Predicting factors of patient satisfaction after varicose vein surgery at a university hospital in Nepal

INTRODUCTION

Varicose veins are a common vascular problem with a high prevalence, yet they are often neglected. The main objective of this study was to explore the patient satisfaction after varicose vein surgery, along with its predicting factors. To our knowledge, no similar study has been conducted in Nepal to date.

METHODOLOGY

This retrospective cross-sectional study included patients who underwent varicose vein surgery at Dhulikhel Hospital from September 2019 to February 2020. The satisfaction level after the surgery was assessed using a 10-point Likert scale questionnaire during a telephone interview with their verbal consent. Descriptive statistics and linear regression were performed to identify the predicting factors of patient satisfaction.

RESULTS

Among a total of 84 patients interviewed, 53.6% were male. The mean age of the participants was 43.13 ± 13.62 years. The mean patient satisfaction score was 42 ± 5.5, with nursing service, discharge teaching and hospital service being the highest scoring items in terms of patient satisfaction. Linear regression revealed age ≤40 years as a predictor of higher patient satisfaction (β=0.258, p=0.015) while early stage of varicose veins (β=-0.233, p=0.026) and duration of post-operative follow-up (β=-0.25, p=0.021) were negative predictors of patient satisfaction. This means that patients with C2-C3 venous disease and longer duration of postoperative follow-up tended to have lower satisfaction scores.

CONCLUSION

The overall patient satisfaction following varicose vein surgery was very good, and the major predictors of better satisfaction were age ≤40 years, C4-C6 clinical classification of venous disease and the shorter duration of follow-up after surgery.

Awareness and perception of an Indian dental professional in context to the process and their role in disaster victim identification as a taskmaster

Forensic odontology is a young area in India. However, it has been used as an integral component in a various medicolegal cases in India. However, the involvement of a dentist in mass disasters still needs to be well recognized. The role of the dentists in any unforeseen circumstances is to contribute as an adjunct hand in Disaster Victim Identification (DVI) which is in an emergent stage in India. This study aimed to assess an Indian dental professional's knowledge and awareness of their role in DVI. A pre-tested, self-administered anonymous questionnaire consisting of 6 open-ended and 14 close-ended questions was mailed to the participants. A total of 441 responses were recorded. The study indicated adequate knowledge and awareness among dental practitioners. Conversely, only a handful of people had first-hand autopsy experience. Thus, to supplement the skills needed to work at ground zero, it is recommended to develop hands-on training programs for dentists in each state of India. Also, creating a pool of experts in each state of India can strengthen the task force.

Appendiceal Neuroendocrine Tumor Mimicking Acute Appendicitis

Appendiceal carcinoids are the most frequent tumors arising from the appendix, comprising between 32 and 57% of all the appendiceal tumors. The gross appearance of the appendix showed perforation at the tip with 30 ml of periappendicular collection. On histopathological examination, carcinoid tumor on the tip of appendix was found with tumor cells arranged in tubules, acini and nests infiltrating the muscularis propria and sub serosa. Perineural and vascular invasion was not seen. Immunohistochemistry for Synaptophysin was positive with Ki-67 labelling index of 2%. We present a case of appendiceal neuroendocrine tumor with the chief complaint of acute appendicitis.

The Need of Endodontic Therapy among Patients Attending Tertiary Care Center in Central Nepal

Background Dental caries is considered as the most prevalent oral disease in Nepalese population that frequently needs endodontic therapy or root canal treatment (RCT). Pulp infection is one of the most common sequels of dental caries which when left untreated leads to pulpal necrosis and peri-radicular diseases. Patients usually reports to the dental hospital after there is pain, sensitivity, swelling or fracture of the tooth structure which usually impedes their normal routine of daily life. RCT is one of the efficacious therapeutic procedures that can save the teeth retaining its aesthetics and function. Objective To determine the need of RCT among patients attending Tertiary Care Hospital. Method A cross-sectional epidemiological study was conducted in the Department of Conservative Dentistry and Endodontics over the period of one year from April 2019 to April 2020. Ethical approval was taken from the Institutional Review Committee Kathmandu University School of Medical Sciences. In total, 7566 records of the patients that needed endodontic therapy and other treatments were collected and the need of endodontic therapy versus other treatments were assessed. The data obtained were analyzed using the SPSS version 20. The association between various patient-related variables were calculated by chi square test and mean, standard deviation, frequency and percentage were calculated using descriptive statistics. P value was set at < 0.05 for statistical significance. Result Among the total study population, (n=7566), the mean age was 34.97±14.34 years among which 4387 (58%) were females and 3179 (42%) were males. The type of treatment required by the study participants were significantly associated with age and sex (p < 0.001) and p < 0.001, respectively). Conclusion The findings of this study concluded that there was an increased need for endodontic therapy among patients visiting the department compared to other treatments. There was a significant association between gender and age showing females and elderly patients in greater need for endodontic therapy.

A rare case of persistent lateral marginal vein of Servelle in Klippel Trenaunay Syndrome: A successful surgical management

Introduction and importance

Klippel-Trenaunay Syndrome (KTS) is a rare congenital vascular disorder characterized by capillary malformation, varicosities, and tissue overgrowth. It usually affects the unilateral lower extremities manifesting commonly as pain, localized rise of temperature, and venous tortuosity. However, in severe cases, ulceration, cellulitis, and chronic lymphatic malformation may be present. Management is mostly supportive and involves the use of compression stockings.

Case presentation

Here, we report a case of KTS with a persistent lateral marginal vein of Servelle managed with radiofrequency ablation along with sclerotherapy of selected perforators. On a two-year follow-up, the symptoms had resolved and Doppler ultrasonography revealed resolution of the defective vein along with the absence of incompetent perforators.

