Bacteriology of endotracheal tube biofilms and antibiotic resistance: a systematic review

Bacteria commonly adhere to surfaces and produce polymeric material to encase the attached cells to form communities called biofilms. Within these biofilms, bacteria can appear to be many times more resistant to antibiotics or disinfectants. This systematic review explores the prevalence and microbial profile associated with biofilm production of bacteria isolated from endotracheal tubes and its associations with antimicrobial resistance. A comprehensive search was performed on databases PubMed, Embase, and Google Scholar for relevant articles published between 1st January 2000 and 31st December 2022. The relevant articles were exported to Mendeley Desktop 1.19.8 and screened by title and abstract, followed by full text screening based on the eligibility criteria of the study. Quality assessment of the studies was performed using the Newcastle-Ottawa Scale (NOS) customized for cross-sectional studies. Furthermore, the prevalence of antimicrobial resistance in biofilm-producers isolated from endotracheal tube specimens was investigated. Twenty studies encompassing 981 endotracheal tubes met the eligibility criteria. Pseudomonas spp. and Acinetobacter spp. were predominant isolates among the biofilm producers. These biofilms provided strong resistance against commonly used antibiotics. The highest resistance rate observed in Pseudomonas spp. was against fluoroquinolones whereas the least resistance was seen against piperacillin-tazobactam. A similar trend of susceptibility was observed in Acinetobacter spp. with a very high resistance rate against fluoroquinolones, third-generation cephalosporins and carbapenems. In conclusion, endotracheal tubes were associated with colonization by biofilm forming bacteria with varying levels of antimicrobial resistance. Biofilms may promote the occurrence of recalcitrant infections in endotracheal tubes which need to be managed with appropriate protocols and antimicrobial stewardship. Research focus should shift towards meticulous exploration of biofilm-associated infections to improve detection and management.

Therapy-related Acute Myeloid Leukemia in Non-Hodgkin Lymphoma Survivors: Risk, Survival Outcomes and Prognostic Factor Analysis

BACKGROUND

Therapy-related acute myeloid leukemia (tAML) is a serious complication in patients with Non-Hodgkin lymphoma (NHL) exposed to chemotherapy or radiation. This extensive database study aims to quantify the risk of tAML in NHL and determine the impact of tAML on the overall survival (OS) of patients with NHL.

MATERIALS AND METHODS

Patients diagnosed with NHL and de novo AML from 2009 to 2018 were identified from the Surveillance, Epidemiology, and End Results database. Multiple primary standardized incidence ratio (SIR) sessions of the SEER*Stat software were used to calculate SIR and the absolute excess risk of tAML. Overall survival (OS) was evaluated using Kaplan-Meier curves and compared using log-rank tests. Multivariate analysis was used to study the role of each covariate on OS in patients with tAML.

RESULTS

The SIR of tAML was 4.89 (95% CI 4.41-5.41), with a higher incidence of tAML observed for age <60 years, NHL prior to 2013 and within 5 years of diagnosis, and those who received chemotherapy. NHL patients with tAML had lower OS than those without tAML (5-year OS 59% vs. 13%, p < 0.001). Patients with tAML showed worse OS than de novo AML in univariate analysis (5-year OS 13% vs. 25%, p = 0.001) but not in multivariate analysis (HR 0.93, 95% CI 0.82-1.04, p = 0.21). Age ≥60 years and lack of chemotherapy were associated with poor OS in tAML subcategory.

CONCLUSION

Age, time since NHL diagnosis, and receipt of chemotherapy directly influence the risk of development of tAML in NHL survivors.

Intraglandular Foreign Body - Unusual Aetiology of Submandibular Gland Sialadenitis

Obstructive sialadenitis of submandibular gland is commonly due to sialoliths and strictures in the Wharton's duct. Other endogenous pathologies include mucous plugs and polyps. Foreign bodies of Wharton's duct and submandibular gland are rare. Retrograde migration of foreign bodies via ductal orifice, traversing the ductal system to its final intraglandular location is an even rare entity. These often present with painful swelling of the gland and at times with a purulent sialitis. Diagnostic modalities include plain radiography, ultrasonography, sialography, as well as computed tomography and magnetic resonance imaging. Treatment includes antibiotics, incision and drainage of abscess, and removal of foreign body either surgically (intra-oral approach or sialadenectomy) or more recently via sialoendoscopy. This is a case report of 30 years male with accidental cannulation of Wharton's duct with grass that eventually got lodged in the deep lobe of the gland, and was managed with sialadenectomy.

Prevalence, Associated Factors, and Impact of Workplace Violence among Physicians

BACKGROUND

There is a dearth of objective data and studies pertaining to the prevalence and consequences of workplace violence against physicians in Nepal. This study aims to assess the prevalence, associated factors, and implications of workplace violence on Nepalese physicians.

METHODS

We conducted a cross-sectional study from March 2021 to August 2021. Nepal Medical Council-certified physicians currently working in Nepal were included in the study. Baseline characteristics, types of violence experienced, patterns, psychosocial impacts, and changes in patient management were collected.

