Nepal Medical Journal

Prevalence of GeneXpert Positive in Sputum Negative with Clinico-radiologically Case Suggestive of Pulmonary Tuberculosis.

Bibek Rajbhandari — 2019-10-04

Introduction: Tuberculosis remains of public health concern, particularly in highly endemic regions.1 It accounts globally for 3 million deaths annually. Pulmonary tuberculosis is primarily diagnosed by identification of Mycobacterium tuberculosis using sputum smear microscopy.2 Clinicians often depend on alternative diagnostic algorithms based on patient symptoms and chest X-ray findings, which have low sensitivity which may lead to either over or under diagnosis of pulmonary tuberculosis. The GeneXpert assay has been shown to have an accuracy comparable to that of culture.3 The sensitivity of a single GeneXpert result in smear-negative, culture-positive cases is 72.5%; the sensitivity increases with repeated testing.4 Xpert has been found to be a cost-effective method for smear-negative TB diagnosis in comparison to traditional methods in resource-limited settings. The aim of the study was to find the prevalence of Genexpert Positive in Sputum negative cases.

Methods: This descriptive cross sectional study was done in Bir Hospital, Mahabouddha, Kathmandu for 1 year after taking ethical clearance. Data was collected and entry was done with point estimate at 95%. Sample size was calculated using the standard formula. Convenience Sampling technique was used, data analysis was done with SPSS Microsoft Excel Sheet.

Results: Prevalence of Genexpert Positive in Sputum negative cases was part to be 27.27%.

Conclusions: Present study showed GeneXpert could be used as a diagnostic tool for the diagnosis of tuberculosis by correlating the clinicoradiological features to this infectious disease. With judicious case detection and implementing appropriate measures, TB incidence, prevalence and morbidity can be minimized to a greater extent.

Keywords: acid fast bacilli; tuberculosis; X-ray.

Obstetric Emergency Drill: Does it Change our Knowledge and Skill?

Rosina Manandhar — 2019-10-10

Introduction: Obstetric emergencies are unpredictable and inappropriate management of such events can result in serious maternal and neonatal morbidity and mortality. Simulation and drill provides obstetric emergency training in a safe environment with an aim of improving clinical outcome. The aim of this study was to evaluate the impact of obstetric emergency training on the change in the knowledge, clinical skill and teamwork performance of the participants in the management of common obstetric emergencies: eclampsia, shoulder dystocia and post-partum haemorrhage.

Methods: A hospital based interventional study was conducted amongst 11 residents, 4 medical officers and 45 interns. Pre-training and post-training assessment of the knowledge by using Multiple choice questions (MCQs), clinical skills by using Objective Structured Clinical Examination (OSCE) and teamwork performance by using Mayo High Performance Teamwork Scale (MHPTS) was undertaken in each of the modules: Eclampsia, Shoulder dystocia and Post-partum haemorrhage. Training intervention was undertaken by using standardized lectures and simulated clinical emergency scenarios. The changes in MCQs, OSCE and MHPTS scores were analyzed.

Results: There was a significant improvement in the mean MCQ score (p-value ˂0.001) and OSCE score (p-value ˂0.001), overall and individually, in each module. After the training, a greater number of participants could perform the clinical skill components. There was also a significant improvement in post training MHPTS score (p-value˂0.001). Conclusions: Obstetric emergency drill and training significantly increased the knowledge, clinical skills and teamwork performance of participants in the management of important obstetric emergencies.

Keywords: eclampsia; obstetric emergency; post-partum haemorrhage; shoulder dystocia; simulation.

Comparative Study of Intrathecal Dexmedetomidine versus Fentanyl as an Adjuvant to 0.5% Heavy Bupivacaine in Lower Abdominal Surgeries

Chitra Thapa — 2019-10-10

N/A

Efficacy of Intravenous Tranexamic Acid in reducing Blood Loss in Elective Cesarean Delivery

Sebak Shrestha — 2019-10-10

N/A

An audit of Pediatrics Inpatients in General Pediatrics Department of Tertiary Care Children’s Hospital

Prakash Joshi — 2019-10-10

Introduction: In Nepal currently there are very few reports about disease spectrum in pediatric inpatients. This study was conducted to determine the pattern of morbidity among pediatric inpatients aiming that the result thus obtained will help in proposing strategies for future healthcare planning and resource allocation.

