A Hospital Based Study of Pterygium in Tertiary Care Hospital of Nepal

Background Pterygium, a triangular fibrovascular subepithelial growth of degenerative bulbar conjunctival tissue over the limbus onto the cornea, is one of the common ocular conditions that may result in discomfort, tearing, photophobia and significant visual impairment. Little is known about its epidemiology in Nepalese context. Objective The current study aims to analyze the epidemiology of pterygium in a hospital-based population in Kavre District, a mid hilly region of central Nepal. Method This was a prospective hospital based study carried out in the Department of Ophthalmology in Dhulikhel Hospital, Kathmandu University Hospital for a period of one year from January to December 2013. All the patients with pterygium, aged 21 years and above attending the outpatients department were included into the study. The epidemiological data was collected using a standard questionnaire and complete ocular examination was performed by the Ophthalmologist. Result A total of 7925 patients were seen in the Ophthalmology outpatient department during a one year period, out of which 5622 patients (age range 20-80 years) were eligible for the study. A total of 137 patients, 43(31.4%) males and 94 females (68.6%) had different grades of pterygium with mean age of 48.6± 12.8 years. The overall prevalence of pterygium was 2.4 %. Majority of the patients with pterygium were between 41-60 years. Fifty-eight percent of pterygium were of grade I followed by 41% of grade II. Unilateral and nasal pterygia were common. Conclusion The prevalence of pterygium is low in this hospital based population, majority of cases affecting females and old age population.

Yield of intensified tuberculosis case-finding activities using Xpert(®) MTB/RIF among risk groups in Nepal

SETTING

Twenty-two districts of Nepal, where intensified case-finding (ICF) activities for tuberculosis (TB) were implemented among risk groups under the TB REACH initiative in collaboration with the National TB Programme from July 2013 to November 2015.

OBJECTIVES

To assess the yield of TB screening using an algorithm with smear microscopy followed by Xpert(®) MTB/RIF.

DESIGN

A descriptive study using routinely collected data.

RESULTS

Of 145 679 individuals screened, 28 574 (19.6%) had presumptive TB; 1239 (4.3%) of these were diagnosed with TB and 1195 (96%) were initiated on anti-tuberculosis treatment. The yield of screening was highest among people living with the human immunodeficiency virus (PLHIV) (6.1%), followed by household contacts (3.5%) and urban slum dwellers (0.5%). Among other risk groups, such as prisoners, factory workers, refugees and individuals with diabetes, the yield was less than 0.5%. The number needed to screen to diagnose an active TB case was 17 for PLHIV, 29 for household contacts and 197 for urban slum dwellers. Of 11 525 patients from ICF and the routine programme, 112 (1%) were diagnosed with multidrug-resistant TB.

CONCLUSION

There was a substantial yield of TB cases among risk groups such as PLHIV and household contacts. Although the yield in urban slum dwellers was found to be moderate, some intervention should nonetheless be targeted because of the large population and poor access to care in this group.

Risk Factors of Preinvasive and Invasive Cervical Cancer

Aims: The objective of this study was to assess the risk factors of preinvasive and invasive cervical cancer.Methods: This was a prospective hospital based case control study conducted from April 2012 to April 2013, which included 91 patients in each group. Among cases, 34 were Cervical Cancer and 57 were Cervical Intraepithelial Neoplasia. Simple random method was adopted for selecting patients. Prefixed questionnaire was used. Statistical analysis was done using SPSS 19.0.Results: In multivariate analysis, history of abnormal vaginal discharge and cigarette smoking were significantly associated with cervical cancer (p value of 0.001 and 0.003 respectively) and Cervical Intraepithelial Neoplasia (p <0.001). Whereas, early age at first sexual intercourse ≤ 16 years and more than one sexual partner of husband had only borderline significance for Cervical cancer (p value 0.049 and 0.038 respectively).Conclusions: Cigarette smoking and abnormal vaginal discharge were significantly associated with cervical cancer. 

Visual Outcome after Treatment with High Dose Intravenous Methylprednisolone in Indirect Traumatic Optic Neuropathy

BACKGROUND

Traumatic optic neuropathy is an acute injury of the optic nerve due to trauma. It is an ocular emergency, requiring early treatment though there is no proven standard treatment protocol for the condition. Various studies have shown improvement in vision after intravenous steroids, but not statistically significant. Studies have revealed even optical decompression surgery is not the ultimate treatment because of no significant improvement of vision. Our study aims to assess visual outcome after high dose (1 gram) of intravenous methylprednisolone in cases with indirect optic neuropathy.

METHODS

This was a non-randomized interventional study carried out in Kathmandu Medical College Teaching Hospital from May 1st 2013- June 1st 2014.

RESULTS

There were 10 cases with indirect traumatic optic neuropathy included in the study. Four cases received IV methylprednisolone and six cases were observed without steroid treatment. Traumatic optic neuropathy was observed more in males[8 (80%)]with higher number in age group 21-30 years old. The visual recovery after intravenous steroid treatment was rapid and beneficial in cases with vision better than Non Perception of Light (NPL), even in cases presented 4 days after the trauma.

CONCLUSIONS

There was rapid and beneficial improvement in visual acuity after high dose of intravenous steroid treatment in cases with indirect traumatic optic neuropathy with vision better than Non Perception of Light (NPL).

Slip pulse and resonance of the Kathmandu basin during the 2015 Gorkha earthquake, Nepal

Detailed geodetic imaging of earthquake ruptures enhances our understanding of earthquake physics and associated ground shaking. The 25 April 2015 moment magnitude 7.8 earthquake in Gorkha, Nepal was the first large continental megathrust rupture to have occurred beneath a high-rate (5-hertz) Global Positioning System (GPS) network. We used GPS and interferometric synthetic aperture radar data to model the earthquake rupture as a slip pulse ~20 kilometers in width, ~6 seconds in duration, and with a peak sliding velocity of 1.1 meters per second, which propagated toward the Kathmandu basin at ~3.3 kilometers per second over ~140 kilometers. The smooth slip onset, indicating a large (~5-meter) slip-weakening distance, caused moderate ground shaking at high frequencies (>1 hertz; peak ground acceleration, ~16% of Earth's gravity) and minimized damage to vernacular dwellings. Whole-basin resonance at a period of 4 to 5 seconds caused the collapse of tall structures, including cultural artifacts.

