Tribhuvan University Teaching Hospital

Intravenous ketamine is increasingly used for refractory and super-refractory status epilepticus (RSE/SRSE), yet its efficacy and optimal use remain uncertain. We therefore aimed to synthesize the available evidence to quantify the effectiveness of ketamine in achieving seizure cessation and to explore differences in treatment characteristics between patients who respond and those who do not. We conducted a systematic review and meta-analysis to estimate the pooled seizure cessation rate associated with intravenous ketamine. Secondary analyses compared ketamine initiation timing, dosing, and infusion duration between patients who achieved seizure cessation (responders) and those who did not (nonresponders). Fourteen studies comprising 388 adult patients (249 responders, 139 nonresponders) were included. The pooled seizure cessation rate with ketamine was 64% (95% CI 49%-76%) with moderate heterogeneity (I 2 = 54.1%). Sensitivity analysis showed no single study substantially influenced results, supporting robustness. Responders received ketamine earlier (3.2 ± 2.6 days) than non-responders (4.3 ± 2.6 days), mean difference of -0.90 days (95% CI: -1.31 to -0.49; p < 0.0001). The mean maintenance dose was 2.5 ± 1.4 mg/kg/hr (responders: 2.5 ± 1.3; nonresponders: 2.6 ± 1.4), with no significant difference between groups (mean difference -0.14 mg/kg/hr; 95% CI -0.45 to 0.18; p = 0.39). Infusion duration averaged 5.0 ± 4.2 days in both groups, with no significant difference (mean difference -0.07 days; 95% CI -1.02 to 0.88; p = 0.88). Ketamine discontinuation due to adverse events was rare (0.7%, 3/55 patients). Intravenous ketamine demonstrates consistent effectiveness and safety as an adjunctive therapy in RSE/SRSE. However, the timing of initiation cannot be reliably linked to improved clinical outcomes given current methodological limitations and heterogeneity across studies. Future prospective research using standardized definitions and rigorous temporal data collection is needed to clarify whether the timing of ketamine initiation independently influences therapeutic success and to define its optimal integration within established status epilepticus (SE) treatment algorithms. The systematic review was registered (June 7, 2024) with the International Prospective Register of Systematic Reviews (PROSPERO, CRD42024549523).

Congenital lung abnormalitiesare commonly encountered in the recent era of multi-modality fetal imaging. Congenital lung abnormalities encompass a diverse range of developmental disorders affecting the lung parenchyma, airways, and vascular structures. The anomalies, such as congenital pulmonary airway malformations (CPAM), bronchopulmonary sequestration, and congenital lobar overinflation (CLO), can present with varying degrees of severity, from asymptomatic cases to life-threatening respiratory distress. Ultrasound (US) plays a crucial role in the prenatal detection of these abnormalities, providing real-time imaging and facilitating early diagnosis and management planning. Magnetic resonance imaging (MRI), on the other hand, provides detailed morphological insights, particularly for complex cases. Its ability to visualize soft tissue structures and vascular anomalies without ionizing radiation makes it an indispensable tool in fetal and pediatric imaging. The combined use of US and MRI enhances diagnostic accuracy for fetuses with congenital lung abnormalities. These modalities continue to evolve, offering promising advancements in the understanding and management of these conditions. In this review article, we present a spectrum of common and uncommon congenital lung abnormalities, along with their typical imaging findings in US and MRI, and an approach to diagnosis.

