Nepal Medical College Journal

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Achieving distal locking without an image intensifier.
(2007-12-27) Giri, S K
The tibia is commonly fractured bone frequently caused by high energy trauma leading to the complications and major disabilities. Different types of intramedullary nails have been employed by surgeons over 500 years. Today, the intramedullary interlocking tibial nailing is the leading modality of treatment because of its biomechanical advantage over the other modalities. This procedure is done in the advanced centers under the C-arm image intensifier. Yet, there is no facility of C- arm image intensifier in the operation theatre at the tertiary level public hospitals in Nepal. Most of the peripheral hospitals do not have portable X- ray facility. The purpose of this study was to study the success rate of distal locking in the intramedullary nailing of tibial shaft fractures with the aid of distal aiming device (DAD). The distal locking were done in 65 tibial shaft fractures. In this technique the distal hole was directly visualized after proper drilling. All the distal locking could be done without image intensifier. So this technique can be useful where the imaging facilities are not available and even in the advanced centers to avoid radiation hazards.
Acute bacterial meningitis in Nepal.
(2007-06-29) Tiwari, Kiran Babu; Rijal, Basista; Ghimire, Prakash; Sharma, Achyut Prasad
This study was conducted at Tribhuvan University Teaching Hospital, a tertiary care hospital in Nepal from January 2001 to March 2002. The prevalence of bacterial meningitis, its causative organisms and their antibiotic sensitivity patterns were studied in cerebrospinal fluid of 448 suspected cases. The prevalence of acute bacterial meningitis was 8.3%. There was no significant association (p > 0.05) of the disease with gender (X2 = 0.0234) and among different age groups (X2 = 6.07875) studied. The causative bacteria were Pseudomonas aeruginosa (24.3%), Klebsiella pneumoniae (16.2%), Staphylococcus aureus (16.2%), coagulase negative staphylococci (10.8%), Escherichia coli (10.8%), Streptococcus pneumoniae (8.2%), Neisseria meningitidis (5.4%), Acinetobacter spp. (5.4%) and Aeromoanas spp. (2.7%). Imipenem was the most effective antibiotic, however, 11.1% of P. aeruginosa, 25.0% of E. coli and 50.0% of Acinetobacter spp. were resistant to the drug.
Acute hemorrhagic conjunctivitis epidemic--2003 in Nepal.
(2003-12-18) Gurung, Reeta; Rai, Shiba Kumar; Kurokawa, Manabu; Shrestha, Mohan Krishna; Thakur, Jaya; Rai, Chandra Kala; Ruit, Sanduk; Ono, Kazuo
This rapid communication present the findings of nationwide outbreak of acute hemorrhagic conjunctivitis (AHC) epidemic occurred in Nepal during summer 2003. Only ten percent of samples showed bacterial and no fungus were grown. On the contrary, viruses were detected in 60.0% cases studied. Of the viruses detected, Adenovirus (ADV), Coxsackie virus (CA24v) and both accounted for 83.3% (30/36), 11.1% (4/36) and 5.5% (2/36), respectively. Interestingly, ADV was detected also from one of the ten a Rupees bill.
Acute renal failure in Nepal Medical College Teaching Hospital.
