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BACKGROUND: The goals of the present study were to explore the presentation of multinodular goiter (MNG) and solitary thyroid nodules (STN) in the sub-Himalayan belt, including the risk of malignancy, and to evaluate whether specialized surgeon training in endocrine surgery has an effect on reducing complications. METHODS: This retrospective study (1998-2003) analyzed 624 patients with thyroid disorders seen in the thyroid clinic of a tertiary care hospital in western Nepal. The findings included 67.7% (n = 423: euthyroid, 297, toxic, 126) multinodular goiters (MNG) and 18.5% (n = 116) STN. Rest of patients of other thyroid disorders were excluded from the study. Ultrasonography and fine-needle aspiration cytology (FNAC) were the available diagnostic adjuncts. To evaluate the role of surgeon training, outcomes were compared between patients cared for by surgeons specially trained in endocrine surgery and those who were not. Prognostic markers indicated aggressiveness of cancers. RESULTS: Of the 539 MNG and STN patients in this series, 236 underwent operation. Of these, 25.7% (139/539) were toxic, and 11.31% had associated carcinoma. Aggressive cancers, like poorly differentiated (4.9%) and anaplastic types (18%), were more common than in series of patients from iodine-sufficient regions. Patients 40-55 years of age were more likely to have toxicity, and those > 60 years of age were more likely to have aggressive cancers. Postoperative complication rates were lower in the group treated by surgeons who had special training in endocrine surgery. CONCLUSIONS: There is a higher incidence of toxicity and malignancy in MNG in an endemic goiter zone. The limited diagnostic and therapeutic facilities in the region under study warrant a high degree of clinical suspicion and judgment, sound knowledge of thyroid physiology, thorough interpretation of hormone test results, and meticulous surgical techniques. The treatment must be individualized with consideration of humanitarian and socioeconomic factors, without compromising the quality of care and its long-term consequences. Aggressive management of malignancy and toxicity with total thyroidectomy is needed as primary therapy in many instances. However, subtotal excision is more useful in carefully selected cases with a small remnant. Specialized training in thyroid surgery appears to be valuable in reducing complications.

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We report a case of a 65 year male with meningitis who had polyuria, severe hyponatremia, volume depletion and very high urinary sodium excretion. He was diagnosed to have cerebral salt wasting syndrome based on clinical and laboratory parameters.

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A 40-year-old woman developed myelopathy manifesting as Brown Sequard syndrome after administration of Anti-venom (polyvalent enzyme-refined equine globulin supposed to neutralise 0.6 mg of standard cobra venom, 0.45 mg of standard krait venom, 0.6 mg of standard Russel's viper venom and 0.45 mg of saw scaled viper venom, manufactured by Serum Institute of India, Pune, India). It was concluded to be an immunological inflammation of the spinal cord after ruling out hematomyelia on imaging. The necessity of antivenom in semipoisonous snake bites have been addressed further in the article.

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AIMS: Prospective, observational data collection of fever patients with regard to aetiology and means of detecting it particularly noting the factors, which quickly helped resolve diagnostic uncertainty. METHODS: Prospective follow-up of patients with clinically non-localizable fever admitted to Manipal Teaching Hospital, Pokhara, Nepal, documenting their temperature response, clinical and lab findings and diagnoses with their response to treatment. RESULTS: Enteric fever 56.8% (25), urinary tract infection 15.9% (7), malaria 9% (4), TB (pulmonary) 4% (2), abscess 4% (2) and hydatid cyst 4% (2). Remaining 4% were due to some other systemic causes. Culture positive: Salmonella typhi positive 32% (8), S. paratyphi positive 20% (5) and culture negative 48%. Response to treatment: enteric fever--(i) first-line drugs (ampicillin/cotrimoxazole) 16% (4), (ii) second-line drugs (ciprofloxacin) 20% (5) and (iii) ceftriaxone 44% (11). CONCLUSIONS: Fever charting as a means to localize Salmonella vs other fevers is still an invaluable clinical tool in adult patients in Nepal. If used judiciously, it can be used as an effective means to diagnose and treat patients of initially non-localizable fevers. Patience must be exercised in starting antibiotics, not until the fever pattern of 2 days suggests enteric, and also while waiting for a response to first-line drugs for Salmonella before one switches over to costlier second-line drugs, with the possible exception of quinolones which may even be used first line owing to their reduced costs (at the danger of wielding a double-edged sword).

