South Hams Hospital

The use of the argon laser in the treatment of vascular birthmarks is discussed and the importance of adequate safety standards is stressed. The Southampton Argon Laser Safety Code is given in detail (Appendix 1 and 2).

Chronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity and mortality in Nepal. It is a progressive lung disease and has a significant impact on the quality of life of patients. Health‐related quality of life (HRQOL) reflects the health‐ and disease‐related facets of quality of life. Limited studies have assessed the impact of COPD on HRQOL and associated factors in Nepal. This study is based on a cross-sectional household survey data from a semiurban area of Western Nepal. A validated Nepali version of St George’s Respiratory Questionnaire (SGRQ) was used to measure the HRQOL. COPD was defined together with post-bronchodilator airflow obstruction and the presence of respiratory symptoms. Post-bronchodilator airflow obstruction was defined as Forced Expiratory Volume in 1st second (FEV1) to Forced Vital Capacity (FVC) ratio < 0.70. COPD was diagnosed in 122 participants, and their median (IQR) total score of HRQOL was 40 (26 − 69); the score of symptoms, activity, and impact area were 53 (37 − 74), 57 (36 − 86), and 26 (13 − 62), respectively. The overall HRQOL was significantly different in terms of age, occupational status, physical activity, and comorbidities. Disease severity and the presence of respiratory symptoms had a significant difference in HRQOL (p = 0.0001). Appropriate measures to improve conditions and addressing the associated factors like respiratory symptoms and enhancing physical activity are necessary and important.

DeVilbiss No. 40 hand-held nebulizers are widely used for quantifying airway responsiveness in large populations using pharmacological agents. We examined the aerosol characteristics of five nebulizers. Within each device, the aerosol output and droplet size were reasonably stable over a wide range of bulb pressures, although there were considerable differences in output characteristics between nebulizers. The droplet size was very large compared to conventional aerosol delivery systems, with a mass median diameter greater than 10 microns for three of the five devices. Between 28-50% of the output was in particles sufficiently small for airway deposition (less than 6.2 microns). A more vigorous compression of the bulb caused a small increase output and a reduction in droplet size, resulting in a much bigger variation in the output of the respirable aerosol (less than 6.2 microns) with changes in bulb pressure. The loss due to evaporation was about 3.5%, causing a similar rise in the osmolality of the nebulizer solution. In view of the variable nebulizer output and the marked between-operator variation in bulb pressure, the characteristics of individual DeVilbiss No. 40 nebulizers should be evaluated by individual operators before use in clinical practice or research.

Introduction: Spinal infection poses a demanding diagnostic and treatment problem for which a multidisciplinary approach with spine surgeons, radiologists, and infectious disease specialists is required. Infections are usually caused by bacterial microorganisms, although fungal infections can also occur. Most patients with spinal infections diagnosed in the early stages can be successfully managed conservatively with antibiotics, bed rest, and spinal braces. In cases of gross or pending instability, progressive neurological deficits, failure of conservative treatment, spinal abscess formation, severe symptoms indicating sepsis, and failure of previous conservative treatment, surgical treatment is required. Case presentation: A 64-year-old male presented to the Outpatient Department with a complaint of pain in bilateral upper extremities for 4 months. The pain was shooting in type, radiating to bilateral arms, forearms, and hands with no aggravating and relieving factors. He is a known case of carcinoma pyriform sinus for which he underwent various cycles of chemotherapy. Ten years later, a tracheostomy was performed for laryngeal edema, and again, an endoscopic gastrostomy was performed due to feeding difficulties. He then developed fever and cervical pain along with pain in the bilateral upper extremities. An infectious etiology was suspected for which multiple antibiotics were started with no positive response. An MRI was performed, which was suggestive of spondylodiscitis probably of tubercular origin. A biopsy was done to confirm the diagnosis, following which antitubercular (HRZE) therapy was started. He was also treated with Duloxetine and gabapentin, which resulted in minor improvements. Subsequent MRIs showed diffuse involvement of the multiple cervical vertebrae along with cord compression. Two stages of anterior corpectomy followed by posterior instrumentation were done. Following the procedure, the patient developed an infection, which was managed with antibiotics. The titanium implant was not removed. A muscle graft was planned with the pectoralis muscle and flap closure was done. The tissue was also sent for Gram stain, AFB stain, and GeneXpert, which showed normal findings. Finally, in tissue culture, Candida albicans was isolated. On performing the enzyme immunoassay test, it was found to be Aspergillus (Galactomannan antigen) positive as well. Antitubercular treatment was stopped. Then, he was managed with an antifungal, oral voriconazole, for the duration of 1 and a half years. Clinical discussion: Patients diagnosed with Candida spondylodiscitis tend to have favorable outcomes, likely linked to timely identification, thorough surgical debridement, and proper azole medication. Our case achieved success by promptly identifying and confirming it through tissue culture, detecting spinal cord compression, decompressing it, and initiating specific antifungal treatment. A delay in commencing antifungal therapy has been associated with poorer outcomes, especially in neurological health. Our patient received voriconazole for a full year, suggesting that favorable outcomes are achievable for fungal spondylodiscitis with swift and appropriate surgery and antifungal medication. Conclusion: In summary, evaluation for fungal infection is essential in all cases of unexplained spinal infection in immunocompromised patients, regardless of presentation. If the antifungal treatment proves ineffective, a surgical approach is typically employed for the management of fungal spondylodiscitis. Our report details a successful case of fungal spondylodiscitis treated with a surgical approach and highlights the potential for a fungal infection to be a causative factor in noncompressive myelopathy, which may be sometimes mistaken for radiation myelitis.

