Journal of BP Koirala Institute of Health Sciences

Uptake of Health Services by People from the Dalit Community

Raksha Thapa, E. van Teijlingen, P. Regmi, V. Heaslip — Sun, 26 May 2019 07:37:28 +0000

DOI: https://doi.org/10.3126/jbpkihs.v1i2.22072

Studies and reports on uptake of health services in Nepal and other low-income countries often focus on limitations due to physical factors, such as travel distance to health facility, or lack of medical facilities or electricity at the health care centre or focus on resources, such as lack of service providers, or lack of appropriately trained staff.

In this editorial article, we highlight the importance of discrimination as a reason for people not seeking available health care. Discrimination is particularly a barrier to service usage among the most deprived people in society, such as the Dalit community in Nepal and South Asia more generally. We discuss the caste-based discrimination in Nepal and its effects on health outcomes of those groups who experience such discrimination.

Keywords: Health Services, Dalit Community

Comparison of the Outcome between Conventional Open Technique and Minimally Invasive Technique Using Dynamic Hip Screw for Fixation of Inter-Trochanteric Fracture of Femur

Rajiv Maharjan, S.R. Paneru, R. Rijal, P. Chaudhary, G.P. Khanal — Sun, 26 May 2019 07:38:52 +0000

DOI: https://doi.org/10.3126/jbpkihs.v1i2.22073

Background: Inter-trochanteric fracture of femur causes significant morbidity and mortality in elderly. Dynamic Hip Screw (DHS) fixation is the most effective and safe method of treatment. Conventional open technique (CDHS) is the popular and familiar one; however, minimal incision technique (MIDHS) has many advantages like: smaller incision, lesser dissection/blood loss, less requirement of transfusion, less painful, faster recovery etc.

Objectives: To Compare CDHS and MIDHS technique of DHS fixation for inter-trochanteric fracture femur in terms of functional outcome, safety and associated complications (if any).

Methods: Eligible patients presenting within study period were randomized into CDHS group (n= 33) and MIDHS group (n= 32). Success of randomization was tested by analyzing demographics, injury characteristics and pre-op. clinical data (p> 0.05). They were followed up at 2, 6, 12, 24 and 52 weeks post-op. for clinico-radiological and functional assessment.

Results: The duration of surgery, lag screw positioning, post-operative hospital stay and surgical site infection were not significantly different between the groups. However, need for blood transfusion, length of incision and post-operative VAS score for pain were significantly lesser for MIDHS group than CDHS group (p< 0.05). Patients in MIDHS group started walking with aids significantly earlier in post-operative recovery period. The Harris Hip Score at final follow-up and grading of the results and surgical complications were not significantly different between the groups.

Conclusion: The minimal incision technique had various immediate / short term advantages over conventional technique; like: minimal scar, minimal soft tissue dissection / less blood loss requiring less transfusion, lesser pain in post-operative period and ability to ambulate early.

Keywords: Dynamic hip screw, Intertrochanteric fracture, Conventional technique, Mini-incision technique, Harris Hip Score

Cytomorphological Spectrums in Tuberculous Lymphadenitis: Understanding the Stages of Disease

Anju Pradhan, P. Poudyal, P. Upadhyaya, S. Pokhrel — Sun, 26 May 2019 07:39:37 +0000

DOI: https://doi.org/10.3126/jbpkihs.v1i2.22074

Introduction: Tuberculous lymphadenitis is the most common form of extrapulmonary tuberculosis and one of the main causes of lymphadenopathy. Fine Needle Aspiration Cytology (FNAC) has played a substantial role in diagnosis of tuberculous lymphadenopathy and it has become a first-line diagnostic technique. The aim of this study was to describe and understand the spectrum of cytomorphological changes seen in tuberculous lymphadenitis corresponding to stages of disease and to associate the cytomorphological changes with Acid Fast Bacilli (AFB) positivity.

