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We present here the second documented case of severe immune checkpoint inhibitor-induced myocarditis successfully treated with abatacept. The patient was started on pembrolizumab for stage IIIA malignant melanoma, and after the first dose was admitted for worsening shortness of breath and weakness. Her symptoms were refractory to high-dose steroids and she decompensated rapidly necessitating cardiopulmonary resuscitation and subsequent intubation and mechanical ventilation. Intravenous immunoglobulin and plasmapheresis did not invoke significant improvement, so abatacept was then initiated. She began to show improvement and was eventually discharged to a skilled nursing facility. This case highlights a severe adverse reaction to an immunomodulator class steadily growing in its application. Providers of all specialties should be aware of the side effects and treatment options. Our case demonstrates that continued investigation into the utilisation of CTLA-4 agonists in the treatment of severe adverse reactions like myocarditis caused by pembrolizumab is required.

Pancreatic cancer (PC) is a major gastrointestinal cancer in terms of worldwide incidence and mortality. Despite advances in diagnostic and treatment modalities, the mortality of PC is still a serious concern in both sexes. Immune therapy using inhibitors of immune checkpoints, especially inhibitors of programmed cell death protein 1/programmed cell death ligand-1(PD-1/PD-L1), offer huge benefits to cancer patients. This review describes an up-to-date information on the role of PD-1 and PD-L1 in the development of immune tolerance in PC alongside the current clinical trials and the known outcomes citing the available literature. We also included the details on PD-1/PD-L1-mediated signalling in maintenance of PC stem cells and metastasis. We reviewed the critical information on safety, tolerance, and efficacy of clinically important regimens of PD-1/PD-L1 blocking agents and targeted therapeutics. This review elucidates the underlying mechanisms of PD-1/PD-L1 alliance in tolerance of the immune system, maintenance of stem cells, and metastasis promotion as well as design regimens with high safety and excellent tolerability and efficacy for management of PC in advanced stages.

A 45-year-old man presented with right upper abdominal pain and low-grade fever for 2 weeks. Laboratory investigations showed polymorphonuclear leukocytosis with normal liver function tests. Ultrasound scan showed a heteroechoic lesion in the right lobe of the liver with mobile echogenic foci

A 40-year-old woman presented with acute-onset colicky abdominal pain. On physical examination, the patient was afebrile with a heart rate of 95 beats per minute. Abdomen was soft with tenderness in the periumbilical location. No rebound tenderness or guarding was noted. There was no palpable mass.

The microbiome assisted tumor microenvironment (TME) supports the tumors by modulating multiple mechanisms. Recent studies reported that microbiome dysbiosis is the main culprit of immune suppressive phenotypes of TME. Further, it has been documented that immune suppressive stimulate metastatic phenotype in TME via modulating signaling pathways, cell differentiation, and innate immune response. This review aims at providing comprehensive developments in microbiome and breast TME interface. The combination of microbiome and breast cancer, breast TME and microbiome or microbial dysbiosis, microbiome and risk of breast cancer, microbiome and phytochemicals or anticancer drugs were as used keywords to retrieve literature from PubMed, Google scholar, Scopus, Web of Science from 2015 onwards. Based on the literature, we presented the impact of TME assisted microbiome dysbiosis and estrobolome in breast cancer risk, drug resistance, and antitumor immunity. We have discussed the influence of antibiotics on the breast microbiome. we also presented the possible dietary phytochemicals that target microbiome dysbiosis to restore the tumor suppression immune environment in breast TME. We presented the microbiome as a possible marker for breast cancer diagnosis. This study will help in the identification of microbiome as a novel target and diagnostic markers and phytochemicals and microbiome metabolites for breast cancer treatment.

Renewable energy-based smart grids are famous nowadays due to their high intellectual properties. The world is starting new inventions in renewable energy-based electrical power generation systems to reduce global warming. However, a single renewable energy source cannot maintain a proper energy management system and reliability of power towards loads. Hence, integrating two or more systems is very important and can form a smart grid with an appropriate energy management system. Effective energy management system for a 4-wire 1-MW smart grid system is proposed in this paper. The system is composed of three solar plants and three wind farms with a battery bank. The battery energy management system can operate the complete system as a smart grid with the proper design of the controllers. The maximum power points of PV plants are tracked using a hybrid algorithm that merges the merits of Modified Invasive Weed Optimization and Perturb and Observe (P&O). Thus, the maximum power is obtained under partial shading conditions. The P&O algorithm is also developed to track the maximum power of wind farms. All the loads and generation units are connected in a ring-configuration distribution with a centralized battery energy management system. The loads are selected to be unbalanced, nonlinear and reactive to simulate practical cases. TS-Fuzzy based common inverter controller is implemented to maintain acceptable power quality, which is linked to the battery. The proposed inverter controller can work as a reactive power compensator, active power filter, voltage regulator under unbalanced load, and power balancing device between generation and load. Extensive Hardware-in-Loop (HIL) results are presented to validate the effectiveness of the proposed system.

Even in developing countries like Nepal, prevalence of ST-elevation myocardial infarction has been shown to be increased with rise in prevalence of conventional risk factors like diabetes, Hypertension, smoking, dyslipidemia and obesity. Our aim is to retrospectively analyze for various risk factors and angiographic patterns of coronary artery disease in patients with ST-elevation myocardial infarction undergoing Primary Percutaneous Intervention.During the period of 1 year (January 2019 to December 2019), 816 patients presented to our ER with acute STEMI, among them 437 (53.6%) patients underwent primary PCI strategy and among them 22 (5.3%) patients were died. Thirty-six (4.4%) patients received thrombolysis, among them 5 (13.9%) patients were died while remaining 343 (42.0%) patients were managed conservatively and among them 20 (5.8%) were died. The mean age of patient who underwent primary PCI was 58.5±12.7 years range from 25 years to 99 years. Among them 55-75 years old 217 (49.6%) were highest in number followed by55 years old 180 (41.2%). Males 318 (72.8%) were predominant. Among those who underwent primary PCI, hypertension 214 (49%) was the most common risk factor, followed by smoking 198 (45.3%), diabetes mellitus 123 (28.1%), dyslipidemia 53 (12.1%) and family history of premature coronary artery disease 18 (4.1%). Among those patients, 292 patients (66.8%) had single vessel disease, 99 patients (22.7%) had double vessel disease, 41 patients (9.3%) had triple vessel disease and 5 patients (1.1%) had non-significant coronary artery stenosis. Left anterior descending (53.3%) was the most frequently found culprit artery, followed by right coronary artery, left circumflex, ramus intermedius and left main artery.Fifty percent of patients presented with acute ST-elevation myocardial infarction and underwent primary PCI were between 55-75 years of age. Hypertension and smoking were the most common risk factors present in those patients. Single vessel disease was most prevalent with left anterior descending found to be the most commonly involved coronary artery followed by right coronary artery and left circumflex.

BACKGROUND: National-level data of cancer patients’ readmissions after ST-segment elevation myocardial infarction (STEMI) are lacking. OBJECTIVES: The primary aim of this study was to compare the rates and causes of 30-day readmissions in patients with and without cancer. METHODS: Among patients admitted with STEMI in the United States National Readmission Database (NRD) from October 2015–December 2017, we identified patients with the diagnosis of active breast, colorectal, lung, or prostate cancer. The primary endpoint was the 30-day unplanned readmission rate. Secondary endpoints included in-hospital outcomes during the index admission and causes of readmissions. A propensity score model was used to compare the outcomes of patients with and without cancer. RESULTS: A total of 385,522 patients were included in the analysis: 5956 with cancer and 379,566 without cancer. After propensity score matching, 23,880 patients were compared (Cancer = 5949, No Cancer = 17,931). Patients with cancer had higher 30-day readmission rates (19% vs. 14%, p < 0.01). The most common causes for readmission among patients with cancer were cardiac (31%), infectious (21%), oncologic (17%), respiratory (4%), stroke (4%), and renal (3%). During the first readmission, patients with cancer had higher adjusted rates of in-hospital mortality (15% vs. 7%; p < 0.01) and bleeding complications (31% vs. 21%; p < 0.01), compared to the non-cancer group. In addition, cancer (OR 1.5, 95% CI 1.2–1.6, p < 0.01) was an independent predictor for 30-day readmission. CONCLUSIONS: About one in five cancer patients presenting with STEMI will be readmitted within 30 days. Cardiac causes predominated the reason for 30-day readmissions in patients with cancer.

