The advancement in the craniofacial surgery has imposed challenges on the attending anesthesiologist for the successful conduct reconstructive surgery. The anesthesiologist remains a key person in the multidisciplinary tasks involved in such surgery. Most of these patients belong to smaller age group and have difficult airway due to various syndromes associated with it. The other major problems faced by the anesthesiologist in such surgery are intra-operative hypothermia due to prolonged surgery and significant blood loss as well as fluid shifts associated with it. A well-equipped intensive care unit is a must for the post-operative care of such patients. Even the adult patients coming for maxillofacial trauma surgery require careful vigilance both intra-operatively as well as post-operatively due to frequent difficult airway associated with it. A careful pre-operative evaluation and discussion with the surgeons, proper planning for airway management, intra-operative care and post-operative intensive care backup is required for the successful outcome in these surgeries. The current review is an attempt to describe in short the important anesthesia aspects and challenges related to various cranio-maxillary lesions.

Background and Objective: Low cardiovascular fitness (CVF) in children has been associated with increasing cardiovascular and metabolic risk in later life. CVF with respect to specific social and geographical factors such as rural and urban area of residence has not been addressed in developing countries. Various studies have been done in populations abroad to document varying and contradictory results. The present cross-sectional study was hence undertaken to compare the CVF of adolescents from rural and urban areas of Belgaum district. Materials and Methods: 305 children from secondary schools from rural and urban areas of Belgaum district were recruited through simple random sampling. The children underwent measurement for baseline parameters such as resting heart rate, blood pressure, skin fold thickness, height and weight. Questionnaire about their daily life-style parameters such as television watching, daily physical activity and mode of transport to school were recorded. Outcome measures included the beep test to evaluate CVF. Results: After data analysis, the rural group was found to have significantly higher values of maximal oxygen consumption when compared with their urban peers (P = 0.000). The rural children reported higher duration of daily physical activity and more use of active means of transport to school. Conclusion: The study concluded that rural children had higher CVF as compared to their urban counter parts.

Introduction: Mosquito borne diseases such as dengue, chikungunya, and malaria are clinically indistinguishable and diagnosis is solely upon laboratory findings. In an endemic area, early diagnosis of dengue requires detection of all the three markers (NS1, immunoglobulin (Ig) M and G simultaneously to distinguish primary and secondary infection. Aim: To assess the value of all dengue markers by rapid immunochromatography test (ICT) in early diagnosis. Materials and Methods: A total of 120 blood samples collected from patients with fever were tested for dengue markers by rapid ICT. Results: Of the 120 samples tested, 41 (34%) were positive for one or more of the three markers. Of the 41 samples, NS1 only was positive in 10 (24%), IgM only in two (5%), IgG only in 10 (24%), NS1 and IgM in two (5%), NS1 and IgG in one (2%), IgM and IgG in eight (20%), and triple positive (NS1, IgM, and IgG) in eight (20%). Of the 41 cases, NS1 alone was detected in two patients (5%) who came on 1-2 days of illness. Conclusion: Rapid ICT detecting NS1, IgM, and IgG is much valuable in emergencies as a screening test for early diagnosis and management. Rapid tests should be confirmed by enzyme-linked immunosorbent assay (ELISA). Still, "gold standard" tests in the diagnosis of dengue are virus isolation or molecular methods.

Background: Pulmonary tuberculosis can be easily diagnosed by simple techniques such as microscopy. However, extrapulmonary tuberculosis (EPTB) often presents a diagnostic dilemma. Microscopy and culture have proved to be insensitive techniques for diagnosis of EPTB. There is an urgent need for rapid and sensitive diagnostic methods. Aim: The present study was conducted to evaluate the role of polymerase chain reaction (PCR) in the early diagnosis of clinically suspected cases of EPTB. Materials and Methods: A total of 80 clinical specimens comprising pleural fluid, cerebrospinal fluid, ascitic fluid, fine-needle aspiration biopsy, and pus and biopsy from clinically suspected EPTB cases were processed and followed up by conventional methods and PCR using MPB64 primer. Results: Tuberculous pleural effusion (71%) was found to be the most common clinical presentation of EPTB. Overall, PCR could detect EPTB in 61.2% cases. Microscopy and culture could detect 18.7% and 22.5% EPTB cases, respectively. PCR was positive in all tissue samples suggestive of tuberculosis on histopathological examination. Of the 62 EPTB patients who responded to antituberculosis treatment (ATT), 49 patients were PCR positive. Conclusion: PCR using MPB64 had a significant advantage over the conventional methods to detect the presence of M. tuberculosis in specimens of clinically suspected EPTB patients for early diagnosis of tuberculosis.

