Acid Peptic Disease among Patients with Acute Abdomen Visiting the Department of Emergency Medicine in a Tertiary Care Centre.

Introduction: Acid peptic disease is caused by excessive acid secretion or weakened mucosal defense. Symptoms include epigastric pain, bloating, and nausea. Factors like gastric acid, Helicobacter pylori infection, alcohol consumption, smoking, and stress contribute to peptic ulcers. Imbalances between offensive and defensive factors can lead to ulcers. Acid-related disorders impact the quality of life and mortality. Accurate diagnosis and prompt treatment are vital. This study aimed to find out the prevalence of acid peptic disease among patients with acute abdomen in the Department of Emergency Medicine in a tertiary care centre. Methods: A descriptive cross-sectional study was conducted from 2 April 2022 and 2 April 2023 among the patients presented in the Department of Emergency Medicine in a tertiary care centre. Ethical approval was obtained from the Institutional Review Committee. All patients presenting with acute abdominal pain in the Emergency Department were included in the study. Patients not giving consent were excluded from the study. Convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. Results: Out of the 400 patients with acute abdomen, the prevalence of acid peptic disease was found to be 87 (21.75%) (17.71-25.79, 95% Confidence Interval). Conclusions: The prevalence of acid peptic disease among patients with acute abdomen was found to be lower than in other studies performed in similar settings. Keywords: acute abdomen; gastroenteritis; Helicobacter pylori; peptic ulcer.

Aberrant neural activity in prefrontal pyramidal neurons lacking TDP-43 precedes neuron loss.

Mislocalization of TAR DNA binding protein 43 kDa (TARDBP, or TDP-43) is a principal pathological hallmark identified in cases of neurodegenerative disorders such as amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD). As an RNA binding protein, TDP-43 serves in the nuclear compartment to repress non-conserved cryptic exons to ensure the normal transcriptome. Multiple lines of evidence from animal models and human studies support the view that loss of TDP-43 leads to neuron loss, independent of its cytosolic aggregation. However, the underlying pathogenic pathways driven by the loss-of-function mechanism are still poorly defined. We employed a genetic approach to determine the impact of TDP-43 loss in pyramidal neurons of the prefrontal cortex (PFC). Using a custom-built miniscope imaging system, we performed repetitive in vivo calcium imaging from freely behaving mice for up to 7 months. By comparing calcium activity in PFC pyramidal neurons between TDP-43 depleted and TDP-43 intact mice, we demonstrated remarkably increased numbers of pyramidal neurons exhibiting hyperactive calcium activity after short-term TDP-43 depletion, followed by rapid activity declines prior to neuron loss. Our results suggest aberrant neural activity driven by loss of TDP-43 as the pathogenic pathway at early stage in ALS and FTD.

Stereotaxic Viral Injection and Gradient-Index Lens Implantation for Deep Brain In Vivo Calcium Imaging.

A miniature fluorescence microscope (miniscope) is a potent tool for in vivo calcium imaging from freely behaving animals. It offers several advantages over conventional multi-photon calcium imaging systems: (1) compact; (2) light-weighted; (3) affordable; and (4) allows recording from freely behaving animals. This protocol describes brain surgeries for deep brain in vivo calcium imaging using a custom-developed miniscope recording system. The preparation procedure consists of three steps, including (1) stereotaxically injecting the virus at the desired brain region of a mouse brain to label a specific subgroup of neurons with genetically encoded calcium sensor; (2) implantation of gradient-index (GRIN) lens that can relay calcium image from deep brain region to the miniscope system; and (3) affixing the miniscope holder over the mouse skull where miniscope can be attached later. To perform in vivo calcium imaging, the miniscope is fastened onto the holder, and neuronal calcium images are collected along with simultaneous behavior recordings. The present surgery protocol is compatible with any commercial or custom-built single-photon and two-photon imaging systems for deep brain in vivo calcium imaging.

Obstructed Hemivagina and Ipsilateral Renal Anomaly Syndrome Rare Obstructive Uterovaginal Anomaly: A Case Report.

