Background:Adrenal insufficiency is characterized by inadequate cortisol production, with or without aldosterone and adrenal androgen precursor deficiencies. This can make it difficult for the body to respond to stress and maintain essential functions. The symptoms of adrenal insufficiency are often non-specific, leading to delayed diagnosis and frequent misinterpretation. Case illustration:We report three cases of adrenal insufficiency: (1) a 61-year-old male with autoimmune polyendocrine syndrome II (cortisol 4.76 μg/dl baseline →10.6/12.2 post-adrenocorticotropic hormone; thyroid-stimulating hormone 369 IU/ml); (2) a 55-year-old female with secondary adrenal insufficiency due to partial empty sella syndrome (free T4 0.03 ng/dl; luteinizing hormone/follicle-stimulating hormone/prolactin ↓91-97%; and (3) a 37-year-old male with adrenal tuberculosis (bilateral enlargement on CT). In all the cases, the diagnosis is established through clinical evaluation and imaging followed by effective management with hormone replacement therapy. Conclusion:Atypical presentations of adrenal insufficiency require a high degree of clinical suspicion to ensure timely diagnosis and effective management.
Vertebrobasilar dolichoectasia (VBD) is characterized by vascular elongation, widening, and tortuosity of cerebral vasculature. There are only a few reported cases of VBD as a cause of hydrocephalus. Here, we report a case in a 55-year-old male who presented with sudden vomiting for a day and worsening of headache for two weeks. He was diagnosed with CT imaging with angiographic findings: thrombosed saccular aneurysm of the vertebral artery along with dolichoectasia of the anterior and posterior circulation.
BACKGROUND:Despite the burden of tobacco use, access to cessation support in South Asia remains scarce. OBJECTIVE:This review evaluates the effectiveness of tobacco cessation interventions delivered in clinical settings in South Asia. METHODS:Five relevant databases were searched from inception to February 2025. Eligibility criteria included randomized and non-randomized studies evaluating behavioral, pharmacotherapy, and multicomponent interventions delivered in clinical settings in South Asia. Data on study setting and design, participant information, intervention, comparator, and outcomes were extracted. Meta-analyses using random-effect models were conducted where possible. Certainty of evidence was assessed using GRADE. RESULTS:Thirty-seven studies were included (22 randomized and 15 non-randomized). Interventions involved pharmacotherapy (n = 6; 16.2%), nicotine replacement therapy (n = 7; 18.9%), behavioral counseling (n = 12; 32.4%), or combined/multicomponent interventions (n = 12; 32.4%). Most studies were conducted in India (n = 26; 70.3%), followed by Pakistan (n = 6; 16.2%), Nepal (n = 3; 8.1%), and two studies (5.4%) were multi-country in India, Pakistan, and Bangladesh. Pooled analyses demonstrated higher quit rates among intervention versus control for continuous abstinence at 0-3 months (RR: 1.21, 95%CI: 1.06 to 1.37) and >3 months (RR: 1.68, 95%CI: 1.1.4 to 2.47), and for point abstinence at >3 months post-intervention (RR: 2.03, 95%CI:1.35 to 3.08). Heterogeneity was high for all analyses (I2 range: 94% to 97%). Combined behavioral and pharmacotherapy interventions were most effective (RR: 1.70, 95%CI: 0.98 to 2.92), although not statistically significant (p = 0.06). CONCLUSION:Tobacco cessation interventions delivered in clinical settings in South Asia are effective, particularly when combining behavioral support with pharmacotherapy. However, evidence is limited by methodological weaknesses.
Introduction and importance: Swallowed foreign body in children is a common and frequent emergency, with most of them passing through the gut without complications. Ingesting multiple magnets or a magnet along with another metallic object, however, poses a significant risk to the bowel due to potential complications such as obstruction, pressure necrosis, perforation, and fistulation. Case presentation: We report a 5-year-old boy presenting with an alleged history of swallowing twin ball magnets a month prior to presentation, remaining largely asymptomatic until imaging revealed their presence. Acutely, an invasive procedure was avoided by a successful endoscopic retrieval, while close, protracted follow-up showing no complications further reduced the morbidity. Clinical discussion: Swallowed twin magnets may go unnoticed in children, presenting later with varied complications. A high index of suspicion is imperative for diagnosis, while knowledge of the hazards associated with delay can guide the modality of management. Conclusion: Swallowed twin magnets, whenever accessible, can be successfully managed by endoscopic retrieval; however, the possibilities of perforation, bleeding, and bowel fistulation require vigilant observation.
Abstract Background: Endovenous thermal ablation (EVTA) is the current standard treatment for symptomatic varicose veins. While tumescent local anesthesia is preferred in high-resource settings, general anesthesia (GA) and spinal anesthesia (SA) remain commonly used in resource-limited environments. Comparative evidence between these modalities in EVTA is limited. Objectives: The objective of this study was to compare postoperative pain, recovery profile, perioperative outcomes, complications, patient satisfaction, and cost between GA and SA in patients undergoing EVTA. Methods: This prospective randomized controlled trial was conducted at a tertiary care center in Kathmandu, Nepal, over 12 months. One hundred adult patients with symptomatic primary varicose veins (CEAP C2–C6) undergoing radiofrequency ablation were randomized into GA ( n = 50) and SA ( n = 50) groups. The primary outcome was postoperative pain assessed using the Numerical Rating Scale at 6 and 24 h. Secondary outcomes included procedure duration, time to ambulation, hospital stay, complications, patient satisfaction, quality of life (Aberdeen Varicose Vein Questionnaire), return to normal activity, and treatment cost. Results: Postoperative pain scores were comparable between groups at all time points ( P > 0.05). Procedure duration and intraoperative hemodynamic events were similar. GA was associated with significantly earlier ambulation (138.5 vs. 190.6 min, P < 0.001) and shorter hospital stay (3.2 vs. 6.4 h, P < 0.001). However, GA had higher rates of postoperative nausea and vomiting (PONV) (32% vs. 6%, P < 0.001), whereas SA showed increased urinary retention (42% vs. 4%, P < 0.001). Treatment cost was significantly higher in the GA group. Patient satisfaction was higher with GA at discharge but similar at follow-up. Quality of life improved significantly in both groups without intergroup differences. Vein occlusion rates at 3 months were identical (96%). Conclusion: Both GA and SA provide comparable pain control and procedural efficacy in EVTA. GA enables faster recovery but is associated with higher cost and PONV, whereas SA is more cost-effective but delays ambulation and increases urinary retention. Anesthesia choice should be individualized based on clinical and resource considerations.
