Successful management of idiopathic rapidly progressive glomerulonephritis with corticosteroids and cytotoxic agent

A 19 years old, male patient presented with symptoms of smoky urine for 2 weeks, puffiness of face and diminished urine output for 3 weeks associated with occasional lower abdominal and flank pain. Patient's history, clinical findings and available investigations were strongly suggestive of Idiopathic Rapidly Progressive Glomerulonephritis. The patient showed excellent response to glucocorticoid and cytotoxic agent.     

A case report and overview of organophosphate (OP) poisoning

A case of organophosphate (OP) poisoning who recovered after requiring almost 1000 mg of atropine, 10 gm of PAM and ventilatory support for 7 days is presented here. The overview of organophosphate poisoning and its management is given. With the approach adopted, the mortality reported in the general medicine unit in the central hospital in Nepal is 7.4%. The two important aspects of the management are vigilance of the atropine drip, especially at night, and other physical and psychological support care of the patients.     

Retrospective histopathological analysis of various neoplasms of different parts of the gastrointestinal tract seen at the Kathmandu University Teaching Hospital (KUTH), Dhulikhel, Nepal

Objective: To find out the spectrum of various histopathologic types of primary neoplasms of different parts of the gastrointestinal tract (oesophagus, stomach, small intestine, colorectum, anal canal) seen at the Kathmandu University Teaching Hospital (KUTH), Dhulikhel as there exists a worldwide wide variation in the distribution of various neoplasms of different parts of the gastrointestinal tract, which appears largely due to exogenous factors rather than due to inherent differences between populations. Materials and methods: This was a retrospective study. It was carried out at Kathmandu University Teaching Hospital (KUTH), Dhulikhel, Kavre, Nepal. All neoplasms of the gastrointestinal tract seen at the KUTH during the period 1st January 2004 to 31st December 2004 were included in this study and examined by light microscope (LM). Results: A total number of 18 cases of neoplasms of the gastrointestinal tract were seen. Out of these, 3 (16.7%) were of the oesophagus (all squamous cell carcinoma), 10 (55.5%) were of the stomach (six intestinal type and four diffuse type), 2 (11.1%) were of the small intestine (one was lymphoma of the mucosa associated lymphoid tissue - MALTOMA and other was a malignant gastrointestinal stromal tumour - GIST), 3 (16.7%) were of the colorectum (all adenocarcinoma), and none was of the anal canal. Conclusion: Relatively large number of cases of the carcinoma of the stomach were found in our this small series of the cases of the gastrointestinal tract in comparison to the Western countries. Key words: Neoplasms, gastrointestinal tract, gastric carcinoma intestinal type, gastric carcinoma diffuse type, Kathmandu University Teaching Hospital (KUTH).     

Enteric fever: Diagnostic value of clinical features.

Objectives: to evaluate the diagnostic value of clinical symptoms and signs in enteric fever and to propose a clinical diagnostic criterion. Design: Prospective observational study Setting: Kathmandu Medical College, Teaching Hospital, Kathmandu, Nepal Materials and methods: febrile patients with clinical diagnosis of enteric fever were included in the study with the aim of confirming diagnosis with blood culture, or bone marrow culture and evaluating the diagnostic accuracy of various clinical signs and symptoms. Results: 64% of the clinically diagnosed cases had blood/ bone marrow culture positive. The diagnostic accuracy of the various symptoms and signs excluding fever was between 42%-75.5%. Majority of the symptom and sign did not have very high diagnostic accuracy. Hence a diagnostic criterion was proposed and clinical features with diagnostic accuracy more than 50% were taken into consideration. Major criteria included fever with diagnostic accuracy of 64%, headache with accuracy of 75.5% and relative bradycardia with an accuracy of 66%. Minor criteria included vomiting, diarrhoea, Splenomegaly, chills and abdominal pain /discomfort with diagnostic accuracy of 57%, 55%, 55%, 53% and 51% respectively. Finally after combination of various major and minor criteria a final diagnostic criterion was proposed having an accuracy of 66% and including both major and minor clinical symptom and sign. Conclusion: clinical diagnosis of enteric fever will be very helpful in a country like ours. Though none of the clinical symptoms and sign have very high diagnostic accuracy a diagnostic criteria may be helpful. Criteria including both major and minor signs and symptoms would be the most appropriate diagnostic tool as it includes the important abdominal symptoms and signs of enteric fever. Key words: enteric fever, clinical features, diagnostic criteria.     

George McBean

A study currently underway in Nepal aims to discover how quicklystandards of visual literacy can be improved by teaching severalkey clues to picture interpretation. Among non-literate populations,this could help to bring improvement to the effectiveness ofextension workers in health, and many other areas. It is notedthat research in the visual literacy field has given clear indicationsof the type of illustration most likely to be understood bypeople with limited exposure to printed materials. Such researchhas led to emphasis on a particular style of simplistic illustrationtypical of health and other development programmes in many thirdworld countries. However, it is hypothesized that increasedexposure to illustrated materials affects response. Making illustrationsmerely ‘understandable’ may not then be sufficientto challenge entrenched behaviour patterns which require morecreative and imaginative interpretations.     

