9.8%) and dizziness (9.8%); in the dorsal subtype, headache (12.2%) and vomiting (12.2%). Whereas headache (22.2%) and lateropulsion on standing (14.6%), swaying on the Romberg test (14.6%), nausea/vomiting (14.6%) were common in the large subtype, and nausea/vomiting (19.5%) and headache (17.1%) in the lateral subtypes. Whereas, in rostrocaudal classification, the rostral subtype (61%) was more common than the caudal subtype (31%). There was no significant variation in symptoms based on the rostrocaudal classification of LMS. CONCLUSION: The common clinical manifestations are different for different radiological subtypes of LMS. Further comprehensive studies are essential to understand the prevalence of symptoms in different radiological subtypes and the clinical-radiologic correlation in LMS.

Peripheral Leukocytosis and Clinical Outcomes After Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (SAH) has a high morbidity rate. Following SAH, a powerful systemic inflammatory response ensues contributing to delayed neurological deterioration and outcome. The aim of this study is to investigate if peripheral leukocytosis following SAH impacts clinical outcomes. METHODS: This is a retrospective, observational, single tertiary center study of patients with SAH who underwent microsurgical clipping between 2017 and 2020. The study's inclusion criteria were aneurysmal SAH on baseline computerized tomography (CT), age above 18 years, and hospital admission within 72 hours of bleeding. Traumatic SAH, arteriovenous malformations, and mycotic aneurysms were all excluded. On admission, leukocyte counts were recorded. Demographic and clinical variables were compared between the two groups (TLC ≤12,000 and >12,000). The impact of peripheral leukocytes on clinical outcomes in terms of the Glasgow Outcome Score (GOS) was analyzed. Mann-Whitney U test for continuous variable and Fisher exact test or chi-square test for categorical variables were used for calculation of P-value. A P-value of 0.05 or less was considered statistically significant. RESULTS: Among 90 patients who underwent clipping of ruptured aneurysms, 40 (44.4%) were anterior communicating artery (ACOMM) aneurysms, and 21 (23.3%) were middle cerebral artery(MCA), and 16 (17.8%) were posterior communicating artery (PCOMM). Clinically 57 patients (63.3%) had a World Federation of Neurosurgical Societies (WFNS) grade 1, 17 patients (18.9%) had a grade 2, four patients (4.4%) had a grade 3, and two patients (2.2%) had a grade 4. On radiological examination, six patients (6.7%) had fisher grade 1, 23 patients (25.6%) had grade 2, 22 patients (24.4%) had grade 3, and 39 (43.4%) had grade 4 SAH distribution. Clinical results were poor in 30 individuals (33.3 %), but good in 60 patients (66.7 %). On admission leukocytosis (>12,000) was seen among 34 (37.8%). Leukocytosis (>12,000) was associated with poor WFNS grade (>2); however, statistical significance was not seen with clinical outcome in terms of GOS. CONCLUSION: Poor clinical grade of patients following aneurysmal SAH is associated with peripheral leukocytosis; however, peripheral leukocytosis is not associated with poor outcomes.

Pituitary apoplexy presenting as isolated third cranial nerve palsy: case series.

Pituitary apoplexy (PA) is caused by a sudden increase in pressure in the pituitary region due to acute hemorrhage, infarction or necrosis. PA can also be caused by restricting blood supply to the nerve due to compression of the internal carotid artery. Acute third cranial nerve palsy (third CN) secondary to PA is a rare medical emergency caused by bleeding within a growing mass within the sella turcica. We presented two cases of PA with isolated third CN palsy treated with transsphenoidal pituitary decompression. PA is therefore an important differential diagnosis to consider in patients with isolated third nerve palsy. The prognosis for isolated third nerve palsy in PA appeared successful, with variable recovery from medical and surgical intervention.

Takayasu Arteritis Presenting As Epileptic Seizure: A Case Report.

