Mental Health Problems and Social Media Exposure during the COVID-19 Pandemic among Adult Population of Nepal

Background The COVID-19 pandemic is a significant global health crisis that poses a threat to a person's psychological well-being. A very large number of people got exposed to social network sites during this period which can be hazardous and cause psychological difficulties. There is no prior research or limited studies in this area during emergencies in Nepal. Objective To assess the mental health issues and examine their relationship with social media exposure in adults. Method A descriptive cross-sectional study was conducted by using a validated scale of Depression, Anxiety, and Stress (DAAS-21) and the Insomnia Severity Index (ISI) among 18 years above adult population. Data were collected through an online survey. Descriptive statistics was used to describe sociodemographic data. Binary logistic regression analysis were performed to examine the relationship between psychological problems and social media exposure. Result Out of 422 participants, the overall prevalence of depression, anxiety, stress, and insomnia among the study population were 32%, 28.4%, 24.5%, and 47% respectively. Additionally, 86.5% of individuals said they were frequently exposed to social media. Age, ethnicity, gender, past health problems, and health status were significantly associated with psychological problems. Further, social media exposure was associated with gender and marital status. There was no evidence of an association of psychological problems with social media exposure. Conclusion Depression, anxiety, stress and insomnia are common mental health problems found in the adult population during the time of the first wave of COVID-19 pandemic and highly affected were under 25 years age. Female and unmarried adults are using more social media.

Assessing Spectrum of Fractures in Elderly; Perspective on Tertiary Care Hospital of Nepal

Background There is an increasing life expectancy and a surging elderly population in the last few decades, leading to a higher incidence of fractures in the elderly. The health care of the elderly in Nepal is below par and there are no studies done to evaluate the spectrum of fractures in the elderly. Objective To evaluate the demographical and epidemiological aspects of fractures in the elderly (≥ 65 years) presenting to a tertiary care hospital in Nepal in a 15 years' timeline. Method This study was a retrospective epidemiological study conducted in the Department of Orthopedics, Dhulikhel Hospital, Kathmandu University Hospital (DH, KUH), Nepal. The patients of age ≥ 65 years having traumatic injuries, admitted in the orthopedics ward from 2006 January to 2020 December were included. Patient demographics, site of injury, fracture incidence, mechanism of injury, hospital stay duration, and mode of treatment (surgical/ conservative) were evaluated. Result Of the 787 patients with an average age of 73.65 ± 7.5 years, 54% were females. Peritrochanteric fracture was the most common fracture (29.4%) followed by spine (18.3%). The most common mechanism of injury was fall on the labeled ground (38.6%). The incidence of fragility fractures (peri-trochanteric, proximal humerus, spine, and distal radius) was increasing with age. Conclusion Females, peritrochantric fractures, and trivial trauma are the most common occurrences for fractures in elderly. The incidence of fragility fractures is increasing with age but the overall incidence of fractures compared to other studies is low. Higher incidences of road traffic accidents (RTA) and compound fractures among the elderly are serious public health concerns that highlight the importance of primary preventive measures.

Bacterial Flora and Antibiotics Sensitivity Pattern in Chronic Rhinosinusitis Outpatient Cases in Tertiary Care Hospital

Background Chronic rhinosinusitis is a disease that afflicts a significant percentage of the population and causes considerable long-term morbidity. The initial treatment is clinical evaluation followed by starting empirical antibiotics. With the use of empirical antibiotics there is a possibility of aggravating the disease and leading to the persistence of chronic sinusitis. In order to start a protocol for rational use of antibiotics, we need to have the bacteriological profile in cases of chronic rhinosinusitis along with the sensitive group of antibiotics. Objective To determine the bacterial flora in nasal swab of patients with chronic rhinosinusitis and identify the sensitive antibiotics for the bacterial isolate. Method A prospective, cross-sectional study was conducted in ENT Head and Neck Department of tertiary care hospital. The study population was the patients with clinical diagnosis of chronic rhinosinusitis whose nasal swabs were taken during nasal endoscopy and sent for culture and sensitivity. The data were entered in Microsoft Excel and analyzed using statistical computer program Statistical Package for the Social Sciences (SPSS). The ethical approval for the study was taken from Ethical Committee of Kathmandu Medical College. Result There were 60 (87%) bacterial isolate growths out of 69 samples of which 49 (82%) were gram positive and 11 (18%) were gram negative. The most common bacteria isolated was S aureus (42%) followed by Cogaulase neagative Staphylococcus (25%). Conclusion Among gram positive isolates, amoxycillin was the most sensitive antibiotic and among gram negative isolates, ceftriaxone, levofloxacin, imipenem, meropenem and piperacillin were most sensitive antibiotics. In this study, we have determined the bacterial flora from endoscopic nasal swab of the sinuses in chronic rhinosinusitis patients and identified the sensitive antibiotics. This study would help us prescribe rational antibiotics in cases of chronic rhinosinusitis.

Comparison of Papile versus Laterality-Based Al-Abdi System to Predict Neurodevelopmental Impairment in Extreme Preterm Infants after Severe Germinal Matrix Hemorrhage-Intraventricular Hemorrhage: A Retrospective Comparative Observational Study

BACKGROUND AND PURPOSE

The traditional Papile classification system for severe germinal matrix hemorrhage-intraventricular hemorrhage is limited in objectivity and interrater variability for accurate prediction of neurodevelopmental impairment in extremely preterm infants. Many extremely preterm infants with severe germinal matrix hemorrhage-intraventricular hemorrhage are still offered "redirection of care" in spite of the recent evidence suggesting that many of these infants can have normal outcomes. Therefore, it is important to consider the laterality and extent of brain hemisphere involvement while classifying severe germinal matrix hemorrhage-intraventricular hemorrhage to predict neurodevelopmental impairment. The aim of the present study was to compare the Al-Abdi system with the Papile system for their accuracy in predicting neurodevelopmental impairment in extremely preterm infants with severe germinal matrix hemorrhage-intraventricular hemorrhage.

MATERIALS AND METHODS

This is a retrospective study of extremely preterm infants with severe germinal matrix hemorrhage-intraventricular hemorrhage admitted to a tertiary neonatal intensive care unit (2006-2016). Cranial sonograms were independently re-reviewed by 2 radiologists as per the Al-Abdi system. The prognostic statistical indices for both systems to predict neurodevelopmental impairment were calculated.

RESULTS

A total of 91 infants with severe germinal matrix hemorrhage-intraventricular hemorrhage survived, and 83 (median gestational age, 26.3 weeks; and median birth weight, 890 g) completed developmental assessment. The receiver operating characteristic areas under the curve to predict neurodevelopmental impairment by the Papile versus Al-Abdi systems were 0.702 versus 0.723, respectively (P = .474). Corresponding Al-Abdi cutoff scores of 19, 20, 21, and 22 demonstrated increased specificity (76.36%-85.45%) and correct classification (69.88%-72.29%) to predict moderate-to-severe neurodevelopmental impairment.

CONCLUSIONS

The Al-Abdi system is comparable with the Papile system for predicting neurodevelopmental impairment for extremely preterm infants with severe germinal matrix hemorrhage-intraventricular hemorrhage, with higher Al-Abdi scores being more specific. This finding may prove useful for neonatal health care providers and parents in their decision regarding "continuation of care." Future multicentric studies are warranted to ascertain the validity of individual Al-Abdi scores.

552 A Single Centre Retrospective Study of Outcomes in Open Liver Surgery

Aim

Despite advances in laparoscopic surgery for liver resections, an open approach remains the most frequent approach for complex liver resections for benign and malignant conditions. The aim of this study was to evaluate the clinical outcomes of patients undergoing open liver resections at a single tertiary HPB centre.

Method

All patients undergoing open liver resections between March 2018-July 2020 were included. Clinical and pathological data was reviewed for all patients and data collected including demographics, indication for surgery, complications, length of hospital stay and 30- and 90-day mortality.

Results

A total of 51 patients underwent open liver resection with median age of 65 (IQR 60.5-70.5). Indication for surgery included CRC metastasis (45%), HCC (27%), Intrahepatic cholangiocarcinoma (8%), Cholangiocarcinoma (8%), other metastasis (8%). The median hospital stay was 8 days (IQR 6-15). Complications were noted in 17 patients (Clavien-Dindo Classification III (8%) and IV (12 %). 6 patients had post op bile leaks, 4 with grade B and 2 with grade C bile leaks. 8 patients had post hepatectomy liver failure (5 Grade A, 2 Grade B, 3 Grade C). No mortality was noted at 30 and 90-day time-points.

Conclusions

Our outcomes in terms of morbidity, mortality and hospital length of stay are similar to that in published literature.

Osteosynthesis of Neck of Femur Fracture below 65 years of Age: does timing of surgery influence osteonecrosis, nonunion and functional outcome?

