Journal of Nepal Health Research Council

Scientific Publications among Novice Researchers: Dilemma to Decision and a Way Forward

Pradeep Belbase — 2020-02-17

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Existing Laws to Combat Road Traffic Injury in Nepal and Bangladesh: A Review on Cross Country Perspective

Shafina Shafiq — 2020-02-17

Background: Road traffic accidents is a leading cause of injury and death globally. The consequences of road traffic accidents are prominent in developing countries that can least afford to meet the health services, economic and societal challenges. Nepal and Bangladesh are two developing country of South Asia who bear a large share of burden due to road traffic injuries.
Methods: A non-systematic review of relevant documents using Google scholar and PubMed as well as review of relevant legal documents was done.
Results: Nepal and Bangladesh have traffic laws including all the key risk factors as recommended by the World Health Organization except the child restraint systems laws. The existing laws for both countries include speed, drunk driving, use of seatbelts and motorcycle helmet, driver license, vehicle condition, overloading and accident related compensations.In both the countries for post-crash response, national emergency care access number has partial coverage and in Nepal there are some provisions related to trauma registry.Vulnerable groups are pedestrians with majority of male and higher mortality found in rural areas than urban areas for both the countries.
Conclusions: Both the countries have traffic laws that focus on the prevention of road traffic accidents and protection of victims. However, amendments in the existing laws are required for confronting immediate challenges of increasing accidents and injuries that both the countries face every year.
Keywords: Bangladesh; Nepal; road traffic injury; road traffic accident; traffic acts and laws.

Understanding, Experience and Response to Sexual Harassment among the Female Students: A Mixed Method Study

Radhika Thapalia — 2020-02-17

Background: Sexual harassment has received global attention and has been recognized as a public health problem with increased physical and mental health risks among the victims. This study attempted to assess understanding, experience, response and effect of sexual harassment among the secondary school female students in Kathmandu, Nepal.
Methods: It was a mixed method study conducted among 441 secondary level female students. In quantitative component, a structured questionnaire was used to collect information relating to socio-demographic characteristics, and understanding, experience, response and effect of sexual harassment from 441 participants from three clusters (schools) of Tokha Municipality, Kathmandu. For qualitative method, two focused group discussions were conducted to assess the understanding of and response to sexual harassment. Quantitative and qualitative data were analyzed using Chi square test and thematic analysis method respectively.
Results: Around 76% of the participants had experienced some forms of sexual harassment in their life. Sexual harassment was significantly associated with religion and parental occupation. Majority of participants who faced sexual harassment reported that the perpetrators were strangers and they either ignored it or did nothing at the time of events. School, roads and public places were the most common settings where participants encountered sexual harassment.
Conclusions: Sexual harassment is prevalent among female secondary students in Kathmandu. However, they lacked a clear understating of and ways to respond to sexual harassment. Raising awareness to recognize and respond to different forms of harassment and to change the victim-blaming attitudes can be a potential strategy for tackling the problem in Nepalese society.
Keywords: Abuse; sexual harassment; victimization; violence.

Newborn Service Readiness of Primary Level Health Facilities of Eastern Mountain Region of Nepal

Ambika Thapa Pachya — 2020-02-17

Background: Newborn service readiness is facility’s observed capacity to provide newborn services and a pre-requisite for quality. Newborn services are priority program of government and efforts are focused on infrastructure and supplies at peripheral health facilities. Study describes health facility readiness for newborn services in four domains of general requirements, equipment, medicines and commodities, and staffing and guidelines.
Methods: Convergent parallel mixed method using concurrent triangulation was done in public health facilities providing institutional deliveries of two randomly selected districts- Taplejung and Solukhumbu of Eastern Mountain Region of Nepal. Face to face interview and observation of facilities were done using structured questionnaire and checklist; in-depth interviews were done using interview guideline from November 2016 to January 2017. Ethical clearance was taken. Descriptive analysis and deductive thematic analysis were done.
Results: Mean score of newborn service readiness was 68.7±7.1 with range from 53.3 to 81.4 out of 100. Domains of general requirement, equipment, medicine and commodity, supervision, staffing and guideline were assessed. The gaps identified in general requirements were availability of uninterrupted power supply, means of communication and referral vehicle. Clean wrappers and heater for room temperature maintenance were identified during interviews to be part of the readiness. All health facilities had trained staff while retention of skill was of concern. There was felt need of enforcing adequate training coverage to suffice the need of human resources in remote.
Conclusions: Efforts of improving transportation, heater for room temperature maintenance, trainings with skill retention strategy, utilization of guidelines, availability of skilled birth attendance could result increased and improved newborn service readiness.
Keywords: Eastern mountain region of Nepal; health facility readiness; newborn service readiness.