Clinical discussion

In cases with venous malformation with the persistence of embryonic avalvular venous structures, like the lateral marginal vein of Servelle, surgical intervention is warranted especially at a younger age to reduce the risk of future thromboembolic events and recurrence.

Conclusion

Varicosities of the lateral marginal vein of Servelle can be managed successfully by radiofrequency ablation and adjunct sclerotherapy in selected cases.

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Klippel-Trenaunay Syndrome (KTS) is a congenital vascular disorder which usually affects the unilateral lower extremities.

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Endovenous treatment of the greater saphenous vein is gradually becoming popular in the treatment of KTS.

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This case is managed by radiofrequency ablation of lateral marginal vein of Servelle.

A Study of Trauma Patients in the Emergency Department of a Tertiary Care Hospital in Nepal during Lockdown in COVID-19 Pandemic

Background The nationwide lockdown was imposed upon by the Government of Nepal with regards to the COVID-19 pandemic. Even during times of limited mobility and travel, trauma cases were presenting to the hospital. Objective To asses trauma patterns among patients presented to the Emergency department in Dhulikhel hospital during the lockdown period. The assessment of the burden of trauma during the pandemic could aid in planning allocation of resources and improving trauma care. Method A retrospective cross-sectional study design was used to assess all patients with a history of trauma during the period of lockdown announced by the Government of Nepal for COVID-19 from March 24 to June 14, 2020. Result Among 2097 patients that visited the emergency department, 23% were trauma cases. In comparison to the corresponding time-period in 2019, trauma cases reduced by more than half (54.5%). The majority of patients utilized ambulances as a means of transportation; a few patients utilized Dhulikhel emergency medical services. The most common mechanism of injury was fall injury, followed by motor vehicle accident and physical assault. Traumatic brain injury occurred in 30% of patients. Of all patients, 71% were discharged after initial treatment, 26% were admitted to different wards and 3% were referred to other health centres. Conclusion Fall injury is a crucial public health concern followed by motor vehicle accident among trauma patients even during the pandemic condition. Thus, emergency rooms should aid in planning for preparedness, mitigation of trauma during situations like these, in planning the allocation of resources and improving trauma care.

Isolation and Intensive Care (ICU) Service, Surge Capacity and Pandemic Training in Government Designated COVID-19 Clinics and Hospitals of Nepal

Background The coronavirus pandemic preparedness and response activities began in Nepal after the detection of the first case on 24 January 2020. Highest daily case record in June 2020 was 671, but it reached above 5,000 in October 2020. Objective This study assessed preparedness and response status of government designated COVID-19 clinics and various level hospitals. Method A web-based survey was conducted among government designated COVID-19 clinics and Level hospitals in June 2020. The Medical Operations Division of the COVID-19 Crisis Management Center (CCMC) retained contact list of focal person in each facility for regular updates. Forty-nine out of 125 clinics and all level hospitals (five Level-1, 12 Level-2, three Level-3) provided responses. Result There were 25 or less isolation beds in the majority of COVID-19 clinics (83.7%) and Level-1 hospitals (60%), whereas the majority of Level-2 (92%) and Level-3 hospitals (67%) had arranged >25 beds. Only five clinics, one Level-1 hospital, six Level-2 and two Level-3 hospitals had a surge capacity of additional 20 or more isolation beds. Only one-fourth of the designated health facilities had arranged separate isolation facility for vulnerable population. Majority of the designated clinics and Level-1 hospitals had five or less functional ICU beds and functional ventilators. Very few Level-2 hospitals had > 10 ICU beds and > 10 ventilators. Healthcare workers in the majority of facilities were trained on donning/doffing, hand washing, swab collection, and healthcare waste management, but, a very few received formal training on patient transport, dead body management, epidemic drill, and critical care. Conclusion This study revealed insufficient preparation in COVID-19 facilities during the initial phase of pandemic. The findings were utilized by the government stakeholders at central, provincial and local levels for scaling up surge capacity and improving health services at the time of case surge. As the pandemic itself is a dynamic process, periodic assessments are needed to gauze preparedness and response during different phases of disease outbreak.

Abstract PO-081: Cancer clinical trial access during the COVID-19 pandemic

Introduction: Cancer clinical trial conduction during the COVID-19 pandemic required a rapid move to virtual engagement to support participant and research team safety. We were faced with the challenge of translating our approach from in-person to virtual engagement for recruitment, enrollment, and delivery of the study intervention. We present our strategies to conduct cancer clinical trials focused on cancer risk reduction during the COVID-19 pandemic. Subject Recruitment: Our multimodal approach utilized online platforms and established approaches like posters, flyers, and collaborating with community health workers to recruit participants. Our virtual engagement strategies include direct outreach to potential participants via email, the electronic medical record (EMR), and social media. Contact via email and the EMR was guided by study-defined eligibility criteria. Social media outreach was through institutional Twitter, Facebook, and video channel accounts. Twitter posts and chats were employed. Enrollment: e-consenting and remote consenting processes were instituted via REDCAP. Delivery of the Educational Risk Reduction Intervention: We also conducted the intervention using the Zoom platform and through a recorded video of the educational risk reduction intervention, which is shared with the participant via REDCAP. Challenges: As documented by others, the greatest challenge to virtual engagement is lack of internet access and lack of digital literacy. These factors have a greater impact on underserved populations, including the elderly, those with low socioeconomic status, those located farther from the cancer center, and racially/ethnically diverse populations. Conclusion: By translating study outreach and processes to virtual engagement, we were able to facilitate clinical trial access across diverse community subgroups and support subject participation in clinical trials during the COVID-19 pandemic.

Citation Format: Ashithkumar Beloor Suresh, Subecha Dahal, Christopher Gantz, AnaMaria Lopez. Cancer clinical trial access during the COVID-19 pandemic [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-081.