Methods: This was a descriptive cross sectional study conducted at Kanti Children’s Hospital from January 2017 to December 2017, after taking ethical approval from Institutional Review Committee (Ref. no:14/075-076) of the hospital. Data on age, sex, diagnosis, date of admission and discharge was extracted from hospital record of 5,128 admitted children. Data were entered into MS Excel and analyzed using SPSS 16. The results were expressed as number, proportion and median.

Results: Out of 5,128 admitted patients 3,240 (63.18%) were male and 1,888 (36.81%) female. Children between 1 to 60 months were 3,225 (62.89%) of which infant constitute 1617 (50.13%). The leading causes of hospitalization were pneumonia, sepsis, enteric fever, bronchiolitis, congenital heart diseases and nephrotic syndrome constituting 898 (17.51%), 658 (12.83%), 274 (5.34%), 268 (5.22%), 227 (4.42%) and 221 (4.30%) of total admission respectively. System-wise, respiratory tract infection 1,308 (25.50%) was most common followed by ‘Other infectious diseases’ 1069 (20.85%), nephrology 607 (11.83%), gastro-intestinal tract 592 (11.54%), neurology 487 (9.49%), hematology 281 (5.47%) and cardiac system 278 (5.42%).

Conclusions: Majority of the children affected were under-five, residing outside the capital city. Respiratory infection and other infectious diseases were major cause of childhood morbidity. Programs like Integrated Management of Neonatal and Childhood Illness (IMNCI) needs to be strengthened, in resource poor country like ours.

Keywords: Inpatients; morbidity; neonate.

Neutrophil to Lymphocytic Count and SOFA Score as Prognostic Marker in Patient With Sepsis

Prasanna Rajbhandari — 2019-10-10

Introduction: Neutrophil-to-lymphocyte ratio is calculated from the white cell differential blood count, a marker that has been used as a prognostic index when assessing patients suffering from several clinical syndromes, including sepsis. The aim of this study was to find out the relationship between Neutrophilto- lymphocyte ratio and the commonly used severity score of SOFA in a population of emergency admitted adult patients with sepsis as prognostic marker in a tertiary center.

Methods: This observational analytical study was conducted in the Emergency Department of the Tribhuwan University Teaching Hospital based on data extracted from 155 patients consecutively enrolled, suffering from sepsis of multiple origin. The study period was from June 2017 until August 2017. Neutrophil-to-lymphocyte ratio and SOFA score were calculated as prognostic marker in septic patients upon hospital admission.

Results: Out of 144 patients included in the study, mean age of patients was 51.02 ± 20.96, among which 144 (32.6%) were male and 144 (67.3%) were female, most common source of infection was respiratory system in 45 patients followed by gastrointestinal system in 38 patients , the overall 28 day mortality was observed in 144 (22.92%). There was a strong correlation between SOFA score and NRL (p < 0.05). The sensitivity of NRL was 78.8% and specificity 73.9% at a cut off value of 8.75 and sensitivity of SOFA was 84.8% and specificity 73% at a cut off value of 6.5.

Conclusions: The Neutrophil-to-lymphocyte ratio and SOFA score both proved to be similar as a simple infection marker with discriminatory capacity in predicting prognosis in infectious admissions.

Keywords: neutrophil-to-lymphocyte ratio; prognosis; sepsis; SOFA score

Effectiveness Of Positional Stretching Of Coracohumeral Ligament In Addition To Ultrasound In Patient With Adhesive Capsulitis

Bikash Shrestha — 2019-10-10

Introduction: Adhesive capsulitis is an idiopathic condition of the shoulder characterized by onset of pain and movement restriction and symptoms can last up to 2 years and longer. The primary goal of intervention is to improve ROM, pain and decrease disability. The objective of the study is to determine the combined effect of positional stretching of coracohumeral ligament and ultrasound therapy in patient with adhesive capsulitis.