Knowledge and Attitude Regarding Pubertal Health among Adolescent Girls

Binita Dhakal — 2020-02-17

Background: Adolescence is a critical period and is associated with physical and psycho-social changes induced by puberty, which builds personality, behaviour, and future health of the adolescents. Thus, the aim of the study was to find out the knowledge and attitude regarding pubertal health of adolescence girls.
Methods: A descriptive cross sectional study was conducted in Bharatpur Metropolitan City’s secondary level schools. A total of 183 adolescent girls were selected using probability simple random sampling from 5 schools out of total 43 schools which were also selected by simple random sampling technique. Data was collected by using structured self-administered questionnaire for knowledge and likert’s scale was used for attitude regarding pubertal health.
Results: Study findings revealed that 61.4% of the students belonged to early adolescence (11-14) age group with the mean age 14.27±1.33 years. Majority (80.3%) had moderate level of knowledge and around half (48.6%) had positive attitude. Knowledge and attitude varied with the respondents’ level of education (p=0.001), relation to sibling (p=0.013) and source of information by elder sister (p=0.022), teachers/school (p=0.001).Moderately positive correlation was found between knowledge and attitude which was highly significant (r=0.395, p<0.001).
Conclusions: Majority of respondents had moderate level of knowledge and half of the respondent had positive attitude regarding pubertal health. Findings of the study emphasizes on improvement in education of adolescent girls which can help uplift health status and minimize vulnerability to health issues of pubertal health.
Keywords: Adolescents; attitude; knowledge; pubertal health; puberty.

Maternal and Obstetric Factors Associated with Low Birth Weight

Dilip Kumar Yadav — 2020-02-17

Background: Low birth weight is a factor associated with perinatal, neonatal and post-neonatal morbidity and mortality and is associated with development of chronic diseases in adulthood. This study aimed to identify the maternal and obstetric factors associated with low birth weight in selected hospitals of Nepal.
Methods: Matched case control study was conducted in two tertiary level hospital of Nepal during May 2017 to April 2018. There were 368 mothers with single full term live low birth weight babies (cases) and 736 mothers with single full term live normal birth weight babies (controls) matched on babies’ gender and place of delivery included in the study. Multivariable conditional logistic regression analysis was used to eliminate the effects of potential confounders and to identify the independent effect of various risk factors associated with low birth weight.
Results: A total of 1104 respondents (1 case : 2 controls) were included in the study. Multivariable conditional logistic regression analysis revealed that maternal height <146 cm [AOR 5.14, (95%CI:2.03-13.01),(p=0.001)], maternal weight ?50 kg [AOR 3.75,(95%CI:2.15-6.56), (p<0.001)], primi-parity [AOR 4.58, (95%CI:1.71-12.25),(p=0.002)], multi-parity [AOR 3.01,(95%CI: 1.11-8.12),(p=0.030)], rest in day time ?2 hours [AOR 3.68, (95%CI: 2.01-6.75),(p<0.001)], rest in night time for <8 hours [AOR 5.76, (95%CI: 2.32-14.33), (p<0.001)], Iron and folic acid consumption for ?60 days [AOR 5.47, (95%CI: 2.73-10.95),(p<0.001)], Iron and folic acid consumption for 61-120 days [AOR 3.04, (95%CI: 1.90-4.87),(p<0.001), no calcium consumption [AOR 3.00, (95%CI: 1.78-5.04),(p<0.001)] were the significant risk factors associated with Low birth weight
Conclusions: Height and weight of women, parity, duration of rest in day time and night time, consumption of Iron and folic acid and calcium were the maternal and obstetric determinants for the occurrence of low birth weight.
Keywords: Birth Weight; case control; low birth weight; maternal and obstetric factors; normal birth weight.

Effect of Hand Held Vibrating Tools on Nerve Conduction Study in Dental Residents

Rekha Limbu — 2020-02-17

Background: Repetitive exposure to vibration has been shown to induce peripheral nerve dysfunction. Dentists are exposed to handheld vibrating tools in their daily clinical practice. Most of the studies are done in dentists who have symptoms such as paresthesia and numbness of the hands. Thus, we conducted the study to explore the effect of vibration on nerve conduction variables in apparently healthy asymptomatic dental residents.
Methods: This cross-sectional study enrolled 22 dental residents and age matched 22 medical residents as controls. Nerve conduction study was performed in median and ulnar nerves of both hands.
Results: Anthropometric and cardiorespiratory variables were comparable between the groups. There were no statistically significant differences between dental and medical residents in the sensory conduction variables (right median onset latency=2.05±0.27 vs 1.91±0.21, p value=0.07; right median amplitude =27.80±8.11 vs 29.55±7.04, p=0.45; right median conduction velocity = 59.54±7.05 vs 61.06±5.15, p= 0.42) and motor conduction variables (right median distal latency = 2.87±0.38 vs 2.87±0.38, p= 0.94; right median distal amplitude=10.71±2.19 vs 11.10±2.37, p=0.58; right median conduction velocity= 70.57±13.16 vs 68.53±7.73, p= 0.54) of median and ulnar nerves. Further, there was no significant difference between the dominant and non-dominant hands of dental residents.
Conclusions: Hand held vibration tools did not alter nerve conduction study parameters of dental residents.
Keywords: Dentists; nerve conduction study; vibration.