Effect of diabetes mellitus on coronary plaque characteristics and progression by serial Coronary Computed Tomography Angiography (CCTA)

Background

Diabetes Mellitus (DM) is a major risk factor for coronary artery disease (CAD) and associated poor outcomes. There is a higher incidence of major adverse cardiac events in patients with DM than those without DM. Coronary plaque characteristics measured by CCTA are correlated with adverse cardiovascular (CV) outcomes.

Purpose

We sought to evaluate coronary plaque characteristics as well as rates of progression of coronary plaque burden as measured by serial CCTA in patients with DM and those without DM.

Methods

The study population included a total of 403 participants (mean age 61.4±11.4 years, 53% men; median scan interval 1.5 years) who were prospectively enrolled in serial CCTA trials. We identified 212 participants with DM and 191 participants without DM, who had undergone serial CCTA. Coronary Plaque volumes were measured and characterized as low attenuation plaque (LAP), total non-calcified plaque (TNCP) and total plaque (TP) using semi-automated plaque analysis software (Qangio medis). Multivariate linear regression was used to examine the effect of DM on coronary plaque progression.

Results

Patients with DM had greater rates of progression of normalized TP volume (median change in annualized plaque (IQR): 39.1 (9.9–114.4) in DM vs 23.5 (4.1–63.8) mm3 in non-DM, p=0.001), TNCP volume (21.6 (3.3–60.8) in DM vs 8.7 (0.1–35.6) mm3 in non-DM, p=0.003) and LAP volumes (0.7 (−0.6 to 7.8) in DM vs 0.1 (−0.4 to 1.9) mm3 in non-DM, p=0.04). After adjusting for relevant risk factors and baseline plaque, the annualized rates of progression were higher in patients with DM by 28% for TP (p=0.004), 27% for TNCP (p=0.011), 23% for fibrous plaque (p=0.026) and by 42% LAP (p=0.050), compared to those without DM.

Conclusion

Patients with DM have significantly higher rates of coronary plaque progression, including vulnerable LAP, than those without DM. Our findings reveal differences in rates, burden and characteristics of coronary plaque progression in patients with DM vs those without DM. These results provide mechanistic understanding of natural history of coronary atherosclerosis in this vulnerable population, that could explain the increased risk of CV events among patients with DM. Coronary atherosclerotic phenotyping by CCTA could serve as a potential surrogate measure for risk stratification and evaluation in clinical trials to examine therapeutic strategies in this vulnerable population.

Funding Acknowledgement

Type of funding sources: None.

Distress screening for patients with a history of cancer during the COVID-19 pandemic

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Background: Although a diagnosis of cancer is widely accepted as resulting in significant levels of distress, distress itself cannot be considered benign and screening for distress is considered a best practice metric for patients receiving oncological care. Endorsed by NCCN, the Distress Thermometer (DT) considers a cutoff score of 4 or greater to identify patient with clinically relevant levels of distress. We hypothesized that the COVID-19 pandemic would manifest with higher levels of stress and anxiety in most persons by compounding the distress experienced by patients with a diagnosis of cancer. Methods: Patients with a new diagnosis of cancer underwent distress screening with the DT prior to a clinical appointment at a NCI-designated academic cancer center. Patients who scored 4 or higher were discussed at an Interprofessional Supportive Medicine patient conference or referred to oncology social work for appropriate evaluation and therapeutic care. By mid-March 2020, the SKCC catchment area was under a public health emergency with limited access to non-essential healthcare; therefore, we present data from 1/1-3/15/20 (pre-pandemic), 3/16-6/7/20 (pandemic peak with 2000+ daily cases in late April and peak daily deaths 300+ in May), and 6/8-8/30/20 (daily cases generally less than 700 except for occasional levels of 1000-in July and daily deaths less than 40 daily). Results: In the pre-pandemic time period, 60% of patients assessed reported a score of 4 or higher. During the subsequent periods—the first pandemic peak and the first post-pandemic period—the incidence of an elevated distress screen (4 or higher) was relatively stable at about 30%. Conclusions: Contrary to expectations, the DT screen identified less patient distress during the pandemic compared to pre-pandemic. Our results may be due to multiple factors—changes in processes and procedures to prioritize DT screening as pandemic risk became more apparent; an increased use of telemedicine; and the compounding of new, non-cancer related stressors resulting in the greater resiliency noted in disaster psychology. For example, during the first pandemic peak when the majority of patients were seen via telemedicine, the opportunity afforded by telemedicine for safety and decreased risk for COVID-19 infection may have reduced the overall distress experience. In addition, the compounding of stressors—the diagnosis of cancer, the risk of the pandemic, and its economic and financial stressors—may have influenced distress perception. Future work incorporating multiple distress assessment points may help better understand the impact of the layers of stress experienced by persons with cancer.[Table: see text]

Knowledge, Attitude, and Practices Related to COVID-19 among Healthcare Personnel in a Tertiary Care Hospital in Nepal: A Cross-sectional Survey

Background COVID-19 is significantly affecting the healthcare system globally. As a result, healthcare workers need to be updated on the best practices for the proper management of the disease. Objective The purpose of this study was to assess the knowledge, attitude, and practices (KAP) related to COVID-19 among healthcare personnel. Method This was a cross-sectional study conducted among medical personnel at Dhulikhel Hospital Kathmandu University Hospital using a semi-structured questionnaire on KAP related to COVID-19 from May 8th to June 8th, 2020. We analyzed survey data by using descriptive statistics. Spearman rank correlation, chi-square test and binary logistic analysis were used to examine the association between sociodemographic characteristics with KAP related to COVID-19. Result Among 220 participants, the majority were nurses (60%) followed by doctors (27.7%), paramedics (10%) and technicians (2.3%). The results showed that 68.6% of healthcare personnel had a good knowledge with appropriate practices (98.5%) and negative attitude (59.3%). In the multivariate binary logistic analysis, the healthcare workers with the clinical experience level of one to five years (OR:.42, 95% CI:.19- .96) and more than 5 years (OR: .16, 95% CI: .04-.63) were significantly associated with negative attitude. The confidence score for managing COVID-19 (OR:1.16, 95% CI:1.02-1.34) was significantly associated with an optimistic attitude. Conclusion Healthcare workers are knowledgeable about COVID-19 and proactively practising to minimize the spread of infection but lack optimistic attitudes. Hence, the constantly updated educational programmes related to COVID-19 for targeted groups will contribute to improving healthcare workers' attitude and practices.

