Journal of KIST Medical College

Research and Publication

Rupesh Mukhia — Thu, 30 May 2019 12:49:06 +0000

Welcome to our inaugural issue of Journal of KIST Medical College (JKISTMC). JKISTMC is a multi-disciplinary, open-access, peer-reviewed, biannually published scientific journal. The journal is the official publication of KIST Medical College, Lalitpur Nepal. KIST Medical College was established with a promise of commitment to excellence in holistic health care, medical education and research. This first issue of the journal is an example of this noble objective of encouraging and promoting the scholar research activity and sharing them to wider range of readers.

In this inaugural Issue we have nine original articles, one case report, one review article, two book reviews and one view point. It is very encouraging for us to receive such diverse yet good quality papers, we would like to thank our contributing authors.

Though there are various reasons for research, we believe that it is done to update our existing practice of health care for overall benefit of the patients. Most of us will probably say that publication will serve only to achieve promotion in the race of faculty ladder from lecturer to professorship but having been involved in academic institutions where you have to deal with practice and principle of medical education, skill and attitude, you have to demonstrate academic talent to peers and your juniors to follow. So rather than compulsion, lets cultivate a culture of scientific research writing and publication and more importantly sustain it. JKISTMC is here to serve as one of the motivating factors as author-friendly, reader-friendly and rich in information medium to carry medical science forward.

When considering for research and publication, every researcher should follow the basic principle of intellectual honesty, however, one of the burning issues regarding publication at present time is the quality of the research papers and unethical practices associated with it. Sad but true, a huge pressure simply to increase the number of publication for promotion has become a major factor for such condition to arise. According to Lackovic, 10,000 scientific papers are published every day worldwide. (1) This is the result of “Publish or perish” syndrome which indicate quantitative rather than qualitative evaluation of scientific papers. Hence question might arise are we heading for corrupt scientific medical literature.2 Citation index is the parameter to gauge your publication. Impact factor (IF) of journal is a measure reflecting the average number of citation to recent articles published in the journal.3 If we look at the data, however, only 45% of the articles published in 4500 top scientific journals are cited within the first 5 years of publication.4 Only 42% of the papers receive more than one citation, 5-25% of these are self-citation by the authors or journals. Majority of publication goes uncited. This means that neither they are appreciated by the peers nor they are of any importance in improving patient care. 2

Medical Students’ Perceptions about Good Teacher

Rano Mal Piryani, Sunil Piryani, Balman Singh Karki — Thu, 30 May 2019 12:49:59 +0000

Introduction: A good medical teacher is one who facilitates the growth of students, make significant impact on the lives of students and pave the way in making quality healthcare professional. The objective of this study was to identify the importance of attributes of good teachers from students’ perspectives.

Methods: This descriptive study was conducted in KIST Medical College, Lalitpur, Nepal. The questionnaire containing four attributes of good teacher were distributed among students of third year MBBS of third batch in August 2013. The students endorsed each attribute on 5 Likert’s scale- 1= Extremely important, 2= Very important, 3= Important, 4= to some extent important and 5= Not important. The data was analyzed using IBMS SPSS version 20.

Results: Overall all students gave importance to all four attributes assessed for a good medical teacher in this study (2.83± 0.90, 3.04± 0.92, 3.05±0.84, and 2.95±0.88). Majority of the students perceived that the teacher must explain concepts/ideas (75%), stimulates interest in subject (63%), demonstrate enthusiasm in teaching (73%) and use appropriate teaching technique (70%).

Conclusion: The findings of this study are consistent with the various studies conducted on perceptions of students about attributes of a good medical teachers but cannot be generalized as the data was collected only from third year MBBS students of one medical college of Nepal. It is recommended to conduct study involving all years of medical, dental, nursing and pharmacy students and teachers from randomly selected schools of Nepal, compare the findings and recommend strategy for teaching learning of students and training of teachers.

Keywords: Attributes; good teacher; medical teacher; Nepali students’ perception.

