Nepal Medical College Journal

STUDY OF RED CELL INDICES AND RETICULOCYTE COUNT IN PERSON WITH ANEMIA AT A TERTIARY CARE HOSPITAL OF KATHMANDU

S Pudasaini, PP Pant, N Kafle, S Maharjan, A KC, S Shrestha — Tue, 04 Jun 2019 08:55:03 +0000

Anemia is not a disease but a clinical feature of some other underlying problems. It is one of the mostcommon public health problems in developing countries. The prevalence of anemia differs according tothe age group. A cross sectional observational study was conducted in a tertiary hospital, over a period ofsix months (January 2018 to June 2018). All the cases of anemia in different age group with hematologicalinvestigations (hemoglobin and red blood cell indices) including reticulocyte count during the studyperiod were included. A total of 274 blood samples of persons with anemia were evaluated. The mean ageof the patients was 41.4 ± 25.37 years. Anemia was more commonly seen in females (68.2%) than males(31.8%) in our study. The most affected age group for anemia was person ≥ 15 years followed by children< 5 years. The least affected group was children of 12- 14 years. Microcytic anemia (decreased MCV anddecreased MCHC) was observed in children of 12- 14 years and macrocytic anemia (increased MCV) wasseen in group ≥ 15 years. Red cell distribution width (RDW) was more elevated in children of 12 -14 yearsand showed that there was significant variation of size of RBC in this group. Reticulocyte count was higherin children < 5 years and lower in children of 12- 14 years. Significant correlation was noted for hematocrit
and reticulocyte count. This study revealed that the prevalence of anemia increases with age and wasmore common in females. Baseline study of red blood cell indices and reticulocyte count will help us indiagnosing the type of anemia and in further management.

Keywords : Anemia, hemoglobin, hematocrit,red cell indices, reticulocyte

Anatomical variations of the paranasal sinuses and the nasal cavity

KK Shrestha, R Acharya, RR Joshi, S Maharjan, D Adhikari — Tue, 04 Jun 2019 08:55:51 +0000

Computed tomography (CT) of the para-nasal sinuses (PNS) has nowadays become the investigationof choice for the diagnosis of sinonasal diseases. Numerous sinonasal anatomic variants exist and arefrequently seen on CT scans. A sound knowledge of these variations is important not only for diagnosisbut also for planning surgery in order to avoid complications. The aim of this study is to investigate thefrequency of these variations in patients with sinonasal symptoms and also to determine their relation tosinonasal disease if any. A total of 76 patients were included in the study from August 2017 to July 2018 ofwhich 43 (56.6%) were males and while 33 (43.4%) were females with male to female ratio of 1.3:1. The agesof patients ranged from 14 to 72 years with a mean age of 33.2±14.2 years. Out of 76 patients, 68 (89.5%)had at least one type of anatomical variation while 8 (10.5%) had no variation. Only one variation wasseen in 39 (51.3%) patients while 29 (38.2%) had two or more variations. The most common variant wasdeviated nasal septum (DNS), occurring in 49 (64.5%) patients followed by concha bullosa (CB) and aggernasi cell (AN) seen in 15 (19.7%) and 14 (18.4%) patients respectively. Genderwise, anatomical variationswere seen more in males but the difference was not statistically significant. Some variations were seenmore on the right sidewhile others on the left. Some variations were present bilaterally. The differencewas not statistically significant. The presence of DNS was statistically significant in the study population (pvalue 0.012 in nonparametric chi square test). The age group 14 to 30 years showed maximum variationsthough not significant statistically. Therefore, during management of patients with sinonasal symptoms,these variations need to be addressed, if required, surgically. Proper knowledge of both common anduncommon sinonasal variations in our community could help in better surgical planning and overallmanagement of sinonasal disorders

Keywords : Anatomical variations, computedtomography (CT) scan, paranasalsinuses

Community based screening for diabetes and prediabetes using the Indian Diabetes Risk Score among adults in a semi-urban area in Kathmandu, Nepal

V Silvanus, N Dhakal, A Pokhrel, BK Baral, PP Panta — Tue, 04 Jun 2019 08:56:11 +0000