Pattern of Dental Problems among Patients Visiting a Dental Hospital during COVID-19 Pandemic

Background Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and Nepal is a part of this worldwide corona virus disease. In this critical situation, the patients have a sense of insecurity visiting dental hospital. Objective To assess the pattern of dental problems in patients visiting a dental college during COVID-19. Method A descriptive cross-sectional study was conducted in Dental Hospital of Kathmandu Medical College and Teaching Hospital from May to August 2020. The patients visiting the Dental hospital were assessed for dental problems. Data were analyzed in Statistical Package of Social Sciences version 20. Frequency and percentage for pattern of dental problems were calculated. Result Most of the patients of age group of 14 to 31 years 530 (36.53%) had dental problems during the survey period. Out of total patients having dental emergency, 739 (50.93%) were males and 712 (49.07%) were females. Majority 545 (37.56%) visited the dental hospital for endodontic consultation followed by emergency consultation for oral surgical procedures 298 (20.54%). Least consulted dental emergency condition was prosthodontic consultation 18 (1.24%). Conclusion The study findings showed that the major dental problems in patients causing emergency visit to dental hospital during COVID-19 pandemic period were dental pain and swelling requiring endodontic consultation and the least need felt is prosthodontic consultation.

Spleen in the thorax: A case report on traumatic diaphragmatic rupture

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Diaphragmatic rupture is a rare complication of abdominal trauma.

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Herniation of abdominal contents can occur following diaphragmatic rupture.

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Spleen was present in the thorax in a case following blunt abdominal trauma.

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Care should be taken when inserting a chest tube in suspected cases.

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Treatment is surgical via Laparotomy or Thoracotomy.

Introduction

Most of the cases of diaphragmatic rupture occur following abdominal trauma and herniation of abdominal organs into the thorax can occur.

Presentation of case

Twenty three years old male presented after a blunt abdominal trauma following a road traffic accident. Investigations revealed a left sided diaphragmatic rupture with herniation of spleen and stomach into the left hemithorax. Surgical repair of the defect was done and splenectomy had to be done due to extensive splenic laceration. Two third of the spleen was found in the left hemithorax.

Discussion

Diagnosis of diaphragmatic rupture can be missed in cases of polytrauma. High clinical suspicion with aids from imaging modalities help in the diagnosis. In suspicion of herniation of abdominal contents into the thorax, one should be careful in insertion of chest tube in view of damaging the herniated organs. Treatment is surgical repair and reduction of herniated contents.

Conclusion

Although a rare entity, diaphragmatic rupture can occur in cases of abdominal trauma. High clinical suspicion with imaging helps in the diagnosis.

Spatial variability in the risk of death from COVID-19 in Italy

OBJECTIVES: Italy has been badly affected by the COVID-19 pandemic and has one of the highest death tolls. We analyzed the severity of COVID-19 across all 20 Italian regions.METHOD: We manually retrieved the daily cumulative numbers of laboratory-confirmed cases and deaths attributed to COVID-19 in each region, and estimated the crude case fatality ratio and time delay-adjusted case fatality ratio (aCFR). We then assessed the association between aCFR and sociodemographic, health care and transmission factors using multivariate regression analysis.RESULTS: The overall aCFR in Italy was estimated at 17.4%. Lombardia exhibited the highest aCFR (24.7%), followed by Marche (19.3%), Emilia Romagna (17.7%) and Liguria (17.6%). Our aCFR estimate was greater than 10% for 12 regions. Our aCFR estimates were statistically associated with population density and cumulative morbidity rate in a multivariate analysis.CONCLUSION: Our aCFR estimates for Italy as a whole and for seven out of the 20 regions exceeded those reported for the most badly affected region in China. These findings highlight the importance of social distancing to suppress transmission to avoid overwhelming the health care system and reduce the risk of death.

Spatial variability in the risk of death from COVID-19 in Italy

OBJECTIVES: Italy has been badly affected by the COVID-19 pandemic and has one of the highest death tolls. We analyzed the severity of COVID-19 across all 20 Italian regions.METHOD: We manually retrieved the daily cumulative numbers of laboratory-confirmed cases and deaths attributed to COVID-19 in each region, and estimated the crude case fatality ratio and time delay-adjusted case fatality ratio (aCFR). We then assessed the association between aCFR and sociodemographic, health care and transmission factors using multivariate regression analysis.RESULTS: The overall aCFR in Italy was estimated at 17.4%. Lombardia exhibited the highest aCFR (24.7%), followed by Marche (19.3%), Emilia Romagna (17.7%) and Liguria (17.6%). Our aCFR estimate was greater than 10% for 12 regions. Our aCFR estimates were statistically associated with population density and cumulative morbidity rate in a multivariate analysis.CONCLUSION: Our aCFR estimates for Italy as a whole and for seven out of the 20 regions exceeded those reported for the most badly affected region in China. These findings highlight the importance of social distancing to suppress transmission to avoid overwhelming the health care system and reduce the risk of death.