(2008-06-03) Chhetri, P K; Manandhar, D N; Pahari, L R; Chhetri, S S; Chaudhary, S K
Total 45 patients (male 27 and female 18) of acute renal failure (ARF) admitted in Nepal Medical College Teaching Hospital over a period of 12 months (1st of Baisakh 2064 BS to 31st of Chaitra 2064 BS) were enrolled in the study. Sixty four percent of study population were of age group 21-60 years. Acute Gastroenteritis 33, sepsis 5, hemorrhage 2, others 5 were the different causes of ARF. Serum creatinine of the study population before and after treatment was 4.35 +/- 2.72 and 1.38 +/- 0.72 mg/dl respectively. Similarly serum urea before and after treatment was 101.78 +/- 57.56 and 42.60 +/- 30.46 mg/dl respectively. Thirty three patients were managed by non dialytic modality of therapy and 12 patients needed hemodialysis. Blood urea of those patients who underwent nondialytic therapy was significantly less than of those who underwent hemodialysis (80.65 +/- 38.21 vs. 151.08 +/- 66.22; p = 0.004). Serum creatinine was also significantly lower in nondialytic therapy group (3.15 +/- 1.15 vs. 7.64 +/- 3.10; p = 0.000) ARF patients with very high urea, creatinine and disturbed electrolytes required dialysis. Average session of hemodialysis was 3.4. Thirty five patients were cured, 6 left against medical advice, 3 were discharged on request, and one patient of sepsis expired during the course of treatment. Acute gastroenteritis was the leading cause of ARF and outcome was excellent even without dialysis in most of the cases provided the treatment was started early and appropriately.
Admission eligibility criteria and academic success of the BSc Nursing at BPKIHS, Nepal.
(2004-12-22) Pokhrel, Nita; Mehta, Ram Sharan; Khanal, Sudhanshu Sharma; Niraula, Surya Raj
Present study was under taken to evaluate the admission eligibility criteria and academic success of BSc Nursing at BP Koirala Institute of Health Sciences in eastern Nepal. The average BSc Nursing scores were significantly associated with the performance in School Leaving Certificate (SLC), Entrance, BSc I, BSc II, BSc III and BSc IV but not with ISc score.
Age related changes in cholesterol level among the patients with subclinical hypothyroidism in eastern Nepal.
(2006-09-06) Pokhrel, Subarna; Baral, Nirmal; Sridhar, Magadh Gopal; Lamsal, Madhab
This study was undertaken at Biochemistry Department (BPKIHS) from 2001 to 2002. The aim of this study was to assess whether subclinical hypothyroidism is associated with abnormal cholesterol level in different age groups. Of the cases referred to the department, 398 euthyroid controls, 189 hypothyroid cases, 179 hyperthyroid cases and 181 subclinical hypothyroid cases were enrolled for further analyses. Both the sexes showed increased total cholesterol levels in hypothyroidism, and were not significantly changed in hyperthyroidism than in euthyroid controls. Female subclinical hypothyroid cases of age group 45-59 years and both the male and female cases of age group > or = 60 years had significantly (p < 0.01) elevated total cholesterol levels (196 +/- 37.36 mg/dl vs.169.37 +/- 29.12 mg/dl, 211.5 +/- 30.48 mg/dl vs. 151.54 +/- 55.84 mg/dl and 225 +/- 25.05 mg/dl vs. 181.73 +/- 32.95 mg/dl respectively) as compared to euthyroid controls. When data were analyzed at 33 and 45 years of age cut offs, the cases of > or = 33 years age in both hypothyroid male and female showed significantly (p < 0.01) elevated cholesterol levels (222.66 +/- 29.26 mg/dl vs. 156 +/- 37.09 mg/dl and 231.66 +/- 46.17 mg/dl vs 198.1 +/- 48.72 mg/dl respectively) where as subclinical hypothyroid female showed increased total cholesterol level (211 +/- 31.2 mg/dl vs. 157.95 +/- 45.92 mg/dl) at > or = 45 years age cut off. It is concluded that hypothyroidism not the hyperthyroidism is associated with increased total cholesterol level in the cases of this region, and we advise routine screening for cholesterol level in both the sexes of hypothyroid (for > or = 33 years) and female subclinical hypothyroid (for > or = 45 years) cases in this area, as they have high risk for higher cholesterol levels and developing related disorders.
Allergic bronchopulmonary aspergillosis--a case report.
