Occipital Condyle Fracture – A Diagnosis Requiring High Suspicion

Traumatic injury causing occipital condyle fractures (OCF) are very rare. They are of critical clinical importance owing toimportant anatomical structures that need considerations of the occiput-atlantoaxial joint complex. Early diagnosis is of paramount importance since there may be associated lower cranial nerve palsies along with cervical spinal instability. Sometimes, this can be a diagnostic challenge in acute stage because of the inability to diagnose this injury with plain radiographs. To avoid this, high index of suspicion and relevant investigation of the craniocervical junction is indicated. Hence it helps in early recognition and diagnosis of OCF thus preventing possible neurological impairment. Here, we report a case of a 58 -year-old male who presented with complaints of neck pain and headache following physical assault

Case Report: Levetiracetam causing acute liver failure complicating post-operative management in a neurosurgical patient [version 1; peer review: 2 approved]

Background: Herein we report a rare case of acute liver failure due to levetiracetam, which has been considered to have an excellent safety profile with minimal hepatic side effects. Case presentation: A 55-year-old male patient presenting with sudden onset dizziness, slurring of speech and headache was operated for posterior fossa cerebellar hematoma. His post-surgical period was complicated by development of icterus with elevation of liver enzymes. After ruling out common inciting factors, it was decided to stop levetiracetam which was given prophylactically for preventing seizures owing to presence of external ventricular drain. From the next day patient had dramatic improvement in liver functions and sensorium. Conclusions: We would like to highlight this side effect that is potentially life threatening, though rare, of levetiracetam, which is very commonly used in today’s practice and fast superseding all other time-tested antiepileptics

Use of Smart Mobile and Web Application Kobotoolbox/ Kobocollect for Community Health Diagnosis: Sharing Experience from the Remote Area of Nepal

Community Health Diagnosis (CHD) is part of teaching-learning activities at medical and public health schools to recognize the health-related issues in the community, identify social and other problems in depth, and find solutions by shaking hands with community people. Every year, the household survey is conducted by medical, nursing, and public health students as a part of CHD. Our experiences revealed that the student faces several challenges while using paper-based data collection and management during CHD. To overcome such challenges, we used a web-based and smart mobile application called KoboToolbox/KoboCollect to conduct household surveys in CHD in remote areas of Nepal for the first time. Our experience suggests that mobile-based Applications can be used conveniently in CHD which saves time and money for students as well as for schools and can conserve the environment trees. Those students who are not familiar with smart technology need to be trained before using this app

Concurrent Eloquent Area Bleeds in a Patient with Uncontrolled Hypertension

Uncontrolled hypertension being the most important risk factor for intracerebral hemorrhage (ICH) often leads to solitary hematoma whereas multiple spontaneous simultaneous ICH is not common, and occurrence of bilateral hemorrhage is a rare entity with normal bleeding parameters with very few case reports so far. Here, we report a 67-year-old man with a past medical history of uncontrolled hypertension who was brought to the emergency department due to severe headache, worsening confusion for 1 day. An urgent non-contrast brain Computed Tomography (CT) performed immediately revealed bilateral intracerebral hemorrhage (ICH) of the same age in the right putamen and left thalamus. Our patient had a non-traumatic ICH, with low GCS (5/15) at presentation. He was managed conservatively with antihypertensives and antiedema measures. He was discharged in stable condition GCS 14/15 with left hemiparesis (3/5). At last follow up he was recovering well.Due to the rarity of spontaneous intracranial bleed in patient with normal bleeding parameters, it is particularly interesting to report this rare case presentation

Pediatric brain abscess clinical profile, management and outcome at tertiary care centre in Nepal