Development and Validation of an Information Booklet Aimed at Promoting Mental Health for Pregnant Women with a History of Abuse

Diksha Sapkota — 2020-02-17

Background: Mental health needs of victims of domestic and family violence are often overlooked. A booklet was designed to help women update their knowledge and skills in effective coping with domestic and family violence and support them in developing effective stress reduction and problem management techniques. In addition, this booklet is believed to serve as a reference for further use. This paper describes the development process and validation of the information booklet. This booklet was used during an intervention trial conducted in Nepal to educate abused pregnant women.
Methods: This methodological study involved three stages: bibliographical survey, development of the booklet, and validation by specialists in the relevant fields and representatives of the target audiences. A total of eight experts, currently working in the field of domestic violence and/or midwifery, and 15 representatives of the target participants were involved in the validation process. A minimum Content Validity Index of 0.78 was considered for content validation, and minimum agreement of 75% for face validation.
Results: The booklet presented a global Content Validity Index of 0.92. The overall level of agreement within the target participants was 86.3%, which was higher than the minimum recommended level. Both subject experts and participants positively evaluated the adequacy, coverage and readability of contents of the booklet.
Conclusions: The booklet was validated using content and face validity. This validated booklet is expected to be an effective tool for communication that would help pregnant women cope better with domestic and family violence and adopt strategies to remain emotionally healthy.
Keywords: Booklet; development; domestic violence; validation studies.

Lung Cancer in a Tertiary Hospital in Nepal: Clinical-Radiological Profile and Histological Subtypes

Ashesh Dhungana — 2020-02-17

Background: Lung cancer is the most common cancer worldwide and in Nepal. Non small cell carcinoma is the commoner histological type. The incidence of adenocarcinoma subtype is increasing globally. This study aims to evaluate the clinical-radiological and histological profile and the diagnostic yield of various modalities in the diagnosis of lung cancer at a tertiary hospital in Nepal.
Methods: This is a prospective cross-sectional study conducted at National Academy of Medical Sciences, Kathmandu. Patients presenting with clinical and radiological features consistent with lung cancer and undergoing tissue sampling were included. The clinical and radiological characteristics, distribution of various histological subtypes and the diagnostic yield of various modalities were evaluated.
Results: Of the 253 patients screened, 77 meeting the inclusion criteria were enrolled into the study. Lung cancer was diagnosed in 53 patients. Forty (75.5%) patients had non small cell carcinoma and 13 (24.5%) had small cell carcinoma. Among the non small cell variants, 20 (37.7%) had adenocarcinoma and 19 (35.9%) had squamous cell carcinoma. Hitopathological diagnosis of lung cancer was established in 39 of the 42 (92.9%) patients by bronchoscopy. Image guided biopsy and/or aspiration yielded the diagnosis in 13 (24.5%) patients. The diagnostic yields of endobronchial biopsy, needle aspiration, bronchial brush and bronchial wash cytology were 86.5%, 70%, 63% and 34.3%respectively.
Conclusions: The result of this study concurs with the global trend of rising incidence of adenocarcinoma subtype. Bronchoscopy remains the most commonly used tool for diagnosis of lung cancer and combination of procedures such as biopsy, bronchial brush, needle aspiration and bronchial wash provided the highest yield in our study.
Keywords: Bronchoscopy, Histological subtypes, Lung cancer, Tertiary hospital, Nepal.

Assessment of Zinc Status Among Pregnant Women Attending a Tertiary Level Hospital of Sunsari District, Nepal

Man Kumar Tamang — 2020-02-17

Background: Zinc deficiency is one of the major public health problems especially in developing countries, with an estimation of over 80% of pregnant women to be zinc deficient worldwide. Maternal zinc deficiency elevates the risk of foetal growth restriction. This study aimed to assess zinc deficiency and to examine the factors associated with zinc status among pregnant women attending a tertiary level hospital in Sunsari district, province no. one, Nepal.
Methods: Pregnant women were selected by using time frame consecutive sampling at B. P. Koirala Institute of Health Sciences, Dharan from September to November 2018. Data on nutritional, socio-demographic and reproductive profiles were collected using a semi-structured questionnaire. Blood was collected from each pregnant woman to estimate serum zinc concentration by atomic absorption spectrophotometry. Association between serum zinc concentration and predictor variables were assessed using chi-square test.
Results: A total of 156 women participated in the study. The prevalence of zinc deficiency among the pregnant women was 22.6%. Our data did not show association of any of the socio-demographic, nutritional and reproductive variables with serum zinc status (p-value>0.05) in chi-square.
Conclusions: Zinc deficiency was found to be prevalent in our targeted population. However, community based studies need to be conducted for exploring more precise relationship between zinc status and other variables.
Keywords: Nepal; nutritional factors; pregnant women; zinc status.