Obstructed Hemivagina and Ipsilateral Renal Anomaly syndrome is a rare obstructive uterovaginal anomaly involving both mesonephric and paramesonephric ducts. It usually presents after menarche with non-specific symptoms like pelvic pain, dysmenorrhea, or paravaginal mass and examination findings of paravaginal or pelvic mass. Because of non-specific symptoms and signs, the diagnosis is usually overlooked, which leads to complications like endometriosis, tubo-ovarian abscess compromising patient’s fertility, and quality of life. Therefore, in presence of these nonspecific clinical features along with imaging findings of uterine didelphys and unilateral renal agenesis, this syndrome should be considered in the diagnosis. We present a case of a 17-year-old lady with Obstructed Hemivagina and Ipsilateral Renal Anomaly syndrome, diagnosed by finding of paravaginal mass on examination and uterine didelphys with ipsilateral renal agenesis in USG and managed successfully by resection of vaginal septum. Keywords: ipsilateral renal anomaly;paravaginal mass;uterovaginal anomaly.

Phytochemical Screening, Free Radical Scavenging and α-Amylase Inhibitory Activities of Selected Medicinal Plants from Western Nepal.

Background: More than 700 plants are reported to be used for medicinal purposes in Nepal; however, many of them are not studied for their scientific evidences. The aims of the present study were the estimation of the total phenolic and flavonoid contents, and the evaluation of the free radical scavenging and α-amylase inhibitory activities of five selected medicinal plants from western Nepal: Aeschynanthus parviflorus Wall. (Gesneriaceae), Buddleja asiatica Lour. (Loganiaceae), Carica papaya L. (Caricaceae), Drepanostachyum falcatum (Nees) Keng f. (Gramineae) and Spondias pinnata (L. f.) Kurz (Anacardiaceae). Methods: The total phenolic content (TPC) and total flavonoid content (TFC) were measured using Folin-Ciocalteu's phenol reagent and aluminium chloride methods, respectively. A 1,1-diphenyl-2-picrylhydrazyl (DPPH) free radical scavenging assay was used to evaluate the free radical scavenging activity and an α-amylase inhibitory assay was carried out to determine the in vitro antidiabetic activity. Results: The phytochemical screening of five hydroalcoholic plant extracts revealed the presence of various secondary metabolites, including alkaloids, flavonoids, reducing sugars, saponins, terpenoids and tannins. The amounts of total phenolics and flavonoids were found to be the highest in B. asiatica leaf extract, which also showed the most potent free radical scavenging activity. Extract of C. papaya fruits showed the highest α-amylase inhibitory activity, whereas the extracts of B. asiatica leaves and S. pinnata leaves exhibited moderate activity. Conclusions: Some of the medicinal plants selected in this study showed high TPC and TFC values and potent bioactivities. These results may provide the scientific evidences of the traditional uses of these plants. However, further detailed studies on bioactive compounds isolation and identification and evaluation of in vivo pharmacological activities should be performed in future.

Ethnomedicinal Uses of Plant Resources in the Machhapuchchhre Rural Municipality of Kaski District, Nepal.

Background: Medicinal plants are being used by the majority of the population throughout the world for their primary health care needs. The reliance is also prevalent in Nepal, aided by its ethnic and biological diversity. This study aimed to catalogue the ethnomedicinal knowledge of plants used by local people of Machhapuchchhre Rural Municipality of Kaski district. Methods: Data were collected between February 2017 and April 2018 from eight different villages of the Kaski district by using semi-structured interviews, guided field works, focus group discussions, and in-depth interviews. The reported traditional uses were supported by local assistants, cataloguing vernacular names and crosschecking with the earlier published and gray literature. Results: A total of 105 medicinal plants, belonging to 58 families and 99 genera were documented to treat 70 different diseases and ailments. The highest numbers of plants (37) were used for gastrointestinal disorders and the lowest (4) were used for female genital disorders. Commonly used parts were underground portions (28 species) followed by fruits and seeds (25 species each). The most preferred dosage form was juice, used for 50 ailments, and the oral route was the most favored route of administration (77 species). The medicinal properties of 22 plant species were found hitherto unreported in the district. Conclusions: The study area was found to be rich in plant resources and the people have ample knowledge on the use of medicinal plants. Due to a lack of proper documentation, conservation, and cultivation practices, valuable plant species are at risk of extinction. Thus, appropriate conservation measures and scientific assessment of plant-lore in the district is immediately required.