RESULTS

Out of 318 responses received, 302 responses met the inclusion criteria and were included in the final analysis. One-hundred and ninety (62.9%) respondents had ever faced workplace violence. Madhesh Province had the highest prevalence (81.5%). Verbal abuse (93.2%) was the most common type of violence encountered. We found a significant association between workplace violence and hours worked each week. We also found an association between workplace violence and years of experience. Our study found a significant increase in stress/depression/anxiety/idea of persecution, sense of defeat, job turnover, and loss of productivity/income with the increase in severity of workplace violence.

CONCLUSIONS

Workplace violence is largely prevalent among Nepalese physicians. In the aftermath of workplace violence, a physician can undergo a multitude of adverse psychosocial consequences leading to a further decrease in productivity. More insights through research, formal training, and policy implementation are necessary to overcome this largely ignored problem of the medical fraternity in Nepal.

Risk of second primary malignancy in patients with primary myelofibrosis: a SEER database study

Prior studies report a greater incidence of second primary malignancy (SPM) among patients with myeloproliferative neoplasms, although the true risk in primary myelofibrosis (PMF) has not been elucidated. We utilized the Surveillance, Epidemiology, and End Results database to evaluate the risk of SPM in PMF patients and analyzed the effects of sociodemographic factors on the risk of SPM. Out of 5273 patients, 385 patients (7.30%) developed SPM. SPM occurred at SIR of 1.95 (95% CI 1.76-2.15) and AER of 149.01 per 10,000 population. A significantly higher incidence of melanoma (SIR 1.76, 95% CI 1.01-2.86), lymphoma (SIR 3.38, 95% CI 2.28-4.83), and leukemia (SIR 27.19, 95% CI 23.09-31.81) was observed. The risk was significantly higher in patients ≤60 years, males, chemotherapy recipients, within 5 years of PMF diagnosis, and for PMF diagnosed after 2009.

Effect of Age and Socioeconomic Factors in the Utilization of Chemotherapy in Acute Lymphoblastic Leukemia (ALL): A SEER Database Study of 16,196 Patients

INTRODUCTION

The use of multiagent chemotherapy in acute lymphoblastic leukemia (ALL) has resulted in improvement in overall survival (OS), albeit to a different extent across various age groups. This large database study aims to assess the disparity in the utilization of chemotherapy in ALL in the real-world setting.

MATERIALS AND METHODS

Using the Surveillance, Epidemiology, and End Results database, patients with ALL diagnosis from 2006 to 2016 were identified. Baseline characteristics were compared between the groups who did vs. did not receive chemotherapy using χ² test. Multivariable logistic regression was used to evaluate the association between various sociodemographic factors and the receipt of chemotherapy in the entire cohort and in different age groups.

RESULTS

Out of 16,196 patients, 1258 patients (8%) did not receive chemotherapy. There was a steady increase in the number of patients who did not receive chemotherapy with advancing age: 2.5% (0-18 years), 5.2% (19-40 years), 9.3% (41-65 years), and 36.2% (>65 years). There was an upward trend in the receipt of chemotherapy in patients >65 years over the last decade. In multivariate analysis, the likelihood of receiving chemotherapy decreased with advancing age, single or widowed status, low income and educational status, and lack of insurance. Insurance status was an independent predictor of receipt of chemotherapy across each age category.

CONCLUSION

A significant proportion of patients >65 years do not receive chemotherapy in the United States. Age, marital status, income, education, and insurance status contribute to the disparity in utilization of chemotherapy.

Impact of Insurance on Overall Survival in Acute Lymphoblastic Leukemia: A SEER Database Study

INTRODUCTION

Insurance status at diagnosis remains an important barrier to health care access and adherence to treatment. Here, we aim to assess the impact of insurance status, and age on overall survival (OS) in patients with acute lymphoblastic leukemia (ALL).

MATERIALS AND METHODS

Using the Surveillance, Epidemiology, and End Results database, we identified all patients younger than 65 years of age diagnosed with ALL from 2010 to 2016. OS was estimated for each group using the Kaplan Meier curves and compared based on insurance type using a log-rank test. Multivariate analysis using Cox proportional hazard regression model was used to assess the effect of insurance status on OS.

RESULTS

A total of 9057 patients were included in the analysis. Medicaid beneficiaries had worse 5-year OS than insured patients (HR 1.33, 95% CI 1.08-1.63, P = .006) in 0-18 years age group. Despite chemotherapy, patients older than 18 years showed poor OS in all insurance categories. Patients on Medicaid showed inferior OS compared to insured in 19-40 years (HR 1.46, 95% CI 1.21-1.76, P < .001) and 41-65 years age group (HR 1.27, 95% CI 1.09-1.49, P = .003). Interestingly, no significant difference was observed in the OS between the Medicaid and uninsured groups in each age category.

CONCLUSION

Our large database study demonstrates that insured status is associated with better OS in ALL across all age groups. Further studies to develop effective strategies to bridge health care disparities areessential.