Background: Maternal mortality ratio of Nepal is one of the highest (380/100000 live births) among the South East Asian countries, where majority of the births take place at home without the assistance of skilled attendant. Latest estimates revealed that only 36.0% births were attended by skilled attendants in Nepal. Objective: To examine the pattern of institutional deliveries among the mothers in Dadeldhura District of Nepal. Materials and Methods: A community-based cross-sectional quantitative study was conducted in Dadeldhura district during October 2012 to March 2013 among 516 mothers who delivered within last 1 year. In addition, 3 years records of District Health Office, Dadeldhura were reviewed. Data were collected by trained enumerators through face to face interview using structured interview schedule. Data were analyzed by SPSS (17.0 versions). Percentage, mean, median, standard deviation, and range were calculated. Results: Mean age of the participants was 24.76 ± 3.77 years. The combined proportion of Dalit and Chhetri was 82.8%. About 17.6% participants were illiterates and 81.6% agriculture workers. About 95% had done one time antenatal care (ANC) visit, while only 64.8% had four time ANC visits during index pregnancy. Majority (82.2%) had received ANC services from primary level health facilities. Almost 77.3% had institutional delivery; among them 59.6% delivered at primary level health facilities. About two-third went to facility on foot, where 45.4% accessed delivery care from a health facility with an approximate distance of >5 km. Almost 55.0% had knowledge of at least one complication occurring during delivery and 74.0% were known about the safe delivery incentive program. Conclusions: Institutional delivery rate was good (77.3%) as against national average (37.0%). Majority (59.6%) had delivery at primary level health facilities. Three quarters were known about Safe Delivery Incentive Programme. Strengthening the capacity of primary level health care facilities in terms of skilled attendants and materials to cater the growing acceptance of local level health facility is recommended to scale up safe delivery practices.

The present study was conducted with an aim to assess the relationship between major sociodemographic factors and compliance to prescribed drugs, amongst outpatients in an urban health center in a big city. A cross-sectional, community-based study was conducted in the city of Ahmedabad. Random sampling was used to include 250 cases, who were interviewed in an outpatient department (OPD) set-up, using a semistructured pretested proforma. Acute upper respiratory infections (20.8%) and fever (15.2%) were the most common diagnoses. These patients were followed-up for three revisits. Twenty-eight cases (11.2%) out of the 250 were lost to the study after two follow-ups. These were mostly in the younger age groups, female, in upper social class, and literate. Another startling revelation was that, a very high majority (86-96%) reported at later dates than when they were called to the health center. Analysis of certain sociodemographic characteristics revealed that most of the respondents were in the younger age groups with a female preponderance, had had some form of formal education, and were mostly in the social middle class. Scrutiny showed that while age, education, and social class had an almost inverse relationship with compliance, sex did not influence compliance.