BACKGROUND: Limited data exist regarding outcomes of cryptococcosis in patients without human immunodeficiency virus (HIV), and few studies have compared outcomes of Cryptococcus gattii versus Cryptococcus neoformans infection. METHODS: We conducted a retrospective study in 46 Australian and New Zealand hospitals to determine the outcomes of cryptococcosis in patients without HIV diagnosed between 2015 and 2019 and compared outcomes of C. gattii versus C. neoformans infections. Multivariable analysis identified predictors of mortality within 1 year. RESULTS: Of 426 patients, 1-year all-cause mortality was 21%. Cryptococcus gattii infection was associated with lower mortality than C. neoformans (adjusted odds ratio [OR], 0.47; 95% confidence interval [CI], .23-.95), while severe neurological symptoms at presentation were the strongest predictor of death (adjusted OR, 8.46; 95% CI, 2.99-23.98). Almost all (99.5%) patients with central nervous system (CNS) infection received induction antifungal therapy versus 27.7% with isolated pulmonary cryptococcosis. The most common regimen in CNS disease was liposomal amphotericin B with flucytosine (93.8%; mean duration, 31 ± 13 days). Among patients with CNS cryptococcosis, C. gattii infection was associated with higher risk of immune reconstitution inflammatory response (C-IRIS) than C. neoformans (21% versus 3%, P < .001). Nineteen patients received amphotericin B-based re-induction therapy for suspected relapse, but none had microbiological relapse. Serum cryptococcal antigen positivity and lung imaging abnormalities resolved slowly (resolution at 1 year in 25% and 34% of patients, respectively). CONCLUSIONS: Compared with C. neoformans, C. gattii infection demonstrated lower mortality but higher C-IRIS risk in CNS infection. Severe neurological symptoms were the strongest predictor of mortality.

Heparin-binding protein (HBP) is a granule protein derived from neutrophils, located in secretory vesicles and neutrophilic granules, also known as cationic antimicrobial protein of 37 kDa (CAP37) or azurocidin. This study evaluates the diagnostic and prognostic value of HBP levels in relation to infection, organ dysfunction, and mortality in adult patients. A systematic review and meta-analysis were conducted by searching PubMed, Web of Science, EMBASE, and the Cochrane Database from their inception through June 2024. Original studies assessing HBP levels' diagnostic and prognostic utility in predicting infection and disease severity in critically ill adult patients were included. The primary outcome was the diagnostic and predictive role of HBP in infection and severity. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool was used to evaluate bias risk. A total of 56 studies involving 11,486 patients were included. Pooled analysis showed HBP had a sensitivity of 0.87 (95% CI, 0.82-0.91), specificity of 0.87 (95% CI, 0.79-0.92), and an AUC of 0.93 (95% CI, 0.91-0.95) for infection diagnosis. For prognostic assessment, sensitivity was 0.77 (95% CI, 0.74-0.80), specificity was 0.72 (95% CI, 0.68-0.76), and AUC was 0.81 (95% CI, 0.78-0.85). HBP outperformed procalcitonin (PCT), C-reactive protein (CRP), and white blood cell count (WBC) in diagnosing and predicting critical illness. No publication bias was detected. HBP demonstrates high sensitivity and specificity for diagnosing infections in critically ill adult patients. Additionally, it effectively predicts disease progression, including organ dysfunction and mortality, surpassing traditional biomarkers such as PCT, CRP, and WBC. All that cannot be true for subjects with severe neutropenia.