In Hospital Complications of Atrial Septal Defect Device Closure at Shahid Gangalal National Heart Centre, Kathmandu, Nepal

Chandra Mani Adhikari — 2020-02-17

Background: Atrial deptal defect device closure has become the preferred method in the treatment of atrial septal defect. We aim to study the in-hospital complications of atrial septal defect device closure procedure.
Methods: It was a single center, retrospective study conducted from Febuary 2016 to January 2019. Cardiac catheterization laboratory records of all consecutive patients who underwent atrial septal defect device closure was included and the in-hospital complications were been retrospectively reviewed.
Results: During the study period, a total of 566 patients were attempted for device closure. In 557 (98.4%) of cases device was implanted. Among the 557 patient in which device was implanted 401(71.9%) were female. Age ranged from 5 years to 72 years with the mean of 30.9 years. Transient ST segment elevation 15 (2.6 %)was the commonest complication followed by pericardial tamponade 4 (0.7%), and cardiac arrhythmias 3 (0.5%).
Conclusions: Atrial deptal defect device closure can be done safely with a high success rate and a low complication rate.
Keywords: Amplatzer duct occluder; atrial septal defects; in hospital complications; transcatheter device closure.

Comparative Study on Effect of Rabeprazole Versus Omeprazole in Acid-peptic Disorder with Helicobacter pylori Infection

Sukh Bahadur Gurung — 2020-02-17

Background: Gastritis is one of the common diseases, which is frequently caused by Helicobacter pylori. Triple therapy has resulted significant decrease in morbidity and complications. Newer proton pump inhibitor drug rabeprazole has been introduced in the market. The aim of this study is to compare its efficacy with omeprazole in triple therapy regimen.
Methods: A total of 100 patients who were positive for Helicobacter pylori and gave consent in participating in the study were included. Fifty patients were prescribed omeprazole-based triple therapy and other 50 were prescribed with rabeprazole-based triple therapy. After 2 weeks of triple therapy and 4 weeks of proton pump inhibitor treatment, Helicobacter pylori antigen was tested in faecal material.
Results: Out of 100 patients, there was significant correlation between epigastric pain, nausea and water brash with p value, 0.001. Similarly P-value was < 0.001 among hiatus hernia and reflux whereas p value was < 0.05 between bile reflux, hiatus hernia and reflux. In follow up study, after triple therapy, Helicobacter pylori antigen tests were negative in 94% of the study population, who were prescribed rabeprazole which was similar who were prescribed omeprazole (92%).
Conclusions: Rabeprazole (20 mg) has proved similar Helicobacter pylori eradication rates compared with omeprazole (40 mg) when co-administered with of antibiotics (amoxicillin and clarithromycin) for two weeks.
Keywords: Gastritis; heart burn; hyperchlorhydria; proton pump inhibitors; triple therapy.

Outcome Predictors in Scrub Typhus Requiring Ventilator and Vasopressor Support

Shital Adhikari — 2020-02-17

Background: Age and serum creatinine are known to be predictors of mortality in scrub typhus patients admitted in intensive care unit. This study aimed to explore the factors predicting mortality in patients with scrub typhus requiring both ventilator and vasopressor support in our set up.
Methods: A retrospective analysis of 43 patients with scrub typhus (ELISA IgM positive, optical density ?0.5) admitted in Medical Intensive Care unit of Chitwan Medical College Teaching Hospital between April 2016 to September 2017 was performed considering recovery or death (poor outcome) as outcome measurement. Potential variables (p<0.25) from bivariate analysis were used to perform a multivariate logistic regression analysis (p<0.10) to predict mortality.
Results: The mortality rate was 56% (24/43). Acute respiratory distress syndrome and shock were observed in all 43 patients. The median (IQR) duration of ventilation use and vasopressor use was 53(101) hours and 48(79.5) hours, respectively. On bivariate analysis, an independent and statistically significant association of mortality with age in years (p=0.039), number of vasopressor use (p<0.001) and serum creatinine more than 1.4 mg/dl (p=0.012) was observed and on multivariate regression analysis, these variables were also the predictors of mortality (age in years: p=0.011, ?=0.115, OR=1.211, 95% CI=1.027-1.225; number of vasopressor use: p=0.009, ?=3.705, OR=40.647, 95% CI=2.532-652.425; serum creatinine more than 1.4 mg/dl: p=0.046, ?=-2.205, OR=0.110, 95% CI=0.013-0.961)
Conclusions: In scrub typhus with ARDS and septic shock, increasing age and serum creatinine, and requiring more than one vasopressor to maintain blood pressure are at increased risk of mortality.
Keywords: Mortality; predictors; scrub typhus; shock.