Spectrum of Lesions in Appendectomy Specimens

Sushama Bhatta, Rupesh Mukhia, Kamal Koirala, Bidur Prasad Osti — Thu, 30 May 2019 12:50:05 +0000

Introduction: Appendectomy for acute appendicitis is one of the most common emergency operations. Histopathological evaluation of surgically removed appendix is routinely performed which can occasionally reveal unusual findings. The objective of our study was to evaluate the spectrum of lesions in appendectomy specimens.

Methods: This was a retrospective study of 682 appendectomy specimens conducted at KIST Medical College. Histopathological records of appendectomy specimens were reviewed and the findings were analyzed.

Results: Most common diagnosis was acute appendicitis (43.3%) followed by acute appendicitis with periappendicitis (38.6%); both of which were common in male in the age group of 21-30 years. The rate of negative appendectomy was 4.7% which was significantly higher in female patients (Chi square=14.454, p<0.001). Incidental pathologies observed were granulomatous appendicitis (0.4%) and mucocele of appendix (0.3%).

Conclusion: Routine histopathological examination of appendectomy specimens reveals different pathologies of appendix which helps to decide further management. Keywords: Appendectomy; Histopathology of Appendix.

Comparative Study of Single Incision Laparoscopic Cholecystectomy with Standard Four Port Laparoscopic Cholecystectomy for Symptomatic Cholelithiasis

Thu, 30 May 2019 12:50:16 +0000

Introduction: Laparoscopic cholecystectomy is gold standard treatment for symptomatic gall stone diseases. Conventionally, it is performed by standard four port technique. Recently, single incision laparoscopic cholecystectomy (SILC) is increasingly being used which is newly developed technique. The aim of this study is to compare the outcome of standard four port laparoscopic cholecystectomy versus single incision laparoscopic cholecystectomy (SILC).

Methods: The study was prospective study conducted in Nobel Medical College Teaching Hospital (NMCTH), Biratnagar. Total 200 patients with diagnosis of symptomatic cholelithiasis admitted through OPD of our hospital were included in the study. The patients were equally divided in two equal groups: 100 in standard four port laparoscopic cholecystectomy (Group A) and 100 in single incision laparoscopic cholecystectomy (Group B) .All age groups and both sexes were included.

Results: Out of 200 patients with symptomatic cholelithiasis, Mean age of the patients in Group A was 41.65±14.37 years and that in Group B was 40.29 ± 14.15years [p=0.500]. The mean operative time in Group A was 37.81±8.39 minutes where as in Group B it was 32.75±7.52 minutes[p<0.001].The mean postoperative pain at 8 hours in Group A was 8.34 ±0.97 and in Group B 8.66 ±0.81[p=0.012], at day one Group A5.45±1.12 and in Group B5 .94±1.29 [p=0.005], at day two Group A 3.74±1.13 and in Group B4.18±1.34[p=0.013].Mean duration of Hospital stay in Group A was 2.39±0.65 and in Group B 2.64±0.67 [p=0.008].In two weeks and subsequent 3 months follow up period, scar look cosmetically better in SILC.

Conclusion: Single incision laparoscopic cholecystectomy is almost comparable with four port laparoscopic cholecystectomy; however, single incision laparoscopic cholecystectomy will be better options for patients concerned about cosmetics.

Keywords: Four port laparoscopic cholecystectomy; single incision laparoscopic cholecystectomy (SILC); symptomatic gall stone disease

Awareness and Knowledge about Uterine Prolapse with the use of Brochure as Health Education Tool

Thu, 30 May 2019 12:50:27 +0000

Introduction: Uterine prolapse is a main public health problem of reproductive age women in Nepal with the prevalence of 17 to 27%. The aim of this study was to assess the effectiveness of a health education tool developed as a brochure for awareness about uterine prolapse. This will contribute to the effort of increasing awareness on various aspects of uterine prolapse among community people by the creation, evaluation and dissemination of this particular awareness brochure.