An Experience of Video Based Training on Basic Life Support.

INTRODUCTION: Basic life support is foundation to save lives. In contrast to the developed countries, there is still no national standard BLS training module in Nepal. Basic life support training is being provided by various institutions but lack in consistency and coordination. The Nepal basic life support Course is the video based training in Nepali language with reference to recent advances which was intended for all health care personnel of Nepal in urban as well as rural setting. We aimed to describe the features of this video based training module in local language, to analyse the differences of knowledge before and after the training and to find out the participants perception and satisfaction with this course. METHODS: This is a descriptive cross-sectional study based on data of trainings conducted over the study period. Ethical approval was taken. The post-test score was recorded and compared with the occupational using ANOVA. On the spot and delayed feedbacks from the participants were collected voluntarily and summarized. RESULTS: Total of 576 participants (435 clinical doctors, 92 nurses/paramedics, 18 non-clinical doctors and 41 intern doctors) successfully completed the training. The difference in post test scores (mean = 12.9±1.8) among the different occupational background was not significant (P=0.159). The feedbacks from the participants were mostly positive and encouraging. CONCLUSIONS: The knowledge of basic life support improved significantly irrespective of the occupation of the participants. A universal, nationwide video based training module in Nepali language should be developed focusing all health care personnel of urban as well rural Nepal.

Implications of the 2013 ACC/AHA cholesterol guidelines on contemporary clinical practice for patients with atherosclerotic coronary and peripheral arterial disease.

BACKGROUND: Cholesterol management guidelines from the American College of Cardiology/American Heart Association (ACC/AHA-2013) recommend fixed statin dosing (dose depends on age ≤ or >75years) compared to the earlier adult treatment panel III (ATPIII) guidelines which recommended specific low-density lipoprotein-cholesterol (LDL-C) targets. Clinical implications of this recommendation are not known. METHODS: We retrospectively compared cholesterol levels and statin utilization across cohorts with coronary artery disease (CAD) (n=9563), peripheral arterial disease (PAD) (n=596) and CAD+PAD (n=975) by applying both guidelines. The percentage of patients who achieved guideline-specific targets using 2013 ACC/AHA (use of moderate/high intensity statins) or ATPIII guidelines (LDL-C<100mg/dl) was compared between all groups. RESULTS: Using both guidelines, the PAD only group demonstrated lower utilization and lower statin doses than the CAD or CAD+PAD groups. When applying the ACC/AHA guidelines, more patients in the CAD only group (age ≤75 years) were considered at goal as compared to the ATPIII guidelines (92.2% vs. 75%), primarily driven by the group placed on moderate/high intensity statins but had an LDL-C level >100mg/dl. CONCLUSIONS: Application of the ACC/AHA guidelines results in a higher percentage of patients considered to be 'at goal' when compared to the ATP III guidelines without changes in clinical practice. This is due to patients ≤75 years old on adequate statin doses but still have LDL-C levels >100mg/dl, thereby raising concerns that physicians may not pursue alternate LDL reduction strategies since they are now considered at goal despite LDL-C >100mg/dl. Lipid management of PAD patients remains sub-optimal as compared to CAD and CAD+PAD.

Optimal Medical Management Reduces Risk of Disease Progression and Ischemic Events in Asymptomatic Carotid Stenosis Patients: A Long-Term Follow-Up Study.