Risk, overall survival, and prognostic analysis of therapy-related acute myeloid leukemia in non-Hodgkin lymphoma survivors

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Background: Therapy-related acute myeloid leukemia (tAML) is a serious complication in patients with Non-Hodgkin lymphoma (NHL) exposed to chemotherapy or radiation. tAML demonstrates high risk characteristics and poorer outcomes compared with de novo AML. We aimed to quantify the risk of tAML in NHL, determine factors associated with overall survival (OS) in tAML, and compare them with de novo AML. Methods: Patients with a histologic diagnosis of NHL and de novo AML from 2009 to 2018 were identified from the Surveillance, Epidemiology, and End Results (SEER) 18 database. AML that developed at least 1 year after the diagnosis of NHL was classified as tAML. Multiple primary standardized incidence ratio (SIR) sessions of the SEER*Stat software (version 8.3.9) were used to calculate SIR and absolute excess risk (AER) of tAML based on - age, sex, race, year of diagnosis, chemotherapy, radiotherapy, and interval from NHL diagnosis. The 95% confidence intervals (CI) and p-values were generated using multivariate Poisson regression model. OS of both tAML and de novo AML was assessed using Kaplan Meier curves and then compared using log rank test. The roles of various factors on OS in tAML and de novo AML were evaluated using multivariate cox proportional hazard regression. Results: A total of 373 patients with tAML (N for NHL = 301,903) and 23,360 patients with de novo AML were included in the analysis. More de novo AML cases were ≥70 years compared to tAML (41.1% vs 32.7%, p < 0.001). The risk of development of tAML was significantly higher in ages < 60 years compared to 60-69 years and ≥70 years (SIR 14.0, 95% confidence interval [CI] 11.79-16.51 vs SIR 4.87, 95% CI 4.00-5.86 vs SIR 2.80, 95% CI 2.32-3.34, p < 0.0001). Patients who received chemotherapy were more likely to develop tAML than the non- recipients (SIR 8.44, 95% CI 7.51-9.44 vs SIR 1.75, 95% CI 1.37-2.21, p < 0.0001). The risk of tAML was higher within 5 years of NHL diagnosis (SIR 5.05, 95% CI 4.49-5.67 vs SIR 4.39, 95% CI 3.49-5.45, p < 0.001). There was no statistically significant difference in SIR based on sex, race, receipt of radiotherapy, and year of diagnosis. The median OS and 5-year OS were- 8 months and 13.1% for tAML and 10 months and 27.6% for de novo AML. On multivariate analysis, tAML was not found to be an independent predictor of OS (HR 0.93, 95% CI 0.82-1.04, p = 0.21). Age ≥60 years (age 60-69 years: HR 1.53, 95% CI 1.08-2.15, p = 0.01, age ≥70 years: HR 1.93, 95% CI 1.40-2.66, p < 0.001) and no chemotherapy (HR 1.82, 95% CI 1.40-2.35, p < 0.001) were associated with poor OS in tAML subcategory. Conclusions: Our large population-based study shows increased risk of tAML within the first 5 years of NHL diagnosis, younger NHL survivors, and chemotherapy recipients. Older age and no chemotherapy predispose to dismal OS in tAML.

Risk of second primary malignancy in patients with primary myelofibrosis: A SEER database study

e19079

Background: Primary myelofibrosis (PMF) carries a poorer prognosis compared to other BCR-ABL-negative myeloproliferative diseases (MPD), and there is increased risk of early mortality due to blast transformation, thrombosis, bleeding complications, and progression of disease. Prior studies report greater incidence of second primary malignancy (SPM) among MPD patients, although the true risk in PMF has not been elucidated. We performed a large database study to evaluate the risk of SPM in PMF patients and analyzed the effects of sociodemographic factors on the risk of SPM. Methods: We used the Surveillance, Epidemiology, and End Results (SEER) database to identify all patients with a histologic diagnosis of PMF from 2009 to 2018. SPM was defined as any subsequent malignancy that developed at least 1 year after the diagnosis of PMF. Using multiple primary standardized incidence ratio (SIR) session of the SEER*Stat software (version 8.3.9), we calculated SIR and absolute excess risk (AER) of SPM for the entire cohort of PMF and also stratified based on age, sex, race, marital status, receipt of chemotherapy, follow-up duration, and year of diagnosis. We generated the 95% confidence intervals (CI) and p-values assuming Poisson distribution of the observed incidences of SPM. Results: A total of 5,273 patients with PMF were included in the analysis, of which 342 patients (6.4%) developed SPM. SPM occurred at SIR of 1.97 (95% CI 1.77-2.18, p<0.05) and AER of 151.87 per 10,000 population. A significantly higher incidence of melanoma (SIR 1.96, 95% CI 1.14-3.14, p<0.05), lymphoma (SIR 3.45, 95% CI 2.31-4.96, p<0.05), and leukemia (SIR 26.87, 95% CI 22.69-31.59, p<0.05) was observed. There was no statistically significant difference in SIR based on sex, race, marital status, follow-up duration, and receipt of chemotherapy. The risk was significantly higher in patients ≤60 years vs patients >60 years (SIR 2.34, 95% CI 1.89-2.86 vs SIR 1.86, 95% CI 1.65-2.10, p 0.01) and for PMF diagnosed after 2009 vs ≤2009 (SIR 2.64, 95% CI 2.26-3.07 vs SIR 1.61, 95% CI 1.40-1.85, p<0.001). Conclusions: Patients with PMF are at a high risk of developing SPM, especially leukemia and lymphoma. Data suggests higher incidence of SPM in patients aged ≤60 years and in the decade after 2009. The impact of ruxolitinib, which was approved in 2011, on the incidence of SPM deserves further study. [Table: see text]

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.