Background Influence of timing of injury surgery interval in outcome of osteosynthesis of neck of femur has always been a matter of debate. Patients in our set up have been surgically treated for neck of femur fracture with wide range of injury surgery interval which could have resulted in varied functional outcome and radiological outcome. Objective To evaluate the difference in functional outcome, femoral head osteonecrosis and non-union in fracture neck of femur fixed within and after twenty-four hours. Method All patients, who had undergone osteosynthesis for the neck of femur fractures via open or closed technique from 2010 to 2018 were analyzed retrospectively. The cases were examined and evaluated in terms of injury surgery interval, fracture union, functional status using Modified Harris Hip Score, complications like femoral head osteonecrosis and non-union. Result Fifty patients with an average injury surgery interval of 34±28 hours were evaluated. Twenty three (46%) cases were included in early surgery group (< 24 hours) and 27 (54%) patients were included in delayed (> 24 hours) surgery group. Incidence of femoral head osteonecrosis was reported in two (4%) cases, both being in delayed fixation group (p=0.49). Non-union was reported in four (8%) patients, one in early fixation group and three in delayed fixation group (p=0.61). The average Modified Harris Hip Score in early fixation group was 87 and in delayed fixation group was 84 (p=0.1). Forty two (84%) cases had a good quality of reduction and eight (16%) had a poor reduction. Non-union and functional outcome significantly differed between the good and poor reduction group (p=0.001 and 0.004 respectively). Conclusion There is no significant difference in the functional and radiological outcome of cases operated before and after 24 hours for osteosynthesis of neck of femur fractures in patients 16 to 65 years age group. However, poor reduction is significantly associated with the increased rate of non-union and poor functional outcome.

The effects of different activating agents on the physical and electrochemical properties of activated carbon electrodes fabricated from wood-dust of Shorea robusta

This study focuses on the effects of activating agents on the physical and electrochemical properties of activated carbon (AC) electrodes, fabricated from wood dust of Shorea robusta. Three different activating agents namely H₃PO_4, KOH and Na₂CO₃ have been used to prepare ACs, which were named as: Sr–H₃PO₄, Sr–KOH and Sr–Na₂CO₃. The ACs were characterized by TGA/DSC, XRD, Raman, SEM, FTIR and BET. All the as prepared ACs were found to be amorphous in nature. The oxygen surface functionality was developed at the surface. The surface area of Sr–H₃PO₄, Sr–KOH and Sr–Na₂CO₃ were found to be 1269.5 m²/g, 280.6 m²/g and 58.9 m²/g respectively. The activated carbon-electrodes were then fabricated and supercapacitive performances were evaluated by “three electrode system” in aqueous 6M KOH using cyclic voltammetry (CV), galvanostatic charge discharge (GCD) and electrochemical impedance spectroscopy (EIS).The GCD performed at 1A/g revealed the specific capacitance values were 136.3 F/g, 42.2 F/g and 59.1 F/g for Sr–H₃PO₄, Sr–KOH and Sr–Na₂CO₃-electrodes, respectively. Energy density for Sr–H₃PO₄ electrode was found to be 3.0 Wh/kg at 99.6 W/kg power densities. Moreover, it also displayed imposing cyclic stability of about 96.9 %, 89.5 % and 78.5 % after 1000 cycles of charge/discharge respectively. The overall electrochemical performance of Sr–H₃PO₄ showed outstanding supercapacitive performances demonstrating the high possibility of this material to be used for the EDLC application in supercapacitive energy storage. The Nyquist plot also showed the lowest internal resistance of about 0.4 Ω for Sr–H₃PO₄ electrode.

Laparoscopic Surgeries in Urology: Initial Burgeoning Experience at National Transplant Centre, Nepal

Background This study focuses on experience of laparoscopic surgery at Shahid Dharma Bhakta National Transplant Centre (SDNTC), Nepal; which could enable us to gain knowledge regarding its benefits over conventional surgery. The present study revealed the frequency of various forms of laparoscopic surgeries done at our centre. Moreover, this study accomplishes laparoscopic donor nephrectomy "a historical milestone achieved in Nepal for kidney transplantation on 18th November 2018" which was the first Laparoscopic donor nephrectomy done in Nepal by Nepalese team. Objective The present study assesses the feasibility and safety of laparoscopic surgery at government hospital of Nepal. Method This hospital based cross-sectional study included all patients of age group 10 to 60 years, coming to outpatient department of SDNTC and those having indications for nephrectomy. We excluded patient having previous history of open surgeries of kidney, bleeding disorders, uncontrolled Diabetes Mellitus and uncontrolled Hypertension. The study duration was 15 months from November 2017 to January 2019. The total number of patients enrolled in the study was fifty where transperitoneal laparoscopic surgery was performed in all 50 patients. The demographic data, indications for surgery, duration of surgery, complications of surgery and perioperative outcomes were analyzed. Result Out of 50 cases, 34 (68%) underwent simple lap nephrectomy, 6 (12%) were lap pyeloplasty, 6 (12%) lap nephrectomy along with ureterectomy of long segment of diseased ureter, 1 (2%) lap radical nephrectomy, 1 (2%) lap donor nephrectomy for kidney transplantation, 1 (2%) lap heminephrectomy and 1 (2%) lap nephrectomy for hydronephrotic non functioning left crossed ectopia. Amongst all nephrectomies, 27 (54%) patients were operated on right side while 23 (46%) patients on left. The median age of the patient was 38.56 years. Out of total cases 32 (64%) were male and 18 (36%) female. The median operative time and hospital stay was 122.3 minutes and 5 days respectively. The median estimated blood loss was 74.1 cc. Only one patient required blood transfusion intra-operatively. 2 (4%) patients were converted to open surgery. Conclusion Laparoscopic surgery is feasible and safe procedure in government setup hospital with less cumbersome procedure and minimum complications associated with it.

Orthopaedic Services during Nationwide COVID-19 Lockdown: Dhulikhel Hospital, Kathmandu University Hospital Experience and Review of Literature

Background The Nepal government issued a nationwide lockdown due to COVID-19 from 24 March to 21 July 2020. This halted elective medical services in our hospital. A number of modifications in the orthopaedic practices at our department were made. Objective This article discusses the impact on orthopaedic load at the Department of Orthopaedics and Trauma, Dhulikhel Hospital, Kathmandu University Hospital during the lockdown. Method This is a longitudinal observational study done during the nation-wide lockdown including all the patients who presented to the hospital requiring orthopaedic consultation. For comparison purposes, the patient numbers from the same date in previous year (2019) were retrieved. Result We received no COVID-19 cases requiring orthopaedics consultation. A total of 1828 patients were seen in the Orthopaedic Outpatient Department, 1077 trauma patients in the Emergency Department, 216 patients were admitted and 210 orthopaedics procedures were performed at the operation theatre. There was 82.21% decrease in OPD patients and 56% less surgeries in OT compared to the same duration of last year. Conclusion There was a great reduction in the patient numbers visiting the hospital, which reflected in decreased number of admission and surgery. A greater part of our work during the lockdown was trauma.

Displaced Intra-Articular Calcaneal Fractures: Evaluation of Clinical and Radiological Outcome Following Open Reduction and Internal Fixation with Locking Branched Calcaneal Plate

Background An introduction of the World Health Organization Surgical Safety Checklist (WHO SSC) is essential to promote surgical safety. Objective To obtain country-specific information regarding the checklist in a leading medical institution in Nepal. Method The present research was a cross-sectional study with a survey conducted among healthcare professionals working in the operation theatre at the Tribhuvan University Teaching Hospital (TUTH) in Kathmandu, Nepal. A questionnaire was distributed to 150 healthcare professionals working in the operating theatre. Responses to the questionnaire were analysed descriptively and regression analyses used to identify factors associated with awareness of the checklist. Result In total, 127 healthcare professionals participated in the study, of whom 118 (92.9%) had been aware of the WHO SSC. A substantial proportion of participants (108, 91.5%) were not satisfied with the prevailing practice whereby the checklist was not routinely used during surgery. Lack of appropriate training was the most prevalent barrier to the checklist use (72, 67.9%), followed by unwillingness of staff to use the checklist (54, 50.9%), and lack of experience (42, 39.7%). The mean score on the survey was 6.0 out of 10. Regarding the results of the regression model on survey scores, surgeons had higher scores compared to nurses (unadjusted coefficient 0.80, 95% CI 0.20-1.40). Conclusion Most of the healthcare professionals were aware of the WHO SSC, however multiple barriers to the checklist use were identified. It is important to establish an effective use of WHO SSC in the operation theatre.

Digital Subtraction Angiography a Door Opener for Neurosurgical Residents who want to Perform Neurointerventional Procedures

Digital subtraction angiography (DSA) has been a fluoroscopic golden investigative tool to know the vascular angiography of the brain and spinal cord. The technique in performing this procedure exposes residents in accessing the major vessels, branches of the arch of aorta, selective angiography and diagnosing different vascular anomalies of brain and spine. They are also exposed to the knowledge of different diagnostic catheters, its manipulation, use of dye and radiation exposure and safety. We would like to share our experience in training and disseminating the knowledge of digital subtraction angiography to the residents.