BACKGROUND AND PURPOSE: To assess the effect of optimal medical management including atherosclerotic risk factor control on ischemic stroke (IS), transient ischemic attack (TIA), carotid revascularization (CRV), and progression of severity of carotid stenosis (PSCS) in patients with asymptomatic carotid artery stenosis (ACAS). METHODS: We conducted a retrospective analysis of patients with ACAS (who had at least 3 serial carotid duplex ultrasounds) for incidence of IS, TIA, and PSCS. RESULTS: Eight hundred sixty-four patients with a mean follow-up duration of 79 ± 36 months were included. IS/TIA and CRV occurred in 12.2% of the patients and PCSS was observed in 21.5% vessels. On univariate analysis it was found that low-density lipoprotein (LDL) levels >100 mg/dL, no statin or low-potency statins, average systolic blood pressure (SBP) ≥140 mm Hg and/or diastolic blood pressure (DBP) ≥90 mm Hg and history of smoking were predictors of the combined endpoint of IS/TIA/CRV and PSCS. On multivariate analysis, it was found that LDL >100 mg/dL, no statin or low-potency statin, SBP ≥140 mm Hg and/or DBP ≥90 mm Hg, and Hx of smoking were independent predictors of PSCS. Similarly no statin or low-potency statin, SBP ≥140 mm Hg and/or DBP ≥90 mm Hg, Hx of atrial fibrillation/flutter, Hx of chronic kidney disease, and PSCS were independent predictors of IS/TIA. No statin or low-potency statin, SBP ≥140 mm Hg and/or DBP ≥90 mm Hg, diabetes mellitus, baseline carotid artery stenosis ≥70%, and PSCS were found to be independent predictors of combined endpoint IS/TIA and CRV. CONCLUSION: Intensive medical therapy in the patients with ACAS results in lower incidence of IS/TIA, CRV, and PSCS with a significant incremental beneficial effect.

Intranasal ketamine for the treatment of patients with acute pain in the emergency department.

BACKGROUND: Pain in the emergency department (ED) is common but undertreated. The objective of this study was to examine the efficacy and safety of intranasal (IN) ketamine used as an analgesic for patients with acute injury with moderate to severe pain. METHODS: This study was a cross sectional, observational study of patients more than 8 years old experiencing moderate to severe pain [visual analog score (VAS) >50 mm]. The initial dose of IN ketamine was 0.7 mg/kg with an additional dose of 0.3 mg/kg if VAS was more than 50 mm after 15 minutes. Pain scores and vital signs were recorded at 0, 15, 30 and 60 minutes. Side-effects, sedation level and patient's satisfaction were also recorded. The primary outcome was the number of patients achieving ≥ 20 mm reductions in VAS at 15 minutes. Other secondary outcome measures were median reduction in VAS at 15, 30 and 60 minutes, changes of vital signs, adverse events, satisfaction of patients, and need for additional ketamine. RESULTS: Thirty-four patients with a median age of 29.5 years (IQR 17.5-38) were enrolled, and they had an initial median VAS of 80 mm (IQR 67-90). The VAS decreased more than 20 mm at 15 minutes in 27 (80%) patients. The reduction of VAS from baseline to 40 mm (IQR 20-40), 20 mm (IQR 14-20) and 20 mm (IQR 10-20) respectively at 15, 30 and 60 minutes (P<0.001). No critical changes of vital signs were noted and adverse effects were mild and transient. CONCLUSION: This study showed that IN ketamine is an analgesic choice for patients with acute injury in moderate to severe pain in an overcrowded and resource limited ED.

Intranasal ketamine for the treatment of patients with acute pain in the emergency department / 世界急诊医学杂志（英文）