Can Laparoscopic Cholecystectomy be a Feasible Standard in a Rural set up too?--An Experience of 348 cases from a Peripheral set up of Western Nepal

BACKGROUND

Gall stone disease is a common reason for admissions in both acute and elective situations and bears significant morbidity in the rural population of western Nepal. The earlier conventional open method of treatment for the same seems to have been largely seeded by the laparoscopic approach owing to its numerous benefits.

OBJECTIVE

To study the clinical profile of patients with symptomatic gall stones with respect to demography and to assess the feasibility of using Laparoscopic cholecystectomy as the next standard in this set up too as guided by the outcome in terms of complications, conversion rates and potential impact it bears on the health and socioeconomic status in this group.

METHOD

A retrospective analysis of all the patients undergoing an attempted laparoscopic cholecystectomy from 1st Jestha 2068 to 30th Jestha 2070 was done. Relevant medical records were reviewed to study demography, various indications for operations, intra operative events including conversions and complications.

RESULT

Of 348 patients 293 (84.19%) were females and 55 (15.80%) were males. The mean age was 38.46 years (range 15-76 years). Most of the patients belonged to the Palpa district of Lumbini zone and many were from other surrounding areas. Gall stone disease was commonest in people of Brahmin ethnicity. The operating time was < 2 hours for most and most had an uneventful recovery with a mean hospital stay of 3.8 days. The rate of conversion to open cholecystectomy was 6.9% (24 out of 348 patients). Post operative complications were noted in 5 patients (1.42%). Of these 1 sustained a major bile duct injury (0.28%) requiring immediate conversion and repair, 3 had post operative bilioma and 1 had diffuse bleeding from the gall bladder fossa all requiring re explorations. There was no mortality in this study.

CONCLUSION

Laparoscopic cholecystectomy is a safe, reliable and a promising option even in the rural peripheral set up. Due to its well known advantages and superiority over the open conventional method and considering the impact that it holds on the overall outcome, morbidity, health and socioeconomic status of the rural population, it can be recommended as an acceptable feasible standard in rural peripheral set up.

Retrospective study of spinal cord injury patients admitted to spinal injury rehabilitation center, Sanga, Banepa, Nepal

Spinal cord injury is a serious problem that affects many facets of an individual's life. This was a retrospective study which included data from all patients admitted to the Spinal Injury Rehabilitation Center (SIRC), Sanga with spinal injuries over a 4 year period between January 2008 and January 2011. The overall objective of the study was to determine the epidemiology of spinal injury patients admitted at the center. Socio-demographic details, mechanism of injury, level of injury, ASIA score and length of hospital stay of the subjects were recorded and analyzed. An incremental pattern was observed in the number of spinal injury patients attending SIRC. In the year 2008, 81 patients of spinal injury were recorded which increased to 122 in 2011. A total of 381 spinal injury patients were included in the study out of which a majority, 73.50% were male, 30.45% belonged to the 21-30 years age group and 23.10% belonged to the 31-40 years age group. A majority of Spinal injury patients, 189 (49.60%), were from the Central region followed by 89 (23.36%) from the Western region. Fall from height (68.24%) was the predominant cause of spinal injury followed by road traffic accident (18.63%). In the study, 213 subjects (55.91%) had ASIA A scoring and thoracic injury (49.34%) was most common followed by lumbar injury (29.66%), cervical injury (17.84%) and sacral injury (3.15%). About Two-fifths (40.42%) of the spinal injury patients were conservatively managed whereas three-fifths (59.58%) underwent surgery and length of stay of patients ranged from 2 to 305 days. This study shows that the young adults, predominantly males in their most productive years of life, are prone to traumatic spinal cord injury which results in personal and family tragedies along with socioeconomic burden to the nation. Thus, recognizing the pattern of traumatic spinal cord injuries, relevant etiological factors and identification of high-risk groups is necessary in designing better methods of prevention.

Allergic BronchoPulmonary Aspergillosis in Nepal

Allergic BronchoPulmonary Aspergillosis (ABPA) is clinically under recognized and often misdiagnosed in Nepal. A total of 15 cases of ABPA were enrolled in this case series. Cases were followed up after the 3 months of start of treatment and clinical responses were assessed. The mean age of the patients was 33.06 ± 9.2 yrs. 80% were male. 26.6% patients were empirically on anti-tubercular treatment at the time of presentation. 40% patients were misdiagnosed and already treated as pulmonary Tuberculosis. 10 patients were previously treated as cases of refractory asthma. Majority of patients had significant eosinophillia and raised total serum IgE. All patients required treatment with bronchodilator and systemic steroid. 80% patients underwent remission with the treatment. Pulmonary Tuberculosis and refractory bronchial asthma are common condition that leads to the misdiagnosis of this disease.

Congenital diaphragmatic hernia; masquarding as hydropneumothorax

Congenital diaphragmatic hernia occurs in about 1 in 3000 births among which over 90% of the patients will be diagnosed either antenatally or will present with respiratory distress in the first few hours of life and about 5% to 30% of diaphragmatic hernias present beyond the neonatal period. The extent of herniation of abdominal viscera into the thorax may vary, leading to acute or intermittent symptoms. The inappropriate insertion of a chest drain, although relieving the symptoms temporarily, may result in serious consequences by damaging intrathoracic abdominal viscera. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-3, 54-56 DOI: http://dx.doi.org/10.3126/jcmsn.v9i3.10223   

Association between Helicobacter Pylori and Gastric Cancer

INTRODUCTION

A casual relation has been thought to exist between Helicobacter pylori infection and gastric cancer. The present study was carried out to find correlation between H. pylori and gastric carcinogenesis.

METHODS

A case control study was performed in the department of endoscopy, Tribhuvan University Teaching Hospital, between January 2008 and February 2009. All patients having carcinoma stomach on endoscopic evaluation later confirmed by histopathological examination were included. Total 50 healthy individuals, with no positive finding in endoscopy were included in control group.