Case report of eventration of diaphragm due to an unknown febrile illness causing phrenic nerve palsy and other multiple nerve palsies

INTRODUCTION

Diaphragmatic eventration can be congenital or acquired. Diagnosis is delayed due to no symptoms or very mild ones and is generally done by imaging modalities. This condition is managed by plication of the affected part of diaphragm by various surgical approaches.

PRESENTATION OF CASE

A forty seven years lady presented with one year long history of abdominal pain, bloating and fullness after meals who was being treated in line of peptic acid disorder. She had developed bilateral foot drop after typhoid fever at seventeen years of age. Clinical examination and imaging with chest x-ray, chest ultrasound and computed tomography scan suggested eventration of left hemidiaphragm. Plication of eventration of left hemidiaphragm was done via mini thoracotomy of the left thorax. There were no postoperative complications and she was discharged on the sixth postoperative day.

DISCUSSION

Acquired eventration of diaphragm is commonly due to traumatic phrenic nerve palsy but rarely can be associated with a history of infection causing nerve palsies. Thoracic ultrasound is an emerging modality for diagnosis supporting X-rays and CT Scans. Plication of eventration with minimally invasive techniques has less number of hospital stay and less pain compared to open approaches.

CONCLUSION

Non-traumatic diaphragmatic eventration due to acquired phrenic nerve palsy following an unknown febrile illness is a rare case to be reported in Nepal. The aim of treatment is expansion of intra-thoracic space which is done by plication of the diaphragm.

Recovery Pattern in Different Surgical Approaches on Thoracic Enhanced Recovery based Fourteen-Step Protocol in Patients Undergoing Cardio-thoracic Surgery at University Hospital of Nepal

Background Cardio-thoracic surgery involves open and minimally invasive techniques. Enhanced recovery after surgery is used for early recovery from surgery. Enhanced recovery after surgery decreases hospital stay duration. Patients undergoing Enhanced recovery after surgery after video assisted thoracic surgery use less pain killers and have less hospital cost. There has not been any study on outcomes on patient who follow physiotherapy protocol designed in our setting. Objective To find the physiotherapy outcomes in patients undergoing thoracic enhanced recovery after surgery (T-ERAS) based 14 step protocol locally designed at Dhulikhel Hospital, Kathmandu University Hospital (DH, KUH). Method This is a retrospective cross sectional observational study. All the cases who underwent cardiothoracic surgery were classified based on the approach of chest surgery performed into groups Sternotomy, Thoracotomy and Video Assisted Thoracic Surgery (VATS) groups. Patients were advised for Thoracic Enhanced recovery after surgery based on the protocol that has been devised at Dhulikhel Hospital. The recovery of patients based on activities they could perform was noted and analyzed. Result Both ICU stay and hospital stay in number of days were highest in thoracotomy (6.04 days) group while that was lowest in video assisted thoracic surgery group (1.67 days). There is a similar recovery until step 5, i.e. 2 days and rapid progression in further steps in video assisted thoracic surgery group while it is much slower in both sternotomy and thoracotomy groups. Conclusion Postoperative mobilization and physiotherapy enhance early healing and decrease hospital stay. Mean hospital stay and ICU stay were shorter for video assisted thoracic surgery cases compared to Thoracotomy and Sternotomy groups and the mean days to achieve different steps varied within the protocol between groups compared.

A case of thymoma in myasthenia gravis: Successful outcome after thymectomy

INTRODUCTION

Thymic abnormalities occur as hyperplasia and thymoma. Myasthenia gravis is commonly present in thymoma. Thymectomy possesses risk due to anatomical proximity with vital thoracic structures and myasthenia crisis.

PRESENTATION OF CASE

Forty five years female with complaints of difficulty swallowing and weakness of upper limb muscles upon investigation showed mass in mediastinum and antibody test for myasthenia gravis positive. Medical management was done for a month followed by thymectomy. There were no intra and postoperative complications. Medical management was stopped one month after surgery and she is symptom free.

DISCUSSION

Thymectomy is the standard of care where median sternotomy is the mainstay approach to surgery. Various other surgical approaches and complications revolving around surgery has been discussed.

CONCLUSION

Surgical removal of thymoma cured myasthenia gravis in our case. We focused on proper preoperative optimization of myasthenia gravis symptoms before thymectomy.

The Trend and Outcomes of Laparoscopic Appendectomy for Complicated Appendicitis in Nepal: A retrospective study from 2014 to 2018 in a University Hospital

Background Globally, appendicitis is the most frequent emergency surgical procedure. Laparoscopic Appendectomy (LA) is recommended as a standard surgical procedure to remove appendix. In Nepal, studies showed improved outcomes of Laparoscopic Appendectomy than Open Appendectomy (OA) in treating acute appendicitis. However, effectiveness of in Complicated Appendicitis (CA) has not yet studied in Nepal. Objective This study aims to assess the temporal trend of Laparoscopic Appendectomy in management of Complicated appendicitis and to compare outcomes with Open Appendectomy. Method The study is a retrospective descriptive study. The outcome measures in the study are age, sex, ethnicity, length of postoperative stay (LOS), and conversion rate. Secondary data of 174 patients with complicated appendicitis were extracted and reviewed from the operation theater records and the discharge summary from the period of 2014 to 2018. Result The mean age of the patients is 33.2 (SD ±19.4). Predominantly increased incidence is observed among male patients (66%). Mean Length of stay was 4.07(SD±2.1) days. Laparoscopic Appendectomy had shorter hospital stays than open and converted cases. The conversion rate was 10.92% for the observation period, and it was in a decreasing trend with the latest of 4.54%. The temporal trend for the percentage of patients who underwent Laparoscopic Appendectomy was increasing in the observation period. Conclusion The utilization of laparoscopic appendectomy in complicated appendicitis is growing in Nepal, and has decreasing conversion rate.