@#BACKGROUND:Pain in the emergency department (ED) is common but undertreated. The objective of this study was to examine the efficacy and safety of intranasal (IN) ketamine used as an analgesic for patients with acute injury with moderate to severe pain. METHODS:This study was a cross sectional, observational study of patients more than 8 years old experiencing moderate to severe pain [visual analog score (VAS) >50 mm]. The initial dose of IN ketamine was 0.7 mg/kg with an additional dose of 0.3 mg/kg if VAS was more than 50 mm after 15 minutes. Pain scores and vital signs were recorded at 0, 15, 30 and 60 minutes. Side-effects, sedation level and patient's satisfaction were also recorded. The primary outcome was the number of patients achieving ≥ 20 mm reductions in VAS at 15 minutes. Other secondary outcome measures were median reduction in VAS at 15, 30 and 60 minutes, changes of vital signs, adverse events, satisfaction of patients, and need for additional ketamine. RESULTS:Thirty-four patients with a median age of 29.5 years (IQR 17.5–38) were enrolled, and they had an initial median VAS of 80 mm (IQR 67–90). The VAS decreased more than 20 mm at 15 minutes in 27 (80％) patients. The reduction of VAS from baseline to 40 mm (IQR 20–40), 20 mm (IQR 14–20) and 20 mm (IQR 10–20) respectively at 15, 30 and 60 minutes (P<0.001). No critical changes of vital signs were noted and adverse effects were mild and transient. CONCLUSION:This study showed that IN ketamine is an analgesic choice for patients with acute injury in moderate to severe pain in an overcrowded and resource limited ED.

Disparities in lipid control and statin drug use among diabetics with noncoronary atherosclerotic vascular disease vs those with coronary artery disease.

BACKGROUND: Diabetes mellitus (DM), coronary artery disease (CAD), and noncoronary atherosclerotic vascular diseases (NCVDs) have similar risks of cardiovascular events and similar recommendations for lipid control. There are limited data regarding lipid control in diabetic patients with NCVD in current clinical practice. OBJECTIVE: To assess current day practice of lipid control in patients with DM with NCVD vs those with CAD. METHODS: We retrospectively identified 3336 patients with DM and known atherosclerotic vascular disease between January 2009 and March 2012. We compared demographic variables, lipid levels, and statin use in diabetics with CAD alone vs diabetics without CAD but with one or more NCVD. RESULTS: There were 234 patients in DM with NCVD group and 3102 patients in DM with CAD group. The DM with NCVD group had a higher mean total cholesterol (152 ± 40 vs 146 ± 42 mg/dL; P = .019) and mean low-density lipoprotein (LDL; 86 ± 35 vs 80 ± 34 mg/dL; P = .04) with only 70% of patients achieving LDL of <100 mg/dL (compared with 80% in the DM with CAD group; P < .001). Statin use was 100% in CAD vs 75% in NCVD group (P < .001). In addition to limited use of more potent statins in the NCVD group, there was also a significantly lower dose of statins used overall. CONCLUSION: Our study demonstrates lower use and less aggressive application of statins among diabetics with NCVD compared with diabetics with CAD, resulting in higher mean LDL and total cholesterol in the NCVD group.

Comparison of lipid management in patients with coronary versus peripheral arterial disease.

Peripheral arterial disease (PAD), similar to coronary artery disease (CAD), is a significant predictor of cardiovascular morbidity and mortality. Guidelines recommend a low-density lipoprotein (LDL) goal of <100 mg/dl for both groups. We assessed whether lipid control and statin use were as aggressively applied to PAD as to patients with CAD. This retrospective study of patients with the diagnosis of CAD, PAD, or both CAD and PAD compared lipid levels and statin use. For comparison of statins, we used a statin potency unit (1 potency unit=10 mg of simvastatin). Among 11,134 subjects (CAD 9,563, PAD 596, and both CAD and PAD 975), mean LDL in the PAD group was higher than the CAD (92 vs 83 mg/dl, respectively, p<0.001) and the combined CAD and PAD groups (92 vs 80 mg/dl, respectively, p<0.001). Fewer patients with PAD achieved a target LDL of <100 mg/dl compared with CAD (62% vs 78%, respectively, p<0.001) and the combined group (62% vs 79%, respectively, p<0.001). Similar differences were noted for a target LDL of <70 mg/dl. Compared with the CAD group, a lesser number of patients with PAD received statin therapy (76% vs 100%, respectively, p<0.001) with lower mean potency unit (5.3 vs 8.1, respectively, p<0.001). In conclusion, our study demonstrated lower use and less aggressive application of statins in patients with PAD compared with patients with CAD, ensuing lower mean LDL in the CAD and combined PAD and CAD groups. Our study suggests that physicians are more aggressive with lipid control in patients with CAD compared with patients with PAD alone.