Toothbrush, an Unusual Foreign Body

Accidental consumption of foreign body is a common presenting complain among patients especially in young age group. Majority of patients can be discharged safely after reassurance while a fraction of patient requires observation and further management. Here we report a case of a 35-year-old gentleman who presented to the out-patient department of our hospital in June 2021 for accidental ingestion of toothbrush. After detailed history and physical examination upper gastrointestinal endoscopy was planned for the patient. Failed endoscopic removal was considered the indication for surgery. A supraumbilical midline incision was used to remove the toothbrush. Following the surgical removal, he was managed conservatively and was discharged without significant complications. We describe this case in detail in addition to reviewing the pertinent literature.

Clinical Profile and Diagnosis of Obstructive Sleep Apnea Syndrome using Overnight Polysomnography in a Tertiary Care Hospital

Background Obstructive sleep apnea is a highly prevalent yet largely under-diagnosed disease that poses a significant burden on the healthcare system. Objective To determine the role of predictors for Obstructive sleep apnea syndrome and its severity in Nepalese population. Method Prospective and analytical study conducted in the Department of Otorhinolaryngology and Head and Neck surgery at Kathmandu University Hospital between March 2018 and June 2020. A total of 85 adult patients with Obstructive sleep apnea with an Epworth sleepiness score greater than 10 were included. Overnight polysomnography was done and scoring of sleep associated events were done according to the American Academy of Sleep Medicine criteria. Participants were classified as simple snoring and mild, moderate or severe Obstructive sleep apnea syndrome groups depending on the Apnea Hypopnea Index values. Relationship of Apnea hypopnea index was analyzed with age, neck circumference, body mass index and Epworth Sleepiness score. Result Simple snoring was seen in 18(21.17%) patients, 14(16.47%) had mild Obstructive sleep apnea, 13(15.29%) had moderate Obstructive sleep apnea, whereas the severe group consisted of 40(47.05%) patients. The minimum Epworth Sleepiness Score was 10 and the maximum was 25. The Apnea hypopnea index correlated positively with Body mass index (p=.010) and Epworth sleepiness score (p <.001). However, Apnea hypopnea index had no association with age (p=.437) and neck circumference (p=.118). Conclusion Health professionals need to be extremely vigilant while examining patients presenting with Obstructive Sleep Apnea. Polysomnography is the investigation of choice in the early identification of this treatable disease.

Comparison of Two Entry Methods for Laparoscopic Port Entry

Background The first step in laparoscopic surgery is to establish the pneumoperitoneum for which many approaches have been introduced to minimize the complications. Although controversies exist regarding the most efficient technique, till now the best entry technique is still unsettled. Objective To compare the safety, operating time and outcome of Direct Trocar Insertion with a well-established and widely practised Open Access Technique. Method This is a prospective study at Nobel Medical College Teaching Hospital from November 2019 to February 2021. Patients were grouped into either of the two groups, Group 1 for Direct Trocar Insertion and Group 2 for Open Access Technique. They were later analysed for major and minor complications of the technique and a comparison of either method was done at the end of the study period. Result A total of 823 patients were enrolled in the study. Among the study population, 411 patients had Direct Trocar Insertion while 412 patients had Open Access Technique. The majority of the operation that was done during the study period was laparoscopic cholecystectomy. Patients in the Open Access Technique group experienced more complications compared to Direct Trocar Insertion group. Conclusion Despite the fear of adopting the Direct Trocar Insertion, this is a safe, better and quick technique for laparoscopic port entry. However, any surgeon practising laparoscopic surgery should be competent to adopt either technique to overcome failure in either process during port entry.

Pilonidal sinus of the cheek: an extremely rare clinical entity-case report and brief review of the literature

Background

Pilonidal sinus is commonly seen at the sacrococcygeal region and few other sites, usually located at the midline, at areas where hairs collect or near protuberances or some adjacent rubbing surfaces. Its presence elsewhere is uncommon. We share an interesting case of a recurrent discharging sinus from the cheek bulge of a male which turned out to be a pilonidal sinus containing tuft of hairs on exploration and wide excision.

Case presentation

A 37 years old hirsute male presents to us with a non-healing discharging sinus at the bulge of the cheek. Exploration after a course of antibiotics showed 2 subcutaneous cavities with tuft of hairs. The area was excised along with a margin, thorough irrigation and curettage was done and the wound was closed primarily; a Z-plasty was incorporated in the central part to break the resultant suture line. Histopathological examination was done to confirm the diagnosis and rule out an off-midline dermoid cyst or an underlying/coexisting malignancy. Post-operative course was uneventful. The patient has been recurrence free for 1.5 years and is satisfied with the nature of the scar.

Conclusions

Pilonidal sinus of the cheek bulge is an extremely rare entity. Complete excision and clinical suspicion are important for cure of this nagging ailment, especially at unexpected areas.