Fixed-dose combination in management of type 2 diabetes mellitus: Expert opinion from an international panel

Type 2 diabetes mellitus (T2DM) is a progressive disease with multifactorial etiology. The first-line therapy includes monotherapy (with metformin), which often fails to provide effective glycemic control, necessitating the addition of add-on therapy. In this regard, multiple single-dose agents formulated as a single-dose form called fixed-dose combinations (FDCs) have been evaluated for their safety, efficacy, and tolerability. The primary objective of this review is to develop practice-based expert group opinion on the current status and the causes of concern regarding the irrational use of FDCs, in Indian settings. After due discussions, the expert group analyzed the results from several clinical evidence in which various fixed combinations were used in T2DM management. The panel opined that FDCs (double or triple) improve patient adherence, reduce cost, and provide effective glycemic control and, thereby, play an important role in the management of T2DM. The expert group strongly recommended that the irrational metformin FDC's, banned by Indian government, should be stopped and could be achieved through active participation from the government, regulatory bodies, and health ministry, and through continuous education of primary care physicians and pharmacists. In T2DM management, FDCs play a crucial role in achieving glycemic targets effectively. However, understanding the difference between rational and irrational FDC combinations is necessary from the safety, efficacy, and tolerability perspective. In this regard, primary care physicians will have to use a multistep approach so that they can take informed decisions.

Orthopaedic Services during Nationwide COVID-19 Lockdown: Dhulikhel Hospital, Kathmandu University Hospital Experience and Review

Background The Nepal government issued a nationwide lockdown due to COVID-19 from 24 March to 21 July 2020. This halted elective medical services in our hospital. A number of modifications in the orthopaedic practices at our department were made. Objective This article discusses the impact on orthopaedic load at the Department of Orthopaedics and Trauma, Dhulikhel Hospital, Kathmandu University Hospital during the lockdown. Method This is a longitudinal observational study done during the nation-wide lockdown including all the patients who presented to the hospital requiring orthopaedic consultation. For comparison purposes, the patient numbers from the same date in previous year (2019) were retrieved. Result We received no COVID-19 cases requiring orthopaedics consultation. A total of 1828 patients were seen in the Orthopaedic Outpatient Department, 1077 trauma patients in the Emergency Department, 216 patients were admitted and 210 orthopaedics procedures were performed at the operation theatre. There was 82.21% decrease in OPD patients and 56% less surgeries in OT compared to the same duration of last year. Conclusion There was a great reduction in the patient numbers visiting the hospital, which reflected in decreased number of admission and surgery. A greater part of our work during the lockdown was trauma.

Clinical Profile of Patients Presenting with Gallstone Disease in University Hospital of Nepal

Background Gallstone disease is one of the most common surgical problem throughout the world. The rise in gallstone disease burden and its wide spectrum of non-specific presentation makes the disease more challenging. Objective To know the various modes of presentation, socio-demographic details of the patients with gallstone disease, any associated factors and its treatment options. Method This is a prospective descriptive study in the patients presenting to Dhulikhel Hospital Kathmandu University Hospital diagnosed with gallstone during May 2018 to April 2020. After receiving ethical clearance from institutional Review committee, the informed consent was taken from all patient involved in the study. The presence of gallstone was confirmed by abdominal ultrasonography (USG). This study included total of 202 patients with gallstone disease. Result A total of 202 individuals with gallstone were included in the study; 48 males (24%) and 154 females (76%). The disease condition was common in age group 31-40 years (26.24%). Majority of the study population consumed mixed diet (92.57%). Out of 202 patients; 52 patients (25.74%) were overweight. In this study series 185 patients (91.58%) were symptomatic. Pain abdomen was one of the commonest symptoms (97.84%) followed by Nausea (28.11%), Dyspepsia (28.11%), Vomiting (18.38%), Fever (1.62) and Jaundice (1.08%). All cases were planned for laparoscopic cholecystectomy however 4 cases had to be converted to open surgery for completion. Conclusion Gallstone disease is a common surgical problem in Female population that presents most commonly with pain abdomen. Laparoscopic cholecystectomy can be easily performed in all cases of gallstone disease.

Unravelling the utility of modern sulfonylureas from cardiovascular outcome trials and landmark trials: expert opinion from an international panel

AIM

The primary objective of this review is to develop practice-based expert group opinions on the cardiovascular (CV) safety and utility of modern sulfonylureas (SUs) in cardiovascular outcome trials (CVOTs).

BACKGROUND

The United States Food and Drug Administration issued new guidance to the pharmaceutical industry in 2008 regarding the development of new antihyperglycemic drugs. The guidance expanded the scope for the approval of novel antihyperglycemic drugs by mandating CVOTs for safety. A few long-term CVOTs on dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor agonists, and sodium-glucose cotransporter 2 inhibitors have been completed, while others are ongoing. SUs, which constitute one of the key antihyperglycemic agents used for the management of type 2 diabetes mellitus (T2DM), have been used as comparator agents in several CVOTs. However, the need for CVOTs on modern SUs remains debatable. In this context, a multinational group of endocrinologists convened for a meeting and discussed the need for CVOTs of modern SUs to evaluate their utility in the management of patients with T2DM. At the meeting, CVOTs of modern SUs conducted to date and the hypotheses derived from the results of these trials were discussed.

REVIEW RESULTS

The expert group analyzed the key trials emphasizing the CV safety of modern SUs and also reviewed the results of various CVOTs in which modern SUs were used as comparators. Based on literature evidence and individual clinical insights, the expert group opined that modern SUs are cardiosafe and that since they have been used as comparators in other CVOTs, CVOTs of SUs are not required.

CONCLUSION

Modern SUs can be considered a cardiosafe option for the management of patients with diabetes mellitus and CV disease; thus CVOTs among individuals with T2DM are not required.

Periodontal Antibodies and All-Cause and Cardiovascular Disease Mortality

Periodontitis is positively linked to cardiovascular disease (CVD), diabetes, cancer, and increased mortality. Empirically derived clusters of IgG antibodies against 19 selected periodontal microorganisms have been associated with hyperglycemia. We further investigated associations between these serum IgG antibody clusters and all-cause and CVD mortality in a representative US population. Participants free of CVD and cancer and aged ≥40 y at baseline (N = 6,491) from the Third National Health and Nutrition Examination Survey (1988 to 1994) were followed up until December 31, 2011. Antibodies were categorized into 4 clusters: red-green, orange-red, yellow-orange, and orange-blue. Over a 23-y follow-up, 2,702 deaths occurred, including 810 CVD-related deaths. In fully adjusted Cox proportional hazard models, the red-green cluster was positively associated with all-cause mortality (tertile 3 vs. tertile 1: hazard ratio [HR] = 1.43, 95% CI = 1.08 to 1.90, P = 0.015). The yellow-orange cluster was inversely associated with all-cause mortality (tertile 3 vs. tertile 1: HR = 0.78, 95% CI = 0.63 to 0.97, P = 0.028) and CVD mortality (tertile 2 vs. tertile 1: HR = 0.57, 95% CI = 0.42 to 0.77, P = 0.005). The orange-blue cluster (composed of antibodies against Eubacterium nodatum and Actinomyces naeslundii) was inversely associated with all-cause mortality (tertile 3 vs. tertile 1: HR = 0.65, 95% CI = 0.55 to 0.78, P < 0.0001) and CVD mortality (tertile 3 vs. tertile 1: HR = 0.65, 95% CI = 0.47 to 0.88, P = 0.007). These antibodies could predict prognosis or be potential intervention targets to prevent systemic effects of periodontal disease if further studies establish a causal relationship.

Serum IgG Antibodies against Periodontal Microbes and Cancer Mortality

INTRODUCTION

Periodontitis is a chronic inflammatory condition initiated by microorganisms and is positively linked to systemic conditions such as cancer, cardiovascular disease, and diabetes mellitus.

OBJECTIVES

To prospectively investigate associations between empirically derived clusters of IgG antibodies against 19 selected periodontal microorganisms and cancer mortality in a representative sample of the US population.

METHODS

We evaluated 6,491 participants aged ≥40 y from the Third National Health and Nutrition Examination Survey (1988 to 1994), who had complete data on IgG antibody titers against 19 selected periodontal microorganisms and were free of cardiovascular disease and cancer. In a prior study, antibodies were categorized into 4 mutually exclusive groups via cluster analysis: red-green, orange-red, yellow-orange, and orange-blue. Cluster scores were estimated by summing z scores of the antibody titers making up each cluster. Participants were followed up to death until December 31, 2011. Cox proportional hazard models were applied to estimate hazard ratios (HRs) and 95% CIs for all-cancer mortality by tertiles of cluster scores.