(2004-12-22) Chokhani, Ramesh; Neupane, Saraswoti; Kandel, Ishwar Sharma
A 24 years old male presented with recurrent symptoms of cough and breathlessness for 6 years but increased in past 6 months. Fleeting radiological opacities, peripheral eosinophilia and central type bronchiectasus in high resolution CT scan gave the suspicion of allergic bronchopolmonary aspergilosis. Confirmation of the diagnosis was done by skin prick and immunological tests. The patient showed an excellent response to oral prednisolone.
Ambulatory blood pressure monitoring: a useful tool to diagnose hypertension and supervise it's treatment.
(2008-06-03) Shrestha, B; Dhungel, S; Pahari, S K
Automatic ambulatory blood pressure monitoring (ABPM) for the diagnosis and treatment ofhypertension(HTN) is not common in Nepal. The purpose of this study is to evaluate various characteristics of hypertensive patients undergoing ABPM before starting antihypertensive treatment and evaluate the adequacy of the blood pressure (BP) control during antihypertensive treatment. ABPM was performed in 108 consecutive patients attending the hypertension clinic of Nepal Medical College Teaching Hospital from 1st March 2005 to 30th April 2007 with DynaPulse 5000A (version 3.20q ) for approximately 24 hours. Male female ratio was 59:49 and age (mean +/- SD) was 47.8 +/- 16.4 years. The maximum use of ABPM (25.9%) was noted in the age group of 40-49 years. Body mass index was 25.7 +/- 3.8. Diabetes was noted in 13% patients. Maximum use of ABPM was observed in Newar ethnic group (56.5%). ABPM was used for the diagnosis of HTN in 62.0% patients and for follow up in 38.0% patients. Severe HTN was seen in approximately half (47.2%) of the hypertensive patients. Majority of the patients (88.0%) had dipper type of HTN. Beta-blocker (35.6%), ACE inhibitor/Losartan (31.1%) and calcium channel antagonist (26.7%) were the usual antihypertensive agents used. Single antihypertensive agent was used in the majority of patients (64.1%). In a small number of patients (42, 38.9%) undergoing ABPM during antihypertensive therapy, the adequacy of control of HTN was very poor.
Analysis of clinical factors affecting the restenosis following percutaneous coronary intervention.
(2005-12-08) Paudel, Badri; Xuan, Guo jing; Chun, Zhang fu
Coronary heart disease (CHD) is a leading cause of morbidity and mortality across the world. Percutaneous coronary interventions (PCI) including angioplasty and/or stenting have revolutionized the effect management of ischemic syndromes in CHD and their symptoms. However, the superimposition of iatrogenic mechanical injury (PCI procedure) on coronary atherosclerosis initiates restenosis that may complicate the patient's clinical course like recurrence of angina, myocardial infarction and cardiac insufficiency. In order to study the possible association of clinical risk factors on the incidence of restenosis; clinical predictors were determined in 98 patients (81 males and 17 females) who all undergone follow-up coronary angiography within 8.2 months after PCI. The mean age was 59.7years (40-80years). 83 patients had recurrence of angina however 15 patients had no symptoms at the follow up. The multivariate analysis of the clinical predictors demonstrated that a significant higher risk of restenosis after PCI was found in patients with hyperlipidemia p<0.05, [RR=1.311(1.018-1.687)]. Longer the history of hyperlipidemia the angina recurrence time is shorter. Besides restenosis is also closely related to male patients (p<0.10). Finally, this study strengthens evidence that restenosis following PCI is higher in patients with hyperlipidemia, and longer the history of hyperlipidemia the recurrence time of angina is shorter.
Analysis of mastalgia cases presented at Manipal Teaching Hospital, Pokhara, Nepal.
(2004-12-22) Shrestha, Sunil; Sen, Tapti
Breast pain (Mastalgia) is a common cause of anxiety among women and frequently leads to a primary care clinic for consultation. This study has been designed to study about mastalgia cases presented at Manipal Teaching Hospital, Pokhara. A total of 221 female patients with breast pain presented at outpatient department of surgery from Jan 2000 to Dec 2001 were enrolled in this study. Overall 36.8% presented with cyclical mastalgia and 43.1% with noncyclical mastalgia. Nonhormonal therapy like reassurance, breast support, reduction in dietary fat intake, VitE, Vit B6 was preferred for initial therapy of mastalgia as it was found to be associated with improvements of cyclical mastalgia and good compliance. Non cyclical mastalgia mostly presented with breast lump and ended with excision of lump.
