Study of caudal ropivacaine with or without dexmedetomidine for postoperative analgesia in paediatric genitourinary infraumbilical surgery: a double-blinded randomized controlled trial.

Various studies have described the use of Dexmedetomidine with local anaesthetic drugs in caudal blocks for the management of postoperative pain in children. This study was designed to determine the analgesic effect of caudal Dexmedetomidine with Ropivacaine in paediatric genitourinary infraumbilical surgeries. Postoperative analgesic effects of caudal Ropivacaine with or without Dexmedetomidine in paediatric genitourinary infraumbilical were evaluated. This study was a prospective, interventional, comparative study conducted after ethical approval from the institute. Informed expressed consent was taken from each patient's guardians. The sample size was calculated to be 31 in each group. The two groups were randomly assigned and the intervention involved caudal epidural injection with either Ropivacaine combined with Dexmedetomidine or Ropivacaine with Normal Saline. Children receiving Ropivacaine with Dexmedetomidine had a significantly prolonged duration of analgesia compared to those receiving Ropivacaine alone (840.35 ± 149.97 vs. 412.90 ± 93.46 min, P < 0.001). Postoperative rFLACC scores were consistently lower in the Dexmedetomidine group, indicating better pain control (P < 0.05 at 6, 12, and 24 h). Total analgesic consumption was lower in the Dexmedetomidine group (500.67 ± 212.92 vs. 741.75 ± 268.06 mg, P < 0.01). No significant differences in adverse effects were observed between the groups. The addition of Dexmedetomidine to Ropivacaine in caudal epidural significantly prolongs analgesia, improves pain control, and reduces analgesic consumption in paediatric genitourinary infraumbilical surgeries.

Systemic lupus erythematosus associated with erythema multiforme: A rare case report of Rowell's syndrome.

Key Clinical Message: Although it is very uncommon, SLE may initially present with recurrent episodes of EM-like rash. Despite the various possibilities underlying their association, prompt identification, and treatment of SLE in patients presenting with EM is important to prevent death or serious organ damage. Abstract: Rowell's syndrome (RS) is an uncommon presentation of systemic lupus erythematosus (SLE) with erythema multiforme (EM)-like lesions associated with specific serological changes, including positive rheumatoid factor (RF), speckled antinuclear antibody (ANA), positive rheumatoid factor, or anti-La antibodies in the serum. Our case, a 41-year-old male, presented with features of EM. Upon investigation, we identified underlying systemic lupus erythematosus, marking a rare instance of SLE presenting for the first time as EM. Classical or true EM is precipitated by trigger factors such as infective agents like the herpes simplex virus, Mycoplasma pneumoniae, drugs like anticonvulsants, antibiotics, and non-steroid anti-inflammatory drugs, any underlying malignancy, or connective tissue disorders, and is not associated with any specific serological abnormalities. EM cases associated with LE lesions where an EM trigger factor is missing are considered an RS diagnostic criterion. In this case report, the importance of considering SLE in patients presenting initially with recurrent episodes of EM-like rash is emphasized. RS should be considered, especially when there is no evidence of triggering factors. Early diagnosis and prompt treatment of SLE are crucial to preventing death and irreversible organ damage.

Haloperidol-induced sudden cardiac arrest in a recently detected HIV and hepatitis C patient: A unique case report.

We herein described a case of a 45-year-old male recently detected with HIV and Hepatitis C who presented with signs of sepsis, developed delirium, and received haloperidol. Surprisingly, 10 min after intravenous administration, the patient developed Torsades de pointes and required immediate resuscitation. The report discusses the limited instances of cardiac arrest linked to haloperidol use, despite its generally perceived safety. The patient had no apparent risk factors, emphasizing the need for increased caution when administering haloperidol, particularly in critically ill patients with HIV and Hepatitis C.

Prevalence and clinical impact of anemia in patients diagnosed with chronic obstructive pulmonary disease: A cross-sectional study.