BACKGROUND: To investigate the association of folate metabolism gene polymorphism with neural tube defects (NTDs) in Chinese population. METHODS: The subjects were divided into two groups, 495 children with NTDs (NTD group) and 255 healthy children (control group). RESULTS: The levels of folic acid, s-adenosine methionine (SAM), and Sam/s-adenosine homocysteine (SAH) in NTD group were lower than those in control group. There were significant differences in hey, SAH, and Sam levels between two groups, but there was no significant difference in folic acid content. High fever in early pregnancy, taking antiepileptic drugs, father's exposure to organic solvents, folic acid deficiency, and mother's diabetes were the important risk factors in NTDs. MTHFR 677C > T gene was a risk factor for NTD in children, while 1298A > C gene was a protective factor. CONCLUSION: Folic acid metabolism markers were different in NTD children and their mothers, and the overall trend showed that folate, SAM, and SAM/SAH levels were decreased, while Hcy and SAH levels were increased; MTHFR 677C > T gene of SNPs was a risk factor for the occurrence of NTDs, and MTHFR 1298A > C gene was a protective factor, and the environmental risk factor had a synergistic effect on occurrence of NTDs.

INTRODUCTION: This single-surgeon, long-term study aims to evaluate open radical cystectomy (ORC) and robot-assisted radical cystectomy (RARC) with Studer urinary diversion in bladder cancer patients in terms of perioperative, oncological, and functional outcomes. METHODS: This was a single-center, single-surgeon study analyzing patients who underwent open versus robotic intracorporeal neobladder (RIN) from January 2009 to January 2020. We recorded baseline characteristics, perioperative variables, outcomes, including cancer-specific survival (CSS) and overall survival (OS), and functional outcomes. RESULTS: The study included 454 patients (242 open, 212 robotic) with an overall follow-up of 120 months. The RIN group had significantly lower blood loss (p < 0.001), more unilateral nerve sparing (p = 0.008), and higher lymph node yield (p = 0.042). The number of 30-day readmissions favored RIN significantly (p = 0.041). Complication rates (major and minor) were similar between groups (p = 0.56 and 0.61, respectively). The RIN group had improved severe daytime continence (p = 0.03), though no significant difference was found in erectile function (p = 0.56). The robotic cohort showed improved 10-year CSS in T3 disease (68.3% vs. 50.5%, p = 0.04). The OS for the entire cohort was 66.5% for the robotic cohort and 61.6% for open at 10 years (p = 0.08). CONCLUSIONS: In this series, RIN had decreased blood loss, an increased lymph node yield, decreased rate of hospital readmissions, lesser hospital stay, and improved severe daytime continence compared to the open approach.

INTRODUCTION AND IMPORTANCE: decades of life. The diagnosis is often delayed due to non-specific symptoms, resulting in many patients presenting with metastases. Treatment options include radical or palliative surgery, radiotherapy, chemotherapy, and immunotherapy. CASE PRESENTATION: We are presenting a case of a 19-year-old female who was diagnosed with anorectal melanoma at an early stage. However, due to the rejection of abdominoperineal resection several times, she developed advanced-stage melanoma with metastasis in the lung, so the patient will undergo colostomy for treatment when complete obstruction is present, following her consent and that of her parents. CLINICAL DISCUSSION: This case demonstrates the importance of early intervention in young patients with anorectal melanoma. The decision to undergo abdominoperineal resection in young patients is challenging and carries long-term lifestyle implications. CONCLUSION: Anorectal melanoma can occur at any age but is extremely rare in young individuals according to medical literature. It may present as a polyp, so this diagnosis should be considered when such a presentation is observed. Early diagnosis and treatment are necessary to improve the overall survival rate and prevent the disease from progressing to a more advanced stage.