Methods: This is a retrospective cytomorphological study of cytologically diagnosed tuberculous lymphadenitis. The recorded details of clinical presentation and site of the lymph nodes were noted. The slides were stained with Papanicolaou, Giemsa and AFB.

Result: There were a total of 203 cases with age ranging from 3- 75 years. Four cytomorphological patterns observed were Necrotising Granulomatous Lymphadenitis (NGL; 45.32%), Granulomatous Lymphadenitis (GL, 18.22%), Necrotising Suppurative Lymphadenitis (NSL; 21.18%) and Necrotising Lymphadenitis (NL; 15.27%). Necrotising patterns were observed in immunocompromised individuals like HIV infected patients, in patients with previous history of tuberculosis and in patients with chronic renal disease. Strong AFB positivity was observed in necrotising patterns. Lymph nodes of head and neck region were the most common site of involvement with cervical being the commonest.

Conclusion: Necrotizing patterns are observed in the later stages of disease or in the immunocompromised patients. Strong positivity for AFB is observed in the smears with necrotizing patterns and less in the granulomatous pattern.

Keywords: cytomorphology, Fine Needle Aspiration Cytology, Granulomatous Lymphadenitis, Necrotising Suppurative Lymphadenitis, Tuberculous Lymphadenitis

cytomorphology, Fine Needle Aspiration Cytology, Granulomatous Lymphadenitis, Necrotising Suppurative Lymphadenitis, Tuberculous Lymphadenitis

Ectopic Pregnancy and its Risk Factors: A Case Control Study in Nepalese Women

G. Bhandari, K. K. Yadav, R. Shah — Sun, 26 May 2019 07:40:40 +0000

DOI: https://doi.org/10.3126/jbpkihs.v1i2.22075

Introduction: Ectopic pregnancy is a significant cause of maternal mortality and morbidity during the first trimester. The major risk factors for ectopic pregnancy include prior tubal infections, previous ectopic pregnancy, previous abortions, use of intrauterine contraceptive devices, contraception failure, tubal surgeries, infertility and use of artificial reproductive pregnancies. This study was carried out to evaluate the effect of different risk factors in the causation of ectopic pregnancies among women in the Nepalese setting.

Materials and methods: This was a case-control study conducted at Kathmandu Medical College comparing 39 cases of ectopic pregnancies with 39 controls consisting of intra-uterine pregnancies. The suspected cases were confirmed through clinical examination, trans-abdominal or trans-vaginal ultrasonography and serum β-hCG levels with further confirmation obtained after laparotomy / laparoscopy among cases who underwent surgery. The two study groups matched with age, gravidity and contraceptive uses were studied. History of previous abortions, previous ectopics and past abdomino-pelvic surgeries were also studied.

Results: There was statistically significant difference in the incidence of contraceptive failure among the two groups (p-value= 0.032) with women with such history having a relative risk of 1.667 with odds ratio of 3.400. The risk posed by previous abortions and previous ectopics wasn’t found significant (RR= 1.000 and 2.053 respectively). The history of past abdomino-pelvic surgeries also showed significant role in causation of ectopics (RR= 1.094).

Conclusion: Among different risk factors studied, the contraception usage was the most significant risk factors. Oral contraceptive pills was the most identified among the contraception used in cases of ectopic pregnancy.

Keywords: Ectopic pregnancy

The Effect of Pterygopalatine Fossa Block (PPFB) during Endoscopic Sinus Surgery (ESS) on Intraoperative Bleeding: A Randomized Control Trial

Deepak Paudel, S.T. Chettri, S.P. Shah, B.P. Shah, S. Manandhar, S. Mishra — Sun, 26 May 2019 07:41:32 +0000

DOI: https://doi.org/10.3126/jbpkihs.v1i2.22076

Background: Bleeding is the frequent intraoperative complication in most of the surgeries and remains a challenge for the surgeons and anesthesiologists. Major blood loss during FESS is rare but even a small amount of bleeding disturbs the endoscopic surgery field, increases the likelihood of complications, lengthens the time of surgery and results in incomplete surgery. The greater palatine canal (GPC) local injection is used to limit posterior bleeding during sinus surgery.

