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P2A (anterior) segment aneurysm of posterior cerebral artery is one of the rare aneurysm of posterior circulation. We report a case of 30 years old right handed young man who presented with features of SAH in Emergency Department and cerebral angiogram confirmed left posterior cerebral artery P2A segment thrombosedfusi form aneurysm. Postoperative recovery was good except left sided ptosis after microsurgical trapping via left temporal approach. Treatment modality and outcome after intervention for P2A segment aneurysm will be discussed.

Trauma to the anterior teeth is a common phenomenon in young children and in adolescents. Uncomplicated crown fracture to the permanent teeth has an intense effect not only on the patient’s appearance, but also on function and speech. This case report describes a novel technique in restoring an uncomplicated fractured maxillary anterior tooth in a young patient with direct composite, which is economical and requires less chair side time.

Liver cirrhosis is the formation of abnormal nodular structure and fibrosis. Globally it accounts for 4 ​% of all deaths. Alcohol, viral hepatitis, and non-alcoholic fatty liver disease are the most common cause of cirrhosis. Cirrhosis progresses from the compensated stage to the decompensated stage. It is end-stage liver disease. Anatomically, the liver is divided into four lobes, the right lobe, the left lobe, the caudate lobe, and the quadrate lobe. This lobe varies in size and location within the liver, the right lobe being the largest. Cirrhosis primarily causes portal hypertension which has a varying impact on the four lobes. The right lobe undergoes atrophy due to its acentric location from a central vein and the caudate lobe undergoes hypertrophy due to its central location from the central vein. Preferential perfusion occurs in the caudate lobe and there is a decrease in perfusion in the right lobe. The early non-invasive diagnosis of cirrhosis is required for safe and curable treatment of early-stage cirrhosis. The size variability induced by cirrhosis plays a significant role in its diagnosis. Two key ratios for early cirrhosis detection are the caudate-to-right lobe ratio and the right-to-left lobe ratio, with the former being more substantial. The caudate-to-right-lobe ratio (C/RL) is a key morphological marker for evaluating liver changes in cirrhosis. A C/RL ratio above 0.65 suggests the presence of cirrhosis, making it a valuable tool in diagnosing the condition. These measurements are non-invasive, safe, and crucial for early diagnosis of cirrhosis.

ABSTRACT Understanding species' dietary ecology and interspecific interactions is crucial for multi‐species conservation planning. In Central Asia and the Himalayas, wolves have recolonized snow leopard habitats, raising considerable concern about resource competition between these apex predators. Using micro‐histological analysis of prey species remains (e.g., hair) in their fecal samples, we determined the prey composition, dietary niche breadth, and the extent of diet overlap between these two apex predators in Shey Phoksundo National Park, Nepal. We analyzed 152 scat samples collected along 89 survey transects from April to June 2021. Our findings reveal a significant overlap in their diets (Pianka's index = 0.93), with snow leopard and wolf scats containing the remains of 11 and 10 prey species, respectively. However, the interspecific difference in prey selection was apparent, with significant deviations between observed and expected prey use indicating non‐random prey selection relative to availability: Snow leopards exhibited a higher occurrence of wild prey items in their diet (55.28%), primarily blue sheep (Pseudois nayaur) (24.83%), whereas wolves relied predominantly on domestic livestock (67.89%), with goats (Capra hircus) accounting for over one‐fourth of their diet (29.15%). Yaks (Bos grunniens) comprised a significant portion of the biomass consumed by both predators, with higher for wolves (43.68%) than snow leopards (36.47%). Overall, the narrow dietary niche breadth with high overlap indicates potential resource competition between snow leopards and wolves. However, a comprehensive understanding of resource competition will require further study on other axes of niche partitioning, including habitat and time. Nevertheless, the region's low prey richness means that, with increasing human influence, any reduction in wild prey or increase in livestock could intensify competition between snow leopards and wolves, which could have implications for livestock depredation.