Diabetes has been recognized as a “global health emergency” with an estimated 9% of adults being affected. However, about half of these adults remain undiagnosed. Conventional screening tools like fasting plasma glucose (FPG), oral glucose tolerance testing (OGTT) and glycosylated haemoglobin (HbA1c) can be inconvenient and expensive in a community-based setting. The Indian Diabetes Risk Score (IDRS) is a simple, non-invasive tool which has been validated for use in the Indian population. Age, abdominal obesity, family history of diabetes and physical activity levels have been weighted for a maximum score of 100. Persons with IDRS of <30 are categorized as low risk, 30-50 as medium risk and those with > 60 as high risk for diabetes. A community based, cross-sectional, analytical study was planned to assess the performance of IDRS among adults in a semi-urban area in Kathmandu, Nepal. A total of 256 (170 female, 86 male) persons without diabetes from 260 households were screened during the study period. A majority (46.09%) were classified as high risk, 44.53% as moderate risk and 9.38% as low risk for developing diabetes. Among them, 162 (63.28%) volunteered for definitive testing. The prevalence of undiagnosed diabetes and prediabetes was 4.32% (95% CI: 1.75% to 8.70%) and 7.14% (95% CI: 3.89% to 12.58%) respectively. IDRS predicted the combined risk of diabetes and prediabetes with sensitivity of 84.21% and specificity of 55.24% in adults with score of 60 and above. The area under the ROC curve (AUC) of IDRS for identifying diabetes and prediabetes was 0.69 as compared to the gold standard (2hour Plasma Glucose) AUC of 0.98. IDRS may be a suitable screening tool for diabetes and prediabetes in the adult Nepalese study population.

Keywords : Diabetes, IDRS, prediabetes,screening, sensitivity, specificity

STRESSORS AND THE LEVELS OF STRESS AMONG THE UNDERGRADUATE MEDICAL, DENTAL AND NURSING STUDENTS OF A MEDICAL COLLEGE IN KATHMANDU

SA Manandhar, T Pramanik — Tue, 04 Jun 2019 08:56:22 +0000

Educational environment in medical schools is highly demanding and stressful due to various factors. Thestudy was aimed to explore level of stress, stressors and the coping strategies among the undergraduatemedical, dental and nursing students of a medical college in Kathmandu. A cross- sectional observationalstudy was conducted among 174 consenting (95 medical, 51 dental and 28 nursing) first year undergraduatestudents with predesigned, pretested, semi-structured questionnaire which included socio-demographicdetails, Kessler psychological distress scale and Medical student stress questionnaire. Average age ofstudents was 19.54±1.28 years. Results revealed that 66.66% of students were under stress with 25.86%having mild, 18.96% having moderate and 21.83% having severe levels of stress. Highest prevalence ofstress was noted among nursing students (75.00%) with 32.14% under severe stress. Among 116 malesand 58 females, males were more stressed (75.00%) than females (50.00%). Most of the students enjoyedmusic and chatted with their close ones to cope with stress. Academic related stressor was found to be themajor stressor (2.65±0.69) with statistically significant association (p< 0.01) with the stress levels amongthe students. Informing students about the “must know” and “good to know” areas of the topics of everysubject may be helpful to decrease the academic related stress. Regular practice of meditation, sports andcultural activities may help to reduce stress.

Keywords : Kessler psychological distress scale,medical student stress questionnaire,stress, stressors

Study of cervical biopsy over a decade at a tertiary level hospital, Nepal

SR Tamrakar, S Shrestha — Tue, 04 Jun 2019 08:56:52 +0000

Cervical carcinoma is the most common gynecological malignancy and almost curable cancer, if identifiedat an early stage. Cervical biopsy remains the ‘gold standard’ for the diagnosis of precancerous cervicallesion. The objective of this study was to review the histopathological findings of cervical biopsy includingcervical polypectomy and hysterectomy specimens at Dhulikhel Hospital from January 2008 to December2018. Out of 2098 cases, almost half of the cases (49.3%) were of Brahmin/Chhetri castes. There weresignificant differences in mean ages among hysterectomy cases (47.55±9.26), cervical biopsy cases(43.08±11.50) and polypectomy cases (33.59±12.47) (p value < 0.005). Out of 925 cervical specimens (cervicalbiopsy and polypectomy), colposcopy and hysteroscopy were performed in 18.2% and 12.7%, respectively.Out of 1173 hysterectomies, there were 110 cases (9.4%) of malignancies and cervical cancer was the most
common (67, 60.9%). The mean age of cervical cancer patients was 52.87±11.94 years. Cervical cancerdetected in age group of 40 – 59 years was significantly high (p value < 0.005). Incidence of cervical cancerwas lowest in Brahmin/Chhetris (2.4%) compared to Newars (3.4%) and other Janajatis (12.8%) and thedifference was statistically significant (p value < 0.005). The findings of thisstudy is useful in updating thehistopathological pattern of cervical biopsies.