Objective: To study the effect of pterygopalatine fossa block on intraoperative bleeding and operative field optimization during endoscopic sinus surgery.

Methods: Prospective double blind randomized control trial. Thirty six patients were recruited in the study who also acted as their own control. PPFB was done only on one side of the nostril and the side was randomized by the lottery; neither the patient nor the operating surgeons were aware of the laterality. Boezaart score was used to quantify the intra-operative blood loss.

Results: Blood loss between block group and non-block group was compared. Patients in block group had more stable hemodynamics with no fluctuations, better visibility of the surgical field and decreased blood loss as compared with non-block group.

Conclusion: Greater palatine fossa block is a useful adjunct in patients undergoing endoscopic sinus surgery. It provided more stable hemodynamics, good operative conditions by lowering blood loss.

Keywords: Bleeding, FESS, Pterygopalatine

Profile of Medico-legal Cases Coming to Emergency ward of B. P. Koirala Institute of Health Sciences

Ajay Kumar Yadav, B. Shah, S.S. Budhathoki, S. Chaudhuri, B.D. Aryal, G.B. Malla — Sun, 26 May 2019 07:43:41 +0000

DOI: https://doi.org/10.3126/jbpkihs.v1i2.22078

Background: Medico-legal case usually presents as an emergency case in any hospital. Profiling of these cases provides with evidence on the burden of the medico-legal cases and identifying ways to better manage these cases in the emergency ward of hospitals.

Objective: To study the profile of medico-legal cases coming to the emergency ward of B. P. Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal.

Material & Methods: We conducted a retrospective review of all medico-legal cases presenting in the emergency ward of BPKIHS from April 2015 to March 2016. The cases were profiled for socio-demography, injury and diagnosis from the medico-legal register at the emergency ward of BPKIHS.

Results: Medico-legal cases comprise almost 10% of all cases at the emergency ward of BPKIHS. A total of 3,715 cases were included in this study. Half (50.0%) of the cases fell in to the category of 25-59 years. Males were almost twice (62.7%) in number, compared to females (37.3%). The top three diagnoses among medico-legal cases are road traffic accidents (41.81%), physical assault (21.13%) and poisoning (20.08%). Other diagnoses were burns, fall injury, sexual assault, self inflicted injury, hanging, gunshot injury, stab injury, machinery injury, drug overdose, blast injury, brought dead, trauma by animal, electrical injury, snake bite and human bite.

Conclusions: There are significant numbers and wide varieties of medico-legal cases that present in the emergency ward of BPKIHS. Given the large number of cases presenting at BPKIHS, there is a potential for future research on medico-legal cases for academic and policy purpose.

Keywords: Medico-legal profile, Road traffic accidents, Injuries in Nepal

Real time Ultrasound Guided Percutaneous Native Renal Biopsy- Approach, Safety and Complications

Ashok Raj Pant, R.K. Rauniyar, M.K. Gupta, B. Bartaula, M. Subedi, S. Dhakal — Sun, 26 May 2019 07:44:36 +0000

DOI: https://doi.org/10.3126/jbpkihs.v1i2.22080

Introduction: Ultrasound guided percutaneous renal biopsy (PRB) is a relatively safe procedure; however, life threatening complications may occur even in current practice. There has been considerable decrease in the risk associated with percutaneous renal biopsy (PRB) in last few decades due to modifications in the biopsy needle as well as advancement in the image guidance.

Objectives: To determine the complications and efficacy and to determine relationship between the clinical/ laboratory findings with rate of complications.

Material and methods: We retrospectively evaluated hospital records of total of 150 patients who underwent PRB between September 2014 to August 2016 in the department of Radio diagnosis and Imaging at B. P. Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal. The renal biopsies had been performed with the current automated biopsy gun under real-time ultrasound guidance. The collected data were entered in MS excel.