Introduction Hypothalamic hamartoma (HH) is a rare developmental disorder presenting with gelastic seizures or precocious puberty attributed to gonadotrophin-releasing hormone expression by the hamartoma. The histogenesis of HH is uncertain, and diagnosis of HH is difficult in small biopsies due to its close resemblance to normal hypothalamic nuclei. TTF-1 and arginine vasopressin (AVP) are associated with gonadotropin-releasing hormone release. Materials and methods In this study, we explored the expression pattern of TTF-1 and AVP in HH and its utility, if any, in diagnosis. We reviewed the clinical, radiologic, and histopathological features of 23 HH diagnosed over the past decade at our Institute. Results The age at presentation ranged from 11 months to 34 years with gelastic seizures (82.6%), precocious puberty (17.4%), and developmental delay (8.7%) as presenting symptoms. On imaging, all the lesions (n = 9) involved the posterior and tuberal group of hypothalamic nuclei, while 5 cases involved the anterior hypothalamus. Anatomically, the lesions involved mammillary body, arcuate and periventricular nuclei. On histopathology, 52% cases revealed nodular arrangement of small neurocytic cells separated by glial stroma. TTF-1 and AVP immunoreactivity was absent in all the cases, whereas in normal hypothalamus, AVP was expressed in periventricular nuclei. Conclusion Our results suggest that immunoexpression of TTF-1 is absent in HH, particularly in those arising from the posterior hypothalamus, and this can be used in small biopsies to distinguish from a normal hypothalamus as well as from posterior pituitary tumors.

Cervical cancer (CC) is the fourth leading cancer in women in the age group of 15-44 years globally. Experimental as well as epidemiological studies identified that type16 and 18 HPV cause 70% of precancerous cervical lesions as well as cervical cancer worldwide by bringing about genetic as well as epigenetic changes in the host genome. The insertion of the HPV genome triggers various defense mechanisms including the silencing of tumor suppressor genes as well as activation of oncogenes associated with cancer metastatic pathway. E6 and E7 are small oncoproteins consisting of 150 and 100 amino acids, respectively. These oncoproteins affect the regulation of the host cell cycle by interfering with p53 and pRb. Further, these oncoproteins adversely affect the normal functions of the host cell by binding to their signaling proteins. Recent studies demonstrated that E6 and E7 oncoproteins are potential targets for CC. Therefore, this review discusses the role of E6 and E7 oncoproteins in metastasis and drug resistance as well as their regulation, early oncogene mediated signaling pathways. This review also uncovers recent updates on molecular mechanisms of E6 and E7 mediated phytotherapy, gene therapy, immune therapy, and vaccine strategies as well as diagnosis through precision testing. Therefore, understanding the potential role of E6/E7 in metastasis and drug resistance along with targeted treatment, vaccine, and precision diagnostic strategies, could be useful for the prevention and treatment of cervical cancer.

Coupled walls with replaceable steel shear link coupling beams are used to minimize the repair cost and downtime of buildings after major earthquakes. In this study, the direct displacement-based design (DDBD) method for coupled walls with steel shear link coupling beams using inelastic displacement spectra is developed. For capacity design, a continuum model of the coupled walls that accounts for the stiffness degradation due to expected damage in the first mode is adopted, to obtain equations to estimate the shear forces and bending moments generated due to higher modes. The effectiveness of the DDBD design method for coupled walls with steel shear link coupling beams is assessed by comparing the drift demands with nonlinear response history analysis (NLRHA) results and for capacity design purposes the shear force and bending moment profiles obtained from NLRHA are compared with the results obtained from the equations derived in this study and the weighted capacity design (WCD) method. The results obtained for 5-, 10-, and 15-story coupled walls with steel shear link coupling beams, show that the proposed design methodology is suitable to achieve the design objectives.

Background: Awake fiber-optic nasal intubation is a gold standard management of difficult airway in temporal mandibular (TM) joint ankylosis. Aims and Objectives: We compared topical lignocaine nebulization with airway nerve blocks for awake fiber-optic nasal intubation in TM joint ankylosis. Materials and Methods: Fifty patients of either gender were randomly allocated into two groups of 25 each. Group I received 10 ml of 2% lignocaine nebulization over a period for 20 min. Group II received bilateral superior laryngeal nerve block and transtracheal recurrent laryngeal nerve block (each with 2 ml of 2% lignocaine). Awake fiber-optic bronchoscopy-guided nasal intubation was done in all patients. All the patients received sedation during the procedure. The intubation time, intubating conditions, vocal cord position, cough severity, and degree of patient satisfaction were recorded. Student’s t-test was used to analyze parametric data, while the Mann–Whitney U-test was applied to non-parametric data and Fisher’s test to categorical data. P

OBJECTIVE Inequities in stillbirth rate according to ethnicity persist in high income nations. The objective of the present study is to investigate whether causes of stillbirth differ by ethnicity in high-income nations. METHODS The following databases were searched since their inception to 1 February 2021: Medline, Embase, Scopus, CINAHL, Cochrane Library, and Global Health. Cohort, cross-sectional, and retrospective studies were included. Causes of stillbirth were aligned to the International Classification of Disease 10 for Perinatal Mortality (ICD10-PM) and pooled estimates were derived by meta-analysis. RESULTS Fifteen reports from three countries (72 555 stillbirths) were included. Seven ethnic groups - "Caucasian" (n = 11 studies), "African" (n = 11 studies), "Hispanic" (n = 7 studies), "Indigenous Australian" (n = 4 studies), "Asian" (n = 2 studies), "South Asian" (n = 2 studies), and "American Indian" (n = 1 study) - were identified. There was an overall paucity of recent, high-quality data for many ethnicities. For those with the greatest amount of data - Caucasian, African, and Hispanic - no major differences in the causes of stillbirth were identified. CONCLUSION There is a paucity of high-quality information on causes of stillbirth for many ethnicities. Improving investigation and standardizing classification of stillbirths is needed to assess whether causes of stillbirth differ across more diverse ethnic groups.

Background and Aims: Worldwide many patients are receiving intravascular contrast media (CM) during interventional procedures. Contrast media are used to enhance visualization and guide percutaneous coronary interventions (PCI).1 However, the use of CM also carries the risk of complications and it is important to be aware of these complications. Complications with CM range from mild symptoms to life-threatening conditions like anaphylaxis, hypotension and renal dysfunction and contrast-induced nephropathy (CIN) is one of them which can have both short and long term consequences.2 This study aimed to know the incidence of CIN in our center and possible predictors associated with it. Methods: This is the single hospital based cross sectional observational study. Patients undergoing primary PCI were enrolled in the study. All the patients underwent thorough history taking and physical examination. Baseline required laboratory investigations were sent. Electrocardiogram and echocardiography screening was done before taking patient to primary PCI as per the protocol of the hospital. Results: The number of patients enrolled in the study was 83 out of which 65(78.2%) were males and mean age was 59.7±13.2. Mean Arterial Pressure (MAP) among the patients was 103.8±21.3. Almost 2/3rd of the population received intravenous fluids. Minimum contrast volume used was 50ml and maximum was 270. When absolute rise in creatinine was considered 12 (14.5%) had CIN and when percent rise was also considered total 28 (33.7%) had CIN. While evaluating the predictors of CIN, higher mean age (p=0.01), hypotension with mean MAP 100ml (p=0.04) was found to be significant. Conclusion: The incidence of CIN in patients undergoing PPCI was similar to the studies done in other parts of the world. Evaluating the predictors of CIN, higher mean age, hypotension and higher contrast volume was the significant predictor.

