Background:Transbulbar sonography for measuring optic nerve sheath diameter (ONSD) is noninvasive bedside technique for detection of raised intracranial pressure. This study aims to evaluate the number of sonographic evaluations required for a novice operator to learn proper measurement of ONSD after a formal training and supervised scanning session.Methods:Three novice operators and one expert operator measured ONSD of 27 healthy volunteers using linear array transducer HFL38x (frequency range of 6–13 MHz) (MicroMaxx®; SonoSite, USA). In each eye, ONSD was measured three times by each observer and mean value was determined. Correlation coefficient was calculated between the novice and the experienced operator and in between the novice operators. Number of scans, after which the significant correlation developed between novice and the experienced operator and between the novice operators, was analyzed.Results:Cronbach's alpha was tested to evaluate the reliability of the values obtained from intra- and interobservations. For all 27 cases, the value of Cronbach's alpha was high: 0.80–0.99 for the right eye and 0.69-0.97 for the left eye. The mean interobserver variations were plotted on a graph which fluctuated largely in the first 17 cases but oscillated around 0.5–0.30 in the last 10 cases.Conclusion:Learning curve for novice operators to measure ONSD is steep and they can be taught to measure ONSD in healthy volunteers by sonography in supervised clinical session with an acceptable clinical precision and accuracy comparable to an experienced operator.

INTRODUCTION: Pulmonary Vein(PV) stenosis(PVS) is a rare yet serious complication associated with ablation for atrial fibrillation(AF)(1). We report a case of PVS that presented with hemoptysis following ablation for AF and successfully, treated with lobectomy. CASE PRESENTATION: A 46 year old female presented with hemoptysis and dyspnea for 2 weeks. She had history of paroxysmal AF for which she got ablation 4 months prior. Her labs showed WBCs 6.5, hemoglobin 10.3 and Cr 0.68. Chest x-ray showed bilateral lower lobe infiltrates and left pleural effusion. CT chest showed patchy left lower lobe airspace opacities. She was started on antibiotic for presumed pneumonia. Further workup revealed ESR of 127, CRP of 4.5 and negative autoimmune panel. Sputum AFB, fungal culture, gram stain and culture were all negative. Her hemoptysis continued despite appropriate antibiotic. CT coronary angiogram was done that showed complete occlusion of left inferior pulmonary vein along with left lower base airspace opacities. She underwent left lower lobectomy. Histopathological analysis of resected lobe showed hemorrhagic infarcts of lung parenchyma. One year following surgery, all her symptoms resolved.

Iatrogenic iron overload, which is not uncommon in patients undergoing long-term haemodialysis, arises from a combination of multiple red cell transfusions and parenteral iron infusions that are administered to maintain a haemoglobin concentration of approximately 10 g/dL. Although iron overload due to genetic haemochromatosis is conventionally managed by phlebotomy, patients with haemoglobinopathies and chronic transfusion-induced iron overload are treated with iron-chelation therapy. However, the management of iron overload in our patient who presented with hepatic dysfunction and immunosuppressive drug-induced mild anaemia in the post-renal transplant setting posed unique challenges. We report on the decision-making process used in such a case that led to a successful clinical resolution of hepatic iron overload through the combined use of phlebotomy and erythropoiesis stimulating agents, while avoiding use of iron-chelating agents that could potentially compromise both hepatic and renal function.

KEY WORDS IntroductionSevere sepsis and septic shock is a major cause of morbidity and mortality. The burden is higher and the outcome is dismal in the low and middle income countries. ObjectiveThis study aims to evaluate the knowledge about severe sepsis and septic shock among the medical officers of emergency department and intensive care unit in Nepal. It is a cross-sectional survey study. MethodologyThe medical officers working in emergency department and intensive care unit were asked to fill up the survey questionnaire, which contained the questions related to the demographics of the participant, about the knowledge of sepsis and the hindrances behind the effective management of septic patients. The percentage of correct answers for each question and average correct response for all the questions were analyzed. ResultsSeventy medical officers from twenty-four hospitals across the country were enrolled in the study. Among them, 39 were working in the emergency department and 31 were working in the intensive care unit. For the individual questions, the percentage of correct answers varied from 8.57% to 82.86% (average 48.16%). As per the response of the participants, lack of knowledge about sepsis and management guidelines, lack of experience for management of sepsis and lack of investigation facilities were considered to be the major barriers for effective management of septic patients. ConclusionsKnowledge and understanding about severe sepsis and septic shock among the medical officers of emergency department and intensive care unit in Nepal is sub-optimal. To improve the outcome of septic patients, efforts should be made to increase the understanding among these first-line health care workers by implementing regular and mandatory training programs. Knowledge, medical officer, septic shock, severe sepsis Affiliation:1.