Analytical study of the management of supracondylar fracture of children in our setup.
(2006-12-16) Singh, Ramesh Prasad; Shrivastava, Mahesh Prasad; Shah, Rant Kewal
We performed a clinical-radiological audit of 142 children with consecutive upracondylar fractures of the humerus over a period of 5 years (1996-2001). The fractures were classified according to the Gartland system; 58 types I, 44 type II and 40 type III. And 87.0% were extension and 13.0% flexion types. These cases were managed by closed reduction and posterior cast application (n= 120) and open reduction with internal fixation (n=22). All the stable fractures irrespectable of types were managed by closed method and all the unstable or failed manipulation cases were operated upon. In total 38 required re manipulation in the cast group and twelve (n= 12) had a varus deformity (ten from closed group and two from operation group). Failure to follow the treatment according to the guidelines led to an unsatisfactory result in 12 patients. We have devised a protocol for the management of these difficult injuries in our setup for optimal outcome.
Anatomical variation in origin and course of the thoracoacromial trunk and its branches.
(2004-12-22) Pandey, Shashi Kant; Shukla, Vijay Kumar
The variations in origin and course of the thoracoacromial trunk (TAT) and its branches were studied in 178 cadavers during the routine dissection from the year 1982 to 2002. The TAT originated from the first part of the axillary artery (AA) in 13.4% cases of the right and 10.6% of the left axilla. The variations in origin of the branches of TAT were divided into three groups. First variation group showed deltoacromial (DA) and clavipectoral (CP) subtrunks of the TAT originating directly from the AA in majority of cases. Second group revealed clavicular branch of the TAT originating from the AA, whereas in the third group all classical branches originated directly from the AA and there was no existence of the TAT. The superior thoracic artery (STA) originated from the TAT in 16.8% (Confidence Interval, CI: 11.12-21.89) cases of the right and 6.1% (CI: 2.59-9.53) of the left axilla and the lateral thoracic artery in 39.8% (CI: 32.01-46.10) cases of the right and 29.3% (CI: 15.01-26.80) of the left axilla. The incidence of variations in origin of the TAT and its branches was found higher on right side. The knowledge of these variations is of anatomical and surgical interest. This information is useful for the surgeons dealing with the axillary region especially in case of reconstructive surgery.
Anesthetic consideration in downs syndrome--a review.
(2008-09-04) Bhattarai, B; Kulkarni, A H; Rao, S T; Mairpadi, A
Downs syndrome constitutes to be the most common chromosomal disorder. Patients with Downs's syndrome are posted for several surgeries including dental procedures and even for facial reconstruction. They are associated with several congenital anomalies in different organ system. There is also increased incidence of atlanto axial instability and risk of spinal cord injury. These children are susceptible to infection and they are also considered to be hypersensitive to the effect or atropine. These all factors modify the anesthetic implication and also anesthetic management in these cases. We have highlighted all these factors and reviewed the anesthetic implication of these child posted for several procedures under anesthesia.
Angiolymphoid hyperplasia with eosinophilia (alhe): a rare entity for otolaryngologist.
(2006-09-06) Ghimire, Anand; Singh, Ishwar; Bhattarai, Manav; Pandey, Sagar Raj
A case of angiolymphoid hyperplasia with eosinophilia (ALHE) is reported. It is a rare and new disease for an otolaryngologist. The difference between the Kimura's disease and ALHE has been discussed. Though it is rare, ALHE should be kept in differential diagnosis for an auricular swelling.
Angle closure glaucoma: a cause for bilateral visual threat.