Cyanotoxins are primarily produced by different species of cyanobacteria, also known as blue-green algae, and have appeared to be environmental poisons that have various toxic effects on animal health, including humans. Cyanotoxins have been linked to the development and promotion of multiple cancers in recent studies. Important cyanotoxins, such as microcystins, nodularins, and cylindrospermopsin, have been found to play significant roles in developing and promoting various cancers. These toxins are generally responsible for oxidative stress, DNA damage, and disrupt cellular signaling pathways thus the development of cancers in various cells. Cancer is a multistep process caused by multiple mutations in normal cells. Microcystin-LR inhibits protein phosphatases (PP1 and PP2A), which leads to abnormal cell proliferation and tumor development. Similar inhibition of PP1 and PP2A is shown by nodularin, and in fact, their mechanism of carcinogenesis is the same as that of microcystins to some extent. Cylindrospermopsin inhibits protein synthesis and thus has genotoxic effects and may promote the development of cancer. Anatoxin-a and saxitoxins are well-known neurotoxins but, are thought to have indirect carcinogenic effects based on the fact that they can induce oxidative stress and DNA damage in cells by producing reactive oxygen species, thus further studies are needed to fully elucidate their role in the development and promotion of cancer. This review provides a detailed account of how different cyanotoxins play a role in the development and promotion of cancer.

This paper presents a design methodology for overvoltage protection across 10kV SiC MOSFETs during turn-off after switch failure in a MV SST Power Conditioning System (PCS) enabled by a cascaded Three-Phase (3P) Three-level (3L) Neutral Point Clamped (NPC) Active Front-End Converter (AFEC) and Dual Active Bridge (DAB) using series-connected 10kV SiC MOSFETs and 10kV SiC JBS diodes. The methodology uses an active voltage clamp at the gate terminal and desat detection technique to identify abrupt open and turn-on switch failures across series-connected 10kV SiC MOSFETs. The analytical model estimates over-current time and turn-off voltage transition by considering bus bar inductance, device base plate capacitance and common mode (CM) choke tied between the heat sink and midpoint of the DC link capacitor. The transition model is used to evaluate the turn-off timing for series-connected MOSFETs, snubber resistors, snubber capacitors, and gate resistors to avoid MOSFET overvoltage during converter shutdown, without affecting the voltage balancing and efficiency during normal operation. The MOSFET turn-off transition during the shutdown has been verified in the Saber RD simulation using the validated Saber RD MAST model of 10kV SiC MOSFETs and 10kV SiC JBS diodes at 13.8kV AC/24kV DC level. The fault isolation and MV SST PCS shutdown have been verified in a real-time environment using HIL setup with Xilinx FPGAs and RTDS, at 13.8kV AC/24kV DC link under PCS operating conditions. The normal operation of 3L-NPC pole hardware with modified snubber resistors, snubber capacitors, and gate resistors is verified by experiments conducted at 7kV DC, 10A load current.

This article addresses the mitigation of dynamic voltage imbalance in series-connected 10 kV silicon carbide (SiC) JBS diodes within a three-level NPC (3L-NPC) converter using active turn-off delay control across complementary series-connected 10 kV SiC mosfets. The implementation of active turn-off delay control in SiC mosfets eliminates the need for passive $RC$ snubbers, which otherwise increase the switching $dv/dt$ mismatch and snubber current across the diodes. In addition, parasitic base-plate capacitance across mosfets and diodes, along with parasitic bus bar and snubber inductance in the commutation path, contribute to turn-off voltage mismatch and snubber loss in series-connected 10 kV SiC JBS diodes. The mismatch in nonlinear capacitance of series-connected devices (mosfets and diodes) and the nonlinear mosfet $i$$-$$v_{gs}$ curve affect the turn-on and turn-off voltage transitions between complementary switching mosfets and diodes, leading to variations in turn-off voltage mismatch and snubber losses. The 3L-NPC converter has eight types of switching transition, complicating the analysis of $RC$ snubber design. This complexity is further increased by nonlinear device parameters, parasitic capacitance, and inductance in the commutation path for each of the eight 10 kV SiC mosfets and four 10 kV SiC JBS diodes. To address these challenges, this research develops a mathematical model for the switching transition between 10 kV SiC mosfets and complementary 10 kV SiC JBS diodes in a two-level clamped inductive switching (CIS) test setup. The model considers the effects of parasitic base-plate capacitance and the absence of an $RC$ snubber due to active turn-off delay control across series-connected SiC mosfets. Subsequently, the mathematical model is refined using an iterative algorithm to account for mismatches in nonlinear device capacitance of mosfets and diodes, as well as the nonlinear $i$$-$$v_{gs}$ curve of mosfets during the switching transition of the diode. This refined model is then used to design the $RC$ snubber for series-connected 10 kV SiC JBS diodes and to optimize the turn-on gate resistance of complementary 10 kV SiC mosfets on two-level CIS test benches (TB1 and TB2). Following this, the design parameters are systematically adjusted using experimental results from 3L-NPC test benches 3 to 5. This article provides simplified steps for the design and analysis of the $RC$ snubber in various test benches, validated by experimental data. The 3L-NPC converter with the final $RC$ snubber design achieved 99.2% efficiency and a 35 V turn-off voltage mismatch. The maximum error between the theoretical model and experimental data is 4.8%.