Methods: The study involved 80 women between the ages of 14 to 59 years who attended the Gynaecological Out Patient Department at KIST Medical College Teaching Hospital from 1st September to 31st October 2017. The knowledge about the uterine prolapse was assessed before and after the administration of awareness tool in the form of the brochure. The participants were first assessed about the knowledge of uterine prolapse before the presentation of the brochure and then they were explained on various aspects e.g. symptoms, causes, prevention and treatment options of uterine prolapse using the brochure with pictures which was prepared by the women who were suffering from the uterine prolapse. After some time they were reassessed using a structured questionnaire. Data were entered into an excel sheet and analyzed. Comparison of knowledge between the pre and post presentation of the brochure was done.

Results: The majority of the participants were in the age group of 20 to 45 years. Maximum numbers of participants (90%) were from other districts and only 10% were from Kathmandu district. Among them, 77% had heard of uterine prolapse (UP) and 23% had never heard of it. Regarding the symptoms of UP, before the presentation of brochure 63.7% didn’t know about the symptoms and after the presentation, 98.7% could cite at least two symptoms. Regarding the cause of the UP, before the presentation of the brochure, only 53.7% could tell about one cause of UP and afterwards, 100% could remember at least 2 causes of UP. Knowledge about treatment options increased to 97.5% from only 56.2% before the presentation of the brochure.

Conclusions: The findings of the study reflect that the use of a brochure in health education was highly effective in enhancing knowledge and awareness about UP. This brochure can be used in more extensive public awareness programs in the community. Keywords: Awareness; Brochure; Effectiveness; Knowledge; Uterine prolapse

A Clinico-Bacteriological Study of Pyodermas at a Tertiary Health Centre

Manisha S Basukala, Reema Shrestha, Geetika KC — Thu, 30 May 2019 12:50:32 +0000

Introduction: Bacterial infections of skin constitute a large proportion of skin diseases. Primary infections are most frequently incited by Staphylococci. They are also the most common invaders in secondary infection. The uncontrolled use of antibiotics has resulted in spread of multiresistant strains of Staphylococcus aureus. The most probable reason is the widespread use of antibiotics and often choosing an inappropriate drug. The objective of the study is to analyze the common primary and secondary pyodermas, the pattern of pathogens involved and their antibiotic sensitivity isolated from pus culture.

Methods: This study was conducted using clinical diagnosis of pyodermas, using pus culture and sensitivity pattern over a period of 1 year from January 2016 – January 2017.The ethical approval for the study was obtained from the Institute’s Ethical Board. Data was analyzed using SPSS … and expressed as descriptive statistics.

Results: During the study period, 118 pus culture and sensitivity reports were analyzed.. Males outnumbered females. Lower extremity was the commonest site of predilection. Primary pyodermas outnumbered secondary pyodermas. 27 Follicultis ( 40.2%) and 14 Infected Scabies(27.5%) were the commonest entities among primary and secondary pyodermas respectively. Staphylococcus aureus was the commonest causative agent in both primary and secondary pyoderma. It showed high sensitivity to Cloxacillin and Cephalexin and a high rate of resistance to Erythromycin and Ampicillin.

Conclusion: In patients with primary pyodermas, Cloxacillin should be the first line antibiotic used, with Erythromycin as a useful but less preferred alternative. The favoured combination of Ampicillin and Cloxacillin has little place in routine treatment of skin infections, except for cellulitis and infected eczemas. A Cephalosporin can also be used in these conditions if single drug therapy is desired. The secondarily infected ulcers are difficult to treat and would probably require the use of combination therapy in view of frequent mixed infections.

Keywords: Pus culture, Resistance, Sensitivity

Abortion-Related Near-Miss at KIST Medical College and Teaching Hospital

Thu, 30 May 2019 12:50:38 +0000

Introduction: This study aims to determine the frequency of abortion-related near-miss events by applying WHO near-miss criteria, the complications and its management associated with the near-miss events encountered at KIST Medical College Teaching Hospital.

Methods: This hospital based descriptive study was conducted from January 2015 to July 2018 in the department of Obstetrics and Gynecology, KIST Medical College and Teaching Hospital. Case eligibility was defined by WHO Near-Miss Guidelines. Medical records of the patients were used to generate the data. The data generated and analyzed included age and parity, clinical conditions for near-miss and management of abortion related near-miss complications. Results were presented in mean ± SD and percentages, wherever applicable.