Background and Aims: Frontal QRS-T angle has been previously correlated with long term mortality in ST-segment elevation myocardial infarction patients. This study aimed to investigate the prognostic value of frontal QRS-T angle and in-hospital outcomes in the setting of ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention. Methods: We evaluated 97 consecutive patients presenting to the emergency department of Shahid Gangalal National Heart Centre with chest pain of less than 12 hours duration, who were subsequently diagnosed as ST-segment elevation myocardial infarction in a prospective observational study. The study was conducted from July 2020 to June 2021.The data evaluation included demographics, clinical variables, electrocardiogram, length of hospital stay and in hospital mortality. Patient outcomes were stratified into three groups according to frontal QRS-T angle. The relationship between mortality and frontal QRS-T angle was tested with chi-square test. The p-value across the groups was again tested for inter-group significance. Results: Out of 97 patients 67 (69.07%) were male and 30 (30.92%) were female., The mean age of study population was 55.8±11.8 years. The patients under study were divided into three groups based on the calculation of fQRST angle as Group 1 (0-45°) being 46(47.4%), Group 2(46-90°) being 20(20.6%) and Group 3 (>90°) with 31(32%) cases. Diabetes and Congestive heart failure (CHF) patients were more likely to have increase in frontal QRST angle (P value 0.029, 0.012 respectively). Atrial fibrillation (AF) was higher among patients in group 3(>90° frontal QRST angle) which was statistically significant (0.012). Although the mean length of hospital stay was higher among patients with highest frontal QRST angle, it was statistically insignificant (p Value 0.062) however, the chance of hospital stay durations significantly increases across three groups at a 5% significance level (p-value: 0.018). In hospital mortality increased with increase in frontal QRST angle with 8.7%, 15% and 22.6% in group 1, 2 and 3 respectively however it was statistically insignificant. Conclusion: Diabetes, CHF and AF patients were more likely to have increase in frontal QRST angle. The chance of hospital stay duration significantly increases with increase in frontal QRST angle Although the in hospital mortality increased with increase in the frontal QRST angle, it was statistically insignificant. A prospective study with larger sample size will help to clarify its association.

Background and Aims: Hypertension being one of the commonest non communicable diseases is major risk factor leading to premature death.1 With development of, the left ventricular strain imaging technique by echocardiography the consequences of hypertension may be identified and intervene earlier. The aim of study was to show abnormalities in cardiac function in the form of left ventricular strain imaging in hypertensive patients with preserved Ejection fraction. Methods: This was a cross-sectional, comparative and observational study done in Shahid Gangalal National Heart Centre and National Academy of Medical Sciences, Bir Hospital Kathmandu which included hypertensive patients with baseline examination including a medical history, clinical examination and a standardized trans thoracic echocardiography and strain imaging examination and the findings were compared among age and sex frequency matched 82 healthy adults in 1 : 2 ratio. The independent paired t test was used for the comparative statistical analysis. Results: We enrolled 240 patients in this study, 158 were hypertensive (mean age 48.5 ±6.1 years with 50.6 % female) and 82 healthy control (mean age 45.62 ±6.3 years with 51.2% female). There was no significant difference in conventional echocardiographic parameters between two groups except for left ventricular mass index and relative wall thickness that was highest in hypertensive group (p value of

Menstrual management (MM) facilities in schools are neglected in low- and middle-income countries. We examined the existing MM facilities, identified the deficient, and collected students' ideas in peri-urban schools of Nepal. The schools had basic MM facilities including water sanitation and hygiene (WASH) infrastructures, gender-segregated toilet facilities with taps, dustbins and running water, provision of emergency sanitary pads, etc. Out of 71 students who reported soiling of dresses with menstrual blood as a common problem, 27% went home and did not return in such situation instead of washing off at school. Forty-six per cent of students used washable absorbents, but washing and drying facilities were lacking, and students adapted by using disposable pads at school and washable at home. Out of 126 students, 106 took days off during menstruation in the past three months with an average of 2.6 days by one student. Sixty-one per cent gave the reason as pain and 39% tiredness for taking days off. Healthcare facilities were lacking in schools, hence, lack of these facilities in schools might be contributing to absenteeism. The traditionally advocated list of MM facilities for schools, largely involving WASH facilities, should be updated, including newly identified factors which were also suggested by students.

Background Ibrutinib is a Bruton’s tyrosine kinase inhibitor used in the treatment of hematological malignancies. The most common cardiotoxicity associated with ibrutinib is atrial arrhythmia (atrial fibrillation and flutter). It is known that patients with cardiovascular disease (CVD) are at an increased risk for developing atrial arrhythmia. However, the rate of atrial arrhythmia in patients with pre-existing CVD treated with ibrutinib is unknown. Objective This study examined whether patients with pre-existing CVD are at a higher risk for developing atrial arrhythmias compared to those without prior CVD. Methods A single-institution retrospective chart review of patients with no prior history of atrial arrhythmia treated with ibrutinib from 2012 to 2020 was performed. Patients were grouped into two cohorts: those with CVD (known history of coronary artery disease, heart failure, pulmonary hypertension, at least moderate valvular heart disease, or device implantation) and those without CVD. The primary outcome was incidence of atrial arrhythmia, and the secondary outcomes were all-cause mortality, risk of bleeding, and discontinuation of ibrutinib. The predictors of atrial arrhythmia (namely atrial fibrillation) were assessed using logistic regression. A Cox-Proportional Hazard model was created for mortality. Results Patients were followed for a median of 1.1 years. Among 217 patients treated with ibrutinib, the rate of new-onset atrial arrhythmia was nearly threefold higher in the cohort with CVD compared to the cohort without CVD (17% vs 7%, p = 0.02). Patients with CVD also demonstrated increased adjusted all-cause mortality (OR 1.9, 95% CI 1.06-3.41, p = 0.01) and decreased survival probability (43% vs 54%, p = 0.04) compared to those without CVD over the follow-up period. There were no differences in risk of bleeding or discontinuation between the two cohorts. Conclusions Pre-existing cardiovascular disease was associated with significantly higher rates of atrial arrhythmia and mortality in patients with hematological malignancies managed with ibrutinib.