Background and Aims: Unlike classically described polycythemia, anemia is found to be more prevalent in patients with chronic obstructive pulmonary disease (COPD). Anemia increases the cost of hospital stay and causes an increased risk of adverse outcomes including death in COPD patients. This study was done to find the prevalence of anemia in COPD patients, the factors associated, and the outcomes of anemic COPD. Methods: It was a quantitative, descriptive-analytical, and cross-sectional study conducted in Tribhuvan University Teaching Hospital's medical wards and the Emergency Room from September 2019 to September 2020. A simple random sampling method was used. Clinical information was obtained, and patients were followed up 3 months after discharge to document the number of exacerbations and deaths if present. Results: The patients in our study had a mean age of 70.80 ± 11.16 years. Most were female. Most (85.5%) had a history of exposure to firewood smoke. Twenty-three percent of the patients had anemia and these patients had significantly greater mortality 3 months postdischarge. Middle-old and old were more likely to have anemia with odds ratio (OR) of 2.55 (confidence interval [CI]: 0.48-13.5) and 13.6 (CI: 1.12-24.2), respectively. Current smokers had less likelihood of having anemia (OR: 0.05, CI: 0.006-0.49). Multivariate analysis showed that age, sex, and smoking status were significant determinants of anemia in COPD. There was no association between anemia and duration of hospital stay. However, mortality was higher at 3 months in COPD patients with anemia (p < 0.001). Conclusion: In COPD patients, anemia is prevalent comorbidity that is significantly linked to higher mortality but not to exacerbations. It is unknown, though, if treating anemia in COPD patients will affect the patient's outcome. Additional research in this area may be possible.

Radiologic finding of intraosseous gas: A rare case of emphysematous osteomyelitis of the foot.

Emphysematous osteomyelitis is a rare but potentially life-threatening infection which is characterized by presence of intraosseous gas. It is a very rare form of osteomyelitis which is complicated by infection with gas forming organisms. In majority of the cases, it has been found to be associated with comorbidities like immunosuppressive therapies, diabetes mellitus, alcohol use, and several others. Early identification on radiologic imaging is necessary to enable implementation of prompt treatment plan.

Safety and efficacy of prophylactic anticoagulation versus therapeutic anticoagulation in hospital-admitted COVID-19 patients: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: COVID-19 disease-related coagulopathy and thromboembolic complication, an important aspect of the disease pathophysiology, are frequent and associated with poor outcomes, particularly significant in hospitalized patients. Undoubtedly, anticoagulation forms a cornerstone for the management of hospitalized COVID-19 patients, but the appropriate dosing has been inconclusive and a subject of research. We aim to review existing literature and compare safety and efficacy outcomes of prophylactic and therapeutic dose anticoagulation in such patients. METHODS: We did a systematic review and meta-analysis to compare the efficacy and safety of prophylactic dose anticoagulation when compared with therapeutic dosing in hospitalized COVID-19 patients. We searched PubMed, Google Scholar, EMBASE and COCHRANE databases from 2019 to 2021, without any restriction by language. We screened records, extracted data and assessed the risk of bias in the studies. RCTs that directly compare therapeutic and prophylactic anticoagulants dosing and are not placebo-controlled trials were included. Analyses of data were conducted using the Mantel-Haenszel random-effects model (DerSimonian-Laird analysis). The study is registered with PROSPERO (CRD42021265948). RESULTS: We included three studies in the final quantitative analysis. The incidence of thromboembolic events in therapeutic anticoagulation was lower in comparison with prophylactic anticoagulation in hospitalized COVID-19 patients and reached statistical significance [RR 1·45, 95% CI (1.07, 1.97) I2 -0%], whereas major bleeding as an adverse event was found lower in prophylactic anticoagulation in comparison with therapeutic anticoagulation that was statistically significant [RR 0·42, 95% CI(0.19, 0.93) I2 -0%]. CONCLUSION: Our study shows that therapeutic dose anticoagulation is more effective in preventing thromboembolic events than prophylactic dose but significantly increases the risk of major bleeding as an adverse event. So, the risk-benefit ratio must be considered while using either of them.

Prevalence of methicillin-resistant Staphylococcus aureus carriage among healthcare workers in South Asia in non-outbreak settings: A systematic review and meta-analysis.

BACKGROUND: This study aimed to estimate the pooled prevalence and sub-group-specific prevalence of Methicillin-resistant Staphylococcus aureus (MRSA) carrier rate among Healthcare Workers (HCWs) in South Asia. METHODOLOGY: We considered prospective and cross-sectional studies published in the English language with participants ≥50 by searching different electronic databases to locate the relevant articles that reported the epidemiology of MRSA. The participants were healthy South Asian nationality HCWs (asymptomatic for any infectious disease) of any age and gender with a definitive diagnosis of MRSA carriage. The result was synthesized for the pooled prevalence of MRSA carriers among HCWs using 95% confidence interval (CI) with DerSimonian and Laird random-effects models. RESULTS: The pooled prevalence of MRSA carriage among HCWs was 9.23% (95%CI; 6.50%, 12.35%) with a range from 0.67% to 36.06%. The prevalence in India, Nepal, Pakistan, Sri Lanka, and Bangladesh was 5.65% (95%CI; 3.65%, 8.03%), 8.83% (95%CI; 6.77%, 11.11%), 17.20% (95%CI; 10.70%, 24.85%), 22.56% (95%CI; 4.93%, 47.83%), and 4.93% (95%CI; 1.88%, 9.20%) respectively. The pooled prevalence of MRSA carriage among nurses and doctors was 8.90% (95%CI; 6.00%, 12.24%) and 6.53% (95%CI; 3.63%, 10.06%) respectively. CONCLUSION: The findings from our study suggests that if the propagation of MRSA continues, then it can lead to a situation of an outbreak. Hence, proper preventive measures are to be adopted to prevent this outbreak.