Results: In the total 150 patients, the efficacy (adequacy of the sample) of the procedure was 97.3%. The complications were seen in 13 cases (8.6 %). Five out of these complications were major with 2 cases requiring blood transfusion. The univariate analysis demonstrated the risk factors for developing complications as follows: low platelet count, prolong PT/INR, elevated Blood Urea Nitrogen (BUN) and serum creatinine value and elevated systolic and diastolic blood pressure. However, elevated diastolic blood pressure and prolong PT/INR were associated with complications in multivariate logistic regression analysis.

Conclusions: The percutaneous renal biopsy is the safe and efficacious procedure to establish histological diagnosis of renal parenchymal disease.

Keywords: Complication, Efficacy, Percutaneous Renal Biopsy (PRB), Safety

Factors Contributing to Kerosene Oil Poisoning in Children

Arun Kumar Singh, P.K. Gurung — Sun, 26 May 2019 07:45:48 +0000

DOI: https://doi.org/10.3126/jbpkihs.v1i2.22081

Introduction: Kerosene has been identified as the most common cause of accidental poisoning around the world with majority occurring to either lower or middle income countries. Kerosene poisoning is identified as the fourth leading cause of injury related mortality in children with highest risk for acute poisoning occurring in child under five years of age.

Objectives: To identify common factors responsible for exposure to kerosene oil poisoning, its presenting features and outcomes in children.

Methods: This was a descriptive study conducted in Department of Pediatrics and Emergency Department, Mayo Hospital / King Edward Medical University Lahore, Pakistan from March to September 2015.

Sixty children between the ages of 6 months to 10 years with history of kerosene oil ingestion/ poisoning were enrolled in the study. Information was obtained from guardians or parents.

Results: Sixty patients with history of kerosene poisoning were seen during the summer season. Age ranged from 6 months to 10 years. Most patients were from the ages 1 and 3 years and 75% were boys. Most children were from poor socioeconomic condition. The containers were soft drink bottles and plastic bottles; and kitchen and stairs were the common sites of storage. Clinical presentations were cough, vomiting and tachypnea. One child in study died after 8 hours secondary to respiratory complication.

Conclusion: Kerosene oil is a common health hazardous substance ingested accidentally by children. There is a need to create public awareness regarding kerosene oil storage and accessibility at home from the younger children.

Keywords: Children, Kerosene Oil, Poisoning, Preventive Measure

Risk Factors and Outcome of Patients with Obstetric Anal Sphincter Injuries (OASIS)

Rabindra D. Bhatt, S. Sitaula, T. Pradhan, T. Manandhar, T. Basnet — Sun, 26 May 2019 07:47:16 +0000

DOI: https://doi.org/10.3126/jbpkihs.v1i2.22082

Background: Anal incontinence is an embarrassing condition that is largely underreported. Obstetric anal sphincter injuries are the most important etiological factors. Anal sphincter injury during delivery is considered to be one of the major risk factors for fecal incontinence in women. After anal sphincter injury at the time of delivery, up to 50% women have complaints of fecal incontinence, mainly because of persisting sphincter defects.

Objectives: To evaluate the risk factors for the occurrence of obstetric anal sphincter injuries during vaginal delivery. To evaluate the outcome of patients with obstetric anal sphincter injuries.

Methodology: A retrospective descriptive study was conducted from 2014 to 2016. Data of all patients with Obstetric Anal Sphincter Injuries (OASIS) over 3 years was collected from the medical record section after ethical clearance from Institutional Review Committee (IRC), BPKIHS. The data was entered in the excel sheet and analyzed using SPSS 17.

Results: The Most important risk factor of OASIS was operative vaginal delivery (vacuum assisted vaginal delivery), followed by birth weight of the baby greater than 3.5 Kg and primigravida.

Conclusion: Patients undergoing operative vaginal delivery, primigravida and birth weight greater than 3 kg are the important risk factors for OASIS. So, patients with these conditions should be handled carefully during second stage of labor to prevent the occurrence of OASIS.