Rationale:Adenoid cystic carcinoma (ACC) is a rare, slow-growing malignant tumor of the salivary glands characterized by perineural invasion and delayed distant metastasis. While pulmonary and osseous metastases are common, isolated hepatic metastasis as the initial presentation is exceptionally rare and diagnostically challenging.Patient concerns:A 70-year-old female presented with right hypochondrial pain and an epigastric burning sensation. She had a long-standing, painless swelling in the right submandibular region for over 10 years, for which she had not previously sought medical evaluation.Diagnoses:Imaging revealed a solitary hepatic mass measuring 11 cm × 11 cm × 9 cm involving segments IV, VII, and VIII with vascular involvement. Histopathology of the liver biopsy showed basaloid cells arranged in cribriform and tubular patterns within a myxoid stroma. Immunohistochemistry demonstrated CK7 and cluster of differentiation 117 positivity in luminal cells and SMA and p63 positivity in abluminal cells, confirming ACC. Fine needle aspiration of the submandibular swelling showed features consistent with ACC, establishing the diagnosis of metastatic ACC to the liver.Interventions:Further imaging and oncologic consultation were undertaken. Surgical resection was not feasible due to the tumor size and vascular involvement. Chemotherapy was offered.Outcomes:The patient declined further treatment after counseling regarding the metastatic nature of the disease and the potential treatment burden.Lessons:Isolated liver metastasis as the initial manifestation of ACC is exceedingly uncommon. Histopathology and immunohistochemistry are essential for diagnosis. Long-term follow-up is crucial due to the risk of delayed distant metastasis and the lack of standardized management guidelines.

Pneumocystis jirovecii pneumonia (PJP) is a life-threatening opportunistic infection in immunocompromised patients. While classically seen in HIV/AIDS, it is increasingly recognised in those receiving lymphodepleting chemotherapy and radiation. Early identification and treatment are critical. A man in his 60s with glioblastoma multiforme on adjuvant temozolomide and cranial radiation presented with a 10-day history of progressive dyspnoea. Home pulse oximetry fell to 70% on room air. CT chest showed bilateral ground-glass opacities. Induced sputum PCR was positive for P. jirovecii; HIV serology was negative. He was started on high-dose intravenous trimethoprim-sulfamethoxazole and a prednisone taper, with de-escalation of broad-spectrum antibiotics. By hospital day 7, he remained on high-flow nasal cannula at 25 L/min fraction of inspired oxygen (FiO₂) 60%, maintaining a peripheral capillary oxygen saturation (SpO₂) ≥92%. He was speaking in full sentences and ambulating without desaturation. This case highlights the need for vigilance for PJP in solid-tumour patients receiving temozolomide and radiation, and the importance of early diagnosis and therapy.

Introduction: Septic shock is a leading cause of mortality and morbidity among children globally. Although dopamine has traditionally been used, emerging evidence suggests epinephrine may be more effective. This study was conducted to identify the proportion of children responding to epinephrine and to document associated survival outcomes and side effects in a resource-limited tertiary setting. Methods: This prospective observational study was conducted over 14 months at a tertiary care university hospital. Ethical approval was obtained from the hospital's institutional ethics committee (Reference number: 184/075/076). We enrolled 31 children aged 1 month to 16 years with fluid-refractory septic shock. Participants received epinephrine infusions at incremental doses starting at 0.1 μg/kg/min and escalating by 0.1 μg/kg/min every 10 minutes to a maximum of 0.3 μg/kg/min until shock resolution. Outcomes included the proportion of shock resolution, survival, and duration of hospital stay. Data were entered in Epidemiologic Information and Microsoft Excel. Results: Shock resolved in 24 (77.40%) patients with epinephrine alone, while 7 (22.60%) patients achieved resolution within the first hour, and 7 (22.60%) required additional vasoactive agents, primarily noradrenaline. Side effects included feeding intolerance in 3 (9.60%) and hyperglycemia in 2 (6.40%) children. There were 7 (22.60%) deaths, and 24 (77.40%) children survived to discharge. Conclusions: Epinephrine could be considered an effective agent for the reversal of fluid-refractory septic shock in children. It appeared to offer survival benefits with minimal life-threatening side effects in this cohort.