Background: Infant feeding is a major determinant of survival, future nutrition and health status of children. Breast-feeding is an unequalled way of providing ideal food for the healthy growth and development of infants. It is also an integral part of the reproductive process with important implications for the health of mothers. Exclusive breast feeding (EBF) is superior to non-exclusive breast-feeding with a protective effect against both morbidity and mortality. This study was aimed to explore the breast feeding practice and affecting factors in Bhaktapur, Nepal. Materials and Methods: Community based cross-sectional study was carried out from February to May 2007 in a rural area of Bhaktapur, Nepal. Total 333 lactating mothers having a child less than 6 months were interviewed using pretested questionnaire with her written consent. Analysis was performed in Statistical Pakage of Social Science-13 version applying appropriate statistics. Results were presented in tabular and narrative forms. Results: Among 333 mothers (mean age ± standard deviation 24.68 ± 4.16 years), majority (76.6%) were 20-30 years. Almost 83.0% were Hindus, 25.8% illiterate, 62.8% house-wives and 53.5% from joint family with low economic status. About 48.0% had a baby of 2-4 months, 86.0% avoided pre-lacteal feeding, 87.1% fed colostrums, 27.9% fed the first milk within half an hour and 55.0% practiced exclusive breast-feeding for 6 months. Child's age, education, religion, occupation, family type and knowledge level were significant (P < 0.05) factors affecting to breast feeding. Conclusion: Despite the high proportion of women initiated breast-feeding early after birth, the prevalence of EBF for 6 months was very low and a large portion had poor practice of breast feeding. Education, relationship of mother with a family member and level of knowledge were found most significant factors. Appropriate measures such as public awareness and effective counseling will support to increase better breast feeding practice.

The diagnosis of typhoid fever in young children is also a dilemma because of its manifestations and typical presentation may not be seen in all cases. Antibodies to Salmonella typhi antigen are developed in the human body, which can be detected as a diagnostic test for the enteric fever. Objective: This study was undertaken to compare the efficacy of WIDAL-test with micro-immunoassay (dot enzyme immunosorbent assay). Method: 40 cases of clinically suspected enteric fever cases were included in this study. Result: In the present study, nearly 92% were positive for micro immunoassay (dot-enzyme immunosorbent assay) by Enterocheck-WB kit, 80% were positive for WIDAL and only 15% were culture positive. Immunoassay positive, but WIDAL negative cases were 20%, whereas WIDAL positive and immunoassay negative cases were only 7.5%. The positive predictivity of micro-immunoassay in diagnosing enteric fever is better than WIDAL both in 1st and 2nd week of illness. Micro-immunoassay done in the study was rapid in diagnosing the case. Conclusion: It is concluded from the present study that the micro-immunoassay (Enterocheck-WB) is better than WIDAL-test in the diagnosis of enteric fever in children.

Aims and objectives: The objective of this study is to find the serum high sensitivity-C-reactive protein (hs-CRP) in acute myocardial infarction patients at the time of admission and their association with in - hospital mortality and morbidity. Materials and Methods: A total of 50 patients of acute myocardial patients followed-up for 7 days in hospital with admission of serum hs-CRP levels. Slide agglutination was used to find the serum hs-CRP levels for qualitative and serial dilution method to carry out the semi-quantitative titration. Results: Among 50 Acute myocardial infarction (AMI) patients, 45 patients had an elevated hs-CRP and five patients had minimal or lower level of hs-CRP on the time of admission. On follow-up for 7 days, 35 out of 45 who had elevated hs-C-CRP developed vascular complications such as left ventricular failure, cardiogenic shock, ventricular ectopy, atrio-ventricular block etc. A total of 5 patients who had a minimal or low level of hs-CRP at the time of admission didn't develop any kind of complication during their hospital stay. Conclusion: Higher the serum hs-CRP levels at the time of admission in patients with AMI greater the patients prone to develop a complication during their hospital stay.

Background: Currently, the standard treatment for femoral shaft fractures in adults is intramedullary nailing. Objectives: Comparative assessment of results with open Kuntscher's nailing (K-nailing) and closed interlocking intramedullary nail in case of fracture shaft femur. Materials and Methods: This pilot project was conducted in a tertiary care hospital of a developing country on 40 patients in a time period of 1 year. A total of 20 patients were treated with intramedullary nailing in the tertiary care hospital while twenty received open fixation with K-nailing in a rural center. Results: There was no significant difference with regard to union rate, implant failure, infection, and fracture alignment between both groups. Conclusion: Open fixation with unlocked femoral nailing is technically less demanding and requires less operating time; additionally, there is no exposure to radiation and cost of the implant is cheaper. So, open K-nailing is still remains an option for the management of noncomminuted isthmus fractures of the femur in a developing country.