Leydig cell tumors (LCTs) are rare testicular neoplasms, representing 1-3% of all testicular tumors. A 65-year-old male presented with a painless left scrotal mass. Ultrasound revealed a 61 × 53 × 35 mm tumor with heterogeneous echogenicity and abundant blood supply. Radical orchidectomy was performed, and immunohistochemistry confirmed LCT with positivity for Inhibin A and calretinin, and negativity for CK, chromogranin, LCA, and low Ki67. Postoperative follow-up at 6 months showed improved condition, no scrotal masses, and normal tumor markers. Finally, LCTs in older males require differential diagnosis; hormonal activity impacts presentation. Conservative management and monitoring are crucial.

INTRODUCTION: Primary hyperparathyroidism is a common endocrine disorder, especially among postmenopausal women, characterized by elevated calcium levels and excessive secretion of parathyroid hormone due to hyperactive parathyroid glands. PRESENTATION OF CASE: A 17-year-old male presented with a painless mass in the maxilla, which developed six months after a cystic lesion was diagnosed in his right knee. Subsequent examinations identified a parathyroid tumor, leading to surgical excision of the right lower parathyroid gland, and the patient developed hypocalcemia postoperatively, indicative of Hungry Bone Syndrome. DISCUSSION: Primary hyperparathyroidism occurs mostly in females aged 50 to 60 and presents with many clinical symptoms and signs, but our patient was a 17-year-old male and had one of the complications of this disease, which is a brown tumor, without the appearance of the common typical symptoms of the disease, which led to excluding the diagnosis of a brown tumor and suspecting a giant cell tumor due to the histological similarity. CONCLUSION: This case report emphasizes the critical need to consider primary hyperparathyroidism in atypical demographics, such as young males. Notably, the formation of a brown tumor prior to overt hyperparathyroidism symptoms suggests potential early complications. This case reinforces the importance of surgical expertise in successful parathyroidectomy in countries without advanced imaging.

Introduction: Patients with Atrial fbrillation (AF) are at fivefold higher risk for Ischemic stroke than in the general population. Although the current therapeutic guidelines recommend the use of anticoagulants for thromboembolic prophylaxis in patients with nonvalvular AF (NVAF) with additional risk factor(s) for stroke, the global registry data show non-adherence to guidelines for the management of stroke in diferent regions of the world. The current study conducted at the tertiary referral cardiac center of Nepal for addressing the risk profle of stroke based on the current risk scores and the use of antithrombotic agents NVAF patients. Methodology: This was a descriptive observational cross sectional study conducted at Shahid Gangalal National Heart Centre (SGNHC), Kathmandu, Nepal from December 2020 to June 2020 which included patients with Nonvalvular AF. The main objective of the study was to study the clinical characteristics, stroke risk profle based on CHA ₂DS₂-VaSc score and risk of bleeding based on HAS-BLED score and the patterns of use of antithrombotic agents in NVAF patients. Results: A total of 79 cases of NVAF were included with 48(60.8%) males and 31(39.2%) females. The mean CHA₂DS₂-VaSc and HAS-BLED score were 2.44±1.2 and 1.51±1.4 respectively. The majority patients 38% had permanent AF followed by 25.5% had paroxysmal AF. Majority of patients were symptomatic with 67.1% presented with palpitation while 32.9% presented with shortness of breath (SOB). Based on the European Heart Rhythm Association (EHRA) AF related symptoms score, 41.8% had EHRA 2a and 2b while 1.3% had EHRA 4 score. The use of anticoagulants in patients with Nonvalvular AF was 41.6%, with NOACS in 33 % and warfarin used in 8.9% cases. The majority of patients 51.8% of study population were using anti-platelet agents with aspirin in 49.3 % and clopidogrel in 2.5 % cases while no medication in 6.3% of cases. Although 70.8% patients had CHA₂DS₂-VaSc score of 2 or more but the use of anticoagulants was only 58.9% with 46.4% NOACS and 12.5% using warfarin among this group of patients. Conclusion: Although the use of anticoagulant with NOACS in patients with higher risk of stroke is increasing, it is still underused in the majority of cases .There is a need of nationwide AF registry and the need of adoption of the current recommended guidelines to increase use of Anticoagulants in patients with Nonvalvular AF patients for the prevention of stroke .