Keywords : Biopsy, cervical cancer,colposcopy, hysterectomy,polypectomy

Renal Replacement therapy in intensive care unit at a tertiary care center in Nepal

PK Chhetri, DN Manandhar, P Poudel, S Baidya, SB Raju, KK Agrawaal — Tue, 04 Jun 2019 08:56:59 +0000

Acute kidney injury is a major complication in intensive care unit patients. It is associated withincreased in-hospital mortality and length of stay. The provision of renal replacement therapy inintensive care is not widely available in resource poor countries like Nepal. The study aims to lookinto clinical profile and outcome of patients who received renal replacement therapy in intensive
care unit. It was an observational study done from 1st October 2016 till 30th September 2017.Patient’s demographic data, indications, biochemical tests, outcomes, modality of renal replacementtherapy were recorded. Statistical package for the social sciences version 17 was used for statisticalanalysis. There were total of 649 admissions in intensive care, among which 148 had kidney relatedcomplications. Of 148 patients, 69 (47%) received renal replacement therapy. Mean age, ureand creatinine on admission were 50.17 ± 18.42 years, 174.54 ± 63.46 mg/dl and 8.05 ± 3.49 mg/dl respectively. They underwent 4.32 ± 3.09 sessions and 14.94 ± 10.88 hours of renal replacementtherapy. Total 42 (61%) had septic shock on admission and underwent sustained low efficiency dialysisas the modality of renal replacement therapy. In-hospital mortality was 19 (28%). Presence of septicshock on admission and mean number of ionotropes required 2.05 ± 1.12 was statistically significantfor in-hospital mortality (p=0.01). About half of the patients were on mechanical ventilation whichwas statistically significant for in-hospital mortality (p<0.001). Sustained low efficiency dialysis canbe done in patients on ionotropes and patients can be switched over to intermittent hemodialysis.

Keywords : Intensive care unit, Nepal, renalreplacement therapy; sustainedlow efficiency dialysis

Screening for Depression in Adolescents in Gokarneshwor municipality-4, Kathmandu

N Shrestha, S Pandey — Tue, 04 Jun 2019 08:57:04 +0000

Depression which is characterized by hopelessness and loss of interest in social activities is commonduring adolescence. However it is often unrecognized and the burden is even more in low incomecountries. It also increases the risk of suicide in future. Hence in a developing country like Nepalit is important that such cases are detected at the early stage preventing further worsening of thecondition. A simple set of questionnaires like Patient Health Questionnaire (PHQ) 9 can be used toscreen for depression. Using this questionnaire screening for depression was carried out in adolescentsof Gokarneshwor municipality, ward 4. Four hundred and twenty participants were selected by theprocess of systematic random sampling. Based on answers to nine questions score was given andadolescents categorized as having no, mild, moderate or severe depression. The PHQ 9 score suggestedthat 13.1% were suffering from depression, out of which 23.6% from moderate to severe depressionwhich required psychiatric consultation. Out of those shown to have some form of depression 40.0%said they had thought of self harm in last 2 weeks. Late adolescence was significantly associated withdepression. Thoughts related to self harm were also six times more in late adolescent age group thanthe early adolescent age group.