Background: Total abdominal hysterectomy (TAH) is a major surgical procedure associated with significant post-operative pain and discomfort. Ultrasound-guided (USG) quadratus lumborum (QL) and transversus abdominis plane (TAP) block are regional analgesic techniques that have role in post-operative pain management after TAH. Aims and Objectives: This study aims to compare quality of post-operative analgesia and analgesic consumption in USG-guided QL block and TAP block in patients undergoing TAH under spinal anesthesia. Materials and Methods: Hundred patients scheduled for TAH were observed over a period of 2 years. The patients who had received either TAP block or QL block were assigned in two groups. Patients who received TAP block after spinal anesthesia were labeled as Group A and patients who received QL block after spinal anesthesia were labeled as Group B. Postoperatively, VAS score, rescue analgesia, analgesic consumption, and hemodynamic parameters were observed at 0, 1, 3 6, 9, 12, 18, 24, and 48 h. Statistical Analysis: Student’s independent t-test was employed for comparing continuous variables. Chi-square test or Fisher’s exact test, whichever appropriate, was applied for comparing categorical variables. P

Introduction: Childhood obesity, caused due to excessive fat accumulation, is one of the leading causes of preventable deaths associated with several non-communicable diseases. In Nepal, there is limited data available on the status of overweight and obesity among school children. The objective of this study was to find out the prevalence of childhood overnutrition among school going children in a municipality. Methods: A descriptive cross-sectional study was conducted from June 2019 to July 2019, in four schools of a municipality selected by simple random sampling. Ethical approval was obtained from Nepal Health Research Council (Registration number 380/2019). Data was collected using census sampling from children aged 5-18 years through self-administered questionnaires to the children’s parents. The data was entered into the Statistical Package for Social Sciences for analysis. Point estimate at 95% confidence interval was calculated along with frequency and proportion for binary data. Results: Out of 379 school children, the prevalence of overnutrition was found to be 38 (10.03%) (95% Confidence Interval= 7.01-13.05). Prevalence of overnutrition was highest in children of age group 10-13 years 23 (60.5%), in females 27 (71.1%), those consuming junk food 4-6 times weekly 14 (36.8%) and those performing daily physical activity less than 60 minutes 24 (63.2%). Conclusions: The prevalence of childhood overnutrition is similar in comparison to other studies done in similar settings.

Among perovskite semiconductors, quasi-two-dimensional (2D) materials are attractive for the pursuit of electrically driven lasing given their excellent performance in light-emitting diodes (LEDs) and their recent success in continuous-wave optically pumped lasing. We investigate the spontaneous photoluminescence emission and amplified spontaneous emission (ASE) of a series of quasi-2D emitters, and their directly analogous 3D materials formed by removing the 2D organic spacer by annealing. Although the PL photoluminescence (PL) (at low optical excitation power) from quasi-2D films with high 2D spacer fractions can be much brighter than that from their 3D counterparts, the ASE thresholds of these quasi-2D materials tend to be higher. This counter-intuitive behavior is investigated through time-resolved photophysical studies, which reveal the emission in the high-spacer-content quasi-2D perovskite can be exclusively excitonic, and the exciton–exciton annihilation of quasi-2D perovskite starts to take over the exciton dynamics at a low exciton density (

Placing the patient in lateral position is an option for implantation of stereoelectroencephalography (SEEG) electrodes that have a posterior entry point. Previous studies reported the accuracy of SEEG electrodes but not specifically in relation to position. The aim of this study was to analyze accuracy of SEEG electrodes by position.Entry point and target accuracy of electrodes implanted in lateral position were compared with electrodes implanted in supine position using a frame-based with robot guidance technique. Subgroup analysis was performed for insular versus noninsular electrodes.Analysis included 23 consecutive patients (11 in lateral position) with 294 electrodes. The entry point error was similar between lateral (median 1.3 mm [interquartile range 0.8-1.9]) and supine (1.2 mm [0.8-1.7]; P = 0.360) position. Target accuracy was better in lateral (1.8 mm [1.3-2.7]) than supine (2.9 mm [2.0-4.4]; P0.001) position. For noninsular electrodes, the median entry point error in lateral and supine position was 1.3 mm (0.8-1.9) and 1.2 mm (0.8-1.7; P = 0.43), respectively. The accuracy was better in lateral position (median 1.7 mm [1.2-2.6]) compared with supine position (2.9 mm [2.0-4.4]; P0.001). The accuracy of insular electrodes was similar in both positions for entry point (lateral: median radial error 1.4 mm, [0.7-1.9]; supine: 1.1 mm [0.6-1.8]; P = 0.833) and target (lateral: median three-dimensional error 2.3 mm [1.6-3.2]; supine: 2.9 mm [2.4-4.5]; P = 0.07).SEEG leads implanted in lateral position exhibit an accuracy and safety profile in accordance with previous studies. In this cohort, target error was smaller in the lateral position, particularly in noninsular electrodes.

Introduction: The COVID-19 pandemic is a major challenge for health care services including safe and effective surgery. This study aims to analyze gynecological surgery delivery during COVID-19 pandemic. Method: Data on gynecologic surgeries performed at Patan Hospital from 01 Jan to 31 Dec,2020 during pre-lockdown , lockdown and post-lockdown period of the COVID-19 pandemic were analyzed from medical record for surgical procedures, blood transfusion, ICU stay, length of hospital stay, mortality, COVID-19 PCR positive cases. Chi-square and Anova tests were used to compare between three periods, p value

BackgroundRapid progression from the first identifiable symptom to the onset of first-episode psychosis (FEP) allows less time for early intervention. The aim of this study was to examine the association between the first identifiable symptom and the subsequent speed of illness progression.MethodsData were available for 390 patients attending a catchment-based early intervention service for FEP. Exposure to non-psychotic and subthreshold psychotic symptoms was retrospectively recorded using semi-structured interviews. Outcomes following the onset of the first identifiable symptom were (1) time to onset of FEP and (2) symptom incidence rate (i.e. number of symptoms emerging per person-year until FEP onset). These outcomes were respectively analyzed with Cox proportional hazards and negative binomial regressions.ResultsAfter Bonferroni correction, having a subthreshold psychotic (v. non-psychotic) symptom as the first symptom was not associated with time to FEP onset [hazard ratio (HR) = 1.39; 95% CI 0.94–2.04] but was associated with higher symptom incidence [incidence rate ratio (IRR) = 1.92; 95% CI 1.10–3.48]. A first symptom of suspiciousness was associated with shorter time to FEP onset (HR = 2.37; 95% CI 1.38–4.08) and higher symptom incidence rate (IRR = 3.20; 95% CI 1.55–7.28) compared to other first symptoms. In contrast, a first symptom of self-harm was associated with lower symptom incidence rate (IRR = 0.06; 95% CI 0.01–0.73) compared to other first symptoms. Several associations between symptoms and illness progression were moderated by the age at symptom onset.ConclusionsAppreciating the content and timing of early symptoms can identify windows and treatment targets for early interventions in psychosis.

Introduction: Body image is the person’s perceptions, thoughts and feelings about his/her body which is a multi-dimensional concept. Body Image Dissatisfaction can be measured using a Body Shape Questionnaire. The main aim of this study was to find out the prevalence of body image dissatisfaction among adolescent girls of a municipality in Kathmandu. Methods: A cross-sectional survey was done from July 2019 to December 2019 among the female students from grade eight to twelve of the selected private schools of Budhanilkantha municipality. Stratified random sampling was done. Body Shape Questionnaire short version was used to measure the prevalence of body dissatisfaction. Data were analyzed using Statistical Package for the Social Sciences version 23. Point estimate at 95% Confidence Interval was done, frequency and percentage were calculated. Results: One hundred ninety seven (75.2%) at 95% Confidence Interval (69.97-80.43) students were found to have body image dissatisfaction, among which Positive Body Image Dissatisfaction was found to be in 85 (42%) respondents which indicates that 112 (58%) respondents with healthy Body Mass Index were dissatisfied with their body shape. Conclusions: Prevalence of body image dissatisfaction was found to be high in adolescent girls though most of the girls had normal body weight and a healthy Body Mass Index.