Methods: 30 subjects were included in the study. Each subjectwas assigned into two groups. One group was treated with ultrasound followed by positional coracohumeral ligament stretching and another group was treated with ultrasound only. The duration of treatment was 3 to 4 weeks (10- 12 sessions) in both groups. Primary outcome measure included ROM and SPADI.

Results: Both groups showed significant improvement but in comparison of two groups, group A (ultrasound followed by positional CHL stretching) was more effective than group B (ultrasound only).

Conclusions: Addition of Positional coracohumeral ligament stretching and ultrasound is effective than ultrasound only in decreasing pain and improving ROM in Adhesive capsulitis.

Keywords: Adhesive capsulitis; Coracohumeral ligament; Positional stretching; ultrasound

Functional And Neurological Outcomes Of Closed Reduction And Percutaneous Pinning In Pediatric Monteggia Fracture

Govinda Pradhan — 2019-10-10

Introduction: The aim of this study was to assess the neurological and functional recovery of children with Monteggia fracture following closed reduction and percutaneous pinning.

Methods: It was a descriptive observational study, patients aged from 3 to 15 years with Monteggia fractures are taken in to consideration during the period between 2074/02/01 and 2074/7/30. Participants were selected on the basis of pre-determined inclusion/exclusion criteria. A total of 33 patients were included in the study. The demographics and pre- and post-operative outcomes were recorded in semi-structured proforma. Data entry, synthesis and descriptive analysis were done using MS EXCEL and SPSS version 16.0.

Results: Total of 33 patients met the inclusion and exclusion criteria. The mean age was 8.21±3.4 years, with sex ratio (m: f) of 1.75: 1. Majority of the patients (57.58%) injured their left elbow and the most common mechanism of injury was fall while playing (36.36%). According to modified classification system for children, 60.61% had class C and 39.39% had class B Monteggia fracture. Five patients (15.15%) presented with PIN injury. All patients were treated with closed reduction and percutaneous pinning (IM RUSH nail) within 2.27±1.30 days after injury. The average duration of surgery was 62.42±23.55 minutes. The average duration of fracture healing was 5.39±1.6 weeks. Jupiter’s criteria for the evaluation of elbow function was used and at the time of cast removal, 6 (18.18%) had excellent, 10 (30.30%) had good, 13 (39.39%) had fair and 4 (12.13%) had poor functional recovery.

Conclusions: This study concludes that most of the pediatric Monteggia fractures (class B and C) can be treated with closed reduction and percutaneous intramedullary nailing using RUSH pins. This technique has very good functional and neurological outcomes with fewer complications.

Keywords: children; functional recovery; Intra-medullary nailing; jupiter’s criteria; Monteggia fractures.

Association of Serum Uric acid with Recent Ischaemic Stroke

Suraj Gyawali — 2019-10-10

Introduction: To evaluate association of serum uric acid with ischemic stroke patients and assess its relationship with cerebrovascular risk factors.

Methods: This was a hospital based cross-sectional observational study conducted at TUTH between May 2016 to May 2017. A total 120 Patients eligible for the study criteria was enrolled for the study. Nonprobability convenience sampling was used for the sampling purpose. All patients ages 40 years or above 40 years with confirmed diagnosis of recent ischaemic stroke were included for the analysis.

Results: Mean ages of the enrolled subjects were 60.63 years ± 11.11 SD and eighty three (69.2%) population were male. Sixty one (50.8%) subjects were smoker and twenty seven (22.5%) were alcoholic. Prevalence of hyperuricemia was 17.5%. Serum uric acid level values were higher in male(69.1%) than female(30.9) population..Higher levels of serum uric acid level were found in both male population who smoked and were alcoholic in contrast serum uric acid levels were higher in both female population who were non smoker and did not consume alcohol in comparison to male. .Likewise, both diabetic and dyslipidemic male and female had higher serum uric acid level in comparison to who were non diabetic and did not consume alcohol. The mean score of serum uric acid level in male and female were significa different (P=0.029). Similalry, serum uric acid level was significantly different in smoker and no-smoker group (p=0.049), hypertensive and non hypertensive (p=0.027) and dyslipidemic and non dyslipidemic group (p=0.005)

Conclusions: Our study showed high prevalence of hyperuricemia in ischemic stroke patients and there was a potential link between serum uric acid and cerebrovascular risk factors, indicating possible role of uric acid as the risk factor of ischemic stroke.