Keywords : Adolescence, Depression,Gokarneshwor-4

Study of children with recurrent pneumonia admitted in a tertiary hospital

P Rijal, L Lama, S Shrestha, P Kakshapati, R Nayak — Tue, 04 Jun 2019 08:57:08 +0000

Recurrent pneumonia usually occurs due to an underlying disorder that negatively affects local orsystemic defence mechanisms. The aim of this study was to find out the prevalence and risk factors
associated with recurrent pneumonia in children and to determine possible strategic plan needed forbetter clinical outcome. Children between 2 months to 15 years old who had a history of 2 or moreepisodes of pneumonia per year, or 3 or more episodes in a life time were investigated prospectively atNepal Medical College Teaching Hospital. Out of 653 children admitted for pneumonia, 74 (11.3 %%) metthe criteria for recurrent pneumonia. Among 74 children with recurrent pneumonia, underlying riskfactors was demonstrated in 65 patients (87.8%). Most common underlying diseases were aspirationsyndrome in 21.6% patients, congenital heart disease in 13.5% patients and bronchial asthma in12.1% children. No predisposing illness could be demonstrated in 12.1% patients. Approximately 1 in9 children with pneumonia in our hospital had recurrent pneumonia. Aspiration syndrome was themost common underlying illnesses for undiagnosed recurrent pneumonia in children.

Keywords : Aspiration syndrome,bronchiectasis, immunedeficiency disorders, recurrentpneumonia

OUTCOME OF MYRINGOPLASTY WITH TEMPORALIS FASCIA AND PERICHONDRIAL-CARTILAGE COMPOSITE GRAFT IN HIGH RISK PERFORATIONS

A Dhungana, RR Joshi, AS Rijal, KK Shrestha, S Maharjan — Tue, 04 Jun 2019 08:57:14 +0000

The objective of this study was to compare the graft uptake results and postoperative hearing ofmyringoplasty with temporalis fascia and cartilage-perichondrial composite graft in high risk
perforations. Patients of age 13 years and above with diagnosis of chronic otitis media – mucosal typewith high risk perforation that is >50% perforation of tympanic membrane, revision cases, absent/eroded handle of malleus, oedematous/unhealthy middle ear mucosa and marginal involvement caseswere included for myringoplasty. Pure Tone Audiometry was done within 1 week before surgery. 80cases were included for myringoplasty which were randomly allocated by lottery method with 40cases each in temporalis fascia group and cartilage perichondrial composite graft group. Graft uptakeresults were assessed after 6 weeks and postoperative hearing was evaluated and compared withinand between the groups. Graft uptake rate in temporalis fascia group and cartilage perichondrialcomposite graft group was 90% and 92.5%, respectively with no significance difference in the graftuptake rate (p = 0.692) between the groups. The mean pre and post-operative air bone gap in temporalisfascia group and cartilage perichondrial composite group were 30.69dB±10.19,16.36±8.37dB and33.73±8.07dB, 20.76±9.47dB, respectively with highly significant difference in both groups (p < 0.001)showing improvement in the hearing after surgery in both groups. The mean air bone gain were14.33dB and 12.97dB in temporalis fascia and cartilage perichondrial composite group respectivelywith no significant difference between the groups (p=0.469). The graft uptake rate and hearingresults after cartilage perichondrial composite graft are comparable to those of temporalis fasciagraft. Furthermore, the cartilage perichondrial composite graft is more rigid and thick so it ismore resistant than fascia to anatomic deformation and necrosis. Therefore, we recommend theuse of cartilage perichondrial composite graft for tympanic membrane reconstruction in high riskperforation without concern about affecting audiometric results.

Keywords : Cartilage-perichondrium,chronic otitis media, high riskperforation, myringoplasty, puretone audiometry, temporalisfascia

Assessment on knowledge, attitude and practice of pharmacovigilance among the healthcare professionals in a tertiary hospital of Kathmandu

R Shakya Gurung, D Shrestha, R Thapa — Tue, 04 Jun 2019 08:57:18 +0000

Pharmacovigilance (PV) is the science and activities related to the detection, assessment, understandingand prevention of adverse effects. Healthcare professionals (HCPs) have an important role in reportingAdverse Drug Reaction (ADR) cases. However under-reporting has been a major challenge in PV. Hence, weassessed the knowledge, attitude and practice (KAP) of HCPs about PV in a tertiary hospital of Kathmandu. Across-sectional study was conducted using pretested questionnaire consisting of 21 closed ended questions(twelve on knowledge, five on attitude, four on practice and one open ended question to know the causesof under-reporting. Out of 520 HCPs, 448 (207 doctors and 241 nurses) participated in the study with theresponse rate of 86.2%. The mean KAP score for doctors was 10.38 ± 2.68 and 9.60 ± 2.32 for nurses. Themajor barriers for under-reporting were identified as the difficulty in deciding if it’s an ADR and lack oftime to report ADRs. No significant correlation between knowledge and attitude of the HCPs was found(r=0, n=448, p< 0.01). However, there was a weak positive correlation between knowledge and practice (r=
0.05, n=448, p< 0.01) and also for attitude and practice (r= 0.09, n=448, p< 0.01). Hence, the HCPs had poorknowledge and practice but positive attitude towards PV. It is therefore strongly recommended to have animmediate educational intervention among the HCPs to improve the spontaneous ADR reporting