Background: Ultrasound guided transvers abdominis plane (TAP) block is a recent modality of managing postoperative pain in lower abdominal surgeries. Aims and Objective: This study was carried out to evaluate postoperative analgesic effectiveness and opioid sparing effect of ultrasound guided transverse abdominis plane block in total abdominal hysterectomy. Materials and Methods: One hundred patients of age group 25 to 65 years enrolled for total abdominal hysterectomy under general anesthesia were studied in the postoperative period at Lal Ded Hospital, Government Medical College, Srinagar over a period of 18 months. Patients who received injection Ropivacaine by ultrasound guided TAP were kept in Group A and others who received only conventional analgesia were kept in Group B. Postoperative pain scores were assessed by VAS score at 1,2,3,4,5,6,12,18 and 24 hours. Time of first rescue analgesia, total opioid consumption and postoperative adverse events were also observed. Results: Postoperative VAS pain scores were significantly reduced at all time intervals in TAP bock group (Group A) when compared with conventional analgesia group (Group B). Mean time for first rescue analgesia was 377 min in Group A as compared to 169 minutes Group B and the difference was statistically significant (p

Neuropathology of drug resistant epilepsy (DRE) has direct bearing on the clinical outcome. Classification of the most common pathologies, hippocampal sclerosis (HS) and focal cortical dysplasia (FCD) have undergone several revisions and studies on the surgical pathology of DRE employing the updated ILAE classification are scarce. Here, we report the neuropathological spectrum of 482 surgically treated cases of DRE from a single institute using the latest ILAE classifications along with clinicoradiologic correlation. Majority of the cases (324, 67.2%) had temporal lobe epilepsy (TLE), with 158 (32.8%) having extratemporal seizure focus. Among TLE, HS was most common (n = 208, 64.2%), followed by neoplasms (42, 13%), FCD (26, 8%) and dual pathology (23, 7%). Less frequent were vascular malformations (cavernoma-3, arteriovenous malformation-1), mild malformation of cortical development (mMCD, 3), gliotic lesions (5), cysticercosis (2), double pathology (2) and polymicrogyria (1). Among extratemporal epilepsies, FCD was most common (46, 29.1%), followed by neoplasms (29, 18.3%), gliotic lesions (27, 17.1%), Rasmussen encephalitis (18, 11.4%), hypothalamic hamartoma (12, 7.6%), malformations of cortical development (10, 6.3%) and vascular malformations (6, 3.8%). Less frequent were double pathology (2, cysticercosis + FCD type IIb, DNET + FCD type IIb), mMCD (2), cysticercosis (1) and dual pathology (1). No underlying pathology was detected in 12 cases (2.5%). Radiopathological concordance was noted in 83%. In 36 cases (7.5%), histopathology detected an unsuspected second pathology that included FCD type III (n = 16) dual pathology (n = 18) and double pathology (n = 2). Further, in four MRI negative cases, histopathology was required for a conclusive diagnosis.

Background: Diabetes Mellitus is one of the most encountered disease in our out patient department and metformin is the first drug of choice to treat Diabetes mellitus. As metformin is one of the cheapest drug, many patients use these drug for long period of time with consultation and without consultations with doctors. Patients under long term metformin use are not aware of Vitamin B12 deficiency and its associated signs and symptoms. In Nepal due to poverty, lack of education and awareness on diabetes mellitus we doctors find much difficult to explain patients on the consequences of diseases. So I decided to do this study which could be much easier to explain patients on effect of metformin of vitamin B12 levels and the consequences life style modifications and supplement of Vitamin B12 to the patients. Methods: This is a Cross-Sectional Study done in the patients with Type 2 diabetes were selected based on inclusion and exclusion criteria. Basic biochemical investigation were sent the lab of the National academy of medical science. Serum B12 assay were done. Vitamin B12 deficiency is defined as values

Designing means and methods to detect the presence of interfacial bubbles and intermetallic compounds (IMCs) during hot dipping solder coating of Cu ribbon, can help in the production of defect-free PV ribbons. A mechanistic study of Cu 6 Sn 5 IMC grain growth and bubble morphology evolution at the solder-substrate interface is performed with phase field simulation. A machine learning model is utilized to identify the occurrence of bubble(s) and IMC at the material interface of liquid solder and solid Cu. The datasets for the microstructural images consisting of bubble(s), IMC and planar solder/Cu interface are generated using in situ synchrotron radiation (SR) imaging experiment techniques. The integration of in situ SR radiography based non-destructive testing experiments with convolutional neural network model to intelligently detect the interfacial microstructures paves the path for potential industrial application of this technique in the smart manufacturing of defect free and reliable PV ribbon material.

Patients over the age of 65 years admitted to hospital with more than six rib fractures have a mortality rate as high as 38%. Of the survivors, 34% are likely to be admitted to an aged care facility. High-quality analgesia is paramount to the mitigation of rib fracture–associated morbidity and mortality. We report a series of ten consecutive patients over the age of 65 years with more than eight fractured ribs. All patients were managed with a novel chest wall block. There were no deaths, and only one patient was discharged into an aged care facility.

Background and Objectives: In Nepal, person aged 60 years and above is considered elderly. The population of Nepal is approximately 30 million, and people aged 60 years and above makes about one tenth of the total population. This study aims to report the main complaints and prevalence of otorhinolaryngological diseases in patients aged 60 years and above, who visited outpatient otolaryngology department of Manmohan Memorial College and Teaching Hospital, Kathmandu, Nepal during study period. Material and Methods: It is a prospective descriptive cross-sectional study done in Manmohan Memorial College and Teaching Hospital, Kathmandu, Nepal for the duration of a year. All patients aged 60 years and above attending to Ear, Nose and throat (ENT) Outpatient Department were included in the study. The information including demographic data, ENT Complaints and physical examination were noted. Analysis of data was done and report was prepared. Results: Total of six hundred and ninety three patients were enrolled over the period of one year for the study. Number of Male and female patients in the study were almost equal. The otological problems had the highest prevalence constituting 51.7% of the study population. More than Twenty eight (28.3 %) percent had oral and oropharyngeal pathologies. Nasal complaints constituted 10.8% of the study population and 9.2% had pathologies related to neck and others. Conclusion: Hearing loss is the most common diagnosis among all the otological pathologies and epistaxis the most common nasal problem. Head and Neck malignancy is also increasing among the geriatric population.

In this work, the solar water collector flow tube geometry is modified as curved and spiral to enhance the system’s performance. The investigation is carried out experimentally under the meteorological conditions of the Kovilpatti region (9°10 ′ 0 ″ N, 77°52 ′ 0 ″ E), Tamil Nadu, India. The flow pipes of the solar water heater are made of copper material which has higher thermal conductivity to recover the water heat as thermal energy. The influence of the mass flow rate (MF) on the flow pipes with respect to the surface temperature for various configurations of the flow tubes is investigated. The two MFs of 0.0045 kg/s and 0.006 kg/s are tested. The MF of 0.006 kg/s yields the maximum efficiency of 73% compared to the other MF. The straight, curved, and spiral tubes yielded the maximum efficiency of 58%, 62%, and 69%, respectively, at 0.0045 kg/s. Similarly, the MF of 0.006 kg/s obtained an efficiency of 62%, 65%, and 73% for straight, curved, and spiral flow tubes, respectively. The economics and exergy of the system are analyzed. The maximum exergy efficiency of the collector is estimated to be 32% for the MF of 0.0045 kg/s for the spiral flow collector, and for the 0.006 kg/s MF, the obtained exergy efficiency is 27% for the spiral flow water heater. The economic analysis revealed that the expense is $0.0608 and $0.0512 worth of hot water produced for the domestic space heating.