RESULTS

Total 37 cases were analyzed. There were 23 (62.2%) males and 14 (37.8%) females. Majority were above 60 years (46%). Blood group A was commonest group found in patients with carcinoma stomach. Distal part, antrum, 20 (54%) was commonest location of tumor and Borrmann type three was commonest endoscopic type of tumor presentation. Majority of patients received triple therapy and H. pylori detection was low in those treated with triple therapy. Distal tumors were significantly associated with increased prevalence of H. pylori positivity. Total incidence of H. pylori in cases was 54% (20/37). In 15 (75%) cases, H. pylori could be detected by both ELISA and biopsy method. Incidence of H. pylori in controls was 64% (32/50). There was no statistically significant difference in H. pylori presence in cases and control.

CONCLUSIONS

Our study couldn't establish association between H. pylori and gastric cancer. More prospective trials can help find out correlation between combination of risk factors and gastric cancer.

HLA antigen distribution in renal transplant recipients and donors

BACKGROUND

HLA typing analysis is important in renal transplant patient. This study is the first report from Nepal to find out distribution of HLA A, B, DR antigen in live related renal transplant recipients and donors from Nepal. The aim of this study was to investigate the distribution of HLA in the live related renal transplant recipients and donors of Nepal.

METHODS

In a retrospective study, HLA patterns were defined in 100 live related renal transplant recipients and donors. One year study is done from June 2011 to May 2012. The study was done by using sequence specific oligonucleotides primers and polymerase chain reaction and assay. Allele frequencies were obtained by direct counting.

RESULTS

A total of 12 HLA-A, 15 HLA-B and 13 HLA-DRB1 alleles were identified at the four-digit level in the live related renal transplant recipients and donors of Nepal. High frequency alleles were HLA-A*11 (34.5%), A*24 (17%), A*33 (13%); HLA-B*15(27%), B*35(19%), B*40 (10%); HLA-DRB1*15 (33.5%), DRB1*12 (21.4%) and DRB1*04 (7.32%).

CONCLUSIONS

These results showed considerable heterogeneity in both HLA class I and class II antigens. To reduce the risk of allograft rejection, transplantation from HLA matched donors is recommended.

Clinicohistopathological correlation in leprosy

BACKGROUND

Leprosy is a chronic, infectious disease caused by Mycobacterium leprae. It is classified into five groups based on clinical, histological, microbiological and immunological criteria (Ridley and Jopling Classification) . However, a great variation has been observed in the interpretation of histopathological examination ok skin biopsies and clinical presentation of the disease.

OBJECTIVE

To correlate clinical diagnosis with histopathological diagnosis of leprosy patients in Nepal.

METHODS

A retrospective hospital-based study was conducted among patients with all clinical types of leprosy, classified as per the Ridley-Jopling classification. Skin biopsies were taken from active lesions in all patients and were stained with Hematoxylin and Eosin stain and modified Fite-Ferraco stain for identification of Mycobacterium leprae. The histopathological findings were compared with clinical diagnoses.

RESULTS

A total 156 patients were studied, out of which 84 (53.8%) males and 72 (46.1%) females between 8 and 86 years of age. The majority of patients 33 (23.57%) were in the age group of 21-30 years and least affected was children below 10 years 1(0.007%).Overall coincidence of clinical and histopathological diagnoses of classification was seen in 115 cases (80.4%). The maximum correlation (95.2%) was noted in LL patients (p value 0.000049) followed by BT(89.74%), TT (73.2%),BL(72.4%), BB(64.7%).

CONCLUSION

Leprosy still continues to be one of the common infectious disease in Nepal and skin biopsy is a useful tool in confirming the clinical diagnosis of leprosy as well as for the therapeutic guide.

Ciprofloxacin susceptibility of Salmonella enteric serovar Typhi and Paratyphi A from blood samples of suspected enteric fever patients

INTRODUCTION: Enteric fever caused by Salmonella enterica serovars Typhi and Paratyphi A is the common clinical diagnosis among febrile patients presenting to hospital in Nepal. The aim of this study was to evaluate the ciprofloxacin (CIP) and other antibiotics susceptibility patterns of Salmonella enterica serovars Typhi and Paratyphi A from blood samples of suspected enteric fever patients visiting KIST Medical College, Kathmandu. MATERIALS AND METHODS: Antibiotic susceptibility test was performed by Kirby Bauer disc diffusion method as per CLSI guidelines whereas MIC determination of ciprofloxacin was performed by agar dilution method. RESULTS: Altogether 64 presumptive Salmonella spp. were isolated from 840 blood samples of suspected enteric fever patients, of which 41 were S. Typhi and 23 were S. Paratyphi A. All Salmonella spp. isolates were sensitive to ceftriaxone and ofloxacin whereas 4 isolates were resistant to ciprofloxacin. One isolates each of S. Typhi and S. Paratyphi A were multidrug resistant. Fifty five isolates of Salmonella spp. were resistant to nalidixic acid (NA) with higher rate in S. Paratyphi A (91.3%) compared to S. Typhi (82.9%). MIC determination of ciprofloxacin revealed that majority of the isolates were resistant to ciprofloxacin and 2 isolates were resistant with MIC value of 4 µg/ml and 8 µg/ml. Importantly, we found simultaneous presence of NA resistance and decreased susceptibility to CIP suggesting that resistance to NA is a reliable indicator of decreased CIP susceptibility. CONCLUSIONS: Disc diffusion test failed to detect the reduced susceptibility of ciprofloxacin. Hence the MIC determination of ciprofloxacin against Salmonella spp. isolates would be important.  DOI: http://dx.doi.org/10.3126/ijim.v1i1.6938Int J Infect Microbiol 2012;1(1):9-13

Histochemical characteristics of calcium binding S100 proteins and bone morphogenetic proteins in chondro-osseous tumors

Immunohistochemical distribution of the Ca2+ binding proteins S100A1, S100A2, S100A4, S100A6, S100B, and bone morphogenetic protein (BMP) in chondro-osseous tumors and lesions, both benign and malignant, was investigated using specific anti S100 protein and BMP antibodies. Chondrogenic tumor cells of chondro-osseous lesions were characterized by the presence of marked staining for S100B and BMP, while they were only faintly reactive for S100A1, S100A2, S100A4 and S100A6. Dense fibrous connective tissue in osseous tumor and ossifying fibroma showed moderate immunoreactivity for S100A1, S100A4 and BMP. Immunoreactivity of S100A2, prominent in epidermal basal cells and associated or homologous cells of epidermal tumors or skin appendages tumors, was not found in cartilage and bone forming cells. Biological roles of S100B in chondroid cells may involve Ca2+-signaling in precalcified tissue, cytoskeletal protein organization and matrix formation since glycosaminoglycan synthesis is mediated by calcium ions. S100B positive cells in chondro-osseous structures also strongly expressed BMP. The present study allowed us to conclude that among the S100 proteins, the S100B in particular and S100A1, S100A4 and S100A6 but not S100A2 may be involved in the process of tumorigenesis of chondro-osseous tumors and BMP may have an important role in the chondroid and osseous differentiation. The detailed biological role of S100 proteins in chondro-osseous tumors is under investigation.