RESULTS

During follow-up for a median of 15.9 y, there were 2,702 deaths (31.3%), including 631 cancer-related deaths (8.1%). After adjusting for multiple confounders, the orange-blue cluster was inversely associated with cancer mortality (tertile 2 vs. tertile 1: HR = 0.67, 95% CI = 0.54 to 0.84; tertile 3 vs tertile 1: HR = 0.62, 95% CI = 0.46 to 0.84). The association between the yellow-orange cluster and all-cancer mortality was also inverse but not significant, and the orange-red cluster and the red-green cluster were not associated with all-cancer mortality.

CONCLUSIONS

Antibodies against Eubacterium nodatum and Actinomyces naeslundii may be novel predictors of cancer mortality. If further studies establish a causal relationship between these antibodies and cancer mortality, they could be targets to prevent possible systemic effects of periodontal disease with potential interventions to raise their levels.

KNOWLEDGE TRANSFER STATEMENT

Periodontal antibodies against Eubacterium nodatum and Actinomyces naeslundii were inversely associated with cancer mortality among adults followed up for an average of 16 y. Periodontal antibodies may predict cancer mortality.

Diversity of Root Canal Morphology in Mandibular First Premolar

Background Mandibular first premolars have been reported to have complex anatomical aberration making them one of the most difficult teeth to manage endodontically. Objective To determine the root canal anatomy of mandibular first premolar in a Nepalese population using decalcification and clearing technique. Method One hundred and fifty extracted mandibular first premolars were collected from Nepalese population. Access cavities were prepared on the occlusal surface of each tooth. Teeth were decalcified by immerging in 5% nitric acid, dehydrated in ethyl alcohol and made transparent using methyl salicylate. Methylene blue dye was injected through access cavity and canal anatomy were observed and classified according to Vertucci's classification. Result The average length of mandibular first premolar was 20.43mm. One rooted teeth were 96% and two rooted were 4%. Vertucci's type I canal configuration was most prevalent (72%) followed by type V (18.6%), type III (3.3%), type II (2.6%) and type IV (2.6%). An unusual configuration was found in one tooth. Isthmus and apical deltas were found in 8.6%) and 14.6% of the cases respectively. Conclusion Type I canal configuration were the most frequently observed root canal configuration in mandibular first premolar followed by type V configuration. Such variation in root canal anatomy should be taken into consideration to ensure successful endodontic therapy of these teeth.

Outcome of Surgical Resection of Craniopharyngioma:Single Center 12 Years' Experience

Background Craniopharyngiomas (CPs) are rare epithelial tumors arising from the Rathke's pouch remnant located along the path of the craniopharyngeal duct accounting for 1.2-4% of all primary intracranial brain tumors, the primary treatment of which is surgery. Objective Whether radical surgical resection or partial resection followed by radiotherapy is a topic of debate. We presented our 12 years single center experience on surgical resection of craniopharyngioma. Method This was a descriptive cross-sectional study conducted among forty-five patients who underwent transcranial resection of craniopharyngioma during a period of 12 years. Data were collected from medical record archives. Glassgow outcome score (GOS), electrolyte imbalance and visual complications were assessed as outcome measure. GOS > 3 was considered favorable while score ≤ 3 was considered unfavorable. Recurrence of tumors were analyzed. Result Out of 45 patients, 28 patients were male with male to female ration of 1.64. Mean age was 32.22±16.42 years. Supra-sellar craniopharyngioma were the most common location. Gross total resection was accomplished in 32 patients (71.1%) while subtotal resection among 13 patients (28.9%). Post-operative Diabetes Insipidus was developed among 35 patients (77.7%). Adamantinomatous craniopharyngioma was the most common histopathological type. Postoperative MRI with contrast was repeated to ascertain the completeness of resection. All patient with subtotal resection received radiotherapy. Follow up period ranged from 3 months to 8 years with mean of 4.2 years. Favorable outcome (GOS>3) was seen among 41 patients while unfavorable among 4 patients. Recurrence seen among 4 patients (8.9%). Overall mortality was 4 (8.8%). Conclusion Gross total excision of craniopharyngioma has a favorable outcome with acceptable morbidity.

Post-Operative Pain and Associated Factors in Patients Undergoing Single Visit Root Canal Treatment on Teeth with Vital Pulp

Background Pain after root canal therapy is unwanted yet common experience for the patient and unpleasant for the dentist so it is always desirable to predict such pain. Objective To evaluate the frequency, intensity and associated factors of post-operative pain after single visit endodontic therapy on teeth with vital pulps. Method A total of 418 single visit root canal treatments were performed on patients of age 18 years and above by two endodontists. Canals were shaped with rotary ProTaper files. After the canal preparation, the canals were obturated, using lateral compaction technique, with ProTaper universal gutta-percha and AH-Plus sealer. Independent factors were recorded during the treatment and characteristics of postoperative pain were later surveyed through questionnaires. The severity of pain was recorded on a visual analogue scale (VAS) of 0-5. The data were analyzed using logistic regression models. Result The prevalence of post-operative pain within first six hours after treatment was high (79.2%) which decreased to 22% at the end of 72 hours however majority (70%) of the patients had mild to moderate pain (VAS 1-2). The factors that significantly influenced post-obturation pain experience were: gender (OR=0.55, 95%CI=0.32- 0.93; p=0.03), tooth type (OR-0.67; 95% CI=10.56-0.81, p=0.00), history of preoperative pain (OR=1.26; 95% CI= 1.04-1.51; p=0.02) and number of canals (OR=2.03; 95% CI=1.40-2.95; p=0.00). Conclusion The prevalence of some level of post -operative pain after single visit root canal therapy was high and was significantly influenced by female gender, increased number of canals, posterior tooth type and positive history of pre-operative pain.

Clinical Outcome following Intra-articular Triamcinolone Injection in Osteoarthritic Knee at the Community: A Randomized Double Blind Placebo Controlled Trial

Background Knee pain is one of the common complaints patients present with in any community based health camps and Osteoarthritis of knee is a usual diagnosis. Injecting a long acting steroid is a common practice to alleviate the symptoms of osteoarthritic knee. Objective To evaluate the clinical outcome of injecting Triamcinolone acetenoid in osteoarthritis of knee in a community set up over a randomized double-blind placebo control trial. Method A prospective, randomized, double blind, placebo control trial was carried out in community after obtaining the ethical clearance from the IRC. Patients with clinically diagnosed osteoarthritis of knee were injected either Triamcinolone or Placebo after recording the baseline scores of the knee by Knee injury and Osteoarthritis Outcome Score (KOOS) - Physical Function Short form (KOOS-PS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Visual Analogue Scale (VAS). The same tools were used at two, six and at twelve weeks post injection to evaluate the functional outcome and pain. Result One hundred and seventeen patients were available for analysis among which, 55(48.7%) patients received Triamcinolone and 58(51.3%) received placebo. The baseline status of knees of two groups was comparable at the start of study. There was significant pain relief in the group receiving Triamcinolone at two and six week but not in twelve weeks. Group receiving placebo had pain relief only for first two weeks. Functional outcome was significantly improved compared to baseline in both the groups until six weeks however, in the triamcinolone group, it was significant until twelve weeks. No major complications were noted. Conclusion Intra-articular injection of Triamcinolone acetenoid is effective in symptoms control and improving functional outcome in clinically diagnosed osteoarthritis of knees in community set up during health camps.

Fetal Ascites Mimicking Maternal Ovarian Tumor: A Rare Cause of Obstructed Labour

Fetal ascites has been diagnosed more frequently these days because of routine ultrasound scanning in pregnancy. However as a cause of dystocia in labour, it is very rare. Twenty four years second gravida of 28 weeks 6 days of gestation presented to labour room with preterm obstructed labour. Abdominal examination revealed less readily palpable fetal parts and distantly localized fetal heart sounds. An urgent ultrasound showed huge maternal ovarian cyst. She then underwent emergency cesarean section; delivered a male baby with grossly distended abdomen. However, the ovaries were normal looking. Routine antenatal ultrasounds help in identifying maternal and congenital fetal anomalies. They also guide in planning the most appropriate management. Whenever fetal ascites is diagnosed antenatally, possibility of dystocia in labour should be kept in mind.