ABSTRACTBackground: Brain abscess in pediatric population is serious life threatening problem. Many risk factors are associated with this entity like congenital heart disease, ear infection and immunocompromised state. Early diagnosis and treatment with minimal invasive procedure has good outcome. Materials and Methods: This is a hospital based cross-sectional study conducted at institute of Medicine (IOM), Tribhuvan University Teaching Hospital Kathmandu, Nepal over the period of 3 years between September 2014 to August 2017. Clinical profile, management and outcome were analyzed. Results: A total of 27 cases were taken for the surgical management in the present study. There were 18 male and 9 female with the male to female ratio of 2:1. Mean age of the study population was 7.08 years. Otogenic Abscess was the most common 37.03% (n=10) and the temporal lobe was the most common site (37.5%). Headache was the most common clinical presentation seen in 74.07 %. All the cases were initially managed with the burrhole and aspiration. Only 14.8 %( n=4) of cases subsequently required surgical excision of the abscess wall. Only18.5 %( n=5) of the cases required multiple session aspiration. Positive culture was seen in 25.9% (n=7). Pseudomonas aeruginosa and E.coli were the commonest organisms grown. Mortality rate was 3.7%.Conclusion: Modern advances in radio imaging and multidisciplinary team involvement has decreased the morbidity and mortality.Keywords: otogenic brain abscess; pediatric brain abscess; tubercular abscess. </p

Iron-Carbene Initiated O–H Insertion/Aldol Cascade for the Stereoselective Synthesis of Functionalized Tetrahydrofurans

Given its earth abundance, cost-effectiveness, and ecofriendly qualities, iron serves as a promising alternative to precious metals in catalysis. This article presents an iron carbene-initiated cascade approach for synthesizing highly substituted tetrahydrofurans at the gram scale. This cascade reaction utilizes readily accessible β-hydroxyketones and diazo compounds and works with iron catalyst loading as low as 5 mol %. This reaction proceeds through an O–H insertion into diazo-derived iron carbenes, followed by an intramolecular aldol reaction to access functionalized tetrahydrofurans in high yields and diastereoselectivity. The versatile nature of this domino sequence accommodates diverse β-hydroxyketones and diazo compounds, streamlining access to synthetically challenging spiroethers. Furthermore, this cascade process offers a route to enantiopure tetrahydrofurans by utilizing a diazo ester bearing a chiral auxiliary, 8-phenylmenthol. Postmodifications of the tetrahydrofuran product provide access to various analogues, including a medicinally relevant oxetane motif. Density functional theory (DFT) calculations substantiate a stereospecific mechanism wherein the intramolecular aldol reaction proceeds via a fused six- and five-membered iron–oxygen transition-state complex, yielding the contrathermodynamic cis-aldol product

Iron-Carbene Initiated O–H Insertion/Aldol Cascade for the Stereoselective Synthesis of Functionalized Tetrahydrofurans

Given its earth abundance, cost-effectiveness, and ecofriendly qualities, iron serves as a promising alternative to precious metals in catalysis. This article presents an iron carbene-initiated cascade approach for synthesizing highly substituted tetrahydrofurans at the gram scale. This cascade reaction utilizes readily accessible β-hydroxyketones and diazo compounds and works with iron catalyst loading as low as 5 mol %. This reaction proceeds through an O–H insertion into diazo-derived iron carbenes, followed by an intramolecular aldol reaction to access functionalized tetrahydrofurans in high yields and diastereoselectivity. The versatile nature of this domino sequence accommodates diverse β-hydroxyketones and diazo compounds, streamlining access to synthetically challenging spiroethers. Furthermore, this cascade process offers a route to enantiopure tetrahydrofurans by utilizing a diazo ester bearing a chiral auxiliary, 8-phenylmenthol. Postmodifications of the tetrahydrofuran product provide access to various analogues, including a medicinally relevant oxetane motif. Density functional theory (DFT) calculations substantiate a stereospecific mechanism wherein the intramolecular aldol reaction proceeds via a fused six- and five-membered iron–oxygen transition-state complex, yielding the contrathermodynamic cis-aldol product