A unusual case of 356 vesical calculii

Multiple vesical calculi are rarely seen in urological practice. Males are affected more than the females. Vesical calculi are usually secondary to bladder outlet obstruction. These patients present with recurrent urinary tract infection, haematuria or with retention of urine. We report a 43 years male patient who presented with acute urinary retention. He had history of trauma over perineal region three years back following which he had recurrent urinary tract infection and thinning of stream. USG abdomen revealed normal upper urinary tract with echogenic debris in partially filled urinary bladder. Renal function test was with in normal limit. Per urethral catheterization failed and over antibiotic cover, patient was posted for cystourethroscopy followed by suprapubic cystostomy under spinal anaesthesia. Membranous urethral stricture found during urethroscopy could be managed by optical internal urethrotomy. On cystoscopy whole of bladder was filled with thick pus like material with multiple large urinary bladder calculi. Open cystolithotomy was done and we were surprised to see 356 stones of various size and shape after removal. Patient made uneventful recovery and discharged after 12 days of hospital stay. Journal of College of Medical Sciences-Nepal,2012,Vol-8,No-1, 44-47 DOI: http://dx.doi.org/10.3126/jcmsn.v8i1.6825

Early experience in ureteroscopy for the management of ureteric stone

Ureteroscopy has revolunized the management of ureteric calculus and it has become the need of every urology center today. The purpose of this study is to report our experience and results in the management of ureteric calculus by semi-rigid ureteroscopy and pneumatic lithotripsy and also to access the safety of procedure in untrained hands. Retrospective analysis of 48 consecutive patients of ureteric calculus treated by semi-rigid ureteroscopy and pneumatic lithotripsy between June 2010 and October 2010 in urology unit, College of Medical Sciences, Bharatpur, Nepal was done. 34 female patients (70.8%) and 14 male patients (29.2%) were identified. Mean age of female was 30.9years (range 17 to 45 years) and that of male was 46.4 years (range 33 to 63years). Mean stone size in female was 8.91mm (range 6.5 to 11.2mm) and in male it was 9.11mm (range 6 to 14.2mm). Lower ureteric calculus was present in 29 and 8(77.1%), mid ureteric calculus in 2 and 2(8.3%) and upper ureteric calculus in 3 and 4(14.6%) female and male patients respectively. Ureteric perforation occurred in 2 patients (4.2%). Ureteric avulsion occured in 1 female patient (2.1%) with upper ureteric calculus. DJ stent was keept in 34(70.8%) cases but in 11 cases (32.6%) DJ stent had to be removed earlier than 4 weeks due to stent related problems. Urine culture was sent before ureteroscopy in all the patients and was sterile in 24 patients (50%), contaminated growth in 12 patients (25%), grew E-coli in 8 patients (16.7%) and Kliebsella pneumonia in 2 patients(4.2%). Average duration of stay was 2.7 days. 5 patients developed fever post operatively, managed by intravenous antibiotics. There was no mortality. Though ureteroscopy has become a boon for the management of ureteric calculus, complications like perforation, ureteric avulsion, residual stone and stone migration are more in upper ureteric calculus and stone size > 1cm. Stenosed ureteral assess can be made with proper guide wire selection and prior dilatation .The procedure is relatively safe even in inexperienced hands. Journal of College of Medical Sciences-Nepal,2011,Vol-7,No-4, 28-33 DOI: http://dx.doi.org/10.3126/jcmsn.v7i4.6738

Internal herniation of sigmoid colon into ladd's band

Ladd's bands are generally known to cause duodenal and small bowel obstruction. Sigmoid colon compression by Ladd's bands has not been reported till now though a few cases of colonic obstruction have been reported. We report a case of sigmoid colon obstruction secondary to its herniation into Ladd's band in a child with intestinal malrotation.DOI: http://dx.doi.org/10.3126/jcmsn.v7i3.6710 Journal of College of Medical Sciences-Nepal, 2011, Vol-7, No-3, 53-55  

Laparoscopic cholecystectomy: An experience at College of Medical Sciences, Teaching Hospital, Bharatpur Nepal

Laparoscopic cholecystectomy is the "gold standard" for benign gallbladder diseases. Laparoscopic cholecystectomy has rapidly gained popularity and it is one of the commonly performed operations in Nepal. Laparoscopic Cholecystectomy first performed by Muhe in 1985. The current descriptive study is carried out in Department of General Surgery, College of Medical Sciences – Teaching Hospital (CMS-TH), Bharatpur to evaluate the result of Laparoscopic Cholecystectomy in symptomatic gallstones disease in our set up with special emphasis on complication rate, morbidity and mortality. The data of all patients who underwent laparoscopic cholecystectomy form March 2008 to March 2009 was entered in standardized proforma and analysed on SPSS 10. Out of 110 patients, 85 (77.27%) were female and 25 (22.73%) were males; the age range from 17 to 70 years mean age being 41.30 years, majority were in age 25–40 years group. Eight (7.2%) patients had bile leak, 2 (1.8%) patients developed port site wound infection. There was no bile duct or colonic injuries. The conversion rate was 7.2% (in 8 patients). There was no mortality. Journal of College of Medical Sciences-Nepal, 2011, Vol-7, No-3, 6-10DOI: http://dx.doi.org/10.3126/jcmsn.v7i3.6701