Assessment of Caesarean Section Rates at Kathmandu Model Hospital Using the Robson’s Ten Group Classification System

Rekha Poudel — 2020-02-17

Background: Aims of this study was to assess the caesarean section rate and identify the indications contributing to the same using the Robson’s Ten Group Classification System at Kathmandu Model Hospital.
Methods: This was a retrospective study conducted at Kathmandu Model Hospital among women who underwent caesarean section from 1 January to 31 December, 2018 and were grouped according to Ten Group Classification System. The overall caesarean section rate and the contribution of each group was calculated.
Results: The overall caesarean section rate was 66.1% (494 among 747 total deliveries) in 2018. Nullipara, singleton cephalic, >= 37 weeks, spontaneous labor (Group 1) was the major (24.2%) contributor to the overall caesarean section rate followed by previous caesarean section, singleton cephalic, >=37 weeks (Group 5, 22.6%) and nullipara, singleton cephalic, >=37 weeks, induced or caesarean section before labor (Group 2, 18.8%). Also, the caesarean section rate was 49.5% in nullipara, thus increasing the trend of caesarean section for previous caesarean section in future.
Conclusions: Efforts must be focused more on Group 1, 2 and 5 to decrease the increasing trend of caesarean section Promoting vaginal delivery in nullipara and facilitating vaginal birth after caesarean are the most relevant areas of intervention.
Keywords: Caesarean section; Robson ten group classification system; vaginal birth after caesarean.

Fetomaternal Outcome in Women with Pregnancy Induced Hypertension versus Normotensive Pregnancy

Amarnath Thakur — 2020-02-17

Background: A hypertensive disorder in pregnancy comprises one of the deadly triad along with hemorrhage and infection-that contributes greatly to maternal morbidity and mortality. The aim of this study was to compare the feto-maternal outcome in pregnancy induced hypertension with normotensive pregnant women.
Methods: A cross sectional prospective study was conducted in Paropakar Maternity and Women’s Hospital from 1st February 2018 to 1st May 2018. All pregnant women seeking help for hypertension during this period was included in the study and were followed up to six weeks of postpartum period.
Results: Total 40 patients were enrolled in each arm. The highest number of pregnancy induced hypertension cases was seen in age group 20-24years (32.5%) and were mostly primigravidas (60%). The commonest symptom in Pregnancy induced hypertension was headache 47.5 %. The mean hemoglobin value was 11.91 gm/dl, mean SGPT (Gestational hypertension 25.44 IU/L, preeclampsia 55.25 IU/L and eclampsia 32.17 IU/L) and mean platelet count was 1, 95,140 lakh/cumm in pregnancy induced hypertension. Mean prothrombin time in gestational hypertension was 13.78±0.7 seconds. Most common maternal complication was preterm labor and fetal complication was prematurity. The most common mode of delivery was vaginal.
Conclusions: Pregnancy induced hypertension was more common in primigravida with young age group of 20-24 years and presented commonly with complain of headache. Preterm labor was the most common maternal complication similarly prematurity was the commonest fetal complication seen in pregnancy induced hypertension. Vaginal delivery was the commonest mode of delivery. Blood investigation showed significant thrombocytopenia in eclampsia and decreased prothrombin time in gestational hypertension.
Keywords: Fetal outcome; maternal complications; pregnancy induced hypertension.

Sex Predictability by Using Mandibular Canine Index

Alok Atreya — 2020-02-17

Background: Canines are known for their higher resistance to trauma and pathological alterations when compared to other teeth. Among all the teeth, canines show highest sexual dimorphism.
Methods: This descriptive cross-sectional study was commenced from January 2019 to April 2019 after the ethical approval from Institutional Review Committee. The maximum mesio-distal widths of right and left mandibular canines and mandibular inter-canine arch width were measured on the cast with the help of a divider and digital vernier callipers. Mandibular canine index was calculated by dividing the mesio-distal width of each mandibular canine with inter-canine arch width. Data was entered and analyzed using Statistical Package for the Social Sciences version 21.
Results: Sex predictability by using mandibular canine index in the present study showed poor sex predictability (57.5% - 62.5%).
Conclusions: Sex determination should be done by other methods and mandibular canine index should be used cautiously in Nepalese population.
Keywords: Canine dimorphism; forensic anthropology; forensic dentistry; forensic identification, sex determination.

Nepali Version of Geriatric Depression Scale-15 – A Reliability and Validation Study

Ajay Risal — 2020-02-17

Background: Geriatric depression is a significant problem in both the developed and the developing world. To identify this condition, Geriatric Depression Scale has been used in different languages and cultural settings; it has proved to be a reliable and valid instrument. However, the Geriatric Depression Scale-15 version in Nepali has so far not been validated.
Methods: The original 15-item version of the Geriatric Depression Scale-15 was translated into Nepali and administered by trained nurses to a target sample aged ?60 years at Dhulikhel Hospital (n=106). Subsequently, the participants were blindly interviewed by a consultant psychiatrist for possible geriatric depression according to the ICD-10 criteria. Cronbach’s alpha checked the reliability. Validity was assessed for three different cut-off points (4/5, 5/6, and 6/7); the related sensitivity, specificity, positive predictive value, and the negative predictive value of the scale were estimated.
Results: The mean participant age was 68.1 (±7.2); males and females, 50.9% and 49.1%, respectively. Cronbach’s alpha was 0.79.The optimal cut-off point was found to be 5/6 with sensitivity and specificity 86.3% and 74.5%, respectively.
Conclusions: Using a standard statistical protocol, a reliable and valid Geriatric Depression Scale-15-Nepali was developed with an adequate internal consistency and an optimal balance between sensitivity and specificity at cut-off point 5/6.The Geriatric Depression Scale-15-Nepali can serve as an appropriate instrument for assessing geriatric depression in epidemiological research as well as in primary health care settings in Nepal.
Keywords: Geriatric depression; internal consistency; sensitivity; South Asia; specificity.