A case of huge ovarian cyst in second trimester: A rare case report.

Introduction: Large cystic masses are rare in pregnancy. Corpus luteum cysts and theca lutein cysts are common are most common among all. Ovarian masses are usually discovered as an incidental finding during routine obstetric ultrasonography. Management depends upon the size of the mass, and the symptoms produced by the mass. Case presentation: Our case describes an incidental finding of a large ovarian cyst during the second trimester, in a 24-year-old female patient. Per abdominal examination revealed a huge mass in the epigastrium, left hypogastrium, and left lumbar region, along with 20 weeks sized uterus. Ultrasonography revealed a cystic mass of 11.9 cm × 11.7 cm X 15.9 cm, with multiple septations and cystic areas. After other baseline investigations, she was planned for surgical removal of the mass. Upon histopathologic examination after surgical excision, the mass was found to be mucinous cystadenoma. Discussion: Large ovarian masses are uncommon during pregnancy. The most common complications of ovarian masses in pregnancy are torsion, rupture, infection, or malpresentation of the fetus. Surgical management can be done if the mass presents with acute symptoms like torsion, or if the size of the mass is greater than 5 cm. Non-obstetric surgery for cyst removal can be done electively during the second trimester, or irrespective of the period of gestation if there are acute symptoms. Conclusion: Large ovarian masses are usually rare during pregnancy. It is necessary to properly evaluate the case of ovarian masses during pregnancy, to decide the appropriate line of management.

A rare incidental finding of an isolated S1 butterfly vertebra: A case report.

Butterfly vertebra is an uncommon type of vertebral anomaly (sometimes referred to as a sagittal cleft vertebra or an anterior rachischisis) caused by persistent notochordal tissue. Butterfly vertebrae of S1, which is rarer anomaly compared to thoraco-lumbar region, may be associated with syndromic causes and usually asymptomatic with a funnel shaped defect seen in imaging which can later give rise to disk problems, facet joint degeneration and chronic low back pain. We here share a case of 35-year female presented with intermittent low back pain diagnosed with S1 butterfly vertebrae as an incidental finding in radiograph and magnetic resonance imaging. Radiologist and orthopedicians should be vigilant about this rare entity as a differential of low back pain and its association with other syndromes.

Pregnancy with heart disease in South Asia: A systematic review and meta-analysis of prevalence and outcome.

Background: The prevalence and paradigm of antenatal heart disease are contrasting between high-income, industrialized, and low- and middle-income countries. In this systematic review, we report the prevalence of heart disease and its spectrum in pregnant women of South Asia. Methods: We searched through different electronic databases (PubMed, Google-scholar, Embase, Cochrane Library) to locate relevant articles. Studies with sufficient data that met our inclusion criteria were included. Two reviewers independently screened the articles. Discrepancies were resolved by other reviewers. Subsequently, data extraction was done using a standardized form and quality assessment of studies using the Joanna Briggs Institute tool. Meta-analysis was done using R software. Results: After various stages of screening 25 studies were included in the final quantitative synthesis. The pooled prevalence of heart disease among pregnant women was 1.46% (95% CI 0.99-2.01). Among those with heart disease, 70.25% (95% CI 64.87-75.38) had Rheumatic heart disease and 18.10% (95% CI 14.39-22.12) had congenital heart disease. The pooled prevalence of preterm labor and delivery among pregnant women with heart disease was 17.63% (95% CI 12.18-23.80). Similarly, the pooled maternal and fetal mortality rates were 26.14 (95% CI 12.47-43.55) and 50.48 (95% CI 29.59-75.83) per 1000 pregnant women with heart disease respectively. Conclusion: As pregnancy, itself is a prolonged state of physiologic stress, heart disease further adds to the risk both for the mother and fetus. Having such a high prevalence, efforts must be made to detect and closely monitor the condition antenatally, and decisions should be made according to the clinical conditions of the patient.

Perception of Cigarette Graphic Health Warnings and Its Impact on Smoking Behavior: A Cross-Sectional Study among Current Smokers of Western Part of Nepal.