High-power laser diodes (LDs) are used in various military, medical, and industrial applications. In this article, the unique driving requirements of a high power pulsed LD array have been presented, and the required converter architecture has been discussed. A two-stage capacitive energy storage based pulsed power converter system consisting of a phase shifted full bridge (PSFB) based capacitor charging power supply (CCPS) and a buck based pulse current source with inductor energy recovery has been adopted. SiC FETs have been employed to increase the pulsed power capability of the switching regulator based pulse current source as an alternative to the conventionally used linear current driver. A reconfigured pulse forming circuit has been proposed for the pulse current source, which mitigates the effect of the output parasitic inductance on the LD without the need for an additional freewheeling diode across the load. The impact of inductor energy recovery on the semiconductor device's transient thermal stress in the pulse current source has been investigated. The tradeoff between the energy storage capacitance and the filter inductor in the pulse current source has been studied. A pulsed LD driver capable of driving 280 V LD arrays has been designed, and a hardware prototype has been built. The complete system has been experimentally demonstrated by generating 50 A current pulses at 250 V output voltage, validating the proposed converter configuration for high pulsed power LD driving applications.

INTRODUCTION Varicose veins are one of the major problems with patients presenting with symptoms of heaviness, tingling sensation, swelling, aching, restless legs, cramps and itching. Other clinical conditions with which patients presents are pigmentation of lower limbs, healed or active venous ulcers, lipodermatosclerosis. We studied various clinical presentations of varicose veins. MATERIAL AND METHODS A cross-sectional observational study was done in all patients presented to UCMS Teaching Hospital from 2021 to 2022.The primary objective was to assess various clinical signs and symptoms of patients with varicose veins. RESULTS Out of 260 patients, 172 were males and 88 were females. The mean age was 43.87±14.31 years. Patients with occupation involving long standing had more incidence of varicose veins with heaviness and aching as the most common clinical presenta- tion. CONCLUSION Security guard, cook, housewife, teacher, farmer occupational people seem to be affected. Heaviness and aching are more common symptoms, least common clinical presentation were bleeding, thrombosis, and ulceration. [ABSTRACT FROM AUTHOR]

The modulation of kinetics and pathways in the ESIPT process of proton transfer probes holds significant potential for advancing applications in bio-imaging, drug delivery, and OLEDs. One effective approach for achieving this modulation is altering the H-bonding donating capability of the surrounding medium. To investigate this, we conducted a comprehensive study on the excited state intramolecular double proton transfer process of [2,2′-bipyridyl]-3,3′-diol (BP(OH)2) within the confined spaces of silica nanochannels, namely, MCM-41. MCM-41, known for its versatile properties, has emerged as a promising host in various fields, such as drug delivery and heterogeneous catalysis. Upon encapsulation within the MCM-41, the double proton transfer process of BP(OH)2 is significantly modulated, which is reflected in both steady-state and time-resolved photophysical experiments. We have observed an almost 100 times increment in emission intensity and a 30 nm blue-shift in the emission maxima when the probe gets encapsulated inside the silica nanopores. Most importantly, the femtosecond up-conversion profile exhibits an interesting feature. The rise component of 10 ps, which was attributed to MK→DK conversion in bulk acetonitrile (MeCN), is not observed when the probe resides inside the MCM-41, suggesting the proton transfer is concerted rather than sequential, like in the case of bulk MeCN. This anomalous proton transfer mechanism inside the nanochannel was attributed to the weak H-bonding donating ability of the silanol groups, which could not stabilize the MK form, and thus favoured the concerted pathway over sequential. Moreover, DFT calculations corroborate the concerted pathway observed in the MCM-41 with the gas-phase calculations and the sequential mechanism observed in bulk MeCN with the solution-phase calculations.