Displaced Intra-Articular Calcaneal Fractures: Evaluation of Clinical and Radiological Outcome Following Open Reduction and Internal Fixation with Locking Branched Calcaneal Plate

Background Calcaneal fractures are common, but are difficult to manage. Immediate concern is soft tissue problems, while long term concern is pain as a sequelae of subtalar arthritis. A consensus has not been reached in the management of calcaneal fractures. Objective This study aims to evaluate clinical and radiological outcomes of the patients managed with open reduction and internal fixation with Calcaneal Locking Plates for the displaced intra-articular calcaneal fractures presenting in Dhulikhel Hospital, Kathmandu University Hospital. Method This was a prospective study, conducted on displaced intra articular calcaneal fractures from January 2014 through December 2016. The patients underwent open reduction and internal fixation with Locking Branched Calcaneal Plates through the extensile lateral approach. Post-operatively, ankle was mobilized after two weeks. Weight bearing was started after 12 weeks. Patients were evaluated clinically with Maryland foot score and radiologically with measurements of Boehler's and Gissane angle. Result Twenty-two cases of calcaneal fractures managed with open reduction and internal fixation with Locking Branched Calcaneal Plates were available for final evaluation. Seventeen of the enrolled patients were males in their third decade of life. On average, calcaneal fractures were operated on seven days after the injury. Sanders Type II were seen in 68.2% of the cases and Sanders Type III were in 31.8%. Mean follow-up duration was 21.5 months. The average Maryland foot score was 77.27. Seventeen cases (77.13%) had good, four cases (18.2%) had fair, and one case (5.5%) had poor outcome score. There was statistically significant improvement in Boehler's and Gissane angle across all enrolled patients. Conclusion Displaced intra-articular calcaneal fractures treated operatively with open reduction and internal fixation with Locking Branched Calcaneal Plates through the extended lateral approach, with proper planning of operation and surgical techniques in soft tissue handling, results in good clinical as well as radiological outcomes.

Fluoroscopy Guided Percutaneous Transpedicular Biopsy for Thoracic and Lumbar Vertebral Body Lesion: Technique and Safety in 23 Consecutive Cases

Background Though some vertebral lesions have typical imaging findings, histological/ microbiological evidence are required for definitive diagnosis and management, specially for tumor and infective lesions so that wrong diagnosis and wrong treatment can be avoided. Conventionally, open biopsy methods are used. With availability of CT scan, MRI, percutaneous transpedicular vertebral biopsy has now become popular as a minimally invasive technique for biopsy of vertebral lesion.Objective To describes technique and to analyzes safety and feasibility of percutaneous transpedicular vertebral biopsy with fluoroscopy guidance for thoracic and lumbar vertebral body lesions.Method Twenty three patients who underwent percutaneous transpedicular vertebral biopsy under fluoroscopy guidance were retrospectively evaluated for demographic data, indication for biopsy, anatomical locations, histological/microbiological diagnosis, complications and final outcome of treatment. True positive, true negative, false positive and false negative cases were defined.Result There were 17 males and 6 female patients of mean age 47 (range 22-73 years). Biopsies were performed in 17 dorsal and six lumbar vertebral bodies. Adequate sample were obtained in all cases. Seventeen patients (12: tubercular pathology, 1: primary tumor, 3: metastasis, 1: osteoporotic fracture) had definitive histological/ microbiological diagnosis. Four patients had no granuloma and tumor. Two had histological features of chronic non specific inflammation. True positive cases were 17, true negative were four and false negative case were two. Overall accuracy was 92%. One patient developed small hematoma at biopsy site.Conclusion Fluoroscopy guided percutaneous transpedicular biopsy of is a safe procedure with high adequacy and accuracy and low complication rate for thoracic and lumbar vertebral body lesion.

Study of Clinical Variables Affecting Long Term Outcome after Microdisectomy for Lumbar Disc Herniation

Background Outcome of lumbar disc herniation are influenced by various clinical, socioeconomic and psychological factors. In the absence of provision of medical insurances, worker’s compensation and sick leave, predictors for outcome after lumbar disc herniation surgery will be different in Nepalese population.Objective To evaluate different clinical variables that can affect outcome after lumbar disc herniation surgery.Method Among 88 patients who underwent microdisectomy for lumbar disc herniation, 63 patients (43 male, 20 female) with follow up at least six months were retrospectively evaluated for clinical variables which can affect Oswestry disability index (ODI) score, its interpretation and Mcnab classification of post operative outcome.Result Average age of patients was 42.54±8.60 years. Mean follow up period was 34.89±23.80 months (range 6 -111 months). Thirty four patients had follow up period > 24 months. Mean ODI score before surgery and at final follow up was 37.87±8.76 vs 7.78±7.7; (p=0.00). Success rate was 90.47% (change in ODI score at least by 10), 93.65% (ODI score interpretation <40%), and 85.71%. (Mcnab outcome excellent and good). Significant correlation was found between age and ODI at final follow up but not with duration of symptoms. Male, non alcoholic, low level of education, numbness as a predominant symptom, disc at L4-L5 were significantly associated with better ODI at final follow up. For ODI score interpretation, gender, smoking habit, presence of leg pain as a predominant symptom were statistically significant factors whereas smoking and drinking habit, level of education, occupation, back pain and numbness as predominant pre-operative symptom, types of disc in MRI were significantly related to Mcnab outcome. There was 9.5% peri- or post-operative complications and recurrence in seven patients.Conclusion Age, gender, smoking and drinking habit, level of education, occupation, types of disc in MRI are important variables for ODI score, ODI score interpretation and Mcnab outcome.

Cross-Sectional Analysis of Alcohol Intake and Serum Antibodies to Oral Microorganisms

The objective of this study was to evaluate the relation between alcohol intake and groups of periodontal antibody titers among individuals with normal glucose tolerance (NGT), prediabetes and diabetes. This was a cross-sectional analysis of the National Health and Nutrition Examination Survey III (NHANES III) 1988–1994 data, among individuals 40 y and older with information on alcohol intake and serum immunoglobulin G (IgG) antibody data against 19 oral microorganisms. Participants were excluded if they did not have teeth, reported that they were taking insulin, or having gestational diabetes. The sample size for this analysis was 3,219. Periodontal antibodies were grouped into four clusters using cluster analysis: Orange-Red, Red-Green, Yellow- Orange, and Orange-Blue. Cluster scores were computed for each individual by summing z-scores of standardized log-transformed IgG titers of antibodies against periodontal microorganisms making up each respective cluster. Each cluster score was modeled as an outcome. Alcohol consumption was assessed in g/day using self-reported number of days of drinking in the past 12 mo and the average number of drinks consumed per day on days when they drank. Overall, alcohol intake was positively associated with periodontal antibodies of the Orange-Red cluster (P. melaninogenica, P. intermedia, P. nigrescens, and P. gingivalis), and inversely associated with the Yellow-Orange cluster (S. intermedius, S. oralis, S. mutans, F. nucleatum, P. micra, C. ochracea) after multivariable adjustment. The association between alcohol intake and the Orange-Red cluster was strongest among individuals with diabetes; this relation was seen among individuals with and without periodontal damage. The Orange-Red cluster was positively associated with periodontal damage among individuals with diabetes. Alcohol intake was not associated with any antibody cluster among individuals with NGT or prediabetes. The effect of alcohol intake on periodontal disease may be greater among individuals with diabetes but this finding needs to be confirmed in prospective studies.

Knowledge Transfer Statement: The results of this study can be used by clinicians when treating patients with periodontal disease and diabetes.

Transmission of Squash vein yellowing virus to and From Cucurbit Weeds and Effects on Sweetpotato Whitefly (Hemiptera: Aleyrodidae) Behavior

Since 2003, growers of Florida watermelon [Citrullus lanatus (Thunb.) Matsum. and Nakai] have periodically suffered large losses from a disease caused by Squash vein yellowing virus (SqVYV), which is transmitted by the whitefly Middle East-Asia Minor 1 (MEAM1), formerly Bemisia tabaci (Gennadius) biotype B. Common cucurbit weeds like balsam apple (Momordica charantia L.) and smellmelon [Cucumis melo var. dudaim (L.) Naud.] are natural hosts of SqVYV, and creeping cucumber (Melothria pendula L.) is an experimental host. Study objectives were to compare these weeds and 'Mickylee' watermelon as sources of inoculum for SqVYV via MEAM1 transmission, to determine weed susceptibility to SqVYV, and to evaluate whitefly settling and oviposition behaviors on infected vs. mock-inoculated (inoculated with buffer only) creeping cucumber leaves. We found that the lowest percentage of watermelon recipient plants was infected when balsam apple was used as a source of inoculum. Watermelon was more susceptible to infection than balsam apple or smellmelon. However, all weed species were equally susceptible to SqVYV when inoculated by whitefly. For the first 5 h after release, whiteflies had no preference to settle on infected vs. mock-inoculated creeping cucumber leaves. After 24 h, whiteflies preferred to settle on mock-inoculated leaves, and more eggs were laid on mock-inoculated creeping cucumber leaves than on SqVYV-infected leaves. The transmission experiments (source of inoculum and susceptibility) show these weed species as potential inoculum sources of the virus. The changing settling preference of whiteflies from infected to mock-inoculated plants could lead to rapid spread of virus in the agroecosystem.