Organized Subdural Hematoma with Thick Membrane in Chronic Subdural Hematoma

Introduction: Chronic subdural hematoma (CSDH) may occasionally contain organized hematoma which can lead to recurrence and other complications after surgery. There is no exact study and data about OHTMF in Nepal so far. The main objective of this study is to study its prevalence and complications. Methods: This is a multicentric retrospective analytical study being carried out at Norvic International Hospital and Annapurna Neurological Institute. We retrospectively analyzed one hundred cases of CSDH between early 2006 to 2010 August. We focused our study mainly on OHTMF. Results: Of 100 cases, majority of the patients were male ranging from 4 to 85 years of age. Bilateral subdural hematoma was found in about 9% of cases. Majority of cases were treated in usual fashion with single burr hole and drain. OHTMF was found in 3 cases (3%) for which craniotomy with radical membranectomy was performed. In 2 cases membrane formation was noticed during surgery, craniotomy with total membranectomy was performed immediately. In one case there was recurrence of CSDH within 10 days of single burr hole evacuation. Craniotomy with membranectomy was performed in 2nd surgery. There was no recurrence after membranectomy. One case developed seizure post operatively. Conclusions: OHTMF is one of the important causes of CSDH recurrence. It has to be treated radically. Different hypthotheses have been postulated regarding thick membrane formation in CSDH. We have tried to discuss these hypotheses. Keywords: burr hole evacuation, craniotomy, CSDH, OHTMF.

Strangulated sigmoid volvulus with severe hypothyroidism: A disastrous combination, our experience

Both sigmoid volvulus and hypothyroidism, can individually have serious repercussions in terms of morbidity and mortality. Even worst, is a combination of these two clinical entities. We report a case of this lethal combination, which had gone into myxedema coma after emergency surgery for strangulated sigmoid volvulus. Patient could be saved because of early identification and meticulous management. It is suggested to have high index of suspicion of hypothyroidism in patients of volvulus. DOI: http://dx.doi.org/10.3126/jcmsn.v7i1.5974 JCMSN 2011; 7(1): 52-56

Antibiotic prophylaxis in low risk patients undergoing laparoscopic cholecystectomy

Laparoscopic cholecystectomy is the 'gold standard' for benign diseases of gallbladder. It has rapidly gained popularity and it is one of the commonly performed operations in Nepal. The need for antibiotic prophylaxis when performing an elective laparoscopic cholecystectomy may not be as important as it is thought in low risk group. Despite, low postoperative infection rate in laparoscopic cholecystectomy in low risk group, the same criteria of antibiotic prophylaxis previously applied to conventional surgery are routinely used for laparoscopic surgery, even though its actual need has not been ascertained. Aim of this study was to assess the efficacy of antibiotic prophylaxis in elective laparoscopic cholecystectomy with respect to postoperative Surgical Site Infection (SSI) in low risk group. Study was carried out in The Department of Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal from May 2005 to June 2006 (14 months).This was a prospective randomized study done on 104 consecutive patients undergoing laparoscopic cholecystectomy. Patients were randomized into case group (group A) and control group (group B) with 52 patients in each group. Two and four patients from Group A and Group B respectively were excluded. In Group A, 50 patients received one gram ceftriaxone intravenously 30 minutes prior to induction of anesthesia and in Group B, all 48 patients received 10 milliliters (ml) of isotonic sodium chloride solution intravenously 30 minutes before induction. In both groups, age, sex, ultrasonogram findings, duration of surgery, American society of anesthesiologists patient classification score, antibiotic administration, bile spillage during surgery, length of postoperative hospital stay and postoperative SSI were recorded. Patients were advised to follow up in Surgical Out-patient Clinic if there was any evidence of SSI within 30 days. SSI was reported and classified as, superficial incisional, deep incisional or space / organ SSI. There were a total of 98 patients included in the study; 50 in Group A and 48 in Group B. In group A, three (6%) patients and in Group B, also three (6.3%) patients had superficial incisional SSI. None of them had deep or organ / space SSI. Comparison of data showed no statistically significant difference between two groups (P- 1.00). DOI: http://dx.doi.org/10.3126/jcmsn.v7i1.5962 JCMSN 2011; 7(1): 12-18

Penile fracture caused by wild bear attack

Interaction between humans and wild animals has increased in recent times because of overlap of habitats. A proportion of this interaction is violent. Usually a large wild animal, like bear, causes significant bony trauma or attacks upper torso of body. We herein present a case of Asiatic black bear attack on an unusual part of body in a 40-year-old man near Nawalparasi, Nepal. The beast attacked genital region causing penile fracture. Patient was managed successfully in three stages. DOI: http://dx.doi.org/10.3126/jcmsn.v7i1.5973 JCMSN 2011; 7(1): 47-51

Distribution and ethnic variation of â-thalassemia mutations in Nepal

This is the first study characterizing spectrum of beta-thalassemia mutations in Nepalese population. Mutations were analyzed in 22 patients using 10 sets of allele-specific primers. Five of the mutations, namely F.S 41/42 (--TCTT), IVS1 nt5 (G-->C), IVS1 nt1 (G-->T), 619 bp deletion and F.S 8/9 (+G), were found to constitute 87.82% of total alleles studied. F.S 41/42 (--TCTT) was the commonest mutation. -88 (C-->T), Codon 16 (--C) and Codon 15 (G-->A), had a combined frequency of 12.18%. Distribution of mutations causing beta-thalassemia in different ethnic Nepalese groups was analyzed. The mutational profile in Nepal share several similarities with that from the two neighboring countries, India and China. Detection of more than one mutation in three cases of thalassemia trait raises the likelihood of existence of multiple mutations in cis in Nepalese thalassemic carriers. Such possibility has to be carefully considered while developing prenatal screening program for Nepalese population.

Organized subdural hematoma with thick membrane in chronic subdural hematoma

INTRODUCTION

Chronic subdural hematoma (CSDH) may occasionally contain organized hematoma which can lead to recurrence and other complications after surgery. There is no exact study and data about OHTMF in Nepal so far. The main objective of this study is to study its prevalence and complications.

METHODS

This is a multicentric retrospective analytical study being carried out at Norvic International Hospital and Annapurna Neurological Institute. We retrospectively analyzed one hundred cases of CSDH between early 2006 to 2010 August. We focused our study mainly on OHTMF.