Keywords : Adverse drug reaction,attitude, knowledge, Nepal,pharmacovigilance, practice

JESS fixator for Metacarpal and Phalangeal fracture

AK Mishra, V Adhikari, P Chalise, P Shrestha, RP Singh — Tue, 04 Jun 2019 08:57:23 +0000

The fractures of metacarpal and phalanges of the hand are the most common injury encountered inemergency department. Most often these injuries are neglected as minor injuries and later on developsa functional limit of the hand. Joshi’s external stabilizing system (JESS) fixator based on the principleof ligamentotaxis, stabilize the unstable and intraarticular fractures of metacarpal and phalangeal andalso provides an environment for rapid soft tissue healing without further damaging the microvascularcirculation. The study includes total number of 38 patients with a diagnosis of fracture of Metacarpal andphalanx of hand admitted in Nepal Medical college and Teaching Hospital who were treated with JESSfixator. The functional outcome after the removal of JESS fixator was assessed by calculating AmericanSociety for Surgery of Hand and Total Active flexion (ASSH TAF). Among the 38 patients, all fractures wentto union with an average union period of 6 weeks. The mean period of treatment for metacarpal fractureswas12 weeks and for phalangeal fractures 16 weeks by which time patients regained full functional activityof hand and returned back to their respective works. The functional outcome assessed by ASSH-TAF scorewas excellent in 28 patients, good in 10 patients and none of them had a poor result. The complication wasseen in 9(23.68%) cases, superficial pin tract infection and K Wire Loosening. JESS fixator is cheap, easilyavailable and less technically demanding, provides with an effective treatment for the metacarpal andphalanges fracture, as it provides adequate stability that allows early rehabilitation with soft tissue careand has got a good functional outcome

Keywords : American Society for Surgery ofHand and Total Active flexion(ASSH TAF), Fixator, Joshi’s externalstabilizing system (JESS), Metacarpaland Phalangeal fracture

Radiological assessment of femoral bicondylar angle among persons attending a tertiary health care

A Pradhan, CP Lama, S Dhungel, SK Ghosh — Tue, 04 Jun 2019 08:57:27 +0000

Femoral bicondylar angle is the angle between an axis through the shaft of the femur and a lineperpendicular to the infracondylar plane. This study aims to assess femoral bicondylar angle measuredfrom radiograph of femur and knee joints obtained from teaching hospitals in Kathmandu Nepal. Totalof two hundred AP view radiograph of knee joint were collected, out of which, 50 each were of male rightand left knee joint and 50 each were of female right and left knee joint. The mean angle for the right malefemur was 7.86° with the range of 5°-10° and mean angle for the right female femur was 8.82° with therange of 6°-11°. On the left side, bicondylar angle ranged in male from 6° -10° with the average of 7.46°andin female range was 6°-11° and average was 8.66°. The bicondylar angle was higher in female on both theside, the difference was statistically significant on the left side (P=0.004) and significant on the right side(P=0.001). The finding of the study showed the femoral bicondylar angles were greater in right femurthan left femur in both sexes. The difference in the bicondylar angle between the right and left femurwas statistically insignificant in both sexes. (male p=0.144, female p=0.541). The result from this study hasshown that femoral bicondylar angles were generally greater amongst the females as compared to themales; greater in right femur than left femur in both sexes.