Thresholds for Spinal Anaesthesia-induced Hypotension During Caesarean Section

Background Spinal anaesthesia is the current standard for caesarean section. Hypotension, a common complication, potentially results in adverse foetal and maternal outcomes. However, hypotension-defining criteria are varied. Objective To identify the blood pressure thresholds for spinal anaesthesia-induced hypotension during caesarean section. Method This is a retrospective cohort study of spinal anaesthesia-induced hypotension that occurred till baby-delivery during caesarean section. Reports on intraoperative hypotension, collected previously from January to December 2019, were reviewed to identify the hypotension-defining thresholds. The thresholds were categorized into systolic blood pressure (SBP) of 80, 90 or 100 mmHg, mean arterial pressure (MAP) of 60, 65 or 70 mmHg, combinations, and others. Parturient and anaesthesia characteristics, and associated hypotensive symptoms were also recorded for descriptive analysis. Result Spinal anaesthesia-induced hypotension was identified in 129 (11.5%) cases among 1116 caesarean sections. Altogether, 12 hypotension-defining thresholds were employed. Thresholds of SBP 90, MAP 60, and SBP 80 mmHg were used in 53 (41%), 28 (21.7%), and 21 (16.2%) cases respectively. Mean maternal age was 28 (±4.22) years and 87 (67.4%) cases underwent emergency surgery. Median sensory blockade level was T4. Nausea-vomiting, bradycardia, and tachycardia were associated during five (3.8%), six (4.6%), and 15 (11.6%) hypotensive incidents respectively. Two cases had unrecordable blood pressure but there was no maternal mortality. Conclusion Systolic blood pressure of 90 mmHg and mean arterial pressure of 60 mmHg included the most common thresholds for spinal anaesthesia-induced hypotension during caesarean section. Identifying the safe and clinically relevant hypotension-defining criteria needs further investigation.

Higher rates of early initiation of breastfeeding associated with health facility delivery in Nepal

Background

Initiation of breastfeeding within one hour from birth is one of the five key essential newborn care messages, implemented along with birth preparedness package since 2008. This study aimed to determine the trend of early initiation of breastfeeding (EIBF) and to assess the effect of health facility delivery on EIBF in Nepal.

Methods

We analyzed the data from the last four nationally representative Nepal Demographic and Health Surveys (NDHS) conducted in 2001,2006,2011 and 2016. Data on the early initiation of breastfeeding was obtained from the mothers of infants born within 24 months prior to the survey. The explanatory variable was the place of delivery, dichotomized as either the health facility, or home delivery. Survey year had a significant interaction with the place of delivery. Multivariable logistic regression was conducted separately on pooled samples before (NDHS 2001 and 2006) and after (NDHS 2011 and 2016) the program implementation. Adjusted odds ratio (AOR) with 95% confidence interval (CI) for EIBF was calculated after adjusting for predetermined covariates.

Results

The rate of EIBF increased by 26.5% points (from 32.8% in 2001 to 59.3% in 2016) among infants delivered in a health facility, compared to an increase by 17.1% points (from 29.9% to 47.0%) among home born infants. EIBF increased by 32.5% points before, compared to 49.7% points after BPP. Delivery in a health facility was associated with a higher odd of EIBF in later years (AOR2.3, 95% CI 2.0,2.8), but not in earlier years (AOR1.3, 95% CI 0.9,2.0). Delivery by caesarean section, first-born infant, and lack of maternal education were associated with a lower rate of EIBF in both periods.

Conclusions

Higher EIBF was associated with health facility delivery in Nepal, only after programmatic emphasis on essential newborn care messages. This implies the need for explicit focus on EIBF at birth, particularly when mother is less educated, primiparous or undergoing operative delivery.

Key messages

The rate of initiation of breastfeeding within an hour from birth is increasing in Nepal, with higher rates in health facility delivery, as shown by the recent four nationally representative surveys. Programmatic focus on essential newborn care messages may have contributed to significant association of higher rates of early initiation of breastfeeding when delivered in health facility.

Child abuse and all-cause mortality in the Canadian population

Background

A history of child abuse is common and is associated with the later occurrence of risky health behaviors, mental disorders, and chronic conditions, strongly suggesting that child abuse may be associated with elevated mortality. However, most of the literature on child abuse has studied psychosocial/behavioral or medical outcomes and have not addressed mortality directly.

Methods

Data from the 2012 Canadian Community Health Survey, linked to the Canadian Vital Statistics Database, were used in the analysis. The CCHS-2012 interview (n = 19,830) retrospectively assessed childhood physical abuse, sexual abuse, and witnessing intimate partner violence before the age of 16. Each type of abuse was analyzed separately using Cox proportional hazards models for all-cause mortality. Hazard ratios (HR) and associated 95% confidence intervals (CI) were estimated with and without adjustment for covariates.

Results

An effect on mortality was observed among men for witnessing interpersonal violence (age-adjusted HR 2.47, 95% CI 1.48-4.12), and severe physical abuse (age-adjusted HR 2.3, 95% CI 1.21-4.36). In each case, the association was not significant for women; the age-adjusted HRs being 0.93 (95% CI: 0.51-1.70) and 0.59 (95%CI: 0.64-2.60) respectively. The association was seen only among those reporting frequent abuse ( &gt; =10 times) and weakened (became not significant) with adjustment for covariates that may mediate the association such as smoking and chronic conditions.