RESULTS

Of 100 cases, majority of the patients were male ranging from 4 to 85 years of age. Bilateral subdural hematoma was found in about 9% of cases. Majority of cases were treated in usual fashion with single burr hole and drain. OHTMF was found in 3 cases (3%) for which craniotomy with radical membranectomy was performed. In 2 cases membrane formation was noticed during surgery, craniotomy with total membranectomy was performed immediately. In one case there was recurrence of CSDH within 10 days of single burr hole evacuation. Craniotomy with membranectomy was performed in 2nd surgery. There was no recurrence after membranectomy. One case developed seizure post operatively.

CONCLUSIONS

OHTMF is one of the important causes of CSDH recurrence. It has to be treated radically. Different hypthotheses have been postulated regarding thick membrane formation in CSDH. We have tried to discuss these hypotheses.

Intraventricular Taenia solium Neurocysticercosis: A Report of Three Cases

Neurocysticercosis (NCC), caused by the pork tapeworm Taenia solium, is reported to be a common condition in Nepal. So far imaging diagnosis was mainstay of the diagnosis. In this paper, we report three patients presenting with neurological symptoms due to intraventricular NCC. We have diagnosed the causative agent as T. solium on molecular basis. Further research is warranted to assess the actual health impact of T. solium in Nepal. Keywords: Intraventricular neurocysticerosis, PCR-RELP, Taenia solium.

Prevalence of vaginitis among pregnant women attending Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, Nepal

Vaginitis is the most prevalent disorder among the pregnant women. The objective of this study was to find out the prevalence of common types of vaginitis among the pregnant women visiting Paropakar Maternity and Women's Hospital in Kathmandu. Among 200 pregnant women included in the study, 78 (39.0%) had vaginitis. Of total 78 positive cases of vaginitis, 29.5% had candidiasis, 52.6% bacterial vaginosis and 1.3% trichomoniasis. Approximately 83% had monomicrobial infection and 16.7% had polymicrobial infection. Vaginitis was common in the age group of 20 to 29 years (41.8%) and 30-39 years (40.0%). Ethnically, Indo-Aryans (40.2%) were mostly infected. The infection rate was the highest among illiterate women (47.6%) and least among the women having education above secondary (23.0%). The positive infection rate was higher in women from rural area (45.2%) than those from urban area (37.3%). Nearly half of the women with agriculture occupation (48.4%) had vaginitis. Vaginitis was common in women with third pregnancy (52.6%). Among 78 vaginitis cases, 53 (67.9%) were asymptomatic cases.

Intraventricular Taenia solium neurocysticercosis: a report of three cases

Neurocysticercosis (NCC), caused by the pork tapeworm Taenia solium, is reported to be a common condition in Nepal. So far imaging diagnosis was mainstay of the diagnosis. In this paper, we report three patients presenting with neurological symptoms due to intraventricular NCC. We have diagnosed the causative agent as T. solium on molecular basis. Further research is warranted to assess the actual health impact of T. solium in Nepal.

Sequential saccharification of corn fiber and ethanol production by the brown rot fungus Gloeophyllum trabeum

Degradation of lignocellulosic biomass to sugars through a purely biological process is a key to sustainable biofuel production. Hydrolysis of the corn wet-milling co-product-corn fiber-to simple sugars by the brown rot fungus Gloeophyllum trabeum was studied in suspended-culture and solid-state fermentations. Suspended-culture experiments were not effective in producing harvestable sugars from the corn fiber. The fungus consumed sugars released by fungal extracellular enzymes. Solid-state fermentation demonstrated up to 40% fiber degradation within 9days. Enzyme activity assays on solid-state fermentation filtrates confirmed the involvement of starch- and cellulose-degrading enzymes. To reduce fungal consumption of sugars and to accelerate enzyme activity, 2- and 3-d solid-state fermentation biomasses (fiber and fungus) were submerged in buffer and incubated at 37 degrees C without shaking. This anaerobic incubation converted up to almost 11% of the corn fiber into harvestable reducing sugars. Sugars released by G. trabeum were fermented to a maximum yield of 3.3g ethanol/100g fiber. This is the first report, to our knowledge, of G. trabeum fermenting sugar to ethanol. The addition of Saccharomyces cerevisiae as a co-culture led to more rapid fermentation to a maximum yield of 4.0g ethanol/100g fiber. The findings demonstrate the potential for this simple fungal process, requiring no pretreatment of the corn fiber, to produce more ethanol by hydrolyzing and fermenting carbohydrates in this lignocellulosic co-product.

Reproduction of intra-radicular surface anatomy of extracted human teeth: comparison of three different materials using injection technique

This in vitro study compared the reproduction of intra-radicular surface anatomy of extracted human teeth taken by silicon, inlay casting wax and acrylic resin using an injection technique to determine which material produced fewer voids. Twenty impressions/patterns using this technique were made for each material and compared with each other on the basis of number, location and size of voids. Length of each dowel impression/ pattern was also compared. The percentage of void free surfaces using silicon, inlay casting wax and acrylic resin were 90%, 100% and 85% respectively. Most of the voids were less than 1mm in size and situated in the middle third of the impression/pattern. There was no significant difference in the length of the impression/ pattern taken by the three materials. Using the injection technique to reproduce the intra-radicular anatomy of the dowel space, all three materials will show predictably good results.

Intracranial Aneurysm with Systemic Lupus Erythematosus Treated by Endovascular Intervention

Systemic lupus erythematosus (SLE) is a chronic disease with multiple pathologies that can affect every organ system of the body including central nervous system. Intracerebral aneurysms and subarachnoid hemorrhage (SAH) are one of comparatively rarer manifestations of central nervous system SLE. Here we present a case of known SLE complicated by the rupture of intra cerebral aneurysm at basilar artery tip which was successfully treated with endovascular coiling. Keywords: cerebral aneurysm, endovascular surgery, SAH, SLE

Study of fibrinogen in patients with diabetes mellitus

Patients with diabetes mellitus have 2 to 4 times increased risk for cardiovascular disease than non-diabetic patients. However this excess risk is not fully explained by the traditional cardiovascular risk factors (Hypertension, Hypercholesterolaemia, Smoking and Obesity) which are also associated with diabetes. Fibrinogen has been identified as an independent risk factor for cardiovascular disease and it is associated with traditional cardiovascular risk factors. This is a descriptive analytical cross-sectional study carried out in Tribhuvan University Teaching Hospital (TUTH) medical outpatient department and Medical ward from June 2005 to June 2006. A total of 120 consecutive patients were enrolled; 30 patients having Diabetes. Next 30 patients having both diabetes and coronary artery disease. Thirty patients having only coronary artery disease but no diabetes. And 30 patients (control) not having both diabetes and coronary artery disease. Fibrinogen was found to be significantly higher in patients with diabetes than control. Fibrinogen was significantly higher in diabetic patients with coronary artery disease than those patients who had only diabetes or coronary artery disease (p value<0.01).