No health without peace

Diabetic retinopathy (DR) is one of the most important microvascular complications of diabetes mellitus and remains a major cause of preventable blindness worldwide. Insulin resistance plays a pivotal role in the development of diabetes and its associated complications. The triglyceride-glucose (TyG) index, a surrogate marker of insulin resistance derived from fasting plasma glucose and triglyceride levels, has gained attention as a simple and practical metabolic marker. However, data linking the TyG index with diabetic retinopathy, particularly in South Asian populations, are still limited. A hospital-based cross-sectional study was conducted at Bir Hospital, Kathmandu, Nepal, between April 2023 and October 2024. Adult patients with diabetes mellitus, excluding those with gestational diabetes, acute illness, non-diabetic causes of hypertriglyceridaemia, conditions affecting lipid or glucose metabolism, prior retinal interventions, or non-diabetic retinal diseases, underwent comprehensive clinical, biochemical, and ophthalmic evaluations. The triglyceride-glucose (TyG) index was calculated as ln [fasting triglycerides (mg/dL) × fasting plasma glucose (mg/dL) / 2], and participants were categorized into quartiles. Diabetic retinopathy was graded using internationally accepted clinical severity scales. Associations were assessed using univariate and multivariate logistic regression, and ROC curve analysis evaluated the discriminatory performance of the TyG index. Among 83 patients with diabetes mellitus (median age 56 years [IQR 48.5-64], 50.6% male, median diabetes duration 6 years [IQR 3-12]), the median triglyceride-glucose (TyG) index was 9.98 (IQR 9.485-10.445). Diabetic retinopathy (DR) prevalence was 48.2%, increasing across TyG quartiles from 9.5% in Q1 to 85.7% in Q4 (p < 0.001), with a significant trend in DR severity (p < 0.001). TyG correlated moderately with HbA1c (Spearman r = 0.54, p < 0.001). In multivariable logistic regression adjusted for age, total cholesterol, and HDL, the odds ratio for DR per standard deviation increase in TyG was 4.00 (95% CI 1.75-9.16, p = 0.001); for Q4 vs. Q1, 24.15 (95% CI 3.15-185, p = 0.002). Findings were robust in sensitivity analyses excluding insulin users (OR 4.35, 95% CI 1.40-13.5, p = 0.011) and outliers (OR 3.80, 95% CI 1.60-9.00, p = 0.002), and stratified by diabetes duration (≥ 5 years: OR 5.20, 95% CI 1.80-15.0, p = 0.002) and sex (males: OR 3.80, 95% CI 1.20-12.0, p = 0.023; females: OR 4.50, 95% CI 1.30-15.5, p = 0.017). TyG predicted DR with an area under the ROC curve of 0.83 (95% CI 0.75-0.91), comparable to HbA1c (0.77, DeLong p = 0.29); optimal cutoff 9.78 (sensitivity 88%, specificity 67%). A higher triglyceride-glucose index was strongly associated with both the presence and severity of diabetic retinopathy. Given its simplicity and reliance on routinely available laboratory parameters, the TyG index may be a useful marker for identifying diabetic patients at increased risk of retinopathy, particularly in resource-limited settings. Not applicable. This was a cross-sectional observational study and did not involve a clinical trial requiring registration.

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Introduction: Injury to recurrent laryngeal nerve (RLN) is significant complication after thyroid surgery that leads to voice changes, aspiration, breathing difficulty if both nerves are injured and impairment in quality of life. The aim of this study was to find the prevalence of recurrent laryngeal nerve palsy following thyroid surgery. Methods: It was a observational study carried out in the department of ENT-Head and Neck Surgery of Maharajgunj Medical Campus and TU Teaching Hospital, Institute of Medicine (IOM). The surgery records between January 2013 and April 2025 were reviewed to document demographic information, type of surgery, paralysis of RLN and its recovery rate at least six months following surgery. The data were recorded in the excel sheet version 16 and percentages, rate, ratio and mean were calculated. The ethical clearance for the study was obtained from institutional review committee (IRC) of IOM (Ref 538 (6-11) E2/081/082). Results: A total of 695 patients underwent thyroid surgery. Recurrent laryngeal nerve palsy occurred in 53 (7.62%) patients and in 66 (6.96%) nerves. The incidence was higher in malignant disease and in patients undergoing thyroid surgery with neck dissection. Unilateral palsy was observed in 40 (5.75%) patients and bilateral palsy in 13 (1.87%) patients, with no requirement for airway intervention. On follow-up, recovery was seen in 38 (70.37%) nerves, while 16 (29.63%) nerves developed permanent palsy. Conclusions: Recurrent laryngeal nerve palsy remains a significant complication of thyroid surgery, particularly in malignant disease and extensive procedures, with most cases showing recovery on follow-up.