Introduction: Diabetes mellitus is a multifactorial metabolic condition marked by high blood sugar levels as well as problems with carbohydrate, lipid, and protein metabolism. Impaired insulin secretion and hepatic gluconeogenesis cause high blood sugar levels. Cortisol in the saliva is the unbound, free hormone, with absolute quantities between 30% and 50% fewer than in blood. The aim of the study was to evaluate the levels of salivary cortisol in normal healthy controls and type 2 diabetics. The objective was to evaluate the morning and evening levels of salivary cortisol in normal and type 2 diabetics by enzyme-linked immunosorbent assay (ELISA). Materials and Methods: 20 patients in the age group of 30 to 60 years with type 2 diabetes with HbA1c

Background: Undifferentiated febrile illness (UFI) includes typhoid and typhus fevers and generally designates fever without any localizing signs. UFI is a great therapeutic challenge in countries like Nepal because of the lack of available point-of-care, rapid diagnostic tests. Often patients are empirically treated as presumed enteric fever. Due to the development of high-level resistance to traditionally used fluoroquinolones against enteric fever, azithromycin is now commonly used to treat enteric fever/UFI. The re-emergence of susceptibility of Salmonella typhi to co-trimoxazole makes it a promising oral treatment for UFIs in general. We present a protocol of a randomized controlled trial of azithromycin versus co-trimoxazole for the treatment of UFI.Methods/design: This is a parallel-group, double-blind, 1:1, randomized controlled trial of co-trimoxazole versus azithromycin for the treatment of UFI in Nepal. Participants will be patients aged 2 to 65 years, presenting with fever without clear focus for at least 4 days, complying with other study criteria and willing to provide written informed consent. Patients will be randomized either to azithromycin 20 mg/kg/day (maximum 1000 mg/day) in a single daily dose and an identical placebo or co-trimoxazole 60 mg/kg/day (maximum 3000 mg/day) in two divided doses for 7 days. Patients will be followed up with twice-daily telephone calls for 7 days or for at least 48 h after they become afebrile, whichever is later; by home visits on days 2 and 4 of treatment; and by hospital visits on days 7, 14, 28 and 63. The endpoints will be fever clearance time, treatment failure, time to treatment failure, and adverse events. The estimated sample size is 330. The primary analysis population will be all the randomized population and subanalysis will be repeated on patients with blood culture-confirmed enteric fever and culture-negative patients.Discussion: Both azithromycin and co-trimoxazole are available in Nepal and are extensively used in the treatment of UFI. Therefore, it is important to know the better orally administered antimicrobial to treat enteric fever and other UFIs especially against the background of fluoroquinolone-resistant enteric fever.Trial Registration: ClinicalTrials.gov, ID: NCT02773407 . Registered on 5 May 2016. [ABSTRACT FROM AUTHOR]

Background: Sexual assault is one of the heinous and barbarous crimes and continues to plague our nation. It is present in every countries cutting across boundaries of culture, race, gender, relationship, social standing and the extremes of ages. The current study aims to analyze the incidence of sexual assault cases, their socio-demographic parameters, incidence to reporting time and relationship of the assailant with the victim and pattern of injury for evaluation of sexual assault. Materials and Methods: The medico-legal reports of 102 sexual assaults cases were retrieved and analyzed retrospectively which was examined by Department of Forensic Medicine from October 2019 to September 2020 at Dhulikhel hospital. All the data were entered in SPSS version 25 and results were ascertained. Results: Out of 102 samples, 52 female victims and 48 accused were analyzed. Two were male victims of sodomy. The mean age was 20.54±10.78 and 27.67±11.08 for victim and accused respectively, the most vulnerable being unmarried teenagers. Most of the accused and victims were familiar with each other (81.25%) and the common incident locale was victim’s own house. Genital injury was seen in 53.85% and general injury in 32.7% of the victims. Only 13.46 % victims and 12.50% of accused were brought for examination on the same day. Genital injury had significant association with age (p=0.003) and day of examination (p=0.029). Four of the victims were positive for pregnancy test. Conclusion: Hence this study aims to highlight that sexual assault is a catastrophe and there is a dire need of educating the vulnerable groups.