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Acquired immunodeficiency syndrome (AIDS) has reached alarming proportions in SE Asia. The magnitude of the epidemic is projected to exceed that of sub-Saharan Africa as we enter the 21st century. Nepal has much in common with India geopolitically and socially and the prevalence of HIV is expected to be no different from the rest of SE Asia. However, evidence thus far paints a different picture altogether--a very low prevalence of HlV even in high-risk population groups. This is surprising, particularly since high-risk behaviour is evidenced by a high rate of drug abuse. In addition, other communicable diseases commonly associated with HIV infection, such as tuberculosis and HBV/HCV infection, are common in Nepal and yet still the prevalence of HIV infection in these patients and in the general population is reported to be low. This paper identifies some of these anomalies and attempts to analyse the reasons for this discrepancy. We emphasize the need for extended survey and strict surveillance to avoid an explosion of this dreaded infection.

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Salmonella typhi is known to produce acalculous cholecystitis and related gall bladder perforation. Following is a documentation of a patient of sub-phrenic abscess and gall bladder perforation which was possibly a result of Salmonella paratyphi A.

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Eighty patients with various thyroid disorders and 20 controls were investigated to determine antibodies against thyroglobulin and microsomal antigens by haemagglutination and immunofluorescent techniques. They were also tested for immunoglobulin profile by radial immunodiffusion methods. Patients with Hashimoto's disease, idiopathic hypothyroidism, and Grave's disease showed significant elevations of IgG. None of the patients with toxic nodular goitre or thyroid adenoma showed any thyroid antibodies while 69.2% patients with Grave's disease, 16% with euthyroid goitre, 58.3% with hypothyroidism and all the patients with Hashimoto's disease had microsomal antibodies by immunofluorescent test. Similarly, all the cases of Hashimoto's disease, 41.6% of those with hypothyroidism, 30% of Grave's disease patients and none of the patients with toxic nodule or thyroid adenoma had thyroglobulin antibodies by haemaglutination test. Evaluation for auto-antibodies may aid the clinician in the overall assessment of various thyroid disorders.

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We previously described a syndrome of congestive heart failure occurring in healthy young men at extreme altitude (Anand et al. Lancet 335: 561-565, 1990). The pathogenesis of this condition is unclear. We therefore measured body fluid compartments, renal blood flow, and a variety of plasma hormones in 10 asymptomatic young men staying above 6,000 m for > 10 wk and compared the results with controls at sea level. Body compartments were measured with isotope dilution techniques and renal blood flow with o-[125I]iodohippurate sodium. There was a marked expansion of all the fluid spaces: total body sodium was 14% above normal (P < 0.05), total body water was 18% above normal (P < 0.05), plasma volume was 33% above normal (P < 0.05), and blood volume was 84.5% above normal (P < 0.001). The effective renal plasma flow was lower than normal by 55% (P < 0.001), but the reduction in the effective renal blood flow was 37% below normal (P < 0.001) because the hematocrit was high (41.6% above normal). Plasma norepinephrine was nearly 3 times normal (P < 0.01), cortisol 3 times normal (P < 0.001), and growth hormone 18 times normal (P < 0.01). Aldosterone was twice normal (P < 0.03). Plasma epinephrine, atrial natriuretic peptide, and plasma renin activity were unchanged. The degree of fluid retention in these normal subjects was similar to that in patients with severe untreated congestive heart failure (Anand et al. Circulation 80: 299-305, 1989), whereas sodium retention and reduction in effective renal blood flow were less.(ABSTRACT TRUNCATED AT 250 WORDS)

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In the present study hormonal responses to 75 gm oral glucose were studied in 34 biopsy proven cases of hepatic cirrhosis and 15 normal subjects. Though fasting blood glucose was similar in both controls and cirrhotics the latter showed higher glucose values throughout the study. The peak of glucose level in cirrhotics was delayed to 60 minutes. Two of 34 (5.8%) cirrhotics showed marginal fasting hyperglycaemia and 44% had (impaired glucose tolerance (IGT). There was no significant difference (P > 0.05) in blood glucose levels in patients with and without varices. The fasting serum insulin was significantly raised in cirrhotics (24.9 +/- 2.2 vs 8.4 +/- 1.2 mu/ml, p > 0.05). Hyperinsulinaemia was significantly marked in cirrhotics with abnormal Oral glucose tolerance test (OGTT) as compared to those who had normal OGTT. The mean fasting serum insulin concentration in patients with and without varices was similar showing thereby that portasystemic shunt in cirrhotics is not the cause for peripheral hyper-insulinaemia. Basal cortisol was similar in cirrhotics and controls though expected fall in cirrhotics like control was absent. Twelve percent cirrhotics had basal human growth hormone (hGH) more than 10 ng/ml. Forty four percent showed paradoxical rise of hGH. hGH has significantly high (p < 0.01) in cirrhotics with abnormal OGTT as compared to those with normal OGTT.

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Clinical aspects of centipede bite as seen in the Andamans are reported. Centipede bite produces excruciating local pain and burning. Local bleeding is common but transient. Occasionally local infection or necrosis develops. Constitutional upset occurs in a small minority. Centipede bites are never fatal and pain-relief is the cornerstone of treatment.

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