Keywords: Birth weight, Childbirth, Obstetric Anal Sphincter Injury, Operative Vaginal Delivery

Opportunistic Fungal Infection in HIV Positive Patients Attending a Tertiary care Hospital in Eastern Nepal

Rinku Sah, R. Gurung, N. Poudyal, R. Baral, S. Rijal, S.K. Bhattacharya — Sun, 26 May 2019 07:49:17 +0000

DOI: https://doi.org/10.3126/jbpkihs.v1i2.22084

Background: HIV infection continues to be a major health problem with more than millions of AIDS related death annually. The risk of opportunistic infections increases with the depletion of CD4+ count in HIV positive patients which are responsible for the high mortality and morbidity. The spectrum of opportunistic infection (OIs) varies from one region to another. This study was carried out to see the occurrence of opportunistic fungal infection among the HIV positive patients in Eastern Nepal.

Method: This was a hospital based descriptive study carried out in Microbiology laboratory, BPKIHS, Dharan, Nepal over a period of one year (15^th May 2013 to 14^th May 2014). Total 60 HIV positive patients with CD4+ count ≤200 cells/mm³ and suspected of having fungal infections were included. Samples were collected after taking an informed written consent from the patient. Isolation and identification was done as per standard Microbiological procedure.

Result: Opportunistic fungal infection was identified in 51.66% patients. The most common fungi isolated were Candida species, Cryptococcus neoformans, Aspergillus species and Dermatophytes respectively being 33.3% (n= 20), 10% (n= 6), 3.3% (n= 2) and 8.3% (n= 5). Candida species comprised 60%, Cryptococcus neoformans 20%, Aspergillus species 5.7% and dermatophytes 14.3% of total fungal isolates.

Conclusion: The common fungus isolated were Candida species, Cryptococcus neoformans, Aspergillus species and Dermatophytes in HIV positive patients in this hospital of Eastern Nepal.

Keywords: Fungus, HIV, Opportunistic Infection

Computerized Tomography of the Brain for Elderly Patients Presenting to the Emergency Room with Acute Confusion State in Eastern Nepal

Shakuntala Kumari, B.K. Rai, R. Bhandari, S.N. Gupta, K. Ahmed — Sun, 26 May 2019 07:51:00 +0000

DOI: https://doi.org/10.3126/jbpkihs.v1i2.22086

Background: Acute confusion is a common reason for presentation of elderly patients to the emergency which may be of neurological or non-neurological origin. Computerized tomography (CT) scans are often routinely ordered to investigate the cause.

Objective: To determine the usefulness of CT scan brain in confused elderly patients.

Methods: A cross-sectional observational study was conducted in emergency room (ER) of B. P. Koirala Institute of Health Sciences over a period of 6 months in 84 patients above the age of 65 years who had CT scan brain done in view of acute confusion. They were reviewed for symptoms, indications of CT scan and presence of focal neurological deficits (FND).

Results: Among patients presenting in confusion and with loss of consciousness or limb weakness, CT scan was abnormal in 90% and 92% cases respectively (p <0.05) whereas those presenting with fever, cough, headache, dizziness, seizure in confusion also had abnormal CT but was statistically not significant (p> 0.05). Out of 84 elderly cases of acute confusion, 52 had FND and the remaining 32 cases were without FND. Among those with FND, 40% and 46% cases had features of ischemic and hemorrhagic stroke respectively. Among the 32 without FND, 66% patients had normal scan and 38% had cerebral atrophy. In patients with Glasgow Coma Scale (GCS) < 9 with FND, 75% had CT scan suggestive of hemorrhagic stroke whereas those with GCS> 13 with FND, 57% and 29% cases had ischemic and hemorrhagic stroke respectively.

Conclusion: CT scan brain for confused elderly should be advised for those with focal neurological symptoms and may be suggested in cases of head trauma or alleged history of fall irrespective of GCS and symptomatology.