Shifting paradigm in brain abscess management at tertiary care centre in Nepal

Aim: Brain abscess is a challenging clinical entity with substantial high case fatality rates despite significant advances in imaging techniques, laboratory modalities, surgical interventions, and antimicrobial treatment.Otogenic and cardiogenic sources are among the most common. Classic clinical presentation is seen in very few cases only. Burr hole with aspiration works well with good clinical outcomes. Control of primary source in cases of ear infection in the single setting results in good outcomes, reduces for additional surgery, and decreases the duration of hospital stay.Methods: This is prospective observational study conducted at Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal over the period of two and a half years (from September 2014 to March 2017).We analyzed the demographic profile, management strategies and outcome of these cases diagnosed with brain abscess using Microsoft Excel 2007.Results: A total of 51 cases were undertaken for surgical management. There were 35 males and 16 females with the male to female ratio of 2.18:1. The mean age of the study population was 16.76 years with age range from 4 months to 60 years. Otogenic source was the most common. Temporal lobe was the most common abscess location. Headache was the most common clinical presentation and was seen in 86.27% of the study population. All cases were initially managed with burrhole and aspiration of the abscess. Only 3.92% (n = 2) of cases subsequently required surgical excision of the abscess wall. Only 11.76 % (n = 6) of the cases required multiple aspiration. Only 19.61% (n = 10) showed positive culture. Pseudomonas aeruginosa and E. coli were the most common organisms grown. Mortality rate among the study group was 3.92%.Conclusion: With the advent of modern technology in neuroimaging, mortality due to brain abscess has significantly decreased. Joint involvement of the otorhinolaryngology team and efforts in addressing the primary source have further helped in improving outcomes in cases of otogenic brain abscess. Hence, source control is of paramount importance in managing the brain abscess

Association between birth by caesarian section and anxiety, self-harm: a gene-environment interaction study using UK Biobank data

Abstract Background Limited efforts have been paid to explore the underlying genetic mechanisms of birth by caesarian section (CS) affecting the risks of adult anxiety and self-harm. Methods Using UK Biobank cohort, the logistic regression model was first applied to evaluate the associations of adult anxiety and self-harm with birth by CS. Using birth by CS as exposure variables, genome-wide by environment interaction study (GWEIS) was then applied by PLINK2.0 to identify associated genes interacting with birth by CS for anxiety and self-harm. Results In the observational study, significant associations were observed between birth by CS and anxiety (odds ratio (OR) = 1.24; 95% confidence interval (CI), 1.12–1.38; P = 4.86 × 10− 5), and self-harm (OR = 1.12; 95% CI, 1.01–1.24; P = 2.90 × 10− 2). GWEIS revealed multiple suggestive genes interacted with birth by CS for anxiety, such as DKK2 (rs13137764, P = 1.24 × 10− 9, adjusted P = 2.68 × 10− 7) and ATXN1 (rs62389045, P = 4.38 × 10− 8, adjusted P = 3.55 × 10− 6). For self-harm, significant gene-environment interactions of birth by CS on self-harm were detected, such as ALDH1A2 (rs77828167, P = 1.62 × 10− 8; rs116899929, P = 1.92 × 10− 8) and DAB1 (rs116124269, P = 3.20 × 10− 8; rs191070006, P = 3.63 × 10− 8). Conclusions Our results suggested that birth by CS was associated with the risk of adult anxiety and self-harm. We also discovered some genes interacted with birth by CS might influence the risk of anxiety and self-harm, which may provide novel clues for the pathogenesis of those mental disorders

Traumatic events during childhood and its risks to substance use in adulthood: an observational and genome-wide by environment interaction study in UK Biobank.

We aimed to explore the underlying genetic mechanisms of traumatic events during childhood affecting the risks of adult substance use in present study. Using UK Biobank cohort, linear regression model was first applied to assess the relationships between cigarette smoking and alcohol drinking in adults with traumatic events during childhood, including felt hated by family member (41,648-111,465), felt loved (46,394-124,481) and sexually molested (47,598-127,766). Using traumatic events as exposure variables, genome-wide by environment interaction study was then performed by PLINK 2.0 to identify cigarette smoking and alcohol drinking associated genes interacting with traumatic events during childhood. We found that the frequency of cigarette smoking was significantly associated with felt hated by family member (coefficient = 0.42, P < 1.0 × 10), felt loved (coefficient = -0.31, P < 1.0 × 10) and sexually molested (coefficient = 0.46, P < 1.0 × 10). We also observed weaker associations of alcohol drinking with felt hated by family member (coefficient = 0.08, P = 3.10 × 10) and felt loved (coefficient = -0.06, P = 3.15 × 10). GWEIS identified multiple candidate loci interacting with traumatic events, such as CTNNA3 (rs189142060, P = 4.23 × 10) between felt hated by family member and the frequency of cigarette smoking, GABRG3 (rs117020886, P = 2.77 × 10) between felt hated by family member and the frequency of alcohol drinking. Our results suggested the significant impact of traumatic events during childhood on the risk of cigarette smoking and alcohol drinking