With the growing rates of vaccination against coronavirus disease 2019 (COVID-19) across the globe, rare side effects have been increasingly noticed on a post-marketing basis. Cases of myocarditis and pericarditis have been reported in the literature following COVID messenger RNA (mRNA) vaccination. However, diffuse alveolar hemorrhage (DAH) following vaccination has not been reported. DAH is a life-threatening clinicopathological entity characterized by bleeding into the alveolar space from pulmonary microvasculature. It presents a diagnostic challenge in the setting of acute respiratory failure, requiring prompt suspicion and workup.We report a case of a 59-year-old male with a recent COVID-19 infection who presented with DAH within eight hours of the first dose of mRNA vaccination (Moderna, Cambridge, MA). Bronchial alveolar lavage was performed, along with imaging of the chest, to confirm the diagnosis. Immunological workup with rheumatoid factor, anti-citrullinated peptide, anti-neutrophil cytoplasmic antibodies (P-ANCA and C-ANCA), anti-glomerular basement antibodies, Anti-double-stranded DNA, C3 and C4 complement levels, and cryoglobulin were all negative. Infectious workup with cultures and PCR from bronchial lavage was also negative. In the absence of any other causes, the etiology was likely deemed to be vaccine-induced DAH. Herein, we also discuss the possible mechanism of vaccine-related DAH and emphasize the need for further studies on vaccine-related adverse events.

Background: Adrenal insufficiency has various nonspecific symptoms, which are often overlooked until the patient presents with a life-threatening adrenal crisis. Our patient presented during the COVID19 pandemic, which further blurred our diagnostic sense. Clinical Case: A 26-year-old female presented with sudden intractable non-bloody non-bilious vomiting occurring every 30 minutes along with sharp epigastric pain radiating to her back, dizziness, and extreme fatigue for the last 2 days. She had similar but milder episodes in the past 2–3 years as well and endorsed unintentional weight loss for the same duration. She had been extensively investigated previously but was misdiagnosed as gastroparesis or anxiety and was prescribed medications for the same (pantoprazole, sucralfate, and Lexapro). On presentation this time, she was hypotensive and tachycardic but partially responsive to IV fluids. Her BMI was 15.31 and the abdominal exam was benign. Her basic labs showed Na 125, K 4.9, Calcium 10.5, Cr 1, WBCs 9K, lipase 8, normal LFTs, TSH 6.96, Free T4 1.18. Infectious workup was done and the patient was started on empirical antibiotics. Negative infectious workup, hypotension partially responsive to IV fluid, along with hyponatremia and borderline high potassium level prompted us to check Cortisol. We found Cortisol of 1.3(very low for the degree of her illness). ACTH stimulation test with 250mcg IV cosyntropin showed cortisol of 1.3 at 30 minutes and 1.1 at 60 minutes confirming the diagnosis of adrenal insufficiency. Further workup revealed a positive 21 hydroxylase antibody and ACTH level of 322 (high due to lack of negative feedback to the pituitary). She was comprehensively tested for other autoimmune diseases which showed positive Endomysial IgA and Tissue Transglutaminase antibodies indicating asymptomatic celiac disease. She improved drastically after starting hydrocortisone. TSH was repeated in 3 months which was normal. Conclusion: The onset of chronic adrenal insufficiency is very gradual with vague presentation and it may go undetected unless illness or other stress precipitates acute crisis as in our patient. Since autoimmune adrenalitis is the most common cause of primary adrenal insufficiency (Addison’s disease), patients with a confirmed diagnosis should also undergo workup for other autoimmune diseases.

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Background: Anesthesia as a distinct specialty has evolved much beyond the boundaries of operation theater but the services are yet under-recognized. This may be partly because of the lack of knowledge about anesthesia and anesthesiologist in general public and also due to lack of effort to raise awareness among the general public. This study was done to assess the knowledge and perception about anesthesia and anesthesiologist in patients undergoing surgery in Nepal. Material and Methods: A total of 719 patients scheduled for elective or emergency surgery in eight hospitals of Nepal were consecutively recruited and interviewed using questionnaire at pre-operative period before evaluation by anesthesiologist or anesthesiology resident. Individual response to each question was graded using three point scale. Results:The age of the patients ranged from 16 to 87 with a mean of 39.5±15.7 years. Only 31.6% and 28.2% had previous surgery and anesthetic exposure respectively. The majority (69.4% and 49.8% respectively) had good knowledge about health care workers present in operation theater and the ones delivering anesthesia. However, knowledge about anesthesia types and anesthetic agents was poor in 48.4% and 51.9% respectively. The knowledge was poor about person responsible for monitoring and maintaining homeostasis (49%), person responsible for resuscitation (46.5%) and management of anesthesia related complications (49.5%). Remarkably, 48.3% of the respondents had average knowledge about who manages post-operative pain. The mean knowledge score for individual patient was calculated and, 11.1%, 83.4% and 5.4% had poor, average and good knowledge respectively. Conclusion: Majority of patients undergoing surgery had average knowledge and perception about anesthesia and anesthesiologist.