Tuberculosis (TB) remains a significant global health challenge, with the Eastern Mediterranean accounting for 8.1% of cases. Miliary tuberculosis (MTB) is a rare form, representing 1%-2% of TB cases and 8% of extrapulmonary cases. This report discusses a 39-year-old woman's case who experienced a generalized tonic-clonic seizure, with a normal chest X-ray delaying her diagnosis of MTB and leading to severe outcomes. It highlights the limitations of chest radiography in detecting MTB and emphasizes the need for chest CT or MRI to identify typical miliary patterns. Prompt treatment is crucial in developing countries facing medical resource shortages due to war and poverty to prevent severe complications from MTB.

INTRODUCTION: Spinal epidural abscess (SEA) is a rare but severe infection occurring in the epidural space of the spinal cord, increasingly associated with invasive spinal procedures and intravenous drug use. Recognizing and accurately diagnosing SEA is crucial due to its potential neurological impact. PRESENTATION OF CASE: A 51-year-old male presented with urinary and bowel obstruction, right-sided hemiplegia, fever, and jaundice. Neurological examination revealed pronounced deficits, while imaging and cerebrospinal fluid analysis confirmed multiple epidural abscesses. Cultures identified Staphylococcus aureus sensitive to vancomycin and meropenem. DISCUSSION: The case underscores the variable presentations and nonspecific symptoms of SEA, highlighting the importance of an accurate medical history and timely imaging for diagnosis. Early intervention with surgical drainage and antibiotic therapy based on culture sensitivity is essential for improving outcomes. CONCLUSION: This case emphasizes the need for heightened awareness of SEA, particularly in patients with risk factors, to ensure prompt diagnosis and treatment to prevent irreversible neurological damage.

Pulmonary blastoma (PB) is a rare and aggressive lung neoplasm, representing 0.25 %–0.50 % of lung cancers and characterized by biphasic histology with both epithelial and mesenchymal components. We report a case of a 16-year-old male non-smoker presenting with hemoptysis and a 2-month history of dry cough and exertional dyspnea. Imaging revealed an ill-defined density in the left lung, and bronchoscopy identified a budding mass in the left bronchus. Biopsy results showed malignant spindle cells, with immunohistochemical staining positive for cytokeratin, vimentin, and TTF1, confirming classic biphasic pulmonary blastoma (CBPB). Further CT scans indicated multiple metastases in the right lung and bones. The patient was referred for palliative chemotherapy due to the tumor's aggressive nature. This case highlights the clinical presentation and diagnostic challenges of PB with endobronchial invasion. • CBPB is a rare lung tumor that exhibits aggressive behavior. • CBPB may invade the bronchial causing endobronchial lesions in a few cases. • More research is needed on CBPB treatment guidelines.

Introduction: Proximal humeral fracture accounts for four to five percentage of all fractures. Undisplaced fractures can be managed conservatively however, for displaced fractures; no particular method is a panacea. In our study we treated displaced proximal humeral fracture with Joshi’s external stabilizing system.&#x0D; Aims: To evaluate functional outcome of displaced proximal humerus fractures managed byJoshi’s external stabilizing system.&#x0D; Methods: This prospective study includedall patients with displaced proximal humerus fracture (Neer’s type two and three); treated with JESS from August 2018 to August 2021at Nepalgunj Medical College, Kohalupurand functional outcome was evaluated using Neer’s criteria at final follow-up. Ethical clearance was obtained from Institutional Review Committee.&#x0D; Results: A total of 40 patients, 23 males and 17 females with mean age of 41.2 years (range from 18 to 60) were included. Mean follow-up duration was 24 ± 1.7 weeks. All fractures united at an average of 13 ± 1.7 weeks. Twenty-nine patients (72.5%) had an excellent result with average score of 92.7 ± 2.3 and remaining 11(27.5%) had satisfactory functional outcome with average score of 84.7 ± 1.7 according to Neer’s criteria. Three patients had bicipital tendonitis that resolved within eight weeks of implant removal while two had pin tract infection which resolved with oral antibiotics and dressing.&#x0D; Conclusion: Joshi’s external stabilizing system is an effective treatment option in patients with displaced proximal humeral fractures.