Permanent Teeth Emergence Time and Sequence in Children of Kavre District, Nepal

Background Population specific standards on the timing and sequence of emergence of permanent teeth are essential in planning dental care for children. There is only a single study on the emergence of permanent teeth in Nepalese children. Objective To determine the standards for permanent teeth emergence time and sequence in children of Kavre district, Nepal. Method A descriptive cross sectional study was conducted in 623 children of age 5 to 14 years from six different schools of Kavre district. The number of permanent tooth erupted except third molar was recorded along with age and gender. Data were analysed using SPSS 20.0. Descriptive statistics was used to determine the number and percentage of permanent teeth emerged at different ages and the mean age of emergence of each tooth. Student 't' test was used to determine the inter jaw differences in the mean age of emergence of each tooth. Result The study population constituted 50.7% boys and 49.3% girls of the total sample. The first tooth to emerge was mandibular first molar, whereas maxillary second molar tended to be the last to emerge in both the genders. Though in general, mandibular teeth tended to precede the corresponding maxillary teeth in emergence but significantly only mandibular central, lateral and second premolar emerged earlier than maxillary.( p ≤ 0.05) Conclusion This study can be used as a reference data for clinical and academic purpose especially for the children of Kavre district, Nepal.

Prevalence of Extended Spectrum Beta-Lactamase Producing Klebsiella Pneumoniae Isolated From Urinary Tract Infected Patients

BACKGROUND

Klebsiella pneumoniae, one of the bacterial agents associated with urinary tract infection has been often implicated as a major extended spectrum beta-lactamase (ESBL) producer in last few decades. This study was designed to assess the prevalence of ESBL producing Klebsiella pneumoniae in urinary isolates at a tertiary care hospital in Kathmandu, Nepal, from July to December 2014.

METHODS

One thousand nine hundred eighty six mid-stream urine specimens were collected aseptically from the clinically suspected patients of urinary tract infections attending Capital Hospital and Research Center, Kathmandu. The samples were processed following standard guidelines as recommended by American Society for Microbiology (ASM) and the isolates including Klebsiella spp. were identified using the specific biochemical and sugar fermentation tests recommended by ASM. Antibiotic sensitivity testing was done by modified Kirby-Bauer disk diffusion method and interpreted following Clinical and Laboratory Standards Institute (CLSI) guidelines. Klebsiella pneumoniae isolates showing resistance upon initial screening with ceftriaxone (30 μg) disc were then confirmed for ESBL production by phenotypic confirmatory disc diffusion test (PCDDT) using ceftazidime (30 µg) and ceftazidime + clavulanic acid (30 µg + 10µg) and cefotaxime (30 µg) and cefotaxime + clavulanic acid (30 µg +10µg) disc as per CLSI guidelines.

RESULTS

Out of a total 1986 specimens investigated, Escherichia coli was isolated in 309 (83.9%) and Klebsiella pneumoniae in 38 (10.3%) cases. Initial screening with ceftriaxone disc revealed 18 isolates of Klebsiella pneumoniae to be resistant. Further testing by PCDDT method confirmed 7 (18.4%) Klebsiella pneumoniae isolates to be ESBL producers.

CONCLUSIONS

Compared to some earlier studies done in Nepal, higher prevalence of ESBL-producing Klebsiella pneumoniae was observed warranting a national surveillance for routine monitoring of ESBL producing Klebsiella pneumoniae isolates.

Acetabular Fracture: Retrospective Analysis of Thirty Three Consecutive Cases with Operative Management

BACKGROUND

With the development of better imaging modalities including 3D CT scan and availability of technical expertise, operative management is increasingly performed for acetabular fracture but many patients in developing countries like Nepal, are still being treated with prolonged skeletal traction.

OBJECTIVE

To analyses epidemiology, types of acetabular fracture and functional and radiological outcome of patients with acetabular fracture treated with open reduction and internal fixation (ORIF).

METHOD

Inpatients hospital records of patients treated with ORIF in between June 2007 to June 2014 were evaluated. Patient's demographic data, mode of injury, injury hospital interval, injury surgery interval, associated injuries, surgical approach, total hospital stay and peri and post-operative complications were recorded and radiological and functional outcomes were evaluated.

RESULT

Thirty three patients (Male: 24 Female: 9) with average age 39 years (range: 21 to 65 years) were operated for acetabular fracture. Twenty one patients (63%) had injury related with motor vehicle accidents and nine (24%) of them had motorbike accidents. Injury hospital interval ranges from 7 to 36 days. Average injury-surgery interval was 21 days and average hospital stay was 22 days. Bicolumnar fractures were found in 15. Nine patients had dislocation of hip and 15 had concomitant other injuries. Biculumanr fixation was performed in 15 patients, posterior column and or wall in nine with Kocher Langenbeck approach and anterior column and or wall in other nine with ilio-inguinal approach. Radiological reduction was anatomical in 18; excellent/good functional outcome was in 26 and radiological outcomes were excellent in 14. Three patients had developed Hypertopic ossification. Follow up period ranged from 6 to 48 months and 15 patients (45%) had follow up >2 years.

CONCLUSION

Acetabular fractur can be effectively managed with ORIF and have predictable and comparable functional and radiographic outcomes. Upgrading the existing facilities and training of orthopedic surgeon for acetabular fracture management is important to shorten injury-surgery interval due to lack of such facilities.

Abstract P4-01-07: Recall for assessment after post-treatment surveillance mammograms in breast cancer

Background: Patients treated for breast carcinoma are usually followed up with regular mammograms. The aims are early diagnosis of locally recurrent disease in the ipsilateral breast or new cancers in the contralateral breast, and to provide reassurance. When the mammograms are considered abnormal patients are recalled for further assessment. The aim of this study is to review all mammographic recalls in a single institution over a 5-year period to study the patient population recalled, reasons for the recall and the outcome.

Materials and Methods: We identified all breast cancer patients who were recalled for assessment following a routine post-treatment surveillance mammogram from April 2010 to March 2015 from the breast unit database. We reviewed their original presentation with breast cancer, treatment received, reason for recall, the assessment process and the outcome. The mammographic follow-up policy of the unit during the study period was as follows; after breast conserving surgery (BCS), yearly bilateral mammograms for 5 years or until the age of 50 whichever the later; following mastectomy, mammogram of the opposite breast at years 1, 3 and 5 post-surgery, and if the patient is aged under 50 after 5 years, 2-yearly till 50 years of age. Patients were then discharged to UK National Breast Screening Programme where mammograms are performed 3-yearly.

Results: During the study period 1809 patients had 3685 surveillance mammograms. 149 patients were recalled (a recall rate of 8% of patients and 4% of mammograms over 5-years). 122 patients had BCS and 27 patients had mastectomy. The original diagnosis was invasive cancer in 131 and DCIS in 18. The reason for recall was a density or mass in 63, microcalcification in 61, distortion in 14 and a mixture of these or other reasons in 11. Eighty one patients were recalled for a problem on the ipsilateral side and 66 for contralateral side (2 patients had bilateral cancer).

Among 149 patients recalled, 50 had further imaging only (further mammographic views, ultrasound or both) after the recall and 79 underwent a needle biopsy under ultrasound or stereo guidance. 8 patients underwent US-guided aspiration of benign cysts. 21 biopsy results were malignant. The final diagnosis was ipsilateral recurrence in 10 patients and contralateral cancer in 11.

Conclusions: There is not much published data in the literature on the outcome of post-treatment surveillance mammograms despite the fact that such mammographic surveillance is commonly practiced. This study shows that over a 5-year period, 8% of the patients and 4% of the mammograms were recalled. A third of patients recalled only required further imaging. Although biopsies were performed in over half the patients, only 14% of patients recalled were proved to have ipsilateral or contralateral carcinoma after the assessment.

Citation Format: Wassermann M, Swinson C, Shrestha D, Kirkpatrick K, Ravichandran D. Recall for assessment after post-treatment surveillance mammograms in breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-01-07.

Assessment of Knowledge Regarding Oral Hygiene among Parents of Pre-School Children Attending Pediatric Out Patient Department in Dhulikhel Hospital

BACKGROUND

Level of knowledge regarding oral hygiene among the parents of pre-school children plays an important role on maintaining the good oral hygiene of their children. In Nepal, sufficient research has not been carried out on this area.

OBJECTIVE

Objective of this study is to assess the level of knowledge on oral hygiene of preschool children's parents attending pediatric outpatient department in Dhulikhel Hospital.

METHOD

A descriptive study was conducted from November 2012 to January 2013 among one hundred parents of preschool children visiting pediatrics outpatient department of Dhulikhel Hospital. Paper and pencil based semi structured questionnaire was used for collecting data. Questions related to demographic information and knowledge were asked. Thirty questions were used for assessing knowledge level. Knowledge score was calculated by allocating one point for each correct answer and zero point for each wrong answer. Analyzed data were presented in terms of numbers and percentages. Total knowledge scores were categorized based on percentage. Knowledge score was categorized on four group - exclusive intervals - namely-poor (0-40%), moderate (40-60%), good (60-80%) and excellent (80-100%). Mann-Whitney U test and Kruskal-Wallis test were applied to check significance difference and chisquare test was used to check association among different background characteristic.