Introduction: The comprehensive goal in forensic anthropology is the identification of skeletal remains for which researchers are constantly working to produce methods that are as accurate as possible. Because of distinct sexual dimorphism, bones of the pelvis and skull are preferred; however, when these bones are unavailable other bones like sternum have to be used as it holds a great deal of sexual dimorphism. Objective: To evaluate sexual dimorphism in the metric parameters of the sternum through MDCT images amongst Nepalese adults. Materials and Methods: Sternal dimensions of 105 study participants (62 male and 43 female) were measured using Computed Tomography (CT) images from Radiology Department of Dhulikhel Hospital. An independent t test was performed to assess the strength of association between different variables and genders. Differences were considered significant at P < 0.05. ROC curve analysis was done to determine the discriminating power of variables for sex determination. Result: The different measurements of sternal lengths were significantly greater in male than females(p95%) in sex determination. Hyrtl’s law could classify 91.9% of the male and Ashley’s rule of 136 could 97.67% of the female. Conclusion: Hence this study made an effort in sexing the sternum in Nepalese population amongst which mesosternal length and total sterna length were found to be best estimators of sex whereas manubrium length and sternal index were not found to be satisfactory.

The propensity of viruses to co-opt host cellular machinery by reprogramming the host’s RNA-interference machinery has been a major focus of research, however, regulation of host defense mechanisms by virus-encoded miRNA, is an additional regulatory realm gaining momentum in the arena of host-viral interactions. The Human Cytomegalovirus (HCMV) miRNAs, regulate many cellular pathways alone or in concordance with HCMV proteins, thereby paving a conducive environment for successful infection in the human host. We show that HCMV miRNA, hcmv-miR-UL148D inhibits staurosporine-induced apoptosis in HEK293T cells. We establish that ERN1 mRNA is a bonafide target of hcmv-miR-UL148D and its encoded protein IRE1α is translationally repressed by the overexpression of hcmv-miR-UL148D resulting in the attenuation of apoptosis. Unlike the host microRNA seed sequence (6–8 nucleotides), hcmv-miR-UL148D has long complementarity to 3’ UTR of ERN1 mRNA resulting in mRNA degradation. The repression of IRE1α by the hcmv-miR-UL148D further downregulates Xbp1 splicing and c-Jun N-terminal kinase phosphorylation thus regulating ER-stress and ER-stress induced apoptotic pathways. Strikingly, depletion of ERN1 attenuates staurosporine-induced apoptosis which further suggests that hcmv-miR-UL148D functions through regulation of its target ERN1. These results uncover a role for hcmv-miR-UL148D and its target ERN1 in regulating ER stress-induced apoptosis.

Abstract Anthropogenic pressures in human‐dominated landscapes often contribute to wildlife mortality. Carnivores are especially vulnerable to human‐induced mortality due to the perceived threat to livestock and humans. Despite having widespread conservation implications, carnivore mortality data have been largely underutilized within Nepal. This study utilized Maxent to identify high‐risk areas and explore the contribution of habitat attributes associated with carnivore mortality using the casualty database within the Gandaki province of central Nepal. We categorized the risk to carnivore species in three taxonomic groups, Felid, Viverridae, and Herpestidae, and identified a 3704‐km2 area within the province at high risk for carnivore casualty. The middle mountains were the riskiest physiographic zone, and the Annapurna Conservation Area represented the largest risk zone among the four protected areas. Agricultural land was the most problematic area in terms of carnivore casualty. The human population was positively associated with high‐risk areas and the number of casualties, whereas protected area cover had a negative association. This study identified that the common leopard was at the highest risk of mortality and therefore would benefit from the implementation of an action plan and species‐specific conservation strategies, especially within identified high‐risk zones. An expansion of protected areas in the middle mountain region would serve to greatly reduce carnivore casualty. Species distribution modeling can be further used with national‐level spatial and temporal mortality data to identify the most prominent casualty times and pinpoint potential casualty locations throughout the country.