Conclusions

As predicted by a broader literature on childhood adversity, child abuse increases the risk of mortality. The effect was significant for severe physical abuse in men, but imprecision due to a limited number of deaths may have rendered other associations non-significant. The study provides some degree of confirmation that child abuse contributes to later life mortality. Hence public health strategies that prevent child abuse and mitigate the harms of the mediators might prevent mortality.

Key messages

Witnessing intimate partner violence is just as harmful as actually experiencing physical abuse. Preventing children's exposure to violence in family is valuable in preventing mortality in adulthood. Enhancing child abuse prevention programs and mitigating the harmful effects of the mediators such as smoking, substance use, and chronic conditions is important in reducing mortality in adult life.

Primary Duodenal Adenocarcinoma: Uncommon Tumor, Uncommon Presentation. A Case Report and Review of the Literature

Introduction

The symptoms of primary duodenal adenocarcinoma, which is a rare but aggressive tumor, are vague and nonspecific and often result in a delayed diagnosis or misdiagnosis. This results in a tumor being diagnosed at an advanced stage when it becomes unresectable secondary to local and distant spread.

Case Presentation

A 64-year-old Nepalese female presented to our hospital with epigastric pain, anorexia, and significant weight loss that developed over two-and-a-half months. Upper gastrointestinal endoscopy showed an ulceroproliferative growth in the first part of the duodenum with no features of duodenal stenosis. Contrast-enhanced computed tomography of the abdomen revealed heterogeneously enhancing, circumferential, asymmetrical thickening in the first part of the duodenum and multiple liver metastases. Biopsy of the mass revealed features suggestive of moderately differentiated adenocarcinoma of the duodenum. She was managed with palliative care during her hospital stay. The unique presentation in our case was that the tumor did not cause stenosis and the patient could consume food till the last day of her life.

Conclusion

In patients with primary duodenal adenocarcinoma, the non-stenotic lesion is also a possibility. Clinicians should always maintain a high degree of suspicion to avoid the delay in diagnosis or misdiagnosis.

Solid Variant of Alveolar Rhabdomyosarcoma of Nasal Cavity

Rhabdomyosarcoma comprises about half of the soft tissue tumors. Approximately 40% of the alveolar subtype occur in the head and neck region. Patients present with unilateral nasal mass with/without lymphadenopathy and with/without orbital manifestations. Diagnosis is aided radiologically by CT scan, MRI along with biopsy and is confirmed by immunohistochemistry. Treatment involves surgical resection, chemotherapy, radiotherapy or a combination of these. In spite of treatments, however, the outcome is poor. This is a case report of 14-year-old male who presented with unilateral nasal mass with proptosis of right eye who was eventually diagnosed as a case of alveolar rhabdomyosarcoma of solid variant.

Profile of Neurosurgical Patients in a Tertiary Level Intensive Care Unit in Nepal

BACKGROUND

Neurosurgery has developed as a separate specialty and neurosurgical patients are some of the most common admitted in the intensive care unit. The objective of the study was to study the profile of neurosurgical patients admitted in level III mixed, medical-surgical intensive care unit in a tertiary level teaching hospital in Nepal with the view to identify the causes of intensive care unit admission, types of neurosurgery performed, outcome of the patients, in terms of intensive care unit stay, mechanical ventilation days and mortality.

METHODS

A retrospective study was designed and all neurosurgical patients admitted to the intensive care unit of our center between 13 April 2017 and 13April 2018 (1st Baisakh 2074 to 30th Chaitra 2074) were enrolled in this study.

RESULTS

A total of 813 patients were admitted in ICU over a period of one year (2074 B.S.) of which 199 (24.48 %) were neurosurgical cases. Among these 170 (85.42%) cases were post-surgical, with 29 (14.58%) being pre-operative patients. One hundred forty nine patients (74.9%) were on mechanical ventilation. One hundred and thirty two (66.3%) patients improved and were transferred to a step down ward. Forty-three (22.5%) died in the intensive care unit, 14 (7.03%) left the hospital against medical advice and 9 (4.5%) patients expired after withdrawal of life support.

CONCLUSIONS

Despite improved care over the recent years the mortality and morbidity of neurosurgical patients is high.

An Audit of An Intensive Care Unit of A Tertiary Care Hospital

Introduction: The patients with the most severe and life threatening illnesses requiring constant monitoring and support are admitted in the intensive care unit. Tribhuvan University Teaching Hospital is the oldest and tertiary referral center hospital in the country with eleven-bedded level III mixed medical surgical ICU. This audit was performed to study the profile of critically ill patients under different headings like diagnosis at admission, primary specialty, outcome of the patients, etc. Methods: A descriptive cross-sectional study was designed and all patients admitted to the intensive care unit of our center between 13 April 2017 and 13 April 2018 (1st Baisakh 2074 to 30th Chaitra 2074) were selected for this study. Results: A total of 813 patients were admitted in TUTH ICU over a period of one year (2074 B.S.) with male patients being more common. Neurosurgical cases were most common at 199 (24.48 %), followed by respiratory cases at 149 (18.32%) and so on. The overall mortality was 246 (32.8%). The overall surgical cases were more common than medical cases with better outcomes. Conclusions: This audit presents the profile of patients admitted in a tertiary level hospital in Nepal, their indications and mortality. The most common patients being admitted were Neurosurgical patients and the mortality was significantly higher compared to ICUs in developed countries.