Objectives: The present study has been undertaken to find out any correlation with the prevalence of nutrient canals in hypertensive patients. Materials and Methods: A comparative study was done on patients with control group comprising of healthy individuals, and a study group of patients with a history of hypertension. An IOPAR of lower anterior region was done using bisecting angle technique and was interpreted for the presence or absence of nutrient canals. The results so obtained were subjected to statistical analysis. Results: We found that the incidence of nutrient canals was significantly higher in the study group as compared with the control group. The incidence of nutrient canals was also found to increase with age till 70 years. Conclusion: Hypertension being one of the most commonly encountered medical problems and many cases being undiagnosed, the presence of nutrient canals though not entirely indicative of hypertension, might increase the suspicion of the condition to be investigated further.

Papillary thyroid carcinoma (PTC) metastasis to distant organs is rare and mainly includes lung and bone. Metastasis affecting oral and maxillofacial region is extremely rare. We describe a case of PTC metastasis to cheek. The patient presented with a painless swelling of the left cheek with a history of total thyroidectomy for papillary carcinoma thyroid 5 years back. Cheek metastasis from papillary carcinoma thyroid is extremely rare. To the best of our knowledge, this is the first recorded instance of cheek metastasis from PTC. Common malignancies can metastasize to unusual sites and although infrequent, may be the presenting feature. The successful management of such cases may be achieved by a multidisciplinary approach.

Calyceal diverticula are rare and unusual lesions in children. We report a case of symptomatic lesion in a 13-year-old male child presenting with pain and recurrent episodes of infection.

Pheochromocytomas are rare catecholamine-secreting tumors that arise from chromaffin tissue within the adrenal medulla and extra-adrenal sites. Due to the excess secretion of hormones, these tumors often cause debilitating symptoms and a poor quality-of-life. Although medical management plays a significant role in the treatment of pheochromocytoma patients, surgical excision remains the only cure. Pheochromocytoma usually has three classic symptoms-headache, sweating and heart palpitations (a fast heart beat) in association with markedly elevated blood pressure (hypertension). Hormones such as catecholamines and metanephrines are measured in a 24 h urine collection and metanephrines may also be measured in the blood, to make a diagnosis of pheochromocytoma. If these are greater than 2 times the normal level, imaging studies are usually done to look at the adrenal glands. We report on three cases of pheochromocytoma, which had unusual presentation.

Elevation of cardiac enzymes and troponins particularly in settings of sepsis and renal failure may cloud the diagnostic picture of acute coronary syndrome in many cases. Interpretation of such elevated enzymes thus warrants caution. It necessitates adequate awareness amongst clinicians, of conditions with such elevation in the absence of myocardial ischemia/infarction as well as those that harbinger false positives. We discuss one such case that posed a diagnostic dilemma and review the pertinent literature.

Congenital mitral stenosis is a relatively rare disorder comprising 0.2% of all congenital heart defects. Hammock mitral valve producing severe mitral stenosis is a rare variant of congenital mitral stenosis. We report a 2-year-old boy who had hammock mitral valve producing severe mitral stenosis with severe pulmonary artery hypertension. He underwent successful surgical repair. Post-surgery, the mitral valve opening was adequate without residual stenosis or regurgitation. Pulmonary artery pressure had normalized. Follow-up data showed he had significant clinical and echocardiography improvement. This is the first reported case of successful surgical repair done for hammock mitral valve from our institute.

Leiomyoma of the female urethra is a rare benign neoplasm arising from the smooth muscles. Here, we report a case of 60 year old female patient presented with pain in the abdomen and dysuria for 2 months. On cystoscopy, external urethral meatus normal. A large, non-pedunculated tumor arising from left lateral wall of urethra extending from bladder neck up to the proximal end of the external urethral meatus. The mass was excised and submitted for histopathological examination. Histology reveals leiomyoma.