Emamectin benzoate (4´-deoxy-4´-epimethylaminoavermectin B1) is a macrocyclic lactone developed for the control of insect pests in edible plant crops. The current study was taken to assess the possible ameliorative effect of piracetam (P) on emamectin benzoate (EMB) induced alterations in energy metabolism in liver, kidney, testis, heart, cerebral cortex, cerebellum and muscle of rats. Rats of normal control group (N) received water and normal diet ad libitum and (EMB as well as EMB+P) group received 5 mg/kg bw emamectin benzoate via drinking water for 4 weeks. After four weeks of EMB treatment, rats of (EMB+P) received piracetam (500 mg/kg bw, iv) for 15 days. The results demonstrate that emamectin benzoate caused a significant increase in lactate dehydrogenase activity and the level of lactate indicating organ damage in treated animals. Piracetam, the so-called ‘nootropic’ drug is mainly used to treat cognitive impairment in aging, brain injuries, as well as dementia. In the present study piracetam treatment caused a significant inhibition of lactate dehydrogenase activity in liver, kidney, testis, heart, cerebral cortex, cerebellum and muscle of rats. The amelioration of toxic effects by piracetam treatment in EMB treated rats indicate that this drug has the potential to mitigate emamectin benzoate induced toxicity in mammalian systems.

Limited data are available on the relationship between seasonal diets and macronutrient and energy intake of domestic Asian elephants. The effects of age, sex and season on the nutrient composition and intake of food were investigated using 16 domesticated Asian elephants of different ages and sexes. There were no significant seasonal differences in the protein content of the major food plants. However, a seasonal variation in the intake of protein was evident. We used geometric modelling of non-protein (NP) neutral detergent fibre (NDF) and protein to examine seasonal nutrient variability within different ages, sexes and physiological states. The model suggested that most individual elephants maintained their recommended metabolizable energy intake from their diet across all seasons. However, we had anticipated less energy intake from poor diet due to less protein and higher NDF in the feeding ground during winter, pre-monsoon and monsoon seasons. Despite eating a lower variety of plants with less protein and higher NDF, elephants maintained a consistent pattern of diet intake in these seasons, suggesting that they acquired the recommended energy intake by regulating their diet, most likely through over-ingesting low-quality, non-complementary food as they did not have the opportunity to select from a variety of plants.

Liquid metal magneto-hydrodynamic-energy-conversion (LMMHDEC) systems have been a matter of great interest and research & development since 1960. The various states of design and development of such systems go through a step-by-step progress with time. This paper highlights the phenomenon of direct thermal energy conversion systems using liquid metal as an electrodynamics fluid and gas/vapour as a thermodynamic fluid. An analysis of the technological drawbacks responsible for low efficiency of these LMMHDEC systems along with possible R & D solutions have been discussed in this technical research paper. The separation of electrodynamics fluid from thermodynamic fluid at various stages of MHD conversion remained an efficiency challenge of the various types of systems. To meet this challenge, a Dual-cycle MHD system has been designed in this paper. Both the fluids viz. thermodynamic and electrodynamics go through a phase change in this cycle. The thermal efficiency is optimized when one fluid goes into a phase change during a cycle and another fluid does not experience any phase change. The information covered in this paper enables an overview of concepts and the background to choose a cycle for a given temperature range.

A Pelton-wheel impulse turbine is a hydro mechanical energy conversion device which converts gravitational energy of elevated water into mechanical work. This mechanical work is converted into electrical energy by means of running an electrical generator. The kinetic energy of the Water-jet is directed tangentially at the buckets of a Pelton-wheel. The Water-jet strikes on each bucket’s convex profile splitter and get split into two halves. Each half is turned backwards, almost through 180° relative to the bucket on a horizontal plane. Practically this angle may vary between 165° to 170°. Normally all the jet energy is used in propelling the rim of the bucket wheel. Invariably some jet water misses the bucket and passes onto the tail race without doing any useful work. This hydro device is a good source of hydro-electrical energy conversion for a high water head. The present work in this research paper deals with some advanced modifications in the conventional Pelton-wheel so that it can be used for low-head and heavy-discharge applications. Both kinetic and potential energy of the water source is consumed by the runner wheel. Considerable gravitational effect of the water jet is exploited by means of some modifications in a conventional Pelton-wheel. A comparatively heavy generator can be run by this modified Pelton-wheel turbine under low-head and heavy-discharge conditions. The modified features provide enough promising opportunities to use this turbine for Mini and Micro hydro power plants.