Keywords : Femoral bicondylar angle, femoraldiaphysis, infracondylar plane andmeasurement of radiograph

Three-port versus four-port laparoscopic cholecystectomy: A Randomized Controlled Trial

R Koirala, TM Gurung, A Rajbhandari, P Rai — Tue, 04 Jun 2019 08:57:31 +0000

Laparoscopic cholecystectomy (LC) is one of the most common surgery performed and is traditionallyperformed using four ports. With the aim of improving patient’s comfort, port numbers have beenreduced to single port. But feasibility and the extra expense that comes with single and doubleport LC has made them less attractive. Three port LC can be a safe alternative to four port LC, andvarious research has shown its safety. This study compares the three port LC with the traditionalfour port LC with the objective of assessing feasibility and benefit of the decreased port number.
We evaluated 217 patients who were randomly allocated for three port and four port LC. Both thegroups were compared for operative time, assessment of postoperative pain, days of hospital stay
and postoperative recovery time after discharge. The parameters were compared using StatisticalPackage for the Social Sciences (SPSS) version 16. Among 217 patients, 123 underwent three port LCand 94 underwent four port LC. The larger number were females (79.7%), and with comparable agegroup of patients. Rate of conversion to open cholecystectomy, postoperative pain scale, analgesicrequirement, average hospital stay and port site infection rates were comparable in both groups ofpatients. The average time taken for operation was less in three port LC than the four port LC butthis was not statistically significant. There is no significant difference between 3 port and 4 port LCin terms of time required for the surgery, conversion rate, complication and duration of hospital stay

Keywords : Four-port laparoscopiccholecystectomy, laparoscopiccholecystectomy, three-portlaparoscopic cholecystectomy

Comparison of polyvinyl acetate sponge and medicated ribbon gauge nasal pack following nasal surgery

S Maharjan, AK Jha, RR Joshi, AS Rijal, KK Shrestha, A Dhungana — Tue, 04 Jun 2019 08:57:37 +0000

Nasal occlusive dressings are routine after nasal surgeries to arrest hemorrhage, to prevent septalhematoma, and to prevent postoperative adhesions. However, patients describe nasal packing
and its removal as their worst experience. Various types of nasal packs are available. Medicatedribbon gauge is the traditional form of nasal pack which consists of an open-mesh cotton as a carrierwhereas “Polyvinyl Acetate’ sponge is a compressed dehydrated material, an improvised one whichincreases in size and compresses blood vessels when rehydrated with normal saline. As Polyvinylacetate sponge is smooth and spongy, it causes less pain and abrasion while in-situ and removal. Thiswas a prospective comparative study done in tertiary hospital of Nepal. Patients were subjected toeither polyvinyl acetate sponge or ribbon gauge nasal pack following nasal surgery. Comparisonswere made in terms of pain score, maintenance of hemostasis and wound healing. There were 154patients in the study with 104 males and 50 females. The pain score when nasal pack was in-situ wassimilar in both groups whereas it was lesser in the polyvinyl acetate group on its removal. However,bleeding and adhesion were found to be similar. Crust formation was less in polyvinyl acetate group.Six synaechia were noted in ribbon gauge group only. Pain was significantly less during removal ofpolyvinyl acetate pack.

Keywords : bleeding, nasal packing, nasalpain, polyvinyl acetate, ribbongauze

Refractive errors and its associated factors among undergraduate medical students in Kathmandu

A Rizyal, JS Sunrait, A Mishal — Tue, 04 Jun 2019 08:57:41 +0000

Refractive error is a defect in the optical system of the eye which prevents light from being brought toa single point focus on the retina, thus reducing normal vision. This optical defect is the second mostcommon cause of visual impairment globally as well in Nepal. At present, there are 285 million visuallyimpaired people in the world. An estimated 4 out of 5 visual impairment (80%) can be prevented or cured,uncorrected refractive errors are the leading cause (42%) followed by cataract (33%). A descriptive crosssectional study was conducted to determine the proportion of undergraduate medical students withrefractive errors in Nepal Medical College, and to identify factors associated with it. A total of 210 medicalstudents volunteered for this study, with 100 males (47.6%) and 110 females (52.4%). The age of thesestudents were between 18 to 26 years, with an average of 20.5 years. The proportion of medical studentswith refractive error was slightly more than half (51.4%), with simple myopia being the leading type(42.9%), followed by astigmatism (7.1%) and simple hypermetropia (1.4%). Parental history of refractiveerror was observed to be significantly associated with that of the medical students. There was also asignificant association between refractive error and the daily use of mobile phones and laptops. However,years spent in medical education were not observed to be significant.

Keywords : Associated factors, astigmatism,medical students, myopia,refractive error