Characteristics of histopathological and ultrastructural features of placental villi in pregnant Nepalese women

The placenta is an important functional unit for gas transfer between mother and fetus. The placental membrane, consisting of trophoblast layer interposed between maternal and fetal blood, plays an active role for intensity of respiration, but no morphological evidence has been documented. Until now, it has been reported that fetal growth retardation and increased fetal mortality rate usually could be seen at high altitude. In an attempt to find the cause of high perinatal mortality rate in Nepal, this study was undertaken to examine pathologically about 1000 Himalayan placentas obtained in Nepal and Tibet since 1977, and the results were compared with those of 5500 Japanese placentas at Saitama Medical School since 1990. In this study, characteristics of ultrastructural features of the Nepalese placental villi investigated in recent years are reported. (1) The gross characteristics of placental pathology in the Himalayan group were represented by marked subchorionic fibrin deposits and increased chorionic cysts in contrast to low incidence of intervillous thrombosis compared with those of the Japanese group. (2) As characteristics of histological findings of the placental villi between Himalayan and Japanese groups, the incidence of chorangiosis and chorangioma in the Himalayan group was significantly higher than that in the Japanese group. (3) Accompanying an increase of vasculosyncytial membrane (VSM) in the villi, thickness and separation of basement membrane of the syncytium in addition to increased apoptosis of syncytial cell nuclei were recognized. (4) As characteristic ultrastructural features of chorionic villi of Nepalese placentas, an increase of mitochondria and cystic formation of rough endoplasmic reticulum (rER), in addition to appearance of lamellar bodies similar to alveolar epithelial type II cell in organellae of the syncytium, were observed. These ultrastructural changes of the placental villous capillaries may be ascribed to hypevascularization caused by the chronic hypoxic state. It is, therefore, presumed that trophoblast cells may play an important role for gas transfer mecha-nism under such a hypoxic state at high altitude.     

Clinicopathological patterns of bladder carcinoma over 1 year: experience from University Hospital of Nepal

Purpose

To define the clinical and pathological patterns of urinary bladder carcinoma from the University Hospital of Nepal.

Methods

This is a retrospective analytical study. Patients with bladder mass who underwent surgery over 1 year and who had data record were included in the study. Demographic profile, type of surgery, findings on clinical examination, cystoscopy findings, histopathological report, tumor stage, and post-surgery adjuvant therapy were analyzed.

Results

Out of 86 patients who underwent transurethral resection of bladder tumor, 77 patients had biopsy-proven malignant bladder tumor. Urothelial cancer was present in 96.1%. Male were 78.6%. The mean age of diagnosis was 65.5?±?11.8 years. Non-muscle-invasive bladder cancer (NMIBC) was 3.7 times more common than muscle-invasive bladder cancer (MIBC). High-grade tumors (58.6%) were more common than low grade (41.4%). The detrusor muscle was present inthe biopsy specimen of 48 patients (64%). Re-TURBT within 2–6 weeks was considered based on histopathology reports for about half of the patients (45.3%). Upstaging and upgrading of the tumor was present in 5.8 and 5.8% of the patients, respectively. Residual tumor without upstaging and upgrading was present in 23.5%. One patient (1.3%) had Clavien–Dindo grade 1, three (4%) patients had grade 2 and two patients (2.7%) had grade 3b.

Conclusion

In the present study, patients with bladder cancer are younger than reported in other studies. Smokers are strongly predisposed. The histological pattern is similar to the Western and Asian populations. NMIBC and MIBC occur in proportion to that described as in other studies. We had a lower rate of recurrence, upstaging and upgrading. We had a lesser rate of acceptance for radical cystectomy in our patients.

     

Neglected medial swivel dislocation of talonavicular joint with calcaneus,cuboid and 5th metatarsal fractures – A case report

Talonavicular dislocation is a rare injury. Isolated medial or lateral talonavicular dislocations without disruption of subtalar joint are known as medial or lateral swivel dislocations respectively, both being extremely rare. We describe a rare case of neglected medial swivel dislocation with concomitant calcaneus, cuboid and 5th metatarsal fracture, which was managed with open reduction and fixation of talonavicular joint with k-wires and an external distractor. At 1 year follow up the patient was mobilizing full weight bearing without any pain or deformity, the radiographs showing well located talonavicular joint and healed calcaneus, cuboid and 5th metatarsal fractures. This is the first reported case of medial swivel talonavicular dislocation with associated calcaneum, cuboid and 5th metatarsal fracture to the best of our knowledge. This case report highlights the importance of maintaining high level of suspicion for diagnosing midfoot injuries in a polytraumatized patient as well as need of accurate and timely reduction of dislocation for good functional outcome.Level of clinical evidenceLevel 4.