Keywords: Computerized tomography, Emergency room, Acute confusion, Elderly

Pattern of Morbidity and Mortality due to Road Traffic Accident at College of Medical Sciences, Chitwan, Nepal

Ava Upadhyay Pohrel, A. Acharya, A. Yadav — Sun, 26 May 2019 07:42:22 +0000

DOI: https://doi.org/10.3126/jbpkihs.v1i2.22077

Background: Road traffic accident (RTA) which is recognized as a public health problem is one of the fastest growing epidemics in the South-East Asian Region. Every hour, 40 people in the region die as a result of collision.

Objectives: To estimate the morbidity and mortality of RTA victims and also to assess the pattern of the RTAs at College of Medical Sciences Teaching Hospital, Bharatpur, Chitwan.

Methods: This was a cross-sectional study including 100 RTA victims who attended College of Medical Sciences Teaching Hospital, Bharatpur during 2013.

Results: Majority of RTA victims were male (76%) and in the age group between 20 and 39 years (48%). Maximum numbers of accidents occurred between 12 noon to 12 midnight (79%). More accident occurred on Friday (23%). Most of the RTAs occurred on motor bike (42.0%) and the most common nature of accident was through collision of the vehicle and fall/slide of moving vehicle (56.0%). Abrasion was the most common injury occurred during the RTA (91%). Almost two-thirds of the victims had laceration, nearly half had swelling and 26% had fractures. Four percentages of victims had fatality. Bad condition of road (37.0%) and speedy driving (23.0%) were the leading causes of RTA. There were 15.0% of victims who were under the influence of alcohol in RTA.

Conclusion: There was high number of male victims with motorbike as the major contributor. Abrasion, laceration and fatality were found. Bad condition of road, speed driving and alcohol habit during driving were found to be the leading causes of RTA.

Keywords: Morbidity, mortality, road traffic accident, Nepal

Prevalence of Histologically Proven Acute Appendicitis and Incidental Carcinoid Tumour in the Practice of Surgical Pathology at BPKIHS

Paricha Upadhyaya, C.S. Agarwal, A.K. Karak, S. Karki, A. Pradhan, T.N. Subba — Sun, 26 May 2019 07:48:07 +0000

DOI: https://doi.org/10.3126/jbpkihs.v1i2.22083

Background: Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention.

Objectives: To determine the relative prevalence of histologically proven acute appendicitis in surgically resected specimens with clinical diagnosis of acute appendicitis and to find out the rate of occurrence of carcinoid tumour as an incidental histologic finding.

Methods:

Type of study- descriptive study

Study unit- all gross specimens received in the department of pathology over a period of twenty months (1.1.2006 to 31.8.2007)

Study sample- Histologic data on 515 appendicectomy samples (clinically diagnosed as appendicitis) of the total 7295 specimens received over a period of twenty months were retrieved from the archives of department of pathology, B. P. Koirala Institute of Health Sciences (BPKIHS).

Exclusion criteria- appendectomy incidental to another surgical procedure.

Results: Appendectomy specimens constituted 7.0% (n= 515; M:F 1.1:1) of all surgical pathologic specimens (n= 7295) at BPKIHS. Following is the breakup of histologic diagnosis: acute appendicitis with or without periappendicitis and gangrenous change (93.6%, n= 482), receding appendicitis (5.4%, n= 28), normal histology (1.0%, n= 5). Carcinoid tumours were detected incidentally in three cases (0.58%) out of the total number of 515 appendectomy specimens.

Conclusion: Analysis of data revealed

A relatively higher prevalence (6.99%) of histologically proven acute appendicitis in this Tertiary health care set up compared to similar data reported in the literature.
Rate of occurrence (0.58%) of carcinoid tumour as incidental finding is similar to that reported in the literature.
Keywords: Appendectomy, Appendicitis, Appendix, Carcinoid Tumor

Randomized Clinical Trial Comparing Botulinum Toxin Injection with Nitroglycerine Ointment for Treatment of Chronic Anal Fissure

Binaya Timilsina, C.S. Agarwal, S. Adhikari, S. Agrawal, R.K. Gupta — Sun, 26 May 2019 07:50:07 +0000

DOI: https://doi.org/10.3126/jbpkihs.v1i2.22085

Background and Objectives: Although surgery is the gold standard treatment for anal fissure, the main concern remains its side effects and complications in terms of permanent incontinence. In recent years, treatment of chronic anal fissure has shifted from surgical to medical. This study compares the efficacy and safety of two non-surgical treatments- botulinum toxin (BTX) injection with nitroglycerine (NTG) ointment for the treatment of chronic anal fissure.