Intracranial aneurysm with systemic lupus erythematosus treated by endovascular intervention

Systemic lupus erythematosus (SLE) is a chronic disease with multiple pathologies that can affect every organ system of the body including central nervous system. Intracerebral aneurysms and subarachnoid hemorrhage (SAH) are one of comparatively rarer manifestations of central nervous system SLE. Here we present a case of known SLE complicated by the rupture of intra cerebral aneurysm at basilar artery tip which was successfully treated with endovascular coiling.

A study of viral hepatitis during pregnancy in Nepal Medical College Teaching Hospital

The present study aimed to find out prevalence and severity of viral hepatitis during pregnancy in the department of Obstetrics and Gynaecology, Nepal Medical College Teaching Hospital. Out of 5602 pregnant women admitted in the ward from 2001-2007; viral hepatitis was seen in 29 cases. HBV was detected in 18/29 (62.0%), HEV in 6/29 (20.6%) and viral hepatitis of undetected serology was seen in 5/29 (17.2%). Serology was undetected in these cases because of financial constraints. The mortality rate was 8/29 (27.5%). Three out of eight cases who expired were HEV positive and five were of undetected serology. Seven out of 8 maternal deaths were in preterm gestation and undelivered. Fulminant hepatitis with hepatic encephalopathy was the commonest cause of death. Hepatitis E was the commonest etiological agent in those who had fulminant disease during pregnancy and was associated with high mortality rate.

Complications of home delivery: our experience at Nepal Medical College Teaching Hospital

A prospective study was conducted at Nepal Medical College Teaching Hospital to find out the complications of home delivery, maternal and fetal outcome and the main factors leading to home delivery. Among the 114 women who were brought to the hospital after home delivery, one was brought dead and one more died shortly after arrival. Sixty point five percent were housewives with no formal occupation, 68.4% were illiterate, 64.0% were multipara, Maximum no. of women belonged to the age group 20-24 years, 15.8% were adolescents, Lasheta (Lama, Sherpa , Tamang) was the most common ethnic group, Most of the women delivered at full term, whereas preterm delivery occurred in 4 (3.6%). Majority (73.7%) of the women had attended antenatal care at least once and half of the women had attended 4 and more visits. More than half had been fully immunized with tetanus toxoid and taken iron supplementation. As the reasons to deliver at home: 32.5% stated to be due to financial limitations, 30.7% due to ignorance and 16.7% due to transport limitations, and rest due to 'other reasons' which were most commonly stated as to be lack of attendant at home, long distance to hospital or delivery occurring too quickly or too late at night to attend the facility of choice. Ninety four point seven percent delivered at home with no trained assistance. Majority of the women (72.8%) were brought with retained placenta or excessive bleeding per vaginum. Twenty one point nine percent of the women were brought in shock needing active resuscitation. Twenty seven point two percent had postpartum hemorrhage. It was found that antenatal services were well utilized, but mothers were less likely to access good quality delivery/postnatal care. Despite the availability of services however, women still went on to deliver at home without any trained assistance, and this effect was greatest for the t less educated, poorer women. Financial and transport limitations appear to be some of the most important factors in women's inability to access skilled care. This important barrier to care will need to be addressed if we intend to improve delivery service to the most vulnerable of women.

Mad honey poisoning: a rare case report of seven cases

The cause of mad honey poisoning is the toxin grayanotoxin, found in honey obtained from the nectar of Rhododendron species on the higher altitudes. This case report is about seven cases of grayanotoxin poisoning that occurred after consumption of wild honey that was brought from the Himalayan belt of Nepal. Most of them presented with symptoms of blurring of vision, diplopia, nasea and vomiting and two of them presented with symptoms of cardiac depression. All of the cases responded well to intravenous fluid and/or pressor agents while none proved to be fatal

Need for improvement of medical records

INTRODUCTION

A medical record is a systematic documentation of a patient's medical history and care for legal and future use. A poor quality medical record can negatively affect patient care and safety. The study aims to assess the adequacy of medical records in Bir Hospital, a central hospital.

METHODS

A cross-sectional study was conducted by analyzing consecutive discharge summaries of patients admitted during a 6 month period in a single unit of a tertiary care center. The discharge summary format of the hospital was taken as the standard and evaluation for adequacy of data entered was assessed. Descriptive statistics were used to analyze various statistical discrepancies.

RESULTS

Patient's condition at discharge was missing in 86 (66.15%). Patient's address was missing in 21 (16.1%) cases. Almost all the discharge sheets lacked mailing address. Total 96 (73.8%) had use of abbreviations diagnosis. Age and sex were missing in 1 (0.76%). Doctor's signature was illegible in 103 (79.3%) and missing in 2 (1.5%) summaries. Doctor's name and their level/position were missing in 118 (90.76%) and 125 (96.1%) respectively. Total 126 patients (96.9%) were not given any instructions on discharge.

CONCLUSIONS

The discharge summaries analyzed were seen to be inadequate especially in documenting course during the hospital stay, condition at discharge, appropriate instructions and the treating physician's details. These can probably be addressed by introducing electronic medical records if feasible. Otherwise, the discharge summary should be standardized and doctors should be trained to write legible, complete discharge summaries.

A study on complication and monitoring of warfarin in post-valve surgery

INTRODUCTION

This study was carried out to determine the incidence of complication related to warfarin in patients with valve surgery and identify potential risk factors for complication and study its monitoring aspects.

METHODS

A combined retrospective and prospective observational study including a total of 185 patients who underwent mechanical valve replacement in Shahid Gangalal National Heart Centre. The study was conducted from 4 November 2006 till 1 February 2007.