Results: There were 5041 total admission in the study period of which 4073 accounts for Obstetric admission and 968 gynecological admissions. There were 320 abortion-related admissions (33.05%) with 37 abortion-related near-miss cases. Near miss morbidity constituted 11.6% of abortion-related admissions. The major factors contributing near-miss events were severe anemia (45.92%) followed by septic shock (27.02%), hypovolemic shock (21.62%), renal failure (2.7%) and uterine perforation (2.7%). Blood transfusion was needed in 24 cases (64.9%); 21 cases (56.7%) required transfusion <5 unit and 3 cases (8.2%) required massive blood transfusion (>5units), 11 cases(29.7%) required ICU management, 1 case(2.7%) required hemodialysis and 1 case(2.7%) required subtotal hysterectomy.

Conclusions: Unsafe abortion is a leading and easily preventable cause of maternal morbidity and mortality.Despite various efforts and liberalization of abortion laws, unsafe abortion remain the major public health concern in developing countries.Abortion-related near-miss cases, are a useful indicator of the most unsafe abortions and a proxy for mortality.

Keywords: Abortion-related near miss; unsafe abortion; WHO criteria

Change in Renal Function after the Use of Intravenous Contrast Media for Contrast Enhanced Computed Tomography - a Hospital-based Quasi Experimental Study

Rupesh Sharma, Awadhesh Tiwari, Sumnima Acharya, Sudeep Regmi, Phanindra Neupane — Thu, 30 May 2019 12:50:53 +0000

Introduction: Iodinated contrast enhanced computed tomography is a common radiological procedure. As 99% of the contrast is excreted via kidneys, we conducted this study to see if there is any change in renal function after the administration of intravenous contrast and also to see the incidence of contrast induced nephropathy in patients with normal renal function.

Methods: This is a hospital based quasi-experimental study comprising a total of 114 patients undergoing contrast enhanced computed tomography. A convenience sampling was done. Precontrast serum creatinine value was recorded. A repeat serum creatinine was assessed within 24-48 hours after contrast administration. Estimated Glomerular Filtration Rate was calculated based on Modification of Diet on Renal Disease (MDRD) formula. The values were analyzed by SPSS 15 using Student’s Paired T Test.

Results: A total of 114 cases were studied. No statistically significant correlation was noted between pre and post contrast serum creatinine and estimated Glomerular Filtration Rate. However, the incidence of contrast induced nephropathy was found to be about 9%. No significant correlation was noted between the change in serum creatinine and age and BMI.

Conclusion: Although there was no significant change in renal function after contrast administration, 9 % incidence of contrast induced nephropathy should warrant a larger population based study.

Keywords: computed tomography; creatinine, iodinated contrast ; nephropathy;renal function

Will Delay in Surgery Affect Outcome in Acute Appendicitis?

Raj Kumar Chhetri, Suman Baral, Neeraj Thapa, Binay KC, Durga Pandit, BB Buda — Thu, 30 May 2019 12:50:59 +0000

Introduction: This study was conducted to evaluate the affect of delay in operation from the time of onset of symptoms and from the time the patient reaches the hospital and its outcome in patients who undergo appendicectomy for acute appendicitis.

Methods: All the patients with acute appendicitis who were operated were included in the study. Post-operative complications mean post-operative hospital stay and histopathological gradings were evaluated in relation to time of onset of symptoms and time from the patient reaches the hospital to the operation theatre.

Results: Total of 76 patients were included in the study. Overall mean hospital stay was 3.71±2.365 days. Negative appendicectomy rate was 10.5% and complication rate was 13.2%. Mean duration of post-operative hospital stay gradually increased as the severity of disease increased though statistically not significant. Patient’s overall elapsed time of more than 3 days had increased tendency to perforate, which was statistically significant. When the patient presented within 24 hours of symptoms, the pathological severity was low. A significant association between the overall elapse time and a more advanced pathology was found but in-hospital delay was not significantly associated with severe pathological grading. Complications rates were not significantly associated with in-hospital delay of upto 12 hours.

