Refractory and super-refractory status epilepticus is a life-threatening neurological emergency, associated with high morbidity and mortality. Treatment should be aimed to stop seizure and to avoid cerebral damage and another morbidity. Published data about effectiveness, safety and outcome of various therapies and treatment approaches are sparse and are mainly based on small case series and retrospective data. Here we report successful management of two cases of super-refractory status epilepticus refractory to anesthetic therapy with midazolam and complicated by septic shock, managed successfully with ketamine infusion.

Radiation exposure to patients was similar during diagnostic coronary angiography with FA, RRA, and LRA. However, LRA was associated with significantly higher operator radiation exposure than were FA and RRA procedures. (Randomized Evaluation of Vascular Entry Site and Radiation Exposure [REVERE]; NCT01677481).

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.

Rapidly, establishing a difficult intravenous access in a dangerously agitated patient is a real challenge. Intranasal midazolam has been shown to be effective and safe for rapidly sedating patients before anesthesia, for procedural sedation and for control of seizure. Here, we report a patient in intensive care unit who was on mechanical ventilation and on inotropic support for management of septic shock and who turned out extremely agitated after accidental catheter removal. Intravenous access was successfully established following sedation with intranasal midazolam, using ultrasound guidance.

Takayasu arteritis is an idiopathic, granulomatous aorto-arteritis that usually affcts young or middle-aged women. The anesthetic management of patients with Takayasu arteritis undergoing cesarean section with COVID-19 is challenging. Patients may have concomitant hypertension, tissue hypoperfusion with the potential for major perioperative cardiovascular complications. The challenges increase considerably in resource-limited settings. We report the case of a 27-year-old primigravida at 39 weeks of gestation with concomitant Takayasu arteritis, chronic hypertension, hypothyroidism, and COVID-19, who underwent an elective cesarean section at our hospital. She incidentally tested positive for SARS-CoV-2 after admission to the hospital. The cesarean section was successfully performed under subarachnoid block. We are not aware of any previous publication describing the anesthetic management in patients with Takayasu arteritis and COVID-19 undergoing cesarean section.

No abstract

Open dislocation of the ankle without associated fracture is extremely rare. Epstein's superior type of hip dislocation is the rarest type of hip dislocation. We reported a case of 50 years Nepalese gentleman who presented with a combination of these two rare orthopedic emergencies with the newly reported mechanism of injury by a garden tractor. Early extensive debridement of the wound with broad spectrum antibiotics coverage, reduction with delta frame external fixator, and postoperative rehabilitation helps in saving limb along with its function.

Abstract. Joshi P, Joshi R, Sapkota RP, Panta M, Chand P. 2023. Vegetation diversity, structure, composition and carbon stock of community managed forests of Mid-hills Nepal. Asian J For 7: 29-36. Depending on management practices, forests can serve as both carbon sinks and sources. The goal of reducing carbon emissions and increasing the carbon sink is thought to be feasible if carbon reservoirs in current forests are protected and conserved. This study was objectively conducted to assess the vegetation diversity, structure, and carbon stock of the Mid-hills of Nepal. The study was undertaken in the Lanta Community Forest, Jajarkot District, Nepal, which has an extent of 38.65 hectares. Data for vegetation analysis and carbon stock assessment were collected using systematic random sampling using quadrats of 10×10 m with a total number of 35 quadrats. Within each quadrat, individual trees and bamboo were identified in the sites, and their height (m) and DBH (cm) were measured. Density, frequency, basal area, and Important Value Index (IVI) were calculated as structural parameters of vegetation. The Above-Ground Tree Biomass (AGTB) and Below-Ground Tree Biomass (BGTB) were calculated using an allometric equation based on tree diameter, height, and wood-specific gravity. The species diversity, species richness, and evenness were found to be 2.2, 2.35, and 0.83, respectively. A total of 14 tree species, with 723 individuals and one bamboo species were recorded. Rhododendron arboreum Sm. had the highest tree density with 211 trees/ha, while Tsuga dumosa (D.Don) Eichler had the highest IVI. Total wood volume, biomass, and total carbon stock were estimated at 15.37 m3 ha-1, 31.99 t ha-1, and 15.03 t ha-1, respectively. There was a strong negative correlation (r = -0.59) between R. arboreum and R. campanulatum D. Don and a strong positive correlation (r = +0.65) between Malus sikkimensis and Machilus species. For the preservation and sustainable management of community forests, information regarding the structure, composition, and dominance of tree species is provided by the study. The establishment of community forests is thus demonstrated in this article as a means of promoting the protection and preservation of regional biodiversity.