Takayasu's arteritis is a chronic granulomatous large-vessel vasculitis condition that affects the large and medium-sized arteries, primarily the heart and its major vessels. The first symptoms and indicators of Takayasu arteritis differ because the afflicted arteries are heterogeneous. Furthermore, vascular lesions might be difficult to identify at first, further complicating diagnosis. Takayasu arteritis presenting as epileptic seizures is rare. Here, we discuss a 20-year-old female who presented with a brief period of unresponsiveness, followed by a tonic stiffening, limb jerks, a postictal period of fatigue, and temporal memory loss. During the acute phase of Takayasu arteritis, high-dose glucocorticoid therapy and immunosuppressive therapy were used to control inflammatory reactions. Her symptoms gradually improved, and she was discharged from the hospital after serial monitoring; her follow-up visits revealed no recurrence.

Psychological Distress and Coping among Pregnant Women during the COVID 19 Pandemic.

BACKGROUND: Mental health of pregnant individuals has been profoundly affected by the COVID-19 pandemic. Effective coping strategies are found to be associated with better psychological wellbeing during the COVID-19 pandemic. The objective of the present study is to assess psychological distress and coping among pregnant women during the COVID-19 pandemic. METHODS: A descriptive cross sectional study was conducted from May 2020 to July 2020 among 115 pregnant women attending obstetric unit of a tertiary care centre using convenience sampling technique. Ethical approval was obtained from the Institutional Review Committee of the Institute. Covid-19 Peritraumatic Distress Index and Brief COPE inventory was used to collect the data. Data entry was done in Microsoft Office Excel 2007 and analysed in SPSS version 16. RESULTS: Psychological distress was found in 2.6% of the participants. Psychological distress was significantly associated with occupation, fear of ANC visit, fear of visit to hospital for other health problems and fear of being alone or without help around delivery. Emotion focused coping was the most commonly used coping strategies among the pregnant women with the mean score of 21.37±3.130. Psychological distress and over all coping strategies had a positive correlation (<0.001). CONCLUSIONS: Psychological distress was found to be low among the pregnant women in this study. Fear of being without help and fear of contacting the virus during the visit to the hospital during the Covid-19 pandemic were the likely reasons of the psychological distress in the pregnant women.

Prevalence of Menstrual Abnormalities and its Effect among Undergraduate Students.

BACKGROUND: Menstrual abnormalities are menstrual problems that women face during their reproductive years. Globally, they are the most prevalent disorders affecting quality of life in females. This study aimed to assess the prevalence of menstrual abnormalities, its effects and health seeking behaviour of the respondents. METHODS: A cross-sectional study of 30 days was conducted among the undergraduate female students of BP Koirila Institute of Health Sceince who were more than 18 years and had attained their menarche. Total number of responses recorded were 137. Data was collected online via google forms and descriptive analysis was done using SPSS 23. RESULTS: Out of 137 participants, 94.89% had menstrual abnormalities. Among which, 75.38% females sought treatment. Dysmenorrhea and Pre-menstrual syndrome were found to be the most prevalent abnormality. The quality of life was affected in most of the females in terms of lack of concentration in study (91.54%), missing the opportunity for socialization (95.39%), inability to perform physical exercises (82.31%), extra hours of confinement to bed (38.46%) and unable to attend lectures (30%). CONCLUSIONS: The prevalence of menstrual abnormalities were high. Quality of life was affected in all the subjects with menstrual abnormality but only few of them were seeking treatment with a professional doctor.

Anxiety among Pregnant Women Attending Obstetrics Unit of a Tertiary Care Centre during the COVID-19 Pandemic: A Descriptive Cross-sectional Study.