Conclusion: Patient delay beyond three days had higher perforation rate but in-hospital delay of up to 12 hours had no significant complications. Therefore, it is concluded that in-hospital delay of up to 12 hours can be managed without risk of increased complication.

Keywords: Acute appendicitis; Appendicectomy;In-hospital delay;Patient delay; pathological grading

Trichobezoar Causing Small Bowel Obstruction

Bidhan Sigdel, Rehan Pradhan, Aanchal Shah, Niroj Banepali, Rupesh Mukhia — Thu, 30 May 2019 12:51:04 +0000

A trichobezoar is a mass of hair accumulated within the gastrointestinal tract. Though stomach is the commonest site of trichobezoar, we encountered a patient with a trichobezoar in the terminal ileum. We present a case report of a 7-year old girl with ileal trichobezoar causing intestinal obstruction.

Keywords: Trichobezoar ; Intestinal Obstruction

The Ergogenic Potentials of Nutraceutical Amino Acids: a Review

Thu, 30 May 2019 12:51:26 +0000

Nutraceuticals are immersing as product that provide association of food with drugs. The global market of nutraceuticals has been excelling over past decades and has established itself as a competitive industry of global market. With increasing public consciousness towards dietary remedy for physical fitness and diseases prevention and treatment, consumption of nutraceuticals is one rise. This gives an equal opportunity to the pharmaceutical, food, agricultural, biotechnology, nutrient supplements sectors to explore and expand more in this field. There is paucity of data on various nutraceutical products and its economic share in Nepalese market. Nevertheless, it can be promising economic outreach of Nepalese pharmaceutical sector which is prospering well in drug production and distribution. Athletes are particularly concerned for their fitness level. They regularly consume various nutraceuticals to enhance their power and performance. Various nutraceutical products targeting a definite functional enhancement are available in the market at present. Consumers should acquire adequate information on use, appropriateness, proper selection and associated effects of nutraceuticals prior to consuming. The manufacturers and distributors should also commit in educating the consumers. This review article aims to analyze the ergogenic potentials amino acid nutraceuticals in various athletes.

Keywords: Amino acids; athletes; exercise; nutraceuticals; nutrition

Perception of Undergraduate Medical Students about Interactive Lecture at Kirkpatrick Level One.

Rano Mal Piryani — Thu, 30 May 2019 12:51:43 +0000

Introduction: Interactive lectures are considered good among educational practices for large class size as learning is an active and interactive process. This study was done to assess the feedback of the students on interactive lectures at Kirkpatrick level one i.e. reaction (perception).

Methods: This descriptive study was done to assess the feedback of the students on interactive lectures at Kirkpatrick level one i.e. reaction (perception).Author delivered interactive lectures in respiratory and nervous system to the students of 3rd year MBBS of KIST Medical College Lalitpur Nepal. The collected data was analyzed using SPSS version 20.

Results: Majority of the students was agreed that the objectives of the interactive lectures were clearly delineated (93%, 3.90±0.995), the facilitator fulfilled his role effectively as per the objectives (96%, 4.03±0.916), the facilitator succeeded in creating friendly environment for learning (90%, 3.96±1.055) and the learning was up to my satisfaction (93%, 3.80±0.957). Overall, students perceived that interactive lectures were effective as they rated interactive lectures on rating scale 1-10 (1 being the least effective and 10 being the most effective) 7.47±1.7.

Conclusion: It appears that continuing interactive lectures may be one possible way to combat the problem of how to better involve students in more active learning within large class size. Alternative technology assisted formats like online interactive lecture; flipped class room format can be utilized for better engagement of the students. Moreover, lectures are not appropriate method for teaching students, higher orders of thinking such as application, analysis and synthesis.