RESULT

It was found that 81% had moderate knowledge, 15% had poor knowledge and 4% had good knowledge about oral hygiene. Median knowledge score was found to be 15 with range 10 to 21. Following variables were found to be significant difference on knowledge category: Education status (p<0.001), education level (p= 0.041), past experience about oral health problem (p = 0.008), Further significant association was found between knowledge category and educational status (p<0.001) and between knowledge category and past experience (p< 0.001).

CONCLUSION

Knowledge regarding oral hygiene was found satisfactory among the parents of preschool children visiting pediatric OPD of Dhulikhel Hospital.

Percutaneous Ilio-Sacral Screw Fixation in Supine Position under Fluoroscopy Guidance

Background Pelvic ring disruption when treated conservatively can be associated with prolonged hospital stay and immobilization, mal-union, chronic pain, limb length discrepancy if they are treated conservatively. Open reduction and fixation in an already compromised soft tissue and hemodynamically unstable patient causes more soft tissue injury, heamatoma, infection and neurovascular injury. Percutaneous ilio-sacral joint fixation can be an alternative technique for sacro-iliac joint injury and sacral fracture.Objective To evaluate technique and safety of percutaneous ilio-sacral screw fixation in supine position under single fluoroscopy guidance for sacral fracture and sacro-iliac joint disruption.Method Twenty one patients either with sacral fracture or sacro-iliac joint disruption with percutaneous ilio-sacral screw fixation with cannulated cancellous screw fixation in between 2008 to 2014 were retrospectively evaluated including AP, inlet and outlet views of pelvis X rays and CT scan. Tile’s classification and Dennis classification were used for pelvis and sacral injury.Result Thirty five percutaneous ilio-sacral screws were placed (Male: 6, Female: 15; range: 15 to 54) for sacral fracture involving zone 2 (8 with sacral fracture only and 5 with pelvis injury; Tile’s type B in four and type C in one) and sacro-iliac joint injury (Tile’s type B in three and type C in five). Commonest mode of injury was motor vehicle accidents (10) followed by fall related injury (6). Injury hospital interval and injury surgery interval was five hours to 13 days and 2 to 20 days respectively. Follow period was 3 months to 6 years. One patient developed post-operative deep vein thrombosis and another patient had post-operative haematoma. Two screws were juxtra-foramial. Good to excellent outcome were in 16 patients, fair in four and poor in one patient (Majeed Scoring).Conclusion Percutaneous ilio-sacral screw fixation for sacro-iliac joint injury and sacral fracture with C arm guidance is safe and minimally invasive technique. Clear images and accurate interpretation of X-rays, CT scans and per operative C arm images are important to avoid malpositioning of screws and iatrogenic neurovascular injuries.Kathmandu University Medical Journal Vol.13(1) 2015; 56-60

Pattern of Sleep in Infants and Toddlers Visiting at a Teaching Hospital in Lalitpur

Introduction: Sleep is an integral part in a child’s health and development. During different stages of development, there are aberrations in normal physiology of sleep which make children more susceptible to various types of sleep problems. This study was conducted to identify sleep pattern and sleep problems in Nepalese children using Nepali translation of Brief Infant Sleep Questionnaire (BISQ) screening tool.Materials and Methods: This was a descriptive cross-sectional study. Data were collected from parents of children aged 6 to 36 months attending paediatric out-patient clinic for general health check-up from July 2013 to December 2013. Nepali translation of the BISQ was used as a screening tool for sleep problems in this study.Results: The study included 553 children (52.4% boys). Mothers completed the questionnaire in 92% of children. Mean total duration of sleep in 24 hours was 11.7 ±1.7 hours. Respondents reported sleep problem in 16.9% of children whereas 20.3% of children had sleep problems according to BISQ criteria. As per this criteria, 2.7% of children had total sleep duration less than 9 hours, 5.9% of children had total night awakening duration of more than one hour, 13.9% of children had night waking >3 times. These BISQ sleep parameters differed significantly in children with and without sleep problems (p<0.001). In addition, children with sleep problem took longer time to sleep than children without sleep problems (p<0.001).Conclusion: Sleep problems are common in Nepalese infants and toddlers according to the BISQ. Screening for sleep problems is highly recommended during health care visits given the prevalence of sleep problems identified by this study to reduce their potential adverse impact.J Nepal Paediatr Soc 2015;35(1):24-30

The Incidence of Thyroid Carcinoma in Multinodular Goiter: A Retrospective Study

Background and Objective: To determine the incidence and the types of various thyroid malignancies in multi-nodular goiter.Material and methods: This is a retrospective study, conducted in Department of ENT and Head and Neck Surgery, National Academy of Medical Sciences Bir Hospital Kathmandu and Alka Hospital Pvt. Ltd Lalitpur. The study period was 3 years from 11 January 2011 to 10 January 2014. The study population consisted of 100 patients who were diagnosed as a multinodular thyroid nodule.Result: The highest frequency was 50 (50%) in 31-40 years. Among the total cases, 28 (28%) were males and 72(72%) females. Histopathological analysis showed that benign multi-nodular goiter was present in 87 (87%) cases, and malignant thyroid lesion in 13 (13%) cases. Among malignancies, papillary carcinoma was found as the commonest malignancy 11 (84.61%) cases followed by follicular carcinoma 1 (7.69%) case and anaplastic carcinoma 1(7.69%) case.Conclusion: The risk of malignancy in multinodular goiter should not be underestimated as significant number of patients with thyroid malignancies present with multinodular goiter.JCMS Nepal 2014; 10(4):18-21

Epidemiological and Outcome Analysis of Orthopedic Implants Removal in Kathmandu University Hospital

Background Orthopedic Implant removal is one of the commonly performed elective orthopedic surgeries. Implants are generally removed after the purpose of keeping implant is solved by healing of the fracture, but there is no consensus whether routine implant removal should be a policy for all fractures that were fixed. Objective This study aims to analyze the epidemiology and outcome of implant removal surgery carried out in the past three years in Kathmandu University Hospital. Methods Patients who underwent implant removal between 2010 January to 2012 December constituted the study cohort. Demographic data, indications, types of hardware and location of fractures were recorded. Similarly, duration of surgery, type of anesthesia and duration of hospital stay were recorded. All the patients who had undergone implant removal in this three years period were called for follow up examination but those who were not able to come were interviewed on telephone. Results There were 275 implant removals constituting 7.8% of total orthopedic operations and 26.3% of fracture fixations. Male to Female ratio was 189: 86. Pediatric age group (34.5%) had the highest incidence of implant removal. Moderate sized implants were the commonest hardwares removed (63.2%). Femur (27.3%) followed by radius (26.9%) were the commonest bone for implant removal. Average operative time was 47.3 minutes with average hospital inpatient stay of 2.6 days. Commonest indication for the implant removal procedure was pain (45%). Conclusion Implant removal procedures are one of the most commonly performed elective orthopedic surgeries. Though, after orthopedic implants removal, pain relief can be expected but it is not so predictive and hence patient should be well counseled before and the indications for implant removal has to be evaluated for better patient satisfaction and safety. DOI: http://dx.doi.org/10.3126/kumj.v11i2.12489 Kathmandu University Medical Journal Vol.11(2) 2013: 139-143

Instrumentation in cervical spine injury: neurological outcome measurement using ASIA impairment scale

Cervical spinal cord injuries make up more than half of all spinal cord injuries. It affects 2-3% of all trauma patients and accounts for 8.2% of all trauma related deaths. Cervical spine surgery has been evolving in terms of surgical technique, equipment, and instrumentation. We have analyzed a series of patients with cervical spine injuries stabilized with various instrumentation techniques. The objective of the study was to evaluate the outcome of instrumentation in cervical spine injury measured on ASIA Impairment Scale. We present prospective observational descriptive analysis, for 36 patients, looking at the clinical and neurological outcomes following instrumentation for cervical spine injuries from Jun 2011 to July 2013. All 36 patients underwent various instrumentation techniques for stabilization and decompression of the cervical spinal cord. The outcome was compared by the ASIA impairment scale. There were 27 (75%) males and 9 (25%) females. The mean age at presentation was 46 years (17-74 years). The most common mode of injury was fall (62%), with ASIA grade C and D, 31% each. C5/6 level was the most common level (26.2%) of injury. The timing of surgery ranged between 8 - 270 days from injury. Out of thirty-six, thirty-two patients were available for follow-up. Eighteen of these patients had spinal cord injury and improved by at least one ASIA grade. It is concluded that instrumentation in cervical spine injury is an effective surgical procedure with minimal post-operative morbidity for the management of cervical injury, allowing an improved physiologic environment for maximal neurologic improvement. The post-operative outcome measured on ASIA impairment scale was comparable to international study.

