Post-Graduate Medical Journal of NAMS

Milestone of PMJN

Dr. Peeyush Dahal — Fri, 24 May 2019 07:51:35 +0000

Professor Keshav Das Joshi and some senior doctors started every month clinical meeting in1980 in Bir Hospital. After starting the clinical meeting all the doctor felt the need of Medical Journal that should be published from their own institution. The dream came true in 1981 whenthe first issue of journal which was named “Proceeding of Bir Hospital” was published.In 1991 the editorial board was formed and the first issue of journal was published with thesupport of some pharmaceutical company like Royal Drugs Ltd. Nepal, Hoechst. The secondissue was publish in 1992 then publication of journal interrupted and souvenir of Bir Hospitalwas continued.Postgraduate Medical Education Committee was formed in Bir Hospital to start postgraduatetraining course in Nepal by Tribhuvan University in 1994. As postgraduate course was startedin Bir Hospital the need of medical journal was felt in Bir Hospital and editorial board wasformed in 1999. It was called PMJN. (Post graduate Medical journal of Nepal) and first issue ofPMJN was published in 2000. NAMS was established in 2003 then it was named as PMJN (Postgraduate Medical Journal of National Academy of Medical Sciences). Professor Joshi, D.B. Karkiand many other senior had contributed a lot in the development of PMJN.Over the years the journal editorship has changed and the tradition continued with manyimprovements. During this period we have learn some and we have to do a lot. Learning isnever ending process. We are learning from senior and junior colleagues and moving forwardto improve our self.

Low Dose Mitomycin C Augmented Trabeculectomy in Advanced Glaucoma

RP Sitoula, DH Lamichhane, A Anwar — Fri, 24 May 2019 07:52:56 +0000

Introduction: Trabeculectomy remains the ‘gold standard’filtration surgery for reduction of intraocular pressure in Glaucoma. Mitomycin C has been found to be useful in preventing closure after filtration surgery. Literature is scarce on efficacy of lose dose Mitomycin Caugmented trabeculectomy in advanced glaucoma.

Method: Retrospective analysis of prospectively collected data from December 2013 to December 2015 was done. All patients with advanced primary Glaucoma (cupping≥ 0.9 with visual field defects and elevated intraocular pressure) who underwent primary trabeculectomy with low dose Mitomycin C (0.2 mg/ml for 2 min) with minimum follow up of one year were included in the study. Outcome was defined based on postoperative Intraocular pressure: hypotony(<6), good(7 – 15),satisfactory (16-21) and poor (>21) mm of Hg. Result: 26 patients (19 males and 7 females)met the inclusion criteria.Both eyes were affected in four patients; therefore 30 eyes were included in final analysis. Mean age was 41.4 years. Following surgery, mean intraocular pressure decreased from 31.3 ± 13.5 mm Hg to 11.2± 4.2mm Hg at 6 monthsand 11.4 ± 4mm Hg at 1 year(paired sample T test, P value <0.001). At 1 yearfollow up, IOP was <6 in 2 patients (6.7%), 7-15 in 23 (76.7%), 16-21 in 4 (13.3%),>21 in 1 (6.3%).There was no case of wipe out phenomenon.

Conclusion: Low dose Mitomycin C (0.2 mg/ml) augmented primary trabeculectomy was found to be safe and effective for treatment of patients with advanced Glaucoma.

Key words: Trabeculectomy, Advanced glaucoma, Mitomycin C, Wipe out phenomenon

Functional Outcome of Primary Kirschner Wire Fixation in two Part Mid Clavicular Fractures

P Baral, AR Bajracharya, D Dutta, S Poudel, GB Shah — Fri, 24 May 2019 07:53:54 +0000

Introduction: Middle third is the commonest site for clavicular fractures. Incidence of highenergy clavicular fractures with comminution and displacement is increasing, for which reduction
and maintenance with braces and bandages are not only uncomfortable with need for frequentmonitoring of loosening and complications, but also insufficient resulting in unacceptablemalunions and nonunions. Intramedullary Kirschner`s wire fixation is a safe and simple procedure,with small incision and little soft tissue dissection. It has good result in terms of patient comfort,union rate, cosmesis, and ease of hardware removal following fracture union. The objective ofthe study was to evaluate the functional outcome, rate and time for union, possible complicationswith primary Kwire fixation of the two part middle third clavicular fractures.
Method: It was a prospective observational study, with in a period of one year, in threegovernment hospitals in Kathmandu. 28 cases with displaced 2 part middle third clavicle fracture
were included. Intramedullary K-wire fixation (2.5mm) was done and outcome was assessedin terms of time of fracture union, complication rate, DASH scores and compared with similar
studies done elsewhere.
Result: 18-50 years old patients, 20 males and 8 females were involved in the study. Fall on thepoint of shoulder was commonest mechanism of fracture(56%).Mean time of union was 7.6 weeks(6-11 weeks).Superficial wound infection was seen in 4 cases, hematoma in 1. There was no nonunion,malunion, k-wire migration, hardware failure, and neurovascular injury. K-wire was removed after
the radiological union of fracture was seen.
Conclusion: Primary intramedullary K wire fixation of middle third two part clavicle fracture isa safe and simple procedure with good functional outcome and recommended as a method of
treatment.
Key words: Clavicle fracture, Open reduction, Internal fixation, K-wire fixation

Clinicopathological Study of Gall Bladder Cancer with special Reference to Gall Stones: 12 years Experience in Tertiary Care Center in Nepal

Fri, 24 May 2019 07:54:42 +0000

Introduction: Gall bladder cancer is most common cancer of the biliary tree and one of thehighly malignant tumors with poor prognosis. Although its incidence is low in west, it is common
in our part of the world. There are very few studies regarding gall bladder cancer in Nepal. Theincidence of gallstones in patients with gall bladder cancer is high. The aim of the study was to
evaluate the clinicopathological aspect of the disease in patients with gallbladder cancer and toAsses the incidence of gallstones in patients with gall bladder cancer.
Method: This was a retrospective study carried out in GI Surgery unit of National Academy ofMedical Science, Bir Hospital, Kathmandu, Nepal. All patients diagnosed as gallbladder carcinomas
during 12 