Globally, tobacco use (smoked, secondhand, and chewing) accounted for 8.71 million deaths, which is 15.4% of all deaths in 2019. Tobacco was ranked first among males and sixth among female in terms of level 2 risk factor for attributable deaths globally. The objective of this study was to identify the perception of cigarette graphic health warnings and their impact on smoking behavior in Nepal. A cross-sectional study using purposive sampling technique was done. Out of 169 respondents, 79.9% were male, 49.1% were illiterate, and 37.9% were above 60 years of age. Eighty-four percent had initiated smoking before the age of 20, and 39.6% had smoked cigarettes for more than 40 years. All the respondents had noticed the graphic health warning on cigarette packages. The majority (80.5%) of the respondents reported that the warning informs about specific health consequences of smoking, and the percentage of respondents believing that warning motivates smokers to quit smoking, encourages smokers to reduce the number of cigarettes smoked per day, and deters potential smokers from starting to smoke was 40.2%, 33.1%, and 30.8%, respectively. More than half of the respondents (50.9%) attempted to quit smoking because of the warning. The implementation of graphic health warnings had favorable perception from majority of smokers and positive impact on smoking behavior of the respondents. Further large-scale research on impact on smoking behavior through repeated cross-sectional studies can be future research priority.

Giant ovarian mucinous cystadenocarcinoma: A case report.

Giant ovarian tumors are rare in the present day due to the early diagnosis and treatment. However, owing to the large size, it can often compress the inferior vena cava and sudden decompression of it during the removal can lead to hemodynamic instability with disastrous outcomes.

Delayed Visual Loss in a Patient with Snake Bite: Case Report of an Unusual Neuro-Ophthalmic Presentation.

Neurotoxin-related optic neuritis (ON) after snake bite is uncommon. Here, we present a case of a 70-year-old female who developed bilateral painless loss of vision after she received treatment with anti-snake venom (ASV). She had only perception of light on assessment of visual acuity on admission which then improved drastically after administration of intravenous methylprednisolone (MP) after making the provisional diagnosis of ON on the basis of history and clinical findings of the patient. Imaging and visual-evoked potential could not be done initially, and they were done after the administration of intravenous MP which had normal findings. ASV, though being a lifesaving treatment, has been sometimes associated with ON.

Neutrophil-lymphocyte ratio as a predictor of adverse outcome in patients with community-acquired pneumonia: A systematic review.

Background: Community-acquired pneumonia (CAP) is the acute infection of lung tissue in an immunocompetent who acquired it from the community. Its incidence and mortality are significant and require a marker to predict the severity and mortality in these patients. Neutrophil-lymphocyte ratio (NLR) is a simple, cheap, and easy-to-use marker and this study describes its role in predicting the adverse outcome in patients with CAP. Methods: PubMed, EMBASE, and Google Scholar were used to search for related studies on February 8, 2021. A total of 186 articles were retrieved upon detailed searching in the databases and search engines. After a series of removing duplicate articles, title and abstract screening, and full-text review; nine articles were found eligible and included in the study. The data from each article were collected in MS Excel and the findings were summarized in this manuscript. Results: The total number of patients analyzed in this systematic review is 3340. The mean age of the patient in the included studies ranged from 61 to 90.4 years. All studies had adverse outcomes as the endpoint of the study, which included in-hospital mortality or intensive care unit (ICU) admission or deterioration from medium and low risk to high risk or 30 days' mortality. The prevalence of endpoint ranged from 5.8% to 44.8%. NLR with a cutoff value of more than 10 was shown to predict mortality compared to C-reactive protein levels, white blood cell count, neutrophil count, lymphocyte level, Pneumonia Severity Index (PSI) level, PSI class, procalcitonin, and CURB-65 (Confusion, Respiratory rate, Blood pressure, 65 years of age and older) in most of the studies. Conclusion: NLR is a simple, easily measured yet promising marker for predicting outcomes in patients with CAP.

Cushing Syndrome in a Pediatric Patient with Topical Steroid Overuse.

Cushing syndrome is a state of hypercortisolism from exogenous or endogenous exposure to glucocorticoids resulting in various clinical manifestations. In this case report, we present a case of a 15-month-old child who presented with cushingoid facies due to over-the-counter misuse of a very potent topical steroid (clobetasol 0.05%) for suspected scabies. Laboratory measurement of urinary free cortisol level was low, and 8 : 00 am basal cortisol level was measured, which was decreased, which confirmed the diagnosis of Cushing syndrome due to exogenous source. Over-the-counter topical steroids should not be used, and one should always consult a registered medical practitioner before using such products. Physicians when prescribing topical steroids should warn patients about the potential side effects of prolonged use of topical steroids.

