Background: This study has compared the difference in serum bilirubin between patients with gangrenous and non-gangrenous appendicitis. Methods: A prospective analytical study of, 141 patients who underwent appendectomy, from March 2010 to March 2011 in Manipal Teaching Hospital, Pokhara, Nepal was carried out. Clinico-demographic data, Alvarado’s score, total serum bilirubin, total leucocyte count and histopathological report of all the cases were collected in a prestructured proforma. Comparison between gangrenous and non-gangrenous appendicitis groups was carried out using independent sample t test, Chisquare test, and direct logistic regression. The data was analyzed using SPSS 11.6 software. Result: Around 43% (61 out of 141) patients had gangrenous appendicitis and statistically significant difference was found between the two groups in total Alvarado’s score, total count and total bilirubin level. The effect size as indicated by eta square statistics was large for total bilirubin (eta squared=0.39) as compared to total Alvarado’s score (0.09) and total leucocyte count (0.05). Direct logistic regression model showed serum total bilirubin as the only independent variable to make a unique statistically significant contribution in predicting gangrenous appendicitis. Conclusion: Pre-operative assessment of serum total bilirubin can serve as an important maker of acute gangrenous appendicitis. DOI: http://dx.doi.org/10.3126/njms.v1i2.6606 Nepal Journal of Medical Sciences. 2012;1(2): 89-92

Background Lesions within the primary motor cortex (M1) and the corticospinal tract (CST) represent a significant surgical challenge with a delicate functional trade-off that should be integrated in the overall patient-centered treatment plan. Methods Patients with lesions within the M1 and CST with preoperative cortical and subcortical mapping (navigated transcranial magnetic stimulation [nTMS] and tractography), intraoperative mapping, and intraoperative provisional histologic information (smear with and without 5-aminolevulinic acid [5-ALA]) were included. This independently acquired information was integrated in a decision-making process model to determine the intraoperative extent of resection. Results A total of 10 patients (6 patients with metastatic precentral tumor; 1 patient with grade III and 2 patients with grade IV gliomas; 1 patient with precentral cavernoma) were included in the study. Most of the patients (60%) had a preoperative motor deficit. The nTMS documented M1 invasion in all cases, and in eight patients, the lesions were embedded within the CST. Overall, 70% of patients underwent gross total resection; 20% of patients underwent near-total resection of the lesions. In only one patient was no surgical resection possible after both preoperative and intraoperative mapping. Overall, 70% of patients remained stable postoperatively, and previous motor weakness improved in 20%. Conclusion The independently acquired anatomical (anatomical MRI) and functional (nTMS and tractography) tests in patients with CST lesions provide a useful guide for resection. The inclusion of histologic information (smear with or without 5-ALA) further allows the surgical team to balance the potential functional risks within the global treatment plan. Therefore, the patient is kept at the center of the informed decision-making process.

PROMs that currently feature in the neurosurgical literature may not address the specific outcomes relevant to neurosurgical practice. There is an emergent need for generic and disease-specific PROMs to be validated in neurosurgical patients and neurosurgery-specific PROMs developed to address unmet needs of patients undergoing neurosurgical procedures.

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Background: Determination of cerebrospinal fluid-adenosine deaminase (CSF-ADA) activity is a reliable means to differentiate tubercular from non- tubercular meningitis. This study was carried out to see the range with mean CSF-ADA levels in meningitis of various etiologies and to see if early diagnosis is possible based on these levels. Methods: A prospective study of 140 children admitted in Manipal Teaching Hospital, from July 2009 – June 2011. Diagnosis was established by clinical findings and relevant investigations and patients were divided in different groups as pyogenic meningitis (PM), partially treated meningitis (PPM), tubercular meningitis (TBM), viral meningitis (VM) and controls. CSF-ADA estimation was done by using spectrophotometer. Results: Out of total 140 patients, 103 were cases of meningitis and 37 were controls. There were 32 cases of PM, 27 cases of PPM, 34 cases of VM and 10 cases of TBM. The mean±SD with range of CSF-ADA was respectively 48±20.37 IU/L (20-70 IU/L), 14.57±6.48 IU/L (2-28 IU/L), 6.40±2.17 IU/L (3-9 IU/L), 8.29±10 IU/L (3-11 IU/L) and 5.27±2.69 IU/L (2-7 IU/L) in TBM, PM, PPM, VM and controls and the value was highest in TBM. The specificity, sensitivity, positive predictive value and negative predictive value of CSF-ADA for TBM were 94.6%, 100 %, 83.3% and 100%. Conclusion: Estimation of ADA activity in CSF can be of great value in early diagnosis of tubercular meningitis. Furthermore it is a simple, reliable, relatively inexpensive test with easy procedure. DOI: http://dx.doi.org/10.3126/njms.v1i2.6608 Nepal Journal of Medical Sciences. 2012;1(2): 97-102

Penfield’s motor homunculus describes a caricaturised yet useful representation of the map of various body parts on the pre-central cortex. We propose a supplemental map of the clinically represented areas of human body in pre-central cortex and a novel subcortical corticospinal tract map. We believe this knowledge is essential for safe surgery in patients with eloquent brain lesions. A single-institution retrospective cohort study of patients who underwent craniotomy for motor eloquent lesions with intraoperative motor neuromonitoring (cortical and subcortical) between 2015 and 2020 was performed. All positive cortical and subcortical stimulation points were taken into account and cartographic maps were produced to demonstrate cortical and subcortical areas of motor representation and their configuration. A literature review in PubMed was performed. One hundred and eighty consecutive patients (58.4% male, 41.6% female) were included in the study with 81.6% asleep and 18.4% awake craniotomies for motor eloquent lesions (gliomas 80.7%, metastases 13.8%) with intraoperative cortical and subcortical motor mapping. Based on the data, we propose a supplemental clinical cortical and a novel subcortical motor map to the original Penfield’s motor homunculus, including demonstration of localisation of intercostal muscles both in the cortex and subcortex which has not been previously described. The supplementary clinical cortical and novel subcortical motor maps of the homunculus presented here have been derived from a large cohort of patients undergoing direct cortical and subcortical brain mapping. The information will have direct relevance for improving the safety and outcome of patients undergoing resection of motor eloquent brain lesions.

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