(2006-09-06) Shakya, Suraj; Gupta, Himanshu Ravi
Glaucoma is one of the leading causes of blindness worldwide. Primary angle closure glaucoma (PACG) is a leading cause ofblindness in East Asian people and known to cause bilateral blindness more frequently than other glaucoma. A retrospective study was thus undertaken to see the visual profile among these cases attending glaucoma unit. Total of 387 cases of angle closure glaucoma were seen in 3 years period. Out of these, 278 (71.8%) were females and 109 were males (28.2%). Among total cases, 61.5% had chronic angle closure glaucoma (CACG) and 38.5% had acute angle closure glaucoma (AACG) in one or both eyes. Bilateral angle closure attack was encountered simultaneously in 16 of the total acute angle closure cases accounting for 10.7%. Vision evaluation at the time of diagnosis among chronic angle closure glaucoma revealed blindness in 97 patients accounting for 20.4%. In acute glaucoma cases, after breaking the acute attack, the prevalence of blindness was found to be 8.9% out of total cases. Bilateral blindness was seen in 17.6% of total cases presented with either acute attack or chronic glaucoma. Mean intraocular pressure (IOP) was 32 mmHg (SD = 9.456) and 44 mmHg (8.67) in CACG and AACG respectively. Cataract was associated in 15.1% of CACG and 12.8% of AACG. Cataract related blindness was presumed to be present in only 4.1% cases of CACG and 14.3% of AACG cases who were blind. (p = < 0.001) Angle closure glaucoma is the frequent cause of bilateral blindness.
Antibiogram pattern of isolates from UTI cases in Eastern part of Nepal.
(2005-12-08) Kumari, Namrata; Ghimire, Gyanendra; Magar, Jeet Kumari Gharti; Mohapatra, Tribhuwan Mohan; Rai, Amreshwar
The present study was conducted to study antibiogram pattern of isolates from urinary tract infection (UTI) cases at a referral hospital in Eastern Nepal. Of the total 2,799 of urine samples studied, 720 (25.7%) were positive for some kinds of bacterial agents. Escherichia coli was most predominant organism (59.0%) followed by Klebsiella sp. (12.6%), Pseudomonas aeruginosa (6.9%), Acinetobacter sp. (5.9%), Enterococcus sp. (4.2%) and others (2.6%). Antimicrobial susceptibility testing was done by Kirby-Bauer's disc diffusion method following National Committee for Clinical Laboratory Services (NCCLS) guidelines. Most strains of Esch. coli and Klebsiella sp. were resistant to Ampicillin and Ciprofloxacin. Ps. aeruginosa and Acinetobacter sp. showed relatively higher resistance to Aminoglycosides. These organisms were often multidrug resistant. Ps. aeruginosa showed 68.0% resistance to even Ceftazidime. For Enterococcus sp. Nitrofurantion and Gentamicin were the drugs of choice. Of the all antimicrobial agents tested, Ciprofloxacin showed most disappointing result.
Antibiotic susceptibility pattern of urinary isolates in Imphal (Manipur), India.
(2007-09-21) Yengkokpam, Chitra; Ingudam, Dayanand; Yengkokpam, Ibotomba Singh; Jha, Bijay Kumar
The present study was conducted to detect aerobic causative agents of urinary tract infection (UTI) and their antibiogram pattern. This study was carried out in the Department of Microbiology, Regional Institute of Medical Sciences (RIMS), Imphal, Manipur, India. A total of 1,109 clean catched midstream urine samples were collected, out of which 459 (40.4%) samples grew potential pathogens causing UTI. Escherichia coli were the predominant 334 (72.8%) bacterial pathogen followed by Klebsiella species 66 (14.4%), non lactose fermenters 19 (4.1%), Pseudomonas species 16 (3.5%) and others. Most of the strains of E. coli were resistance to Ciprofloxacin whereas sensitive to Aminoglycoside. Most of the urinary isolates showed high degree of resistance to Tetracycline, Norfloxacin and Cotrimoxazole. Gentamycin was the drug of choice for most of the strains.