Reasons for Summoning Ambulance Services in the Hilly Region of Nepal

Background Nepal lacks a unified and countrywide emergency medical services system as other developing countries. However, the emergence of ambulance service initiatives in the past decade shows a promising future for pre-hospital care. Nepal Ambulance Service (Est. 2011) and Dhulikhel Emergency Medical Services (Est. 2013) are the existing emergency medical services initiatives in Nepal. Objective To describe the reason for summoning ambulance services and demographics of the patients who were transported by Dhulikhel Emergency Medical Services at Dhulikhel hospital, hilly region of Nepal. Method One thousand three hundred and ninety three patient records at Dhulikhel hospital transported by Dhulikhel Emergency Medical Services during the five-year period (2013 - 2018) were included in the study. Chief complaints and demographic data were collected and categorized into overarching systemic categories. Result Among 1393 patients, majority were female (60.4%) and the most common age group was 20-29 years. The most common reason for calling ambulances was gastrointestinal problem (22.6%). Similarly, respiratory (17%), obstetric and gynecological (15.2%), trauma (12.7%) and neurological (9.6%) problems were other common reasons. The number of respiratory problem was increased during the winter season. The overall percentage of patients arriving at hospital with trauma problems was increased steadily, but it was not statistically significant. Conclusion Gastrointestinal problem was the most common reason, followed by respiratory and obstetric and gynecological problems for summoning ambulances services in the hilly regions of Nepal. The incidence of respiratory problem significantly increased during the winter season.

Assessing the Relationship of Maternal Factors and Family Income with Early Childhood Caries: A Hospital Based Study

Background Earlychildhood caries (ECC) is a multifactorial disease. Maternal factors and family income has major influence on the caries status of children. Objective To assess the relationship of maternal factors and family income with early childhood caries among children attending Pediatric Dentistry department of Dhulikhel Hospital. Method A cross sectional study was conducted among 239 children of age 3 to 6 years attending Pediatric Dentistry department of Dhulikhel Hospital, Kavre, Nepal. Age of child, mother's occupational status,educational level and family income were recorded. Oral examination of child was done to record decayed, missing, filled teeth (dmft). Descriptive analysis was done to observe the caries experience. Chi - square test was used to assess the relationship of caries experience with occupational status, education of mother and family income. Result The mean decayed, missing, filled teeth of the children was7.04±4.10. There was no significant relationship of early childhood caries with occupational status of mother (p=0.675), education of mother (p=0.140) and family income (p=0.158). Conclusion There was no relationship of maternal factors and family income with early childhood caries when surveyed among the children visiting Pediatric Dentistry department of Dhulikhel hospital.

Assessing Health Status of Khanigaun Village Development Committee in Nuwakot District of Nepal

BACKGROUND

Assessing health status is crucial to understand the level of health in the community. Maternal health, child health and behavioral practice on diseases are key issues to assess health status of a community in Nepal. Nationwide surveys and literature suggest that there is improvement in health status of Nepalese community. Thus, the aim of this study was to assess general health status of Khanigaun VDC of Nepal and compare it with regional and national status.

METHODS

A descriptive cross-sectional study was undertaken using semi-structured questionnaire, interview and observation methods. Simple random sampling was done to conduct household survey among 346 (30%) households. Ethical approval was taken from Nepal Health Research Council, Ethical Review Board Results: General Fertility Rate (GFR) of the VDC was found 69.15 per 1000 Women. Literacy rate of the VDC was 71.14% and 74.92% of households depended on agriculture for income. The major health problem of the community was diarrhea followed by unknown fever and respiratory problems. More than 50% of women breastfed their children only up to the age of one year. Contraceptive prevalence rate was 72% and more than two third of women were found to be have delivered their most recent baby at home. It was found that 31% of newborn were born underweight and measles immunization coverage was 89%. After need identification and prioritization, Micro Health Project (MHP) was conducted to create health related awareness among the people through demonstration and exhibition.

CONCLUSIONS

Regular health status assessment of a community people that ultimately helps to plan the health programs and services accordingly.

Inadequate Empirical Antibiotic Therapy in Hospital Acquired Pneumonia

INTRODUCTION

Inadequate empirical antibiotic therapy for HAP is a common phenomena and one of the indicators of the poor stewardship. This study intended to analyze the efficacy of empirical antibiotics in the light of microbiological data in HAP cases.

METHODS

Suspected cases of HAP were followed for clinico-bacterial evidence, antimicrobial resistance and pre and post culture antibiotic use. The study was taken from February,2014 to July 2014 in department of Microbiology and department of Respiratory medicine prospectively. Data was analyzed by Microsoft Office Excel 2007.

RESULTS

Out of 758 cases investigated, 77(10 %) cases were HAP, 65(84%) of them were culture positive and 48(74 %) were late in onset. In early onset cases, isolates were Acinetobacter 10(42%), Escherichia coli 5(21%), S.aureus 4(17%), Klebsiella 1(4%) and Pseudomonas 1(4%). From the late onset cases Acinetobacter 15(28%), Klebsiella 17(32%) and Pseudomonas 13(24%) were isolated. All Acinetobacter, 78% Klebsiella and 36% Pseudomonas isolates were multi drug resistant. Empirical therapies were inadequate in 12(70%) of early onset cases and 44(92%) of late onset type. Cephalosporins were used in 7(41%) of early onset infections but found to be adequate only in 2(12%) cases. Polymyxins were avoided empirically but after cultures were used in 9(19%) cases.