Obligate Myiasis: A Case Series From Nepal

Although maggots are unanonymously linked to carcass or dead tissues, there are reports of its infestation into living tissues as well. Myiasis denotes maggot infestation in living tissue. There are two forms of myiasis namely obligate and facultative. Obligate myiasis denotes maggots feeding on living tissue whereas facultative myiasis represents the opportunistic behaviour of the fly taking advantage of wound or necrotic tissue, laying by eggs which hatch into maggots. Decreased physical activity and poor hygiene leads to maggot infestation. Maggot invasion of living tissues is undesirable occurrence which can best be avoided by improving hygiene. People with low living standards in the developing nations are the occasional victims for maggot infestations. We present cases of obligate myiasis for their uniqueness and rarity.

Galvanic Skin Response as a Simple Physiology Lab Teaching Tool- An Alternative Indicator of Sympathetic Arousal

Background Sympathetic arousal response due to rewarding emotion may not be considered threat to the well-being but such arousal response evoked by fear or punishment can be stressful. When such changes are recorded in lab as biological signals, induced with appropriate stimulus, the observed response may serve as a good indicator of homeostatic alteration. In this study, skin conductance was utilized to record sympathetic response for cognitive load, by application of simple subtraction task. Objective To detect sympathetic arousal by utilization of galvanic skin response during mental arithmetic task. Method Total of eighty two subjects, forty two female and forty male participated in the study. Twenty two subjects were provided mental task to record skin conductance. In sixty subjects, galvanic skin response, pulse rate, respiratory rate and temperature were recorded by appropriate transducers to obtain baseline and task response to detect differential recordings. Subjects performed the mental exercise of arithmetic task (MAT) with transducer placed in upper limbs. Mean of averages for respective variables were statistically calculated from obtained recordings. Result For measured galvanic skin response, 57 subjects showed increased skin conductance (rise in amplitude) whereas, 25 subjects had no rise in amplitude ("A peak") while performing the mental arithmetic task, when compared to control recording. However, in 20 subjects, pulse rate and respiratory rate showed significant rise though, the change in the skin conductance was not significant. Conclusion Galvanic skin response is useful for demonstration of sympathetic activation induced by simple mental subtraction task, and can be utilized along with vital parameters mentioned in this study to discuss in vivo variation that exist as differential for core and superficial sympathetic outflow among individuals.

Imaging localized electric fields with nanometer precision through tip-enhanced Raman scattering

Tip-enhanced Raman scattering may be used to image various aspects of plasmon-enhanced local electric fields with extremely high spatial resolution.

Management of cysto-biliary communication in hydatid cyst of liver

Introduction: Biliary communication of hepatic hydatosis is one of the important complications. It may be minor or major communication. Minor communication is usually diagnosed during operation by the presence of bile stained hydatid fluid on aspiration or bile leak during surgery. However, in major communication, patients present with obstructive jaundice, abdominal pain and cholangitis. Surgical management of major communication is difficult and is associated with high morbidity and mortality.Methods: This is a retrospective study at Tribhuvan University Teaching Hospital, Kathmandu, Nepal over a period of two year (April 15th 2012 to April 15th 2014) and analyzed the medical records of 30 patients admitted and treated for hydatid cyst of liver in surgical ward during that period. Demography, clinical features, management and outcome were analyzed.Results: Of 30 patients with hepatic hydatid cyst operated over a period of two years, thirteen patients had cystobiliary communication. Amongst them, five minor communications were diagnosed during operation and managed with suture plication and omentopexy. Out of the eight major communications, seven were diagnosed preoperatively and all had cholangitis, and one had hydatid cyst of gallbladder and was diagnosed intraoperatively. Among six cases of major communication, five cases required CBD exploration and bile duct reconstruction while partial cholecystectomy was done for hydatid cyst of gall bladder and one case was managed by ERCP sphincterotomy, evacuation of cyst content and stenting. one case was managed with pigtail drain as the patient had infected hydatid cyst and not fit for surgery.Conclusion: Cystobiliary communication is a common complication of hydatid cyst of liver. Therapeutic options are related to size and location of the cyst and size of communication.Journal of Society of Surgeons of Nepal Vol.17(1) 2014: 31-34

The Effect of Vacuum on Venous Drainage: an Experimental Evaluation on Pediatric Venous Cannulas and Tubing Systems