Keywords: cerebrovascular risk factor; Uric acid level, recent ischaemic stroke.

Pattern of Menisci and Cruciate Ligaments Injury of Knee Joint in MRI and Arthroscopy

Santosh Joshi — 2019-10-10

Introduction: The traumatic or internal derangement of the knee requires certain investigations for the establishment of diagnosis. With advances in technology and because of high resolution and accuracy a MRI scan is now a standard for evaluating the knee injuries before a subsequent arthroscopy. When used properly after a thorough clinical examination, an MRI can prove to be an efficient and non-invasive diagnostic tool in the management of knee injuries. On the other hand, arthroscopy is considered as the gold standard method for the diagnosis of such injuries.

Methods: The prospective hospital based study was conducted on fifty one symptomatic patients with knee injuries over a period of one year. All the patients underwent MRI of the knee joint on Philips Achieva 1.5 Tesla MRI Machine in Bir Hospital, NAMS and they were evaluated and cross checked by faculty members. After proper evaluation, diagnostic arthroscopy was done, if needed therapeutic intervention was also performed. The sensitivity, the specificity, the positive predictive value and the negative predictive value of MRI for MM, LM, ACL and PCL were calculated.

Results: A total of 51 patients were included with a mean age of 30.92 years. Left knee was predominantly involved in 56.1% of the cases with 43.9% involvement of right knee. Overall, MRI showed a total of 32 medial menisci tears and 8 lateral menisci tears. There were 5 false negative cases for MMT. MRI revealed tears of ACL in 44 patients and no patient with PCL tear. Arthroscopy revealed ACL tears in 44 cases and confirmed no patient with PCL tear.

Conclusions: MRI is a noninvasive, useful and reliable diagnostic tool for evaluating knee injury and it can be used as a first line of investigation in patients with knee injury.

Functional Outcome Of Mini-Open Carpal Tunnel Release In Carpal Tunnel Syndrome

Sagun Pradhan — 2019-10-10

Introduction: Carpal tunnel syndrome is the most common compression neuropathy in clinical practice and is also the most extensively studied. In Mini-open carpal tunnel release, the transverse carpal ligament is transected using a small open cut at the volar aspect of the proximal palm. The objectives of this study were to determine the functional outcome of mini-open carpal tunnel release procedure, to use the Boston Questionnaire to determine the functional outcome following mini open carpal tunnel release which includes pain, numbness, weakness and fine hand activities.

Methods: This descriptive cross-sectional was conducted in National After informed consent, the cases who meet the informed criteria were examined and relevant details were filled up in the proforma preoperatively and two weeks post-operatively. Assessment of the patient’s symptom severity and functional status was done with the Boston questionnaire.

Results: CTS was most common in the age group of 25-29 years (36.36%) and was predominant in housewives (18.20%). Mean symptom severity scores per person improved from 3.11 pre-operatively to 1.12 post-operatively. Mean functional status scores per person improved from 2.65 pre-operatively to 1.03 post-operatively. There was a statistically significant improvement in postoperative outcomes in our population.

Conclusions: The findings in this study indicate that mini-open carpal tunnel release has a good functional outcome.

Keywords: carpal tunnel syndrome; compression neuropathy; transverse carpal ligament.

Effect of Dexmedetomidine as an Adjuvant to Bupivacaine in Supraclavicular Brachial Plexus Block

Sabin Gauchan — 2019-10-10

Introduction: The objective of this study was to evaluate the effect of 50μg dexmedetomidine on the onset and duration of block and duration of analgesia when used as an adjuvant to bupivacaine in ultrasound guided supraclavicular brachial plexus block.

Methods: Eighty patients of ASA physical status I and II undergoing elective upper limb surgery under ultrasound guided supraclavicular brachial plexus block were randomly divided into two groups: Group D and Group B. Group D (n=40) received 19.5 ml of 0.5% bupivacaine with 0.5 ml (50 μg) dexmedetomidine. Group B (n=40) received 19.5 ml of 0.5% bupivacaine with 0.5 ml normal saline. Onset time of sensory and motor block, duration of sensory and motor block and duration of analgesia was recorded.