Tricuspid regurgitation: pathophysiology and management.

Tricuspid regurgitation (TR) is one of the most commonly encountered valvular problems in clinical practice. Although diagnosed easily with echocardiography, it contributes to significant mortality and morbidity when severe. Once thought to be a benign functional valvular abnormality, TR has received more attention in recent years and different treatment options have emerged. However, there is no consensus regarding the superiority of one treatment approach over another. With the development of percutaneous atrioventricular valves, new horizons are open for exploration in the treatment of TR. Clinical indications of treatment are likely to change with increased use of left ventricular assist devices and increased survival of patients with poor right ventricular function. This review discusses the pathophysiology and management of TR along with newer treatment modalities currently under investigation.

Clinical and laboratory phenotype of patients experiencing statin intolerance attributable to myalgia.

BACKGROUND: Muscle pain without elevation of serum creatine phosphokinase (CPK) (myalgia) is the most common medication-related adverse effect of statin therapy; it occurs in up to 10% of patients who are prescribed statin therapy. Although much is known regarding risk factors for overt myositis, very few studies have provided information on this common form of statin intolerance. METHODS: We defined a detailed clinical and laboratory phenotype of a cohort of patients referred to the lipid clinic of a governmental health maintenance organization for statin intolerance attributable to muscle pain without CPK elevation (myalgia) and characterized their response to alternative lipid-lowering therapy. Baseline and follow-up data were analyzed for 104 patients with statin intolerance attributable to myalgia and 211 statin-tolerant control patients identified from the referral population. RESULTS: Among patients with myalgia, more were white and had hypertension. The prevalence of known risk factors for overt myositis, including renal disease, type 2 diabetes mellitus, thyroid disease, and electrolyte abnormalities, did not differ between statin intolerant and statin tolerant patients. Although individual cases were identified in which the addition of interacting medications was temporally associated with development of statin intolerance, overall use of interacting medications was not more frequent among statin-intolerant patients. The majority of patients were intolerant of two or more statins; however, in more than one-half the cases, successful rechallenge with an alternative statin was accomplished. Despite this and extensive use of nonstatin lipid medications after lipid clinic referral, control of plasma lipoproteins remained significantly worse in statin-intolerant patients. CONCLUSIONS: Statin intolerance attributable to myalgia is a significant barrier to effective treatment of hyperlipidemia. Conventional clinical risk factors for myositis do not appear to predictive of statin-associated myalgia. These findings underscore the need to better define the pathophysiology of statin-induced myalgia and develop methodologies to guide treatment of statin-intolerant patients.

Emerging antiplatelet agents, differential pharmacology, and clinical utility.

The aspirin-clopidogrel combination is the current gold standard antiplatelet regimen following percutaneous coronary intervention and for the treatment of acute coronary syndrome. Despite the clinical benefit of this combination, patients continue to have vascular events. Another purinergic (P2Y(12)) receptor antagonist, prasugrel, became available last year. Although prasugrel is superior to clopidogrel in reducing clinical endpoints, a higher bleeding rate has been identified particularly in high-risk patients. Ticagrelor, a reversible P2Y(12) receptor antagonist currently being evaluated for approval, is also more potent than clopidogrel but has a similar bleeding risk. Two additional P2Y(12) antagonists are being investigated that will be available as an intravenous formulation. Apart from the P2Y(12) receptor antagonists, multiple other agents are being developed with unique mechanisms of platelet inhibition. These agents are being studied as an alternative to or in combination with clopidogrel. The antiplatelet agents currently under development include: thrombin receptor antagonists, phosphodiesterase inhibitors, a thromboxane-prostaglandin receptor antagonist, a serotonin receptor blocker, a platelet adhesion antagonist, nitric oxide-releasing aspirin, a glycoprotein VI antagonist, and a cyclooxygenase inhibitor. The purpose of this review is to describe the efficacy and safety profiles of the emerging antiplatelet agents and their role in the treatment of atherosclerotic cardiovascular diseases.