Introduction: To observe how vacuum assisted venous drainage (VAVD) may influence the flow in a cardiopulmonary bypass circuit with different size of venous lines and cannulas. Methods: The experimental circuit was assembled to represent the cardiopulmonary bypass circuit routinely used during cardiac surgery. Wall suction was applied directly, modulated and measured into the venous reservoir. The blood flow was measured with a flow-meter positioned on the venous line. The circuit prime volume was replaced with group O date expired re-suspended red cells and Plasmalyte 148 to a hematocrit of 28% to 30%. Results: In an open circuit with gravity siphon venous drain, angled cannulae drain more than straight ones regardless the amount of suction applied to the venous line (16 Fr straight cannula (S) drains 90 ml/min less than a 16 Fr angled (A) with a siphon gravity). The same flow can be obtained with lower cannula size and higher suction (i.e. 12 A with and -30 mmHg). Tables have been created to list how the flow varies according to the size of the cannulas, the size of the venous tubes, and the amount of suction applied to the system. Conclusions: Vacuum assisted venous drainage allows the use of smaller cannulae and venous lines to maintain a good venous return, which is very useful during minimally invasive approaches. The present study should be considered as a preliminary attempt to create a scientific-based starting point for a uniform the use of VAVD. Keywords: cardio-pulmonary bypass; experimental study; vacuum assisted drainage.

Effect of Vacuum on Venous Drainage: an Experimental Evaluation on Pediatric Venous Cannulas and Tubing Systems

INTRODUCTION

To observe how vacuum assisted venous drainage (VAVD) may influence the flow in a cardiopulmonary bypass circuit with different size of venous lines and cannulas.

METHODS

The experimental circuit was assembled to represent the cardiopulmonary bypass circuit routinely used during cardiac surgery. Wall suction was applied directly, modulated and measured into the venous reservoir. The blood flow was measured with a flow-meter positioned on the venous line. The circuit prime volume was replaced with group O date expired re-suspended red cells and Plasmalyte 148 to a hematocrit of 28% to 30%.

RESULTS

In an open circuit with gravity siphon venous drain, angled cannulae drain more than straight ones regardless the amount of suction applied to the venous line (16 Fr straight cannula (S) drains 90 ml/min less than a 16 Fr angled (A) with a siphon gravity). The same flow can be obtained with lower cannula size and higher suction (i.e. 12 A with and -30 mmHg). Tables have been created to list how the flow varies according to the size of the cannulas, the size of the venous tubes, and the amount of suction applied to the system.

CONCLUSIONS

Vacuum assisted venous drainage allows the use of smaller cannulae and venous lines to maintain a good venous return, which is very useful during minimally invasive approaches. The present study should be considered as a preliminary attempt to create a scientific-based starting point for a uniform the use of VAVD.

Prevalence of depression among elderly people living in old age home in the capital city Kathmandu

Background: There has been a considerable increase in the numbers of older people in the world population of both developed and developing countries. These populations are thought to be at greater risk for depression. Many researches are conducted on physical wellbeing of elderly but studies regarding depression among elderly, especially in old age home is lesser in the developing countries. Objectives: To assess depression among elderly residing in an old age home in Kathmandu and its association with some of the socio-demographic variables. Methods: One hundred fifty elderly people residing in social welfare centre elderly home, Pashupatinath, Gaushala, Kathmandu, Nepal were selected randomly. Geriatric depression scale (GDS) was applied in all the individuals to assess the prevalence and degree of depression. Results: This study showed that, 47.33% of population had depression. Among the depressed population, 70.42% had mild depression and 29.58% had severe depression. There was significant association between the prevalence of depression and history of physical illness. Conclusion: Depressive disorder is highly prevalent among the elderly population residing in the old age home in Kathmandu with history of physical illness. DOI: http://dx.doi.org/10.3126/hren.v11i3.9634 Health Renaissance 2013;11(3):213-218

Bacteriology and antimicrobial susceptibility of adult chronic dacryocystitis

INTRODUCTION

Chronic dacryocystitis results in chronic infection and inflammation of the lacrimal sac.

OBJECTIVE

To identify the aetiology of chronic dacryocystitis and to determine their antimicrobial susceptibility pattern.

MATERIALS AND METHODS

A cross - sectional study was undertaken including 120 lacrimal swab materials collected from patients aged above 15 years suffering from chronic dacryocystitis.

STATISTICS

Data analysis was done by using software "Win pepi'' ver 7.9.

RESULTS

The bacteria of eight different species were isolated from 76.66 % (92/120) culture positive samples. 85.86 % showed a single and 14.13 % showed a mixed growth pattern. Coagulase negative staphylococci were the most common bacteria (P= 0.018) accounting for 33.96 % followed by Staphylococcus aureus (25.46 %), Streptococcus pneumoniae ( 19.81 % ), Streptococci viridans (5.66 %), Escherichia coli (5.66 %), Haemophilus spp ( 4.71 % ), Streptococcus pyogenes (3.77 %) and Bacillus spp (0.94 % ). Staphylococcus aureus were the most predominant bacteria in mixed growth. Rate of infection was higher in males 81.39 % than in females 74.02 %. Infection was higher in the age group of above 31 years. In the antimicrobial susceptibility test, except staphylococcus aureus, all the Gram positive isolates were 100 % sensitive to chloramphenicol and were least sensitive to tobramycin, but Gram negative isolates were equally sensitive to Chloramphenicol and Nalidixic acid.

CONCLUSION

Coagulase negative staphylococci are the most frequently isolated bacteria. Staphylococcus aureus is predominantly found in mixed growth. Chloramphenicol is the most effective drug of choice for chronic dacryocystitis.