Diagnostic Fibreoptic Bronchoscopy at Tribhuvan University Teaching Hospital

Pankaj Pant — 2020-02-17

Background: Fibreoptic bronchoscopy is one of the most vital procedures performed in health care setting. Globally, several studies have reported findings of fibreoptic bronchoscopy while only few studies have been reported in Nepal. The aim of this study was to perform two year retrospective analysis of diagnostic fibreoptic bronchoscopy at tertiary referral centre.
Methods: A hospital based retrospective observational study was conducted at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Consecutive bronchoscopy reports from June 2017 to May 2019 were included. Data entry and analysis was done in Microsoft Office Excel 2010. Descriptive statistics was performed to obtain clinico-demographic profile of patients, indications and findings of bronchoscopy.
Results: A total of 238 bronchoscopy procedures were analyzed. Mean age of patients was 55.02 years with range from 15 to 84 years. Majority of bronchoscopy were performed in male patients (58%). One hundred and twelve patients (47.05%) had no endobronchial lesion. Endoscopically visible tumor was the most common abnormality seen in 57 (23.9%) patients with highest prevalence in 55-65 years followed by extrinsic compression of bronchial tree seen in 13 (5.5%) patients. Bronchioalveolar lavage for routine examination (n=207) was the most commonly performed procedure during bronchoscopy followed by bronchial biopsy (n=55).
Conclusions: Fibreoptic bronchoscopy is an extremely useful tool for evaluation of tracheobronchial pathology. Baseline bronchoscopic findings from tertiary referral centre in Nepal was obtained in this study.
Keywords: Bronchoscopy; fibreoptic.

Assessment of Airway Parameters for Predicting Difficult Laryngoscopy and Intubation in a Tertiary Center in Western Nepal

Gajal Lakhe — 2020-02-17

Background: The screening tests used for pre-operative evaluation of airway to predict difficult laryngoscopy and intubation have variable diagnostic accuracy. The unanticipated poor laryngeal view is gold standard for defining difficult intubation. We aimed to find out the prevalence of difficult laryngoscopy and intubation, which airway parameter better predicts difficult intubation and whether difficult laryngoscopy is associated with difficult intubation or not.
Methods: This analytic cross sectional study was conducted in 665 ASA I/II adult patients, aged 18-65, without obvious airway pathology undergoing elective surgery under general anesthesia. The pre-operative screening tests included mouth opening, modified mallampatti, ratio of height to thyromental distance, sternomentaldistance and upper lip bite test. Cormack-Lehane grade III/ IV was defined as difficult laryngoscopy and potentially difficult intubation. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy and area under curve at 95% confidence interval was calculated for all five screening tests.
Results: The prevalence of difficult laryngoscopy and intubation was 6.6% (44 cases). The upper lip bite test because of its highest specificity, positive predictive value, negative predictive value, accuracy and area under curve (99.7%; 93.9%; 99.7%; 95.2%; 85.1% respectively) with moderate level of sensitivity (70.5%) was better predictor of difficult intubation than other tests. The difficult laryngoscopy was associated with difficult intubation (p=0.00).
Conclusions: The prevalence of difficult laryngoscopy and intubation was 6.6%.The upper lip bite test was a better predictor of difficult intubation and there was a significant association of difficult laryngoscopy with difficult intubation.
Keywords: Difficult laryngoscopy and intubation; screening tests; upper lip bite test.

Medication Adherence among Hypertensive Patients Attending a Tertiary Care Hospital in Nepal

Tara Roka — 2020-02-17

Background: Drug therapy and adherence to the medication is critical to prevent complications of hypertension and more importantly in countries like Nepal where more than one quarter adults suffer from it. Primary aim was to measure adherence to anti-hypertensive medication and factors associated with low adherence.
Methods: Morisky Medication Adherence Scale was used for measuring medication adherence and a structured questionnaire for measuring background and illness related factors in a cross-sectional study among 216 hypertensive patients in a tertiary care hospital selected through sequential sampling. Data was analysed using descriptive and inferential statistics and results presented with proportion or odds ratio with 95% CI.
Results: It was found that 72% of the patients had low adherence to anti-hypertensive medication, with sub-group differences notably higher among females (77%); among those with co-morbidity (80%); and among those getting medicines free of cost (76%). Post multivariate logistic regression, it was found that patients with co-morbidity had higher odds of having low adherence (Adjusted Odds Ratio – AOR: 2.50; 95%CI:1.28-4.89) than those without; and those who get medicine free of cost had higher odds of having low adherence (AOR: 3.01; 95%CI:1.32-6.86) than those who pay for medicine.
Conclusions: A substantial proportion of hypertensive patients had low adherence to medication. Presence of co-morbidity, getting medicine free of cost, and not having regular follow up were the major factors associated with low adherence to anti-hypertensive medication. Targeted interventions in hospitals and health care centers in Nepal would improve medication adherence.
Keywords: Adherence; hypertension; hypertensive patients; medication; Nepal.