Background: Caesarean section (CS) is one of the most common surgical procedures in the world. Post-operative pain affects both mother and the newborn, particularly the first 48 h after birth. The pain can be terrifying, disturbing the bonding between the mother and the child. Objectives: The aim of this study was to compare the efficacy and safety of continuous bilateral transversus abdominis plane block versus epidural analgesia for post-operative pain relief after cesarean deliveries. Patients and Methods: Sixty Patients of American Society of Anesthesiologists (ASA) physical status I or II, scheduled for cesarean deliveries, were enrolled in this randomized, prospective, double-blind, clinical trial study after approval of the medical ethical committee at Al-Azhar university hospitals, Department of Anesthesia and after patients giving written consents, in the period from January 2020 till August 2020, Our study patients were randomly divided into two equal groups (epidural group and tap group). Results: Epidural block provided significantly prolonged postoperative analgesia and reduced postoperative analgesic requirements as compared to ultrasound guided TAP block in patients undergoing CS. Both analgesic techniques were safe. Conclusion: Epidural analgesia was better than TAP block regarding postoperative analgesia, total analgesic consumption and first time to rescue analgesia TAP block can be alternative to epidural when neuraxial anesthesia was contraindicated.

Telecom towers play the utmost important role in mobile communication whereas riggers (tower workers/climbers) are the backbone to erect and maintain such tower infrastructure. Work on telecom towers includes tower structure work, hoisting and de hoisting of various types of antennas, RF cable laying and connectorization. The purpose of this article is to identify gaps among stakeholders in adopting safety standards to protect telecom tower riggers in Indian telecom domain and proposed framework for establishing Occupational, Safety and Health Administration (OSHA) standards for Indian telecom tower riggers to fill the gap and create a conducive atmosphere among telecom companies and tower infrastructure providers while utilizing the services of riggers. This article tabulates basic parameters that are required to find “rigger-man-hours” on each work/activity of rigger on the telecom tower. This will enable telecom companies to forecast their regular riggers requirement as well to assess the future demand across geographical areas of the country.

No robust evidence is provided by literature regarding the management of intracranial hypertension following severe traumatic brain injury (TBI). This is mostly due to the lack of prospective randomized controlled trials (RCTs), the presence of studies containing extreme heterogeneously collected populations and controversial considerations about chosen outcome. A scientific society should provide guidelines for care management and scientific support for those areas for which evidence-based medicine has not been identified. However, RCTs in severe TBI have failed to establish intervention effectiveness, arising the need to make greater use of tools such as Consensus Conferences between experts, which have the advantage of providing recommendations based on experience, on the analysis of updated literature data and on the direct comparison of different logistic realities. The Italian scientific societies should provide guidelines following the national laws ruling the best medical practice. However, many limitations do not allow the collection of data supporting high levels of evidence for intracranial pressure (ICP) monitoring and decompressive craniectomy (DC) in patients with severe TBI. This intersociety document proposes best practice guidelines for this subsetting of patients to be adopted on a national Italian level, along with joint statements from "TBI Section" of the Italian Society of Neurosurgery (SINch) endorsed by the Neuroanesthesia and Neurocritical Care Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Presented here is a recap of recommendations on management of ICP and DC supported a high level of available evidence and rate of agreement expressed by the assemblies during the more recent consensus conferences, where members of both groups have had a role of active participants and supporters. The listed recommendations have been sent to a panel of experts consisting of the 107 members of the "TBI Section" of the SINch and the 111 members of the Neuroanesthesia and Neurocritical Care Study Group of the SIAARTI. The aim of the survey was to test a preliminary evaluation of the grade of predictable future adherence of the recommendations following this intersociety proposal. The following recommendations are suggested as representing best clinical practice, nevertheless, adoption of local multidisciplinary protocols regarding thresholds of ICP values, drug therapies, hemostasis management and perioperative care of decompressed patients is strongly recommended to improve treatment efficiency, to increase the quality of data collection and to provide more powerful evidence with future studies. Thus, for this future perspective a rapid overview of the role of the multimodal neuromonitoring in the optimal severe TBI management is also provided in this document. It is reasonable to assume that the recommendations reported in this paper will in future be updated by new observations arising from future trials. They are not binding, and this document should be offered as a guidance for clinical practice through an intersociety agreement, taking in consideration the low level of evidence.

Introduction: Seizure is one of the common presentation and reason for hospital admission in children. This study aims to address the etiology and clinical characteristics of the patient. Methods: This was a descriptive, cross-sectional study in which children of age 1month to 15 years presenting with seizure were included. The data was analyzed using SPSS 16.0. Results: Out of 192 patients,126 (65.6%) were males and 66(65.6%) were females with the ratio of 1.9:1. Distribution of events in different age groups were 16.1%(n=31) in group of 1month to 1 years, 63%(n=121) in group of 1yrs to 5 years,12.1%(n=24) in group of 5years to 10 years and 8.3%(n=16)in children above 10years.70.3% had febrile seizure, with the highest incidence in age group of 1 to 5 years. Generalised tonic clonic seizure was seen in 94.3% and focal motor seizure in 5.7%. No difference was seen in distribution of the type of seizure across different age groups (p= 0.192).Presenting complaints were fever in 75.5%, loss of consciousness in 26.0%, vomiting in 25.0% , headache in 23.4%, altered sensorium in 8.3% and focal neurological deficits in 8.3%. 33.9% of children had a family history of seizure. Causes of febrile seizures included upper respiratory tract infection in 82.2%, acute gastroenteritis in 12.6%, urinary tract infection in 3% and pneumonia in 2.2%. Afebrile seizure was idiopathic in 38.6% and identifiable causes in the remaining were sequelae of birth asphyxia in 17.6%, hypoglycemia in 8.8%, neuronal migration defects and neurocysticercosis in 5.3%. No relation was observed between the history of perinatal asphyxia and the age of onset of seizure (p=0.250). Of all the patients 57.8% were discharged without antiepileptic, 27.6% were treated with monotherapy whereas 14.5% required polytherapy to achieve seizure control. Conclusions: Seizure is a common problem in children, with the highest incidence in the age group of 1 to 5 years and febrile seizure is the most common type of seizure in children.

Introduction Intentional pesticide poisoning is a major clinical and public health problem in agricultural communities in low and middle income countries like Nepal. Bans of highly hazardous pesticides (HHP) reduce the number of suicides. We aimed to identify these pesticides by reviewing data from major hospitals across the country and from forensic toxicology laboratories. Methods We retrospectively reviewed medical records of 10 hospitals for pesticide poisoned patients and two forensic laboratories of Nepal from April 2017 to February 2020. The poison was identified from the history, referral note, and clinical toxidrome in the hospitals and from gas chromatography analysis in the laboratories. Data on demographics, poison, and patient outcome were recorded on a data collection sheet. Simple descriptive analysis was performed. Results Among hospital cases (n = 4148), the commonest form of poisoning was self-poisoning (95.8%) while occupation poisoning was rare (0.03%). Case fatality was 5.3% (n = 62). Aluminum phosphide (n = 38/62, 61.3%) was the most commonly identified lethal pesticide for deaths. Forensic toxicology laboratories reported 2535 deaths positive for pesticides, with the compounds most commonly identified being organophosphorus (OP) insecticides (n = 1463/2535; 57.7%), phosphine gas (n = 653/2535; 25.7%; both aluminum [11.8%] and zinc [0.4%] phosphide) and organochlorine insecticides (n = 241/2535; 9.5%). The OP insecticide most commonly identified was dichlorvos (n = 273/450, 60.6%). Conclusion The data held in the routine hospital medical records were incomplete but suggested that case fatality in hospitals was relatively low. The pesticides identified as causing most deaths were dichlorvos and aluminum phosphide. Since this study was completed, dichlorvos has been banned and the most toxic formulation of aluminum phosphide removed from sale. Improving the medical record system and working with forensic toxicology laboratories will allow problematic HHPs to be identified and the effects of the bans in reducing deaths monitored.

