Background: Atrial myxoma remains a rare clinical entity with an incidence of surgically resected cases of 0.5-0.7 per million population and prevalence of < 5 per 10,000. It typically manifests in woman after third decade of life; symptoms vary greatly and may present with arrhythmia, intracardiac flow obstruction, embolic phenomenon, and associated constitutional symptoms. Neurological complications associated with atrial myxoma most frequently include cerebral infarct due to embolus. Cerebellar involvement is very rare and only a few cases have been reported in the literature. Case presentation: A 55-year-old Brahmin man with no history of diabetes mellitus and hypertension, presented with complaints of dizziness, headache, vomiting, double vision, and unsteadiness of gait for 2 weeks. His headache was sudden in onset, of a pulsating type and localized on left temporal side. Vomiting was projectile and bilious. Double vision was present in all directions of gaze and he had uncoordinated movement of his body and tilting to the left side. On examination, his cerebellar functions were impaired. He was thoroughly investigated for the cause of stroke after abnormal magnetic resonance imaging results with normal computed tomography angiography of his brain. Echocardiography and computed tomography of his chest showed a mass attached to intra-atrial septum and prolapsing through mitral valve, which was suggestive of left atrial myxoma. Five days following admission, he developed abdominal pain due to thromboembolism causing splenic and renal infarct. Conclusion: Although rare, atrial myxoma has to be considered a cause of stroke and other embolic phenomenon causing multiorgan infarctions. Early and timely diagnosis of the condition can prevent further recurrence and inappropriate anticoagulant therapy. It would be pertinent to have echocardiography done in patients who present with a stroke, arrhythmias, and other constitutional symptoms. The tumor once detected must be removed surgically as early as possible, which not only reduces serious thromboembolic complications but can be potentially curative.

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Background Caudal epidural analgesia with bupivacaine is very popular in paediatric anaesthesia for providing intra- and postoperative analgesia. Several adjuvants have been used to prolong the action of bupivacaine. Objectives To compare the efficacy of ketamine, fentanyl and clonidine in terms of quality and duration of analgesia they produce when added with caudal bupivacaine by single shot technique in children. Methods Eighty children, age one to ten years, undergoing sub-umbilical surgery, were prospectively randomized to one of four groups: caudal analgesia with 0.75 ml/kg of 0.25% bupivacaine in normal saline (Group B) or caudal analgesia with 0.75 ml/kg of 0.25% bupivacaine with 1 μg/kg of clonidine in normal saline (Group BC) or caudal analgesia with 0.75ml/kg of 0.25% bupivacaine with ketamine 0.5mg/kg (Group BK) or caudal analgesia with 0.75ml/kg of 0.25% bupivacaine with fentanyl 1mcg/kg (Group BF). Post-operative pain was assessed for 24 hours using the FLACC scale. Results The mean duration of analgesia was significantly longer in Group BC (629.06 ± 286.32 min) than other three groups P < 0.05. The pain score assessed using FLACC scale was compared between the four groups, and children in Group BC had lower pain scores, which was statistically significant. The requirement of rescue medicine was lesser in Group BC. Clonidine in a dose of 1 μg/kg added to 0.25% bupivacaine for caudal analgesia, during sub-umbilical surgeries, prolongs the duration of analgesia of bupivacaine, without any side effects in compare to fentanyl or ketamine. Conclusion We conclude that clonidine in a dose of 1 μg/kg, added to 0.25% bupivacaine for caudal analgesia and administered as a 0.75 ml/kg mixture in children, for sub-umbilical surgery, significantly prolongs the duration of post-operative analgesia when compared to 0.75 ml/kg of 0.25% bupivacaine in normal saline than 0.75 ml/kg of 0.25% bupivacaine with ketamine 0.5 mg/kg or 0.75 ml/kg of 0.25% bupivacaine with fentanyl 1 mcg/kg or 0.75 ml/kg of 0.25% bupivacaine alone, without any side effects. Kathmandu University Medical Journal | VOL.10 | NO. 3 | ISSUE 39 | JUL- SEP 2012 | Page 25-29 DOI: http://dx.doi.org/10.3126/kumj.v10i3.8013

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Policy implications from these results indicate the need for support and funding from the Ministry of Health for education for women at hospitals, which must work together to offer newborn care education during the ante-natal and post-natal periods.