CONCLUSIONS

Empirical antibiotics were vastly inadequate, more frequently so in late onset infections. Use of cephalosporins empirically in early onset infections and avoiding empirical use of polymyxin antibiotics in late onset infections contributed largely to the findings. Inadequate empirical regimen is a real time feedback for a practitioner to update his knowledge on the local microbiological trends.

Self-perception regarding dental aesthetics, knowledge and attitude of traumatic dental injury and halitosis among people of Aurabani, Sunsari district of Eastern Nepal

Background and Objectives: Increased concern over dental appearance has been observed during childhood and adolescence to early adulthood. The study was conducted with objectives to assess the self-perception of dental aesthetics, knowledge, attitude and management of dental trauma and halitosis.Materials and Methods: Self-administered questionnaire translated in Nepali language consisting of 32 questions was used. The completed questionnaires were analyzed using descriptive statistics.Results: Out of the total study population, 63% were satisfied with their overall tooth appearance and 71.7% with their tooth color. Twenty-nine percent had experienced dental trauma. More than half of the study population thought that immediate treatment was required after dental trauma. Fifty seven percent of the villagers had halitosis.Conclusion: The research clearly shows that the people of Aurabani VDC were satisfied with their tooth color and overall tooth appearance; however the knowledge regarding emergency management of dental trauma, the cause and management of halitosis was insufficient.JCMS Nepal. 2015;11(1):6-8

Surgical removal of traumatic herniation of buccal fat pad in young children

Intraoral herniation of the buccal fat pad is traumatic lesion of oral cavity occurring in young children. It frequently presents as an expanding pedunculated mass of soft tissue emanating from the buccal mucosa following a minor trauma to the buccal soft tissues. This article aims to report an interesting and rare lesion, wherein a tiny traumatic perforation of the buccal mucosa and buccinator muscle forced a large portion of the buccal fat pad to extrude into the oral cavity in a young boy. Such a situation can alarm any clinician and reinforces the importance of careful history taking and thorough examination, before treating patients.

Exhaled Breath Analysis in Tuberculosis Case Detection: The New Horizon

Sixty years ago, Nobel Prize winner Linus Pauling proposed the concept that human breath is a complex and dynamic gaseous mixture of more than 200 different endogenous volatile organic compounds (VOCs) that are continually being released in different quantities within the internal environment during health and disease. The researchers estimate that more than a thousand chemicals produced in different organ-systems as metabolic end products come out every minute through the respiratory tract. Volatile organic compounds and other products of oxidative stress are a big chunk among these exhaled breath elements.DOI: http://doi.dx.org/10.3126/nje.v3i2.8509

Micronuclei and sialic acid as markers of genotoxic damage in tobacco-related oral lesions

Background: Carcinogens and co-carcinogens act in an additive, synergistic and antagonistic manner. Tobacco is the most common carcinogen related to oral cancer. The aim of this study was to assess the effect of tobacco on the oral epithelium by evaluating genotoxic damage to cells as quantitated by micronuclei and also the alterations to the cell membrane were correlated by the measurement of free sialic acid and protein-bound sialic acid in saliva and in serum. Materials and Methods: Blood samples collected from 15 untreated oral squamous cell carcinoma patients, 15 patients with oral precancerous conditions, 15 tobacco chewers without clinically evident lesion and 15 non-tobacco chewers. Serum and salivary sialic acid levels both in free and bound form were measured spectrophotometrically. Smear was taken from the same patient from the suspicious site and assessment of micronuclei was done by acridine orange method. Results: Serum free sialic acid and micronuclei assessment showed greater level of signifi cance (P=?0.05) between all other groups. This implies it’s potential use as an indicator of oral cancer. Predictability of occurrence of oral Cancer = 0.561+ 0.005× serum protein-bound sialic acid+ 0.244 serum free sialic acid + 0.71 M, where M=mean of micronuclei in 500 exfoliated oral cells. Predictability of occurrence of oral Premalignancy = 0.13+ 0.909× serum free sialic acid+ 0.045 M, where M=mean of micronuclei in 500 exfoliated oral cells. Conclusion: Micronuclei, serum and salivary sialic acid levels may be a good marker for prediction of premalignancy and oral squamous cell carcinoma transformation. Journal of Pathology of Nepal (2013) Vol. 3, No.1, Issue 5, 379-385 DOI: http://dx.doi.org/10.3126/jpn.v3i5.7862

Study of fasting serum lipid and lipoproteins profile in type-II diabetic patients attending NMCTH

Dyslipidemia is one of the primary causes for cardio vascular disease (CVD) and development of myocardial infarction (MI) which often leads to coronary artery disease (CAD). The elevated level of total cholesterol (TC), triglycerides (TG), low-density lipoproteins-cholesterol (LDL-C), and lowered high-density lipoprotein-cholesterol (HDL-C) are the predictable risk factor for CAD with type-II diabetic patient. The present study was undertaken taken with an objective to frame out the lipid profile in type-II diabetic patients attending OPD (outpatient department) of Nepal Medical College Teaching Hospital (NMCTH) Jorpati, Kathmandu. Samples of 148 individuals with age varying from 30-73 were analyzed. Out of which 96 patients were diabetic and 52 were control group. The mean +/- SD (mg/dl) levels of Cholesterol, TG and LDL-C were found significantly higher compared to non-diabetic, and these are statistically significant when compared with healthy control group. The study concludes that the study of accessing fasting lipid profile in type-II diabetic will be a tool of accessing risk for cardiovascular and other coronary artery complications.