Introduction: The disastrous effect of COVID-19 pandemic on the mental health of vulnerable populations like pregnant women should not be neglected. The objective of the study was to find out the prevalence of anxiety among pregnant women attending the obstetrics unit of a tertiary care centre during the COVID-19 pandemic. Methods: A descriptive cross-sectional study was conducted from 16 May 2020 to 30 July 2020 among pregnant women attending obstetrics unit of a tertiary care centre. Ethical approval was obtained from the Institutional Review Committee (Reference number: 365/076/077-IRC). Convenience sampling method was used. Pregnancy-related anxiety questionnaires were used and semi-structured questionnaires were used for sociodemographic data. Point estimate and 95% Confidence Interval were calculated. Results: Out of 115 pregnant women, anxiety was found in 21 (18.26%) (11.20-25.32, 95% Confidence Interval). Conclusions: Anxiety among the pregnant women reported in this study was found to be lower than similar studies conducted in similar settings. Keywords: anxiety; COVID-19; pregnancy.

Birth Defects among Newborns in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: The incidence of birth defects is 2-3% in the general population but it is increasing. An estimated 303,000 newborns die within 4 weeks of birth every year, worldwide, due to congenital anomalies. The objective of this study was to find out the prevalence of birth defects among newborns in a tertiary care centre. Methods: A descriptive cross-sectional study was done in the Department of Obstetrics and Gynaecology and the Department of Paediatrics from 15 June 2016 and 14 June 2019. Ethical approval was obtained from the Institutional Review Committee (Reference number: 142/077/078-IRC). Data of newborns were collected from the hospital records. Convenience sampling method was used. Point estimate and 99% Confidence Interval were calculated. Results: Among 32,695 newborns, birth defects were seen in 169 (0.51%) (0.41-0.61, 99% Confidence Interval). The most common birth defect was musculoskeletal defects seen in 60 (35.50%) newborns followed by central nervous system defect seen in 30 (17.75%) newborns. Conclusions: The prevalence of birth defects among newborns was lower than in other studies done in a similar setting. Keywords: birth defect; congenital malformation; prevalence.

Drug Reaction With Eosinophilia and Systemic Symptom (DRESS) Following Rifampicin Treatment: A Case Report.

Drug reaction with eosinophilia and systemic symptoms (DRESS) is an idiosyncratic severe cutaneous adverse reaction (SCAR) characterized by a skin rash with systemic involvement (e.g., hematological, solid organ abnormalities). Various medications, most commonly anticonvulsants (carbamazepine, phenytoin), antibiotics (vancomycin, amoxicillin), and sulfa drugs (dapsone, sulfasalazine), have been implicated. We report a case of a 75-year-old man with pulmonary tuberculosis under anti-tubercular treatment (ATT Category 1 as per the national guidelines of Nepal) presenting with rash, fever, liver dysfunction, and eosinophilia, a combination of features suggestive of DRESS. According to the national tuberculosis (TB) survey of 2018-2019, over 117,000 people in Nepal were living with TB, including 69,000 newly diagnosed people. In third-world countries, such as Nepal, with a high TB prevalence, and the Southeast Asian region (with a huge percentage of the global burden of TB incidence), the risk of life-threatening adverse drug reactions during ATT is high. However, a good response is seen if it is recognized early and on stopping ATT and receiving a course of steroids and emollients.

Intracellular action potential recordings from cardiomyocytes by ultrafast pulsed laser irradiation of fuzzy graphene microelectrodes.

Graphene with its unique electrical properties is a promising candidate for carbon-based biosensors such as microelectrodes and field effect transistors. Recently, graphene biosensors were successfully used for extracellular recording of action potentials in electrogenic cells; however, intracellular recordings remain beyond their current capabilities because of the lack of an efficient cell poration method. Here, we present a microelectrode platform consisting of out-of-plane grown three-dimensional fuzzy graphene (3DFG) that enables recording of intracellular cardiac action potentials with high signal-to-noise ratio. We exploit the generation of hot carriers by ultrafast pulsed laser for porating the cell membrane and creating an intimate contact between the 3DFG electrodes and the intracellular domain. This approach enables us to detect the effects of drugs on the action potential shape of human-derived cardiomyocytes. The 3DFG electrodes combined with laser poration may be used for all-carbon intracellular microelectrode arrays to allow monitoring of the cellular electrophysiological state.