Evaluation of Sympathetic Response in Offsprings of Hypertensive and Normotensive Parents

Poonam Karmacharya — 2020-02-17

Background: Disturbances of the autonomic nervous system play a crucial role in the pathogenesis and clinical course of many diseases. Sympathetic response is an exaggerated response to stress. Studies have shown that enhanced sympathetic response to stress is an indication of prehypertensive states. Young offspring of hypertensive parents are a good model for assessing sympathetic reactivity prior to clinical hypertension. The aim of this study is to compare the sympathetic response in normotensive offspring of both hypertensive and normotensive parents.
Methods: 100 young normotensives, non-smoking and healthy students (male and female) of Manipal College of medical science with a family history of hypertension and 100 young normotensives students, non-smoking and healthy with a negative family history of hypertension were enrolled in the study. Blood pressures at rest and after Isometric hand grip test and cold pressor test were measured. Statistical analysis was done to compare the blood pressure at rest and after isometric hand grip exercise and cold pressor test using independent t test.
Results: A statistically significant increase in systolic and diastolic blood pressures were observed in normotensive offspring of hypertensive parents, compared to the normotensive offspring of normotensive parents indicating sympathetic overactivity after isometric hand grip exercise and cold pressor test (P<0.001).
Conclusions: Normotensive offspring of hypertensive parents showed increase sympathetic reactivity after stress was given in the form of isometric hand grip exercise and cold pressor test. Thus, normotensive offspring of hypertensive parents are more likely to develop future hypertension and the risk is greater when both the parents were hypertensive.
Keywords: Cold pressor test; Isometric hand grip test; Sympathetic reactivity.

The Effect of the Intercondylar Notch Shape and Notch Width Index on Anterior Cruciate Ligament Injuries

Bibek Basukala — 2020-02-17

Background: Anterior cruciate ligament is one of the commonly injured ligaments in knee. The shape and dimension of the femoral notch has been linked with the risk of anterior cruciate ligament injury. The aim of this study was to study the risk of Anterior cruciate ligament injury with notch morphology in the Nepalese population.
Methods: This study is a case control study. Cases undergoing arthroscopic surgery at 2 tertiary level centers were enrolled. Patients with arthroscopic confirmation of Anterior cruciate ligament tear were taken as case and those without tear were taken as control. Axial Magnetic resonance Imaging sequence was used to study notch. Sections at the level of popliteal groove was taken for study and shapes were identified as A, U and W type, and notch width index was calculated. These variables were correlated with presence or absence of Anterior cruciate ligament tear.
Results: Out of 118 cases, 59 had tear, and 59 had no tear. Tear was found in 74% of Type A notch compared to 30.15% in Type U notch. The femoral notch width index was low in 42.59% of A type notch patients compared to 20.63% with U type notch. Analysis of notch width index among patients with Anterior cruciate ligament tears, showed that 40.67% of Anterior cruciate ligament torn knee had narrow notch compared to 22% in non- injured group, which was statistically significant.
Conclusions: Type A notch and narrow notch both are risk factors for Anterior cruciate ligament tear.
Keywords: Anterior cruciate ligament; injury; notch.

Management of Traumatic Liver Injury in a Tertiary Care Hospital in Nepal

Harish Chandra Neupane — 2020-02-17

Background: The liver is most frequently injured solid organ in abdominal trauma. The non-operative management is the standard treatment for hemodynamically stable patients. This study analyse the epidemiological aspects, injury patterns, treatment modalities and outcome in patients with liver injuries only and associated injuries outside the liver.
Methods: This was a retrospective study in patients with liver injuries admitted from 1st March 2014 to 31st January 2019 at Chitwan Medical College and Hospital, Nepal. The patients were divided into two groups. Group A consisted of isolated liver injury and Group B liver injury with associated injury of other organs. Data were analysed by using descriptive statistics and Mann-Whitney U test.
Results: A total of 61 patients were admitted with liver injury. There were 18 (29.5 %) patients with liver injury alone (group A) and 43 (70.5 %)liver injury associated with other organs (group B). Low grade liver injuries were 48 (78.7 %) and high grade 13 (21.3 %). The operative management was done for one liver injury with biliary peritonitis in group A. In group B, 16 patients required laparotomy and operative management for associated abdomen injuries.
Conclusions: Non-operative treatment modality in hemodynamically stable patients with isolated liver injuries was safe and effective.
Keywords: Liver injury; management; scoring; trauma.