In-vitro assessment of cell-mediated immunity by demonstrating effector-t cells for diagnosis of tuberculosis in Nepalese subjects

The immune response against mycobacterium tuberculosis (MTB) is cell mediated. T-cells become sensitized when they encounter MTB antigens and subsequently activated effector T-cells produce a number of cytokines including interferon- gamma (INF-gamma) to fight the infecting organisms. Demonstration of either production of INF-gamma or presence of effector T-cells sensitized to MTB specific antigens in vitro can be diagnostic for TB infection. Aim of this study was to determine the efficacy of commercially available T-SPOT.TB kit which is used for the in vitro diagnosis of TB infection and to determine if this test has any cross reactivity in leprosy patients. Blood sample was taken from 30 sputum AFB positive, 30 sputum AFB negative healthy controls and 10 cases of paucibacillary leprosy patients. The blood samples were processed to separate peripheral blood mononuclear cells. The final cell suspensions were cultured along with MTB specific antigens namely- Early Secretory Antigenic Target (ESAT-6) and Culture Filtrate Protein (CFP 10) along with negative and positive controls. The production of INF-gamma was demonstrated by enzyme linked immunospot (ELISPOT) assay technique. All AFB positive samples produced INF-gamma after exposure to MTB specific antigens. 4 (16.6%) of healthy controls were also found reactive for INF-gamma. The sensitivity and "specificity" for active disease of the ELISPOT (T-SPOT.TB) in respect to AFB microscopy was 100% and 85.7% respectively. Assessment of CMI against tuberculosis, by demonstrating effector T-cell sensitized to MTB antigens can be use to aid the diagnosis of tuberculosis. T-SPOT.TB has no cross reactivity with leprosy patients.

Resistotypes of Vibrio cholerae 01 Ogawa Biotype El Tor in Kathmandu, Nepal

Cholera continued to be a major diarrheal illness in Nepal and antibiotic resistance has appeared as a serious problem in cholera management. The study aimed at analyzing the distribution pattern of the resistotypes (R-types) of Vibrio cholerae in the Kathmandu valley, Nepal. During June 2008 to January 2009, 210 diarrheal specimens received at National Public Health Laboratory from suspected cholera patients were subjected to standard bacteriological investigation including biotyping and serotyping. Antimicrobial susceptibility pattern of V. cholerae isolates was determined by Kirby Bauer disc diffusion method following CLSI guidelines. A total of 57 (27%) V. cholerae isolated were recovered, all of which belonged to 01 Ogawa Biotype EL Tor. Based on antibiogram, V. cholerae isolates in our study revealed three distinct R-types: R-type I, R-type II and R-type III. All three R types showed resistance to furazolidone, nalidixic acid and cotrimoxazole while sensitive to ciprofloxacin and tetracycline. Additional resistance to ampicillin and erythromycin was observed respectively in R-type II and III. Different R-types showed unique month wise variations (P < 0.05). Differentiation of V. cholerae strains into R-types is an important tool. In addition to direct patient management, it may have implication in identifying the source and spread of infection, and understanding the distribution pattern in a particular geographical region.

Effect of the sixth axial ligand in CS-ligated iron(II)octaethylporphyrinates: structural and Mössbauer studies

The effect of a sixth ligand in a series of low-spin thiocarbonyl-ligated iron(II)octaethylporphyrinates has been investigated. Six-coordinate complexes have been synthesized and characterized by Mössbauer and infrared spectroscopy and single-crystal X-ray structure determinations. The results are compared with the five-coordinate parent complex. The crystal structures of [Fe(OEP)(CS)(1-MeIm)] and [Fe(OEP)(CS)(Py)] are reported and discussed. The 1-methylimidazole and pyridine derivatives exhibit Fe-C(CS) bond distances of 1.703(4) and 1.706(2) A that are significantly longer than the 1.662(3) A reported for five-coordinate [Fe(OEP)(CS)] (Scheidt, W. R.; Geiger, D. K. Inorg. Chem. 1982, 21, 1208). The trans Fe-N(ligand) distances of 2.112(3) and 2.1550(15) A observed for the 1-methylimidazole and pyridine complex are approximately 0.13 A longer than those observed for analogous bis-ligated complexes and are consistent with a significant structural trans effect for the CS ligand. Mössbauer investigations carried out for five- and six-coordinate thiocarbonyl derivatives with several different sixth axial ligands reveal interesting features. All derivatives exhibit very small isomer shift values, consistent with a very strong interaction between iron and CS. The five-coordinate derivative has delta(Fe) = 0.08 mm/s, and the six-coordinate complexes exhibit delta(Fe) = 0.14 to 0.19 mm/s at 4.2 K. The five-coordinate complex shows a large quadrupole splitting (DeltaE(q) = 1.93 mm/s at 4.2 K) which is reduced on coordination of the sixth ligand (DeltaE(q) = 0.42-0.80 mm/s at 4.2 K). Addition of a sixth ligand also leads to a small decrease in the value of nu(CS). Correlations in structural, IR, and Mössbauer results suggest that the sixth ligand effect is primarily induced by changes in sigma-bonding. The structure of [Fe(OEP)(CS)(CH(3)OH)] is briefly reported. Crystal data: [Fe(OEP)(CS)(1-MeIm)] crystallizes in the monoclinic system, space group P2(1)/n, Z = 4, a = 9.5906(5) A, b = 16.704(4) A, c = 23.1417(6) A, beta = 100.453(7) degrees. [Fe(OEP)(CS)(Py)] crystallizes in the triclinic system, space group P1, Z = 5, a = 13.9073(6) A, b = 16.2624(7) A, c = 22.0709(9) A, alpha = 70.586(1) degrees, beta = 77.242(1) degrees, gamma = 77.959(1) degrees. [Fe(OEP)(CS)(CH(3)OH)] crystallizes in the triclinic system, space group P1, Z = 1, a = 9.0599(5) A, b = 9.4389(5) A, c = 11.0676(6) A, alpha = 90.261(1) degrees, beta = 100.362(1) degrees, gamma = 114.664(1) degrees.