Methods: One hundred and twelve adults were assigned randomly to receive treatment with either type A botulinum toxin (15 units) injected into internal anal sphincter or 0.2% nitroglycerine ointment applied thrice daily for 8 weeks.

Results: After 2 months, the fissures were healed in 50 (89.3%) of 56 patients in botulinum toxin group and in 39 (69.6%) of 56 patients in nitroglycerine group (P= 0.01). Seventeen (23%) patients in nitroglycerine group complained of headache while none of the patients in botulinum toxin group had any forms of adverse effects. The recurrence rate of nitroglycerine group was higher than botulinum toxin group at 3 months (4.3% in BTX vs 16.7% in NTG, P = 0.057) and at 6 months (8.5% in BTX vs 36.1% in NTG, P = 0.002).

Conclusion: Although treatment with either topical nitroglycerine or botulinum toxin is effective as an alternative to surgery for patients with chronic anal fissure, botulinum toxin is the more effective option.

Keywords: Chronic anal fissure, Botulinum toxin, Nitroglycerine

Physiological Amputation of Limb (Limb Gangrene) after Tourniquet Application for 12 days following Snake Bite

Ashok Kumar Yadav, R. Bhandari, A.K. Agrahari, R. Gupta, M.K. Shah — Sun, 26 May 2019 07:51:48 +0000

DOI: https://doi.org/10.3126/jbpkihs.v1i2.22087

Background: Application of tourniquet and herbs has been practiced since a long time in patients with different reptiles’ and arthropods’ bite at rural areas of the country, despite various cases of cellulitis and gangrene.

Objective: To report a case of limb gangrene following tourniquet and herb application for snake bite.

Case: A 20-years old farmer, who was bitten by a snake, presented to the Emergency department with complaints of blackish discoloration of his left forearm and hand. After clinical evaluation and investigations, patient underwent surgical intervention.

Twelve days following snake bite, patient felt pain, noticed bleeding from bite site, swelling over his left hand, palpitation, shortness of breath and inability to speak. For which, he sought help from a traditional healer who applied a tourniquet over his left elbow and some herbs over the bite site. He noticed blackening of his fingers, which rapidly progressed to involve his left hand and forearm up to the site of tourniquet. He underwent surgery for the gangrenous limb.

Conclusion: Development of gangrene following tourniquet is an unusual finding in modern day medicine. This case report shows the danger related to tourniquet application and need for measures to prevent such incidents in future.

Keywords: Amputation, Gangrene, Snake Bite, Tourniquet

Pantoprazole Induced Thrombocytopenia: a Case report

Deebya Raj Mishra, K. Dahal, P.P. Gupta — Sun, 26 May 2019 07:52:36 +0000

DOI: https://doi.org/10.3126/jbpkihs.v1i2.22088

Proton Pump Inhibitors serve as the cornerstone of management of Upper Gastrointestinal bleeding. In Nepal, intravenous Pantoprazole is widely used. One of the rare complications of intravenous Pantoprazole is thrombocytopenia which may lead to paradoxical increase in bleeding possibility. Here, we present a 70 year old gentleman who presented with hematemesis and melena and was treated with IV Pantoprazole. The Platelet count started decreasing from the third day onwards following which the patient was switched to Rabeprazole on the fourth day. Platelet count subsequently normalized. Thus, drug induced thrombocytopenia is one of the rare complications that has to be kept in mind with the use of Pantoprazole.

Keywords: Pantoprazole, Thrombocytopenia