Multiple simultaneous intracranial hemorrhages are very uncommon and both supra-and infratentorial hemorrhages are even more rare. Here we report a case of 56 year old hypertensive male with no other significant medical history who presented with a hypertensive emergency. Emergency head computed tomography showed bilateral basal ganglia and midbrain hemorrhages extending to right cerebellar peduncle. The patient made a progressive recovery and finally achieved functional independence. This report shows that hypertension may cause multiple simultaneous supra-and infratentorial hemorrhages and have good prognosis.

Introduction: A functioning arteriovenous fistula (AVF) is essential for maintenance hemodialysis (HD) in a patient with chronic renal failure. This study explores the creation of AVF as an integral activity in a general surgical unit by a general surgeon.

International Journal of Case Reports and Images (IJCRI) is an international, peer reviewed, monthly, open access, online journal, publishing high-quality, articles in all areas of basic medical sciences and clinical specialties.Aim of IJCRI is to encourage the publication of new information by providing a platform for reporting of unique, unusual and rare cases which enhance understanding of disease process, its diagnosis, management and clinico-pathologic correlations. Case Report: A 55-year-old female presented with a 3x3 cm carcinoma in the superomedial quadrant of the right breast, with no palpable regional lymph nodes. She underwent breast conservation surgery with axillary nodal clearance. During axillary dissection, an unusual muscle slip was identified crossing the axilla, connecting the anterior border of latissimus dorsi to the posterior surface of pectoralis major, anterior to the axillary artery, vein and brachial plexus. IJCRI publishes Review Conclusion:Preoperative knowledge is essential to identify such unusual anatomy and to appropriately tackle it to avoid surgical complications and adequate axillary lymph node clearance.

Introduction: Since civilization physicians are upheld at high standard to promote interests of patients and society. In this study we aimed to analyze issues related to patient satisfacti on for better patient care. Methods: There were 145 surgical patients in this cross sectional prospective observational study for elective benign disease. Patient’s response to pre-tested questionnaire before and after surgery was scored was on a 3-point scale. Variables included patient demographics; diagnosis, treatments, complications; counseling, social, financial concern; surgeon’s competency, hospital facilities, pain management and overall satisfaction. Microsoft Excel was used for descriptive analysis. Results: Average age of patients was 44 years and male were 42.7% (62/145). All patients were satisfied for information on diagnosis, complications and hospital facilities. Patients consented for surgery themselves in 96.5%. Financial concern was found in 17.3% and inadequate pain management in 7.6%. Overall,96.5% patients were satisfied. Conclusions: Even though 96.5% patients were satisfied, further analysis revealed there is room for improvement on post-operative pain management (in 17.3%) and financial constrains (in 7.6%) in elective major surgery for benign diseases in our setup. Medical Journal of Shree Birendra Hospital; Jan-June 2012/vol.11/Issue1/9-12 DOI: http://dx.doi.org/10.3126/mjsbh.v11i1.7759

Background: In gallbladder carcinoma, lymph node metastasis is an important predictor of survival. This study assessed the survival with respect to ratio of metastatic nodes to total number of nodes harvested (lymph node ratio, LNR). Methods: Between Jan 2012 to May 2017, 128 patients underwent curative intent resection for gallbladder cancer. In order to achieve a minimum of 3 years follow up, data of 44 patients (Jan 2012 to May 2014) were analysed. LN location was divided into N1 (hepatoduodenal, including 13a (PSPD) and common hepatic artery) and N2 (celiac, SMA and aorto-caval). As the median LNR was 10%, the LNR was divided into three groups: 0%, 10% and > 10%. Survival data was calculated using Kaplan-Meier and Cox regression model used to analyse between groups. Results: 39 patients were available for the study. In total, 633 (mean 16) nodes were retrieved. Among this, 31 nodes were positive in 14 patients. LNR was 10% in 4 (28%) and > 10% in 10 (71%) patients. The median follow-up was 50 months (IQR 43-58). 14 patients died during follow-up. The median disease-free (DFS) and overall survival (OS) were 43.7months (IQR 14-52) and 46 months (IQR 20-54) respectively. The median DFS of patients with LNR >10 % is 14.6 months and LNR 10% is 21.4months; patients with negative nodal disease did not reach median survival (p=0.014). The OS of patients with LNR 10 was 14 months (95% CI: 4.7-24.5). Conclusion: LNR>10 % was associated with adverse prognosis in gallbladder cancer.