Clinical Profile of Acute Poisoning in Children at a Teaching Hospital in Lalitpur

Introduction: Acute poisonings are one of the common cause of emergency visits and hospital admissions and is potentially preventable cause of childhood mortality and morbidity. The objectives of this study were to identify the common type of poisoning in children, to determine types of poisoning according to age and to find out the common age group in which the incidence of poisoning was high.Materials and Methods: It was a descriptive observational study done in a teaching hospital in Lalitpur, Nepal in patients aged 1 month to 18 years who visited the emergency department and were admitted to hospital with history of alleged poisoning from 2009 July to 2014 January.Results: Fifty patients were included. Drugs, kerosene and organophosphorus were most common cause of poisoning. Drugs and kerosene below 10 years of age and organophosphorus and drugs above 10 years of age were common types of poisoning. Maximum numbers (50%) of children with poisoning cases were below five year of age. Mean duration of hospital stay was 2.1days and mean age of poisoning was 7.8 years with a male(54%) predominance. Majority of poisoning occurred at home (84%) and 68% of patients were symptomatic at presentation to hospital with 84% of patients presenting to hospital within six hours.Conclusion: This study showed that drugs, kerosene and organophosphorus were most common forms of poisoning. Young children were most vulnerable for acute poisoning.DOI: http://dx.doi.org/10.3126/jnps.v34i2.10139J Nepal Paediatr Soc 2014;34(2):100-103 

Clinical characteristics of children with febrile seizure

BACKGROUND

Febrile seizure is common in children below five years of age. This study was conducted to evaluate the clinical profile of children presenting with febrile seizure in a teaching hospital.

METHODS

This was a descriptive retrospective study among children presenting with febrile seizure in a teaching hospital from July 2009 to June 2013. Children between six months to six years were included in the study while patients with prior episodes of afebrile seizures, abnormal neurodevelopment and not meeting the age criteria were excluded. Patient's demographic and clinical data were collected from the in-patients records and analyzed.

RESULTS

This study included 103 children with febrile seizure. Out of which 67% were male. Simple febrile seizure and complex febrile seizure were observed in 76.7% and 23.3% of patients respectively. Majority of children (71.8%)had generalized tonic clonic seizure followed by tonic seizures. Most of children (72.8%) who developed first episode of seizure were below 24 months of age with the mean age of 20.7 (±12.1) months. Overall 33% of patients developed recurrence of febrile seizure and first episode of febrile seizure at age one year or below was associated with the seizure recurrence. Upper respiratory tract infections were the commonest cause of fever in these children.

CONCLUSIONS

Febrile seizure was observed predominantly in children below age of two years and simple febrile seizure was the ommonest variety. Recurrence of febrile seizure was common and significantly associated with the first episode of febrile seizure at the age of one year or below.

A comparative study on epidemiology, spectrum and outcome analysis of physical trauma cases presenting to emergency department of Dhulikhel Hospital, Kathmandu University Hospital and its outreach centers in rural area

BACKGROUND

Physical trauma is one of the major cause of mortality and morbidity among young and active age group and its increasing trend is of main concern. There are only few studies concerning the spectrum of physical trauma in Nepal.

OBJECTIVE

This study aims to evaluate the epidemiological spectrum, the extent, severity of the physical trauma and the outcome evaluation of patients with physical trauma over a period of one year in the emergency department of the Kathmandu University Hospital and compare the same parameters with those patients presenting to the various outreach centers of the hospital in the community.

METHODS

Patient treatment files from the emergency department and the reports from various outreach centers were retrieved for a period of one year (May 2011 to April 2012). Epidemiological information, mode, type and anatomic location of injuries were recorded. Outcome evaluation was assessed by number of patients discharged from emergency department of the hospital or the outreach centers after the treatment, patients admitted for inpatient management and referred to other centers for further specialty management.

RESULT

In a period of one year, total 2205 (20%) of physical trauma cases presented to the emergency department and 1994 (6.12%) in the outreach centres. Most commonly involved age group in physical trauma both in Hospital set up and in Community set up were the young adults (15 to 49 years). Fall from height was the commonest mode of injury followed by road traffic accidents among the patients coming to the hospital while significant number of trauma patients coming to outreach centers were due to fall from height. In the hospital set up, 1525 (69.2%) of the cases were discharged while 537 (24.4%) needed inpatient management and 85 (3.8%) needed referral to other centers for the specialty management. In case of outreaches, half of the patients were discharged after the primary treatment and almost another half were referred to the hospital, mainly for need of further investigations.

CONCLUSION

Fall related injuries and road traffic accidents are the most common mode of trauma in the hospital set up and fall related injuries are the single most important mode of trauma seen in the outreaches. Mostly young adults in their active period of life are involved in physical trauma so appropriate preventive measures through public health approach should be included in comprehensive trauma management for reducing mortality and morbidity rates related to physical trauma.

Association between Serum Antibodies to Oral Microorganisms and Hyperglycemia in Adults

We conducted a cross-sectional analysis to evaluate the relationship between serum antibody titers against 19 selected oral microorganisms and measures of hyperglycemia in a large, nationally representative data set. The study population consisted of 7,848 participants from the National Health and Nutrition Examination Survey III (1988-1994) who were at least 40 yrs old, with complete serum IgG antibody data against 19 oral microorganisms. The 19 antibody titers were grouped into 4 categories via cluster analysis--orange-red, yellow-orange, orange-blue, and red-green--named to reflect predominant antibody titers against microorganisms in Socransky's classification scheme for oral microbes. Linear regression models weighted for complex survey design were used in which fasting blood glucose, fasting insulin, and HbA1c were outcomes and antibody cluster scores were exposures, adjusting for potential confounders. Higher orange-red cluster scores were associated with increased hyperglycemia, while higher orange-blue cluster scores were related with decreased hyperglycemia. A 1-unit-higher orange-red cluster score was associated with 0.46 mg/dL higher fasting blood glucose (p = .0038), and a 1-unit-higher orange-blue cluster score was associated with 0.34% lower HbA1c (p = .0257). Groups of antibody titers against periodontal microorganisms were associated with hyperglycemia independent of known risk factors.

Human genital myiasisin extremes of age

Genital myiasis is a very rare entity associated with poor personal hygiene, restricted mobility, and immunosuppressed status and ulcerating lesions. With the reported incidence of only 0.7%, only a few cases have been published so far in literature but none from Nepal. Despite such rare occurrence, we present here two such cases which we encountered in an interval of three days; one in an unmarried teenager and another in a postmenopausal lady with fungating ulcerative growth of vulval carcinoma. Both were successfully managed.

An endodontic practice profile amongst general dental practitioners in Kathmandu: A questionnaire survey

Objective To investigate the endodontic practice profile of general dental practitioners. To explore the materials and methods employed by them in Kathmandu valley. To compare these findings with well acknowledged international academic standards. Methods Questionnaires with 18 closed-ended questions were distributed among randomly chosen 120 general dental practitioners of Kathmandu, working in various government or private hospital or clinics.The data were collected and descriptive statistical analysis was done. Results Out of 120 questionnaires, only 110 that were completely filled were included in the study .Most general dental practitioners (97%) regularly did multi-rooted root canal treatments and followed multivisit root canal treatment.. Radiograph with instrument in canal was used by 80% of general dental practitioners to determine the working length while only 36% used electronic apex locator which is considered to be more reliable. Half of them (57%) used nickel-titanium files for cleaning and shaping but only 23% used crown down technique. Sodium hypochlorite and calcium hydroxide was the most popular irrigation solution and intra-canal medicament respectively. Majority of general dental practitioners (91%) used lateral compaction technique for root canal obturation. Sixty three percent used zinc oxide eugenol as root canal sealer and 46% used endomethasone. They seem to overuse antibiotics in cases requiring endodontic therapy. Only 48% used autoclave for sterilization of endodontic files while 86% never used rubber dam. Eight three percent of them felt the need of further endodontic training and 42% of them preferred post-graduate dental program. Conclusion This study shows that the standard guidelines and new technologies for endodontic treatments are not implemented by many general dental practitioners of Kathmandu and require further endodontic trainings. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-4, 40-50 DOI: http://dx.doi.org/10.3126/jcmsn.v9i4.10235

Distally based sural faciocutaneous and fascial (adipofascial) flap for reconstruction of distal leg, ankle and foot defects

BACKGROUND

Any soft tissue defect in distal leg, ankle and hind foot is still a challenging problem. There are various options for coverage of such defects, but the distally based sural neurocutaneous and neurofascial flap based on the sural nerve and superficial sural artery has been an important option.

OBJECTIVE

To evaluate the efficacy of distally based sural flap in reconstruction of the distal leg, ankle and hind foot soft tissue defects.

METHOD

Seventeen patients with soft tissue defects over distal leg, ankle and hind foot were included in this study. All patients were treated with distally based sural flap. Most of the cases were due to trauma (16 cases) which compromised tendon and bone. One case was of malignant melanoma of sole of hind foot which required wide excision and soft tissue reconstruction with sural flap.

RESULT

In all cases defects were successfully covered. Three showed venous congestion and partial necrosis. One developed secondary infection. One flap failed completely. Mean follow up of patients was 20 months (6-36 months).

CONCLUSION

Sural flap is a good option for reconstruction of distal leg, ankle and foot defects.