RESULTS

There were a total of 141 episodes of bleeding. Among them significant bleeding occurred in 15.7% patients, major bleeding was 3.2 per 100 patient-years (3.8%) and minor bleeding was 11.8 per 100 patient-years (11.9%). Epistaxis (16.8%) was the most common bleeding complication. Menorrhagia was the most common bleeding complication in females with 20.5 per 100 patient-years (27.4%). Thromboembolic complications occurred at the rate of 2.3 per 100 patient-years. Patients on warfarin were outside the INR target range 67.8% of the time, with 21% INR values above range and 46.8% INR values below range. However, dose adjustment was done only 31.8% of times when INR was outside range.

CONCLUSIONS

There is high incidence of bleeding complication in patients on warfarin and hypertension is significantly associated with bleeding. Difficulty in tightly controlling INR probably is related to high incidence of bleeding. Better patient education, stricter adjustment of INR, frequent monitoring of INR at peripheral hospitals and standardization of the test at different hospitals are suggested to reduce the warfarin related complications.

Need for Improvement of Medical Records

Introduction: A medical record is a systematic documentation of a patient’s medical history and care for legal and future use. A poor quality medical record can negatively affect patient care and safety. The study aims to assess the adequacy of medical records in Bir Hospital, a central hospital.Methods:A cross-sectional study was conducted by analyzing consecutive discharge summaries of patients admitted during a 6 month period in a single unit of a tertiary care center. The discharge summary format of the hospital was taken as the standard and evaluation for adequacy of data entered was assessed. Descriptive statistics were used to analyze various statistical discrepancies. Results: Patient’s condition at discharge was missing in 86 (66.15%). Patient’s address was missing in 21 (16.1%) cases. Almost all the discharge sheets lacked mailing address. Total 96 (73.8%) had use of abbreviations diagnosis. Age and sex were missing in 1 (0.76%). Doctor’s signature was illegible in 103 (79.3%) and missing in 2 (1.5%) summaries. Doctor’s name and their level/position were missing in 118 (90.76%) and 125 (96.1%) respectively. Total 126 patients (96.9%) were not given any instructions on discharge.Conclusions: The discharge summaries analyzed were seen to be inadequate especially in documenting course during the hospital stay, condition at discharge, appropriate instructions and the treating physician’s details. These can probably be addressed by introducing electronic medical records if feasible. Otherwise, the discharge summary should be standardized and doctors should be trained to write legible, complete discharge summaries.Key Words: discharge, hospital, records, summaries

Profile of renal diseases in Nepalese children

AIM AND OBJECTIVES

To find out the profile of renal diseases in children hospitalized in the pediatric department of the tertiary care university teaching hospital in Eastern Nepal.

MATERIALS AND METHODS

A retrospective chart review of all the patients admitted at the department of pediatric from April 2002 to March 2007 was carried out for the presence of any renal diseases on the basis of their clinical presentation, laboratory findings and final diagnosis.

RESULTS

A total number of 10,396 children were admitted during the study period out of which 651 (6.3%) children had renal disease. Among them, nephrotic syndrome seen in 222 patients (34.1%) was the commonest renal disease, followed by post streptococcal nephritis in 187(28.7%) and hemolytic uremic syndrome 66(10.1%), other renal diseases seen were acute renal failure in 25 (3.9%), lupus nephritis 24 (3.7%), urinary tract infection in 23 (3.5%) Henoch-Schönlein Purpura (HSP) nephritis 26 (4%), chronic renal failure in 27 (4.2%) and other miscellaneous causes 51 (7.8%).

CONCLUSION

A substantial number of children are hospitalised with renal diseases, and current trends indicate that majority of them are preventable. In near future, there is a need to develop a comprehensive service for the children with kidney diseases in Nepal.

Detection of individuals prone to develop hypertension in their future life

Hypertension is a global burning health problem. Early detection of proneness to hypertension may help an individual to lead a healthy life by altering the life style (by diet restriction, exercise etc.). Subjects at high risk of future hypertension e.g. the persons of hypertensive family and/or having high resting heart rate etc. show blood pressure hyper-responsiveness to stress. Elevated blood pressure due to sympathetic stimulation prevailed longer time in susceptible persons. In the present study sympathetic stimulation exerted through cold pressor test (hand immersion up to the wrist in 4 degrees C water) resulted in elevation of blood pressure and heart rate in all young male normotensive individuals (age 18-35 years, n=72). Nevertheless, blood pressure and heart rate returned to baseline, following 5 minutes of withdrawal of the stressor, in case of volunteers from normotensive families. On the other hand, the subjects whose parents, either or both were reported to be hypertensive showed elevated diastolic blood pressure even after 5 minutes of withdrawal of the said stressor- indicating that the autonomic nervous system in them was not competent enough for lowering the diastolic pressure quickly to baseline as observed in the volunteers from the normotensive families. The present study revealed that the young subjects who showed greater and prolonged responsiveness to diastolic blood pressure due to sympathetic stimulation through cold pressor test are prone to develop hypertension in future.

Centrosome amplification induced by survivin suppression enhances both chromosome instability and radiosensitivity in glioma cells

Glioblastoma is characterised by invasive growth and a high degree of radioresistance. Survivin, a regulator of chromosome segregation, is highly expressed and known to induce radioresistance in human gliomas. In this study, we examined the effect of survivin suppression on radiosensitivity in malignant glioma cells, while focusing on centrosome aberration and chromosome instability (CIN). We suppressed survivin by small interfering RNA transfection, and examined the radiosensitivity using a clonogenic assay and a trypan blue exclusion assay in U251MG (p53 mutant) and D54MG (p53 wild type) cells. To assess the CIN status, we determined the number of centrosomes using an immunofluorescence analysis, and the centromeric copy number by fluorescence in situ hybridisation. As a result, the radiosensitisation differed regarding the p53 status as U251MG cells quickly developed extreme centrosome amplification (=CIN) and enhanced the radiosensitivity, while centrosome amplification and radiosensitivity increased more gradually in D54MG cells. TUNEL assay showed that survivin inhibition did not lead to apoptosis after irradiation. This cell death was accompanied by an increased degree of aneuploidy, suggesting mitotic cell death. Therefore, survivin inhibition may be an attractive therapeutic target to overcome the radioresistance while, in addition, proper attention to CIN (centrosome number) is considered important for improving radiosensitivity in human glioma.