Results: Onset time of sensory block (10.55±4.84 min in Group D vs 12.50 ±5.20 min in Group B) and motor block (15.85±5.9min in Group D vs 18.35±5.6min in Group B) though earlier in Group D as compared to Group B was not statistically significant (p value =.087 for sensory block and p value=.058 for motor block). The duration of sensory block (772.20 ±167.84 min in Group D vs 398.38 ±129.839min in Group B) and motor block (725.63±140.964min in Group D vs 361.88±128.764 min in Group B) was statistically significantly prolonged in Group D (p value= .000 for sensory and p value =.000 for motor block). The Duration of analgesia (845.93±184.545min in Group D vs 430.04±121.307 min in Group B) was also statistically significantly prolonged in group D (p value= .000).

Conclusions: Dexmedetomidine (50 μg) as an adjuvant to 0.5% bupivacaine solution in ultrasound guided supraclavicular brachial plexus block prolongs the duration (sensory and motor) of block as well as the duration of analgesia with no effect on the onset time of block.

Keywords: brachial plexus block; bupivacaine; dexmedetomidine. Correspondance: Dr.

Multi-disciplinary Medico-legal Approach and Challenges in Interpretation of Injury from an Amputated Hand: A Case Report

Jenash Acharya — 2019-10-10

Among various duties of any medico-legal expert, responsibility of Injury Examination Report preparation is encountered routinely in his/her career. Among various challenges faced by the examiner, documenting the injuries becomes exigent when s/he is acquainted with artifact like therapeutic alteration of the injury produced in victim.

We report a case of a victim of electric injuries sustained over both his upper limbs. The requisition to prepare an Injury Examination Report was received from investigating officer a month after the incident. On examination of the patient, the challenge faced was that the injured limbs were amputated a day before the examination, and his body showed no other injuries. An urgent consultation with plastic surgeon revealed that the amputated body part was sent for histopathology analysis. A report was prepared from a formalin soaked amputated bilateral hands in pathology department and handed over to the investigating officer.

Keywords: amputation; electric injury; injury examination report; medico-legal.

A Rare Case of Pulmonary Embolism: A Case Report

Tirtha Man Shrestha — 2019-10-10

Pulmonary embolism in an old patient with a history of coagulation disorder, any recent major surgeries or in a chronic heart or lung diseases is widely reported. Also, a recent history of travel by air with flight distance of more than 5000km or BMI greater than 35 kg/m2 increase risk. However, we report here, a suggestive case of acute pulmonary embolism in a previously well male of 38 years, with a BMI of 25.71kg/m2 without any history of chronic illness or acute exacerbations.

The patient presented in health facility with sudden onset of radiating chest pain and some other nonspecific symptoms. Neither any other significant personal risk factors except smoking, nor any family history of heart/lung diseases were ruled out during initial assessments. On investigations, other routine examinations were normal but T-wave inversion was noticed in lead V1-4 in ECG, Troponin-I was positive and CPK-MB was slightly elevated (27 U/L). Furthermore, no any remarkable changes were noticed in Chest X-ray. Then, the patient was referred to higher center with cardiac facility with provisional diagnosis of Acute Coronary Syndrome for further evaluation and management.

Thereupon, Coronary Angiogram (CAG) was done and the report was normal but echocardiography findings were suggestive of pulmonary Embolism. D-dimer was also elevated (8279.05 ng/ml) but venous doppler study of bilateral lower limb was normal. Finally, CT-PA showed partially occluding thrombus in main pulmonary bifurcation extending into left and right pulmonary artery, its bilateral segmental branches and calcified granuloma was seen in right lobe of liver. Patient was under inj. LMWH and other supportive management during hospitalization. After an uneventful hospital stay for 12 days, general condition was improved and eventually, patient was discharged, with oral warfarin.

Keywords: chest pain; Nepal; pulmonary embolism; risk factors.