Ultrasound has now become an eye of anaesthesiologist and has encouraged for its pervasive use. Its considerable use in the perioperative period for various invasive purposes has added an extra caution to prevent unforeseen complications over blind blocks. The ultrasound-guided thoracic paravertebral block provides excellent perioperative analgesia following thoracic surgery. It can be given as a single shot or a continuous infusion technique placing a catheter. Here the local anesthetic agent is deposited in the paravertebral space from where the spinal nerve emerges which are devoid of coverings and are sensitive to local anesthetics. Even a single-shot block provides analgesia of 4-6 dermatomal levels. The use of local anesthetics using ultrasound not only adds safety measures to minimize procedural complications but also reduces the perioperative requirement of opioids. It also helps in the reduction of postoperative pulmonary complications and early extubation following thoracic surgery. We report a case series where single-shot ultrasound-guided unilateral paravertebral blocks were used as an analgesic technique for the repair of tracheoesophageal fistula in neonates. After delivering anesthesia and confirming the correct placement of the endotracheal tube the neonate was kept on the left lateral position to undergo right thoracotomy and repair of fistula. Scanning at T4 level with a linear probe was done to identify the transverse process, pleura, costotransverse ligament, intercostal muscle, and the paravertebral space where the local anesthetic agent was deposited under aseptic precautions. Tenting of pleura was the endpoint for the completion of the block. The extensive use of various regional anesthetic technique has significantly improved the postoperative outcome of the patients along with adequate perioperative pain management.

Objective We investigated the role of angiogenesis and vascular permeability in the pathogenesis of human drug-resistant epilepsy due to hippocampal sclerosis. Methods Resected hippocampi from 30 histologically confirmed cases of hippocampal sclerosis and 30 age-matched post-mortem controls were examined by immunohistochemical quantitation of vascular endothelial markers, CD31 and CD105 (markers of newly formed vessels), and data were analysed relative to MR volumetry. The blood-brain barrier was evaluated based on immunohistochemistry for IgG, albumin, VEGF and AQP4. Results Mean vascular density in the hippocampus was 8.71/mm2 in hippocampal sclerosis samples compared to 7.94/mm2 in age-matched controls. No statistically significant increase in vascular density was found in hippocampal sclerosis samples. Although no neoangiogenesis was found in hippocampal sclerosis samples based on CD105, breakdown of the blood-brain barrier, enhanced neuronal expression of VEGF, and perivascular seepage of IgG and albumin with uptake within neurons and astrocytes were found. Redistribution of the water channel protein, AQP4, reflected by change from normal punctate labelling to intense diffuse staining in hippocampal sclerosis samples, indicated an altered glia-vascular interface, disrupting blood-brain barrier permeability. Significance Our data show no objective histological evidence of angiogenesis in hippocampal sclerosis samples. When controlled for the confounding variable of hippocampal area, there was no difference in vascular density between cases and controls. A leaky blood-brain barrier and redistribution of AQP4 were identified which may contribute to epileptogenesis. This constitutes the largest study in the published literature evaluating a role of vascular permeability and angiogenesis in human hippocampal sclerosis.

Introduction: Febrile seizure is the commonest cause of seizure in children and appears mostly between 6-60 months of life. The objective of this study is to find out the prevalence of febrile seizure among hospitalized children of a tertiary centre of Nepal. Methods: This is a descriptive cross-sectional study conducted in a teaching hospital of central Nepal, from 2014 January to 2019 December. After obtaining ethical clearance from Institutional Review Committee (Reference number: 2019-038), clinical and demographic data was retrieved from patient record retrospectively and reviewed for completeness and accuracy; those fulfilling the definition of febrile seizure were enrolled in the study. Convenience sampling technique was used. The data was analyzed using Statistical Packages for Social Sciences Version 25. Point estimate is done at 95% Confidence Interval and frequency and proportion was calculated. Results: Out of 4890 cases admitted during the study period, 214 (4.37%) (3.80%-4.94% at 95% Confidence Interval) children were diagnosed with febrile seizure. One hundred thirty one (62%) children had a simple febrile seizure. In majority of the cases, seizure lasted for less than 5 minutes; however, 10 (4.6%) of them presented with febrile status epilepticus, 111 (52%) children had generalised tonic seizure and upper respiratory tract infection was the commonest cause of fever. Conclusions: Prevalence of febrile seizure is significant among hospitalized children and simple febrile seizure is the commonest type. A substantial number of children present in febrile status epilepticus, even though the duration of febrile seizure is brief in most of the cases.

Background & Objectives: Various pathophysiological mechanisms and risk factors have been identified in patients with restless leg syndrome and there exist other factors also that are yet to be identified and are under-researched. Evidence suggests a possible link between Vitamin D deficiency and Restless leg syndrome.The aim was to study the Vitamin D levels in patients diagnosed with RLS and to find a correlation between Vitamin D and RLS. Methods: This was a case-control study carried out in the outpatient department of the Institute of Mental Health and Neurosciences Kashmir.A total of 144 subjects were enrolled in the study. Fifty-one were diagnosed cases of RLS and 93 were healthy controls.The Vitamin D levels were analysed by the chemiluminescent immunoassay method in both cases as well as controls.The descriptive statistics were used for various socio-demographic and clinical variables.The data were analysed by chi-square test, t-test and multivariate logistic regression analysis. Results: The vitamin D levels were significantly low in the RLS group in comparison to the control group. There was a significant correlation between vitamin D levels, vitamin D deficiency and restless leg syndrome (OR= 1.01, p-value 0.005 and OR= 5.40, p-value

Background and Aims: Obstructed Sleep Apnea (OSA) is emerging as a significant problem in South East Asia with the rise of Obesity. Polysomnography (PSG) being expensive in Nepal, is usually deferred. The commonly used screening tools are cornerstone to evaluate clinical possibility and effects of OSA without having to rely on the PSG at the onset in Nepal. In this study, we proposed the use of four sleep related questionnaires separate as well as in combination to clinically predict OSA and its severity. And to do that we have compared these scores with Apnea Hypo-apnea Index (AHI) derived from the gold standard level one PSG. Method This was a prospective randomized trial comparing level one polysomnography with individual scores from Epworth Sleepiness Score, STOP BANG score, Pittsburg Sleep Quality Index and Functional Outcome of Sleep Quality-10 and the composite sleep score derived from all the four. Results 120 patients with clinical suspicion of OSA underwent PSG after filling all four questionnaires. The mean AHI of the study population was 37.65 ± 23.66. STOP BANG had the highest sensitivity for all three groups of AHI (≥5, ≥15 and ≥30), at 92.5%, 93.4%, and 95.2% respectively when compared with ESS, PSQI and FOSQ-10. PSQI showed negative correlation with AHI. The proposed composite score showed no correlation with AHI. Conclusion STOP BANG score and AHI showed good correlation. STOP BANG score had the highest sensitivity for all levels of AHI. ESS showed good PPV and NPV to predict OSA. PSQI had the highest NPV to predict AHI. And FOSQ-10 had the highest specificity, good PPV and good NPV.