Abstract Background Undifferentiated febrile illness (UFI) includes typhoid and typhus fevers and generally designates fever without any localizing signs. UFI is a great therapeutic challenge in countries like Nepal because of the lack of available point-of-care, rapid diagnostic tests. Often patients are empirically treated as presumed enteric fever. Due to the development of high-level resistance to traditionally used fluoroquinolones against enteric fever, azithromycin is now commonly used to treat enteric fever/UFI. The re-emergence of susceptibility of Salmonella typhi to co-trimoxazole makes it a promising oral treatment for UFIs in general. We present a protocol of a randomized controlled trial of azithromycin versus co-trimoxazole for the treatment of UFI. Methods/design This is a parallel-group, double-blind, 1:1, randomized controlled trial of co-trimoxazole versus azithromycin for the treatment of UFI in Nepal. Participants will be patients aged 2 to 65 years, presenting with fever without clear focus for at least 4 days, complying with other study criteria and willing to provide written informed consent. Patients will be randomized either to azithromycin 20 mg/kg/day (maximum 1000 mg/day) in a single daily dose and an identical placebo or co-trimoxazole 60 mg/kg/day (maximum 3000 mg/day) in two divided doses for 7 days. Patients will be followed up with twice-daily telephone calls for 7 days or for at least 48 h after they become afebrile, whichever is later; by home visits on days 2 and 4 of treatment; and by hospital visits on days 7, 14, 28 and 63. The endpoints will be fever clearance time, treatment failure, time to treatment failure, and adverse events. The estimated sample size is 330. The primary analysis population will be all the randomized population and subanalysis will be repeated on patients with blood culture-confirmed enteric fever and culture-negative patients. Discussion Both azithromycin and co-trimoxazole are available in Nepal and are extensively used in the treatment of UFI. Therefore, it is important to know the better orally administered antimicrobial to treat enteric fever and other UFIs especially against the background of fluoroquinolone-resistant enteric fever. Trial registration ClinicalTrials.gov, ID: NCT02773407 . Registered on 5 May 2016.

The pattern of improvement in Neurological status after disc surgery is different. The chronology of improvement in Medical Research Council (MRC) scores, sensory status and improvement in Straight Leg Raise (SLR) test degrees is beneficial in management part to surgeons, relatives and the patients. To assess pattern of neurological outcomes in patients with lumbar disc herniation after microdiscectomy in terms of muscle power, sensory status and SLR. A Quasi experimental study comprising 70 consecutive cases though non-probability purposive sampling technique of both the sexes admitted in Neurosurgery department, Mayo Hospital operated for the 1st time for any disc pathology with no other spinal lesions giving consent themselves or though legal guardians was conducted. Pain for leg and back was measured pre and post-operatively was done by VAS which had 42 days of follow up. Standard Neurological examinations were conducted pertaining to muscle power (by MRC), sensory status and SLR test pre and post-operatively. Variables according to their nature were expressed in the form of Mean±SD, Median (Range) and Frequency (percentage). Mc Neumer’s chi square test and paired t test were used to see association between preoperative and post-operative Neurological status depending on their nature viz: qualitative or quantitative respectively in SPSS version 15. Out of 70 patients 74% were male and 26% were females. Mean±SD of patients was 37.6±13.0 years. Majority were Laborers after housewives. Illiterates, Poor lifting techniques were the most common characteristics in the respective headings of education and employment. Most common level of disc herniation was L4-L5, L5- S1 level (96%) where Prolapse and extrusion were most common MRI findings. As compared to pre-operative (3.4) muscle power 1st and 42nd day power were respectively 4.0 and 4.7 (p=0.001). Pre-operatively only 32 (45.7%) had normal sensation which improved to 38 (54.3%) and 51 (72.9%) respectively in 1st and 42nd day of surgery (p=0.001). Pre-operative mean SLR improved to 98.6 degrees in 1st POD and continued to be the same till 42nd day (p=0.001). All the MRC findings, sensory status and SLR values in each post-operative days were statistically significant with the baseline by paired t test (p=0.001). MRC and Sensory status had same pattern of improvement (r=0.0. p=0.04) unlike SLR which total improvements were see in 1st POD itself. In conclusion, muscle power and sensory improvement follows same improvement pattern whereas maximum SLR improves in the 1st POD itself.

Rhabdomyosarcoma (RMS) is a highly aggressive and rapidly progressive sarcoma. RMS can occur in any part of the human body, however, paraspinal or paravertebral or epidural RMS is very rare in children. We present a case report of 3 year old male child with right paraspinalRMS with intracanalicular extension at L3– S1 level, presented with painful swelling at lower back region. We will review the literature and discuss on epidemiology, diagnosis, management strategy and prognosis of RMS.