Hematocolpos, a rare condition, occurs when menstrual blood or secretory fluid accumulates in the vagina due to vaginal obstruction. It is often caused by various congenital urogenital anomalies. Early diagnosis is crucial to prevent complications such as tubal adhesion, pelvic endometriosis, and infertility. Hematocolpos can present with recurrent abdominal pain in children, which is occasionally missed in the early period of hospital visits. A proper approach to a hematocolpos includes physical examination and imaging findings. Magnetic Resonance Imaging plays a crucial role in diagnosis and guidance for surgical interventions.

We recommend carrying out a detailed history and evaluation for recent or past COVID-19 infection in patients presenting with Sudden Sensorineural Hearing Loss (SSNHL) since SSNHL could be a sequelae of COVID-19 as in our case and timely diagnosis and intervention could significantly improve hearing and quality of life.

Heparin-Binding Protein (HBP) is a granule protein derived from neutrophils, located in secretory vesicles and neutrophilic granules, also known as cationic antimicrobial protein of 37 kDa (CAP37) or azurocidin. This study evaluates the diagnostic and prognostic value of HBP levels in relation to infection, organ dysfunction, and mortality in adult patients. A systematic review and meta-analysis were conducted by searching PubMed, Web of Science, EMBASE, and the Cochrane Database from their inception through June 2023. Original studies assessing HBP levels' diagnostic and prognostic utility in predicting infection and disease severity in critically ill adult patients were included. The primary outcome was the diagnostic and predictive role of HBP in infection and severity. The Quality Assessment of Diagnostic Accuracy Studies 2 tool was used to evaluate bias risk. The study is registered with PROSPERO (CRD42023421081). A total of 56 studies involving 11,486 patients were included. Pooled analysis showed HBP had a sensitivity of 0.87 (95% CI, 0.82–0.91), specificity of 0.87 (95% CI, 0.79–0.92), and an AUC of 0.93 (95% CI, 0.91–0.95) for infection diagnosis. For prognostic assessment, sensitivity was 0.77 (95% CI, 0.74–0.80), specificity was 0.72 (95% CI, 0.68–0.76), and AUC was 0.81 (95% CI, 0.78–0.85). HBP outperformed procalcitonin (PCT), C-reactive protein (CRP), and white blood cell count (WBC) in diagnosing and predicting critical illness. No publication bias was detected. HBP demonstrates high sensitivity and specificity for diagnosing infections in critically ill adult patients. Additionally, it effectively predicts disease progression, including organ dysfunction and mortality, surpassing traditional biomarkers such as PCT, CRP, and WBC.

The clinical effectiveness, safety and usefulness of KN-7 tablet as a new oral application of the prostatic extract, on urinary dysfunction of neurogenic bladder were compared with those of Robaveron injection by the double-blind test method. In the study, 2 tablets t.i.d. and a shot of intramuscular injection 1 ml a day were given successively for 3 weeks. A total of 233 cases were reported from 37 facilities belonging to the KN-7 Clinical Research Group. Some of them were excluded or dropped out. The number of cases used for analysing the effectiveness, safety and usefulness were 214, 232 and 215, respectively. There was no bias between the two groups with a significant homogeneity in the background. In the overall clinical effectiveness, the effective rate including excellent, moderate and slightly effective was 76.9% with KN-7 and 77.4% with Robaveron. In the clinical usefulness, the rate of usefulness of slightly useful or above was 75.0% with KN-7 and 75.7% with Robaveron. There was no significant difference between the two groups in the clinical effective and useful rates at a significant level of 5%. Side effects were observed in 1 of the 114 (0.9%) patients given KN-7 and 8 of the 118 (6.8%) patients given Robaveron. The incidence of adverse reactions with KN-7 was significantly lower than that with Robaveron. Based on the results, it was concluded that KN-7 tablets, 2 tablets t.i.d., would be as effective and useful as a Robaveron injection 1 ml daily and safer than the latter in the treatment of neurogenic bladder.