An Unusual Case of Eosinophilia with Systemic Lupus Erythematosus: A Case Report and Review of Literature.

Eosinophilia can be caused by various conditions, parasitic infection being the most common cause. Here, we present a case of a 17-year male who presented with multisystem involvement and eosinophilia. He was later diagnosed to have systemic lupus erythematosus with eosinophilia which is a rare combination. Despite being a diagnostic challenge, these patients can be well managed with immunosuppressive therapy if recognized in time.

Morgagni hernia in adult: A case report.

INTRODUCTION AND IMPORTANCE: Morgagni Hernia is a congenital diaphragmatic hernia but can rarely present in adults. It occurs due to a congenital defect in the development of the diaphragm. Here we present a case of symptomatic Morgagni hernia diagnosed in a 53 years' female. CASE PRESENTATION: A 53 years' female presented with recurrent chest symptoms and was found to have bowel contents herniated into the right hemithorax on chest X-ray and CECT. Reduction of hernia was done laparoscopically and the hernia was repaired with non-absorbable suture in an interrupted manner. CLINICAL DISCUSSION: Morgagni hernias are mostly diagnosed incidentally on a chest radiograph or can present with cardiorespiratory or abdominal symptoms. Our case was an adult who was diagnosed to have Morgagni hernia presenting with chest symptoms. The investigation of choice to diagnose and evaluate this condition is CECT of chest and repair of hernia without the use mesh is advised in asymptomatic cases also due to feared complications like strangulation and incarceration. CONCLUSION: The treatment of Morgagni Hernia is primary surgical repair which can be done either transthoracically or transabdominally. It is advised that surgical repair should be done even in asymptomatic cases.

Incidental finding of Langerhans cell histiocytosis of temporoparietal bone - A case report.

INTRODUCTION AND IMPORTANCE: Langerhans cell histiocytosis (LCH) is a rare haematological disorder affecting infants and young children and has an estimated incidence of 2-5 cases per million people per year. LCH invades the reticuloendothelial system and causes the proliferation of Langerhans cells and mature eosinophils. LCH involving the temporoparietal bone has rarely been reported in the literature. PRESENTATION OF CASE: A ten-year-old boy presented to the Neurosurgical outpatient clinic with a swelling on the right temporoparietal region following a fall from his bicycle. Local examination revealed a single, 3 × 3 cm, non-tender, cystic, immobile swelling in the right temporoparietal region. On evaluation for recent head trauma, an incidental finding of eosinophilic granuloma was discovered on a CT scan. The FNAC was suggestive of a histiocytic lesion pertaining to a diagnosis of LCH. The patient underwent wide excision of the mass and cranioplasty. A one-month follow-up CT scan of the head had no evidence of residual or recurrent disease. DISCUSSION: Eosinophilic granuloma is one of the three variants of LCH and has a relatively better prognosis. Clinical diagnosis can be challenging and mandates tissue sampling for histopathological examination. Treatment modalities including surgery, radiotherapy, chemotherapy, and steroid injection are used alone, or in combination, depending on the extent and severity of the disease. CONCLUSION: Examining a swelling in the temporoparietal region with no other characteristic symptoms could be a case of LCH. The timely diagnosis and surgical excision with other adjuvant treatment options of this rare pediatric disease would help in a better outcome.

Prevalence of Stroke in Asian Patients with Sickle Cell Anemia: A Systematic Review and Meta-Analysis.

Sickle cell anemia (SCA) is an inherited autosomal recessive disease. It is caused due to point mutation that substitutes glutamate with valine at the sixth amino acid position of the beta chain of hemoglobin molecules leading to the sickling of the red blood cells and decreased structural deformability. Silent cerebral infarcts are the most common neurological complication of SCA, while overt stroke comprises substantial burden in patients with SCA. This meta-analysis aimed to find the pooled prevalence of overt stroke in SCA patients and discuss the importance of screening them. PubMed, Embase, and Google Scholar were the electronic databases used to search the studies. A total of 765 articles were retrieved upon detailed searching in the abovementioned databases. After a series of removing duplicate articles, title and abstract screening, and full-text review, 20 articles were found eligible and included in the study. The total number of participants from all the included studies was 3,956, and pooled prevalence of stroke in patients with sickle cell anemia in Asia was found to be 5% (95% CI: 4%, 6%) with a range from 1 to 41%. Stroke occurrence in sickle cell anemia patients is an emergency complication that needs immediate intervention and management. Because of the high prevalence of stroke in patients with sickle cell anemia, clinicians should focus on its prevention and treatment strategies.