Prevalence of Periodontitis among Rheumatoid Arthritis Patients Attending Tertiary Hospital in Nepal

Sweta Shrestha — 2020-02-17

Background: Rheumatoid arthritis and Periodontitis both are chronic destructive inflammatory disorders characterized by dysregulation of the host inflammatory response and increase in localized and systemically circulating pro-inflammatory cytokines. The objective of this study was to determine prevalence of periodontitis among Rheumatoid Arthritis patients in our setup.
Methods: A crossectional study was done in 43 cases of diagnosed Rheumatoid Arthritis patients visiting to department of Orthopedics of Bir Hospital during the period of July 2016 to January 2017 were examined for presence of periodontitis and its severity. A descriptive questionnaire was also prepared concerning age, sex, personal history. Parameters to be measured were Plaque Index, Gingival Index, Pocket Depth and Clinical Attachment Level.
Results: Prevalence of periodontitis among Rheumatoid Arthritis patients was found to be 86.04% (37) with Mild periodontitis in 9%(4), Moderate periodontitis 56% (24)and severe periodontitis in 21% (9). The commonest age group was 50.41±9. with male to female ratio of 1:3
Conclusions: Periodontitis was common in Rheumatoid Arthritis in our set up. Moderate periodontitis was more frequent. Periodic oral examination of patients with Rheumatoid Arthritis is required to improve periodontal health.
Keywords: Host response; inflammation; periodontal pocket depth; periodontitis; pgingivalis rheumatoid arthritis.

The Declaration of Helsinki on Medical Research involving Human Subjects: A Review of Seventh Revision

Badri Shrestha — 2020-02-17

The pinnacle of success achieved by the medical science and the benefits accrued to the patients have become possible through the medical research where human participants in the research are exposed to hazards inherent to the experiments. To protect the human subjects and to maintain high ethical standards, the World Medical Association has adopted “The Declaration of Helsinki” in 1964. After two years of consultation with the experts throughout the world, the seventh revision of the Declaration was adopted on 19th October 2013 in Brazil. The aim of this article is to review the seventh revision of the Declaration of Helsinki in relation to medical research involving human subjects and highlight the amendments made in the latest revision which are relevant to clinical research in human subjects. The latest revision has made four substantial changes on the existing Declaration, whch include dealing with the compensation of the trial-related injuries, approval of use of placebos in the clinical trials, protection of vulnerable groups and the post-trial provisions. The implications of these amendments in the clinical research are highlighted.
Keywords: Consent; Declaration of Helsinki; ethics; experimental medicine; research; seventh revision.

Calcific Tendinitis in the Elbow Presented as Acute Tennis Elbow

Ravi Bhandari — 2020-02-17

Calcific tendinitis occurs frequently in shoulder and hip region. Its occurrence in elbow joint is frequently misdiagnosed because of its rare incidence and similar clinical presentation with other acute conditions of elbow like trauma, infection and tennis elbow. Characteristic symptoms of this condition are acute onset of pain, tenderness and swelling on the lateral aspect the elbow. Plain Radiograph is the primary modality to distinguish and evaluate this condition. Awareness and familiarity with this condition helps in early diagnosis and avoids unnecessary treatments and biopsy as this condition is self-limited.
Keywords: Calcific tendinitis; self-limited; tennis elbow.

Erectile Dysfunction Secondary to Herpes Zoster

Vikash Paudel — 2020-02-17

Varicella Zoster is dermatomal neuropathic disease caused by reactivation of varicella zoster virus, characterized by vesico-bullous eruptions. The sacral dermatomal involvement in shingles is a rare phenomenon but well recognized cause of urinary retention, bladder dysfunction but rarely erectile dysfunction. We present a case of sacral herpes zoster with erectile dysfunction in a sexually active adult male.
Keywords: Erectile Dysfunction; herpes zoster; Nepal.

The Impact of Federalization on Health Sector in Nepal: New Opportunities and Challenges

Anju Vaidya — 2020-02-17

The promulgation of constitution of Nepal in 2015 has shifted the unitary government of Nepal towards federalism with significant devolution of power to seven newly created provinces, each with their own unicameral legislature. The major challenges during the transition phase in health sector are spillover effects, unclear roles and responsibilities of local authorities, human resource management and strengthening capacity at local level as per local need. Despite these challenges, federalism brings fertile ground for the local government to work more closely with their people; with more effective financing and planning based on evidences and their need.
Keywords: Federalism; health sector; Nepal; challenges; opportunities.

Overview of Obstetric Fistula: From a Developing Country’s Perspective

Ganesh Dangal — 2020-02-17

Obstetric fistula is a hidden tragedy in the developing world, prevention is important and treatment is by surgical repair. However, failure, broken fistula, stress incontinence often demoralizes surgeons and patients.
Keywords: Fistula repair; Obstetric fistula; Obstructed delivery.