Erector Spinae Block for Analgesia : A Safe and Novel Technique with Diverse Applications

Bigen Man Shakya — 2019-10-10

Erector Spinae Block is a paraspinal musculofascial plane block where we inject local anesthetics superficial to the tip of the transverse processes and deep to the erector spinae muscle .It works at the origin of spinal nerves based on cadaveric and contrast study. It is effective and safe regional anesthetic technique. It has a wide variety of applications ranging from acute postoperative pain treatment to chronic pain management. In this series, we report a series of two cases, which include postoperative pain management in Partial Nephrectomy and chronic pain management in Post Herpetic Neuralgia.

Keywords: Analgesia; erector spinae block; regional.

Lightning Maculopathy: A Case Report

Ruchi Shrestha — 2019-10-10

Lightning induced maculopathy is a very rare condition and there are barely any published reports on lightning induced maculopathy in our country. Here we present a case of twenty three years female who presented with lightning induced burns on the neck, chest and abdomen. She had unconsciousness for 3 days after lightening injury for which she was treated in intensive care unit. She presented with complain of diminution of vision in both eyes after 2 weeks. Optical Coherence tomography revealed cystic changes in fovea in right eye and a macular hole in left eye. Lightning injury is a life threatening condition. Lightning maculopathy should always be ruled out which can be best detected on optical coherence tomography.

Keywords: foveal cyst; lightning injury; maculopathy; optical coherence tomography.

Combined Interscalene and Superficial Cervical Plexus Block for Clavicle Surgery: Case Series

Kiran Kumar K.C. — 2019-10-10

General Anesthesia is preferred over regional anesthesia in clavicle surgery. We report 3 cases of clavicle fracture which was performed under USG guided combined Interscalene and Superficial cervical plexus block. All the patients were comfortable and there was no need for additional analgesia. Thus regional anesthesia can be used as a sole anesthetic technique in patients with clavicle fracture and can be an alternative where general anaesthesia and its adverse effects needs to be avoided.

Keywords: clavicle fracture; interscalene brachial plexus block; superficial cervical plexus block. Correspondance: Dr.

Tubercular Osteomyelitis of Tibia: A Case Report

Amin Kumar Shrestha — 2019-10-10

Tubercular osteomyelitis of long bone is extremely rare and very few cases have been reported in literature. We are presenting a case of 43 years gentlemen presented with pain and swelling over lower half of leg for 5 months. There was associated pus discharging sinus and often low-grade fever but no history of weight loss or pulmonary symptoms. X-ray chest was normal. X-rays of involved leg was suggestive of osteomyelitis. Curettage and Biopsy was done, report was suggestive of tuberculous osteomyelitis. As tuberculosis is still common in developing countries like Nepal, for any osteolytic lesion in bone, tubercular osteomyelitis should always be considered in differential diagnosis.

Keywords: extrapulmonary tuberculosis; osteolytic lesion in bone; tubercular osteomyelitis.

Pain Lower Abdomen due to Spontaneous Hematometra: A Case Report

Rojina Manandhar — 2019-10-10

Hematometra is a rare condition that is most commonly associated with congenital anomalies and prior surgical procedures. This is an unusual case of spontaneous hematometra occuring in 32 years old healthy woman with no prior medical or surgical history. Only five cases of spontaneous hematometra without any risk factors have been reported.

Keywords: abdominal pain; Depot medroxyprogesterone acetate; hematometra.

Wild Honey Poisoning: A Case Report

Olita Shilpakar — 2019-10-10

Wild honey is consumed in many parts of the world as an alternative source of medicine with the belief of reducing cardiovascular, gastrointestinal and many other ailments. However, intoxication secondary to consumption of wild honey produced from the nectar of a few species rhododendrons has been encountered due to a toxin known as grayanotoxin. It is a sodium channel toxin causing symptoms like bradycardia, arrhythmias, hypotension, sweating, dizziness and altered sensorium. We report a case of a 58 year old man who presented to the emergency room following ingestion of wild honey with bradycardia, hypotension and altered mental status.

Keywords: bradycardia; grayanotoxin; hypotension; wild honey poisoning.

Imaging Anatomy of Normal Knee Joint using 3.0 T MRI- A pictorial review

Umesh P Khanal — 2019-10-04

With the use of high resolution imaging of knee on 3.0 T MRI, the ligamentous and cartilaginous structures can be elucidated in better details, and diagnosis that had been ambiguous in ye past can be made more con