Keywords: Feedback; Interactive lecture; Kirkpatrick level one; teaching method

Handbook of Abdominal Sonography in Acute Abdomen (ASIAA)

Abishek Thapa, Rupesh Mukhia, Uttam Laudari — Thu, 30 May 2019 12:51:51 +0000

Human beings are blessed with the five senses, however vision are considered the most reliable and important among all; and this rule isn’t the exception in the field of clinical examination. Using sonoscope as extension of the classical clinical examination to assess the underlying pathology of the abdomen adds the advantage to be able to visualize. Hence knowledge of sonoscope gives power for all clinicians in converting imagination into imaging.

We all have come across the case of acute abdomen and despite of our best clinical judgments; it always feels incomplete without the ultrasonoscopy assessment. In order to deal with this challenge, the author of this book, Dr. Deepak raj Singh, has developed a totally new, comprehensive and simplified protocol named ASIAA (Abdominal Sonography In Acute Abdomen), which can be easily learned and practiced by clinicians of all specialties. These days sonoscopes are available in compact sizes which are portable and easy to handle. This gives the ability for sonoscope examination to be carried out at patient’s bedside, making assessment with sonoscope for clinicians more assessable.

Clinical assessment with sonoscope at bedside supplements valuable medical information at tertiary health centers. Where as its uses by all clinicians at remote areas provides basic sonoscopy services and fills the gap of unavailability of radiologist. Thus this promotes the concept of ‘Point of Care’ in sonoscopy in our country, a venture first of its kind.

The main author of this book, Associate Professor Dr. Deepak Raj Singh, is FRCS graduate from Edinburgh. He is the former Head of Surgery Department at Kathmandu Medical College Teaching Hospital and is currently serving as Unit Chief. He has also been officially implementing the practice of Day Care Surgery in Nepal at his private centre. Dr. D.R Singh has been involved in clinical and academic activities for over 20 years where more than eight surgery residents have been directly trained under his mentorship. He introduced the concept of Sonoscope for all clinicians and he has been regularly using and teaching the art of sonoscope for more than a decade.

How Medicines are Born – the Imperfect Science of Drugs

Ravi Shankar, Mohammed A M Alshakka — Thu, 30 May 2019 12:51:58 +0000

Medicines dominate modern life. The process of how medicines are discovered, how they are tested, certified as safe for use in humans and monitored for adverse effects are often not known by the lay public. This book by two Italian scientists has been translated into English and is written in an easy to read and understand style. We enjoyed the frank foreword by the authors. The book delves deep into the history of modern medicines. There are detailed descriptions of the discovery and use of penicillin, insulin, ACE inhibitors, aspirin, low-dose aspirin, streptokinase, and cisplatin. Drug discovery previously was often by chance and the book describes the first drug discovered according to a plan, imatinib. The second chapter deals with ‘Hunting for drugs’. Receptors are among the most important targets of drug action and advances in genetics and molecular biology are providing us with an ever deepening understanding of diseases which is being used to develop appropriate tratements. The authors describe ‘biologicals’ in some detail. Biologicals are becoming increasingly dominant in modern day therapy. Erythropoietin is the best known biological. The authors revisit the statement by Paracelsus about all drugs being poisons and only the dose determining whether a substance is a drug or a poison. They describe is a simple manner different routes of drug administration.

Laboratory studies are the focus of chapter 3. The authors argue why even in the modern era of cell lines and molecular targets, animals still remain essential to evaluate a drug. Animal models are being created for most diseases. The authors end this chapter by describing how the results of animal studies are used to decide on whether to go ahead with clinical trials in humans. Many regard the experiments of James Lind on sailors with scurvy to be the first clinical trial. Recruitment of study participants, informed consent and randomization, having a control group and doing a blinded study as the three pillars of a clinical trial are explained. The four phases of a clinical study are described in a simple and engaging manner.

Eleven Years of the Health Humanities – a Personal Journey

Ravi Shanker — Thu, 30 May 2019 12:52:04 +0000

At present I am facilitating a health humanities (HH) module for a group of medical and nursing students at the American International Medical University (AIMU) in Saint Lucia. This is the third batch of students for whom I and my co-facilitator, Dr Rose are facilitating a health humanities module.