BACKGROUND AND PURPOSE Morphological assessment with conventional magnetic resonance imaging (MRI) sequences has limited specificity to distinguish between paragangliomas and schwannomas. Assessing the differences in microvascular properties through pharmacokinetic parameters of dynamic contrast-enhanced (DCE)-MRI can provide additional information to aid in this differentiation. MATERIALS AND METHODS A prospective study on MR characterization of neck masses was performed between January 2017 and March 2019 in our department, out of which 40 patients with head and neck paragangliomas (HNPGLs) (33 lesions) and schwannomas (15 lesions) were included in this analysis. MR perfusion using dynamic axial T1WI fat suppressed fast spoiled gradient recalled sequence with parallel imaging was performed in all the patients, in addition to single-shot turbo spin-echo axial diffusion weighted imaging (DWI) and routine MRI. ROI-based method was used to obtain signal-time curves, permeability measurements, and mean apparent diffusion coefficient (ADC) to differentiate paragangliomas from schwannomas. Statistical analysis was done to assess the significance and establish a cutoff to distinguish between the two entities. The available images of DOTANOC PET/CT (34 lesions) were analyzed retrospectively. Correlations between the perfusion, diffusion, and molecular PET/CT parameters were done. RESULTS Paragangliomas had a higher wash-in rate, wash-out rate, Ktrans, Kep , and Vp (p

OBJECTIVE. The purpose of this study was to assess the effects of anatomic and technical factors on the long-term outcome of CT-guided lumbar sympathectomy in patients with chronic limb-threatening ischemia. SUBJECTS AND METHODS. Thirty patients (28 men, two women; mean age, 45.8 years) with chronic limb-threatening ischemia and diffuse tibial arterial disease not amenable to revascularization were included. CT-guided lumbar sympathectomy was performed at the L2-L3 level with a 22-gauge Chiba needle and absolute alcohol. Any periprocedural complication was noted. Numeric pain score (1-10 scale) and skin ulcers were assessed before the procedure and 3 weeks, 3 months, and 1 and 2 years after the procedure. According to spread of alcohol, patients were categorized into those with medial spread and those without medial spread (lateral spread group) with the lateral edge of the vertebral body as the reference point. Treatment results were categorized as improved, unchanged, or worsened on the basis of clinical response. RESULTS. There were 22 (73.3%) patients in the medial spread group and eight (26.7%) in the lateral spread group. The mean volumes of alcohol injected per side were not significantly different (p = .50). One major complication occurred in the group with medial spread. Mean numeric pain scores before the procedure and 3 weeks, 3 months, and 1 and 2 years afterward were 7.31, 2.95, 2.47, 2.10, and 2.04 in the medial spread group and 6.25, 4.13, 4.50, 4.35 and 4.32 in the lateral spread group (p < .001). At 2 years, 16 patients in the medial spread group and two patients in the lateral spread group showed clinical improvement (p < .001), and the limb salvage rates were 100% and 87.5%, respectively. Multivariate analysis showed a trend in improvement with smoking cessation, but the difference was not statistically significant (p = .15). The direction of spread of the neurolytic agent, however, was a major determinant of outcome. CONCLUSION. CT-guided lumbar sympathectomy is a simple, safe, and effective procedure. Ensuring medial spread of the neurolytic agent significantly improves long-term results.

Finding the security vulnerabilities and solving the issues in Wireless Sensor Networks (WSN) are mandatory tasks for providing secure data transmission. Attackers or intruders are rising with various types of network harming activities. Due to the open shared medium of WSN, the services can be easily broken. Intrusion Detection System (IDS) helps to keep the network secure against the attackers. At the same time, it is not sufficient against numerous real time attackers. There are plenty of attacks are injected in wireless transmissions. So, taking a deep survey and finding the needs in security perspective are very important jobs. This survey article analyses the problems and solutions given on secure routing and successful watchdog production in WSN. Collectively, this survey helps to understand IDS techniques, WSN characteristics, secure routing, key management techniques and watchdog construction strategies in detail. Finally, this article states some notable problems and solutions for providing optimal watchdog productions. This keeps WSN free from attackers and intruders. As watchdog is a light weight agent, the techniques and protocols used for intrusion detection shall not create maximum overhead and any runtime issues. In this regard, this work analyses various proactive and reactive routing protocols, light weight cryptography techniques and attack types. From the analysis, this deep survey suggests the optimal usage of secure routing protocols and hardware efficient security algorithms. This survey extends its contribution to reveal the adaptability of efficient cryptography techniques, attacks detection algorithms and protocols with real-time watchdogs. This work significantly contributes for watchdog based intrusion detection in low powered WSN. The performance comparisons and the results given in this work deliver the overall technical benefits and limitations of various techniques.

Background: Global emergence of carbapenem-resistant Klebsiella pneumoniae is a major public health concern. Phage therapy – application of lytic phage to kill pathogenic bacteria – is considered as one of the promising alternatives to tackle this antibiotic crisis in recent days. This study aimed to isolate, characterize and evaluate therapeutic efficacy of a novel K. pneumoniae phage in mouse model.Methods: A novel lytic bacteriophage (phage) Kp_Pokalde_002 was isolated against carbapenem-resistant K. pneumoniae (Kp56) and characterized. Safety parameters of the phage were evaluated by bioinformatic analysis of its genome. A lethal dose (~1×107 CFU/mouse) of Kp56 was determined and administrated in the mice. The infected mice were treated with phage Kp_Pokalde_002 at a multiplicity of infection (MOI) 1.0 (~1×107 PFU/mouse) via both oral and intraperitoneal (IP) routes.Results: Isolated phage comprised an icosahedral capsid with a short tail. Based on genome analysis, the phage was strictly lytic belonging the Podoviridae family (T7-like viruses) and free from any virulent and antibiotic-resistant genes. The phage was stable up to 60 °C for 30 minutes and effective between pH 4 to 11 (optimum pH 9). The phage exhibited a short latent period (20 minutes) with burst size of 121 phage particles per infected cell. The infected mice were rescued with the phage therapy via both oral and IP route. Significant reduction of bacterial load (3-7 log10 CFU/ml) in the blood and lung was observed in the treatment group.Conclusions: We provide an evidence of successful phage therapy against carbapenem-resistant K. pneumoniae infected mouse model using locally isolated lytic phage.Keywords: Bacteriophage; klebsiella pneumonia; phage therapy

This study aims to offer novel means for rethinking contemporary business-to-business (B2B) sales operations and the assumptions that underlie them in the digital era. This rethinking relates especially to sales managers’ efforts to facilitate cognitive unlearning in B2B sales management during the ongoing digital transformation taking place in enterprises. Unlearning—the process of purposely reflecting on and discarding old ways of knowing and doing—is crucial to prevent outdated organizational knowledge and routines from becoming a barrier to change. Before adopting new sales practices, sales organizations must first discard old ways of knowing and doing. Drawing insights from unlearning and B2B sales management literature and conducting empirical qualitative research on 31 executives and senior managers operating in various industries, the study outlines a four-phase process for unlearning as well as several key themes within each phase. The findings emphasize how top management facilitates cognitive unlearning regarding digital business transformation in the B2B sales context. The study contributes to sales management literature by introducing cognitive unlearning as a new theoretical angle on the issue of digital transformation. It also offers insights for sales managers on how to elevate and leverage the unlearning of salespeople. publishedVersion

Pisciculture contributes around 1% to India’s gross domestic product and over 5% to the agricultural GDP. The study was conducted in Balikuda, Biridi, Erasama, Jagatsinghpur, Kujanga, Naugaon, Raghunathpur and Tirtol blocks of Jagatsinghpur district. Both purposive and multistage random sampling methods were adopted for selection of the district, gram panchayat, village and respondents. A total of 180 numbers of respondents were selected for the purpose of the investigation. Based on the descriptive statistics, most of the respondents had medium knowledge about the general pond requirement and manuring and fertilization of the culture pond and harvesting. On the other hand, the youth entrepreneurs in pisciculture had low level of knowledge on predatory and weed fish eradication, stocking of the pisciculture. The youth entrepreneurs in pisciculture had high level of knowledge on harvesting of the pisciculture. Under marketing and storage perception factors 40.55 per cent of the respondents were strongly agreed with preservation of undisposed fishes is difficult. The main aim of pisciculture development program was for making substantial contributions to doubling of food production, improving the welfare of youth entrepreneurs, promoting exports and providing food and livelihood security to its rural youth entrepreneurs.