Antiepileptic TDM pattern at a tertiary care hospital in India.
(2006-06-05) Jose, Vinu Mulavarickal; Medhi, Bikash; Pandhi, Promila
Therapeutic drug monitoring, a comparatively new investigational procedure in clinical pharmacology, is considered very beneficial to epilepsy patients though it increase the health care cost. Aim of this study was to determine the pattern of use of antiepileptic drug level monitoring over the last 7 years in our tertiary care centre and to critically comment on its utility. Retrospective data audit of archived data from 1998 to 2004 and age, sex, estimated levels of phenytoin, carbamazepine and phenobarbitone by HPLC were noted down, tabulated and compared. Chi square test was used for analysis. Three thousand five jundred thirty four blood samples of patients requesting for 4213 estimations of phenytoin, phenobarbitone or carbamazepine were received. Among the obtained samples, 44.0% (1058) were of children, 68.0% (2402) were of males, 0.6% (22) patients were getting 3 and 18.0% (635) getting 2, antiepileptic medications. 13.0% (546) samples showed level in the toxic range and 39.0% (1653) in lower range. There was increasing demand observed for estimation of antiepileptic drugs, over the 7 years. The number of abnormal values of phenytoin, phenobarbitone and carbamazepine did not show any significant difference over the years. The pattern was similar to that observed in other countries.
Articular branch of the axillary artery and its clinical implication.
(2003-12-18) Pandey, Shashi Kant; Shamal, Satyanaryan; Kumar, Sushil; Shukla, Vijay Kumar
Origin and course of the articular branch of the axillary artery was recorded in 151 (43.9%) out of 344 axilla during the routine dissection. The branch was observed in 60.5% right side and 39.4% left side of male axilla, whereas in 55.5% right and 44.4% left side of female axilla and the difference was found significant (P < 0.001) among the gender. The orientation of the articular branch on right and left side was of similar proportion in both the sexes. The articular branch entered into the shoulder joint either upper, middle or lower part of the capsule of joint. This articular branch originated mostly from the lateral aspect of second part of the axillary artery below to the origin of the lateral thoracic artery. This is a rare observation and is of importance to clinicians dealing with the shoulder joint.
Assessment of carotid artery dimensions by ultrasound in non-smoker healthy adults of both sexes.
(2006-09-06) Limbu, Yuba Raj; Gurung, Ghanshyam; Malla, Rabi; Rajbhandari, Rajib; Regmi, Shyam Raj
Assessment of carotid artery lumen diameter and intima-media thickness is becoming as a surrogate marker of early evaluation of cardiovascular disease. Present study aims to describe the normal carotid dimensions in healthy adults of both sexes. A total of 123 healthy volunteers including 65 men and 58 women, aged 21 to 60 years (mean +/- SD; 35.66 +/- 8.84 years) were studied. Ultrasound study of both carotid arteries were performed with a 7.5 MHz linear array transducer. Common carotid artery lumen diameter ranged from 4.3 mm to 7.7 mm. Difference was not noted between left and right common carotid artery lumen diameter (5.78 +/- 0.57 mm and 5.86 +/- 0.66 mm), and internal and external carotid artery lumen diameter as well. Both left and right common carotid artery, internal and external carotid artery lumen diameter tended to be larger (p < 0.05) in men than women. Common carotid artery intima-media thickness ranged from 0.4 mm to 0.8 mm. Difference was not noted between left and right common carotid intima-media thickness when separately analyzed among men, women and the entire population. Difference was also not noted in comparison between men and women. Conclusion: Common carotid artery and internal and external carotid artery lumen diameter tends to be larger in men than women among young adults. There is no difference between left and right carotid artery lumen diameter. Common carotid artery intima-media thickness is similar in comparison between left and right and both sexes.

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