Introduction: COVID-19 is an emerging global health pandemic causing tremendous morbidity andmortality worldwide. Chronic symptoms progressing to poor functional status have been reportedin a substantial proportion of COVID-19 patients worldwide. This study aimed to determine theprevalence of functional limitation in COVID-19 recovered patients using the post-COVID-19functional status scale. Methods: A descriptive cross-sectional study was conducted at Tribhuvan University TeachingHospital. COVID-19 recovered patients with reverse transcription-polymerase chain reactionnegative status were included and assessed using the post-COVID-19 functional status scale. Dataentry and analysis was done in Statistical Package for the Social Sciences version 20.0. Descriptivestatistics were performed. Results: A total of 106 patients were included for the final analysis. More than half of the patients(56.6%) reported having no functional limitation (grade 0), while the prevalence of some degree offunctional limitation was observed in 46 (43.4%) patients (grade 1 to 4). Conclusions: Some form of functional limitation should be anticipated after COVID-19 infection.Post-COVID-19 functional status scale can be a valuable tool in determining the prevalence offunctional limitation in COVID-19 recovered patients in acute health care settings. It can potentiallyguide in planning rehabilitative measures in post-acute care management of COVID-19 survivors.

Background Coronavirus disease-19 (COVID-19) is an infectious respiratory disease caused by Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2). Respiratory symptoms and flu-like presentation are the most defined clinical manifestations. However, gastrointestinal symptoms with acute abdomen have been reported in a small percentage, occasionally mimicking acute appendicitis. Hence, the diagnosis of COVID-19 should be suspected and investigated in every case of acute abdomen in the present situation. Case presentation We report a case of a 25-year-old male who presented with features of acute appendicitis. Despite the equivocal ultrasound results, he was scheduled for an emergency appendectomy for Alvarado's score 7 out of 10, who underwent a successful appendectomy. The patient had initially tested negative on an upper respiratory COVID-19 reverse transcription-polymerase chain reaction (RT-PCR) with normal chest X-ray but few hours after the surgery patient developed a high-grade fever. An RT-PCR for COVID-19 was resent following a suspicion that came out to be positive. Clinical discussion Several case reports have suggested a probable association between COVID-19 and appendicitis. This case shows the limited effectiveness of clinical diagnosis for the surgical abdomen in COVID-19 patients as these two conditions share similar symptoms often needing a clinical vigilance. Conclusion This case reports acute appendicitis in a patient who tested positive for SARS-CoV-2 subsequently following emergency appendectomy highlighting the acute gastrointestinal presentation of COVID-19. This case exemplifies the necessity to be familiar with the gastrointestinal symptoms of COVID-19 and maintain a high level of suspicion for COVID-19 infection in cases of abdominal pain.

Background Fentanyl, a synthetic opioid, is a popular choice amongst anaesthesiologists in the operating room. Pre induction intravenous fentanyl bolus is associated with coughing in 28 – 65% of patients. Fentanyl induced cough is not always benign and can be remarkably troublesome at the most critical moment of anaesthesia when airway reflex is lost. Objectives To study the effect of pre emptive use of minimal dose fentanyl through the peripheral venous cannulae on the incidence of cough by a larger bolus of intravenous fentanyl. Methods One hundred and fifty patients aged 18 -75 years undergoing elective surgical procedures were randomized into three groups of 50 each. The first group received 0.5 ml saline 0.9 % intravenously one minute prior to the administration of fentanyl 150μg (3 ml); the second group received pre emptive fentanyl 25μg(0.5ml) prior to the administration of fentanyl 125μg(2.5ml); and the third group received preemptive fentanyl 25 μg(0.5ml), followed by the administration of fentanyl 150μg(3ml).. Based on the number of coughs observed, cough severity was graded as mild(1-2), moderate (3-5),or severe (>5). Results The incidence of fentanyl induced cough was significantly lower in both pre emptive group 4(8%) for 125μg fentanyl and 7(14%) for 150μg than in the saline group 15(30%). Conclusion Pre- emptive use of minimal dose fentanyl 25μg administered one minute before a larger bolus dose of fentanyl (125 or 150μg ) can effectively suppress cough. DOI: http://dx.doi.org/10.3126/kumj.v10i4.10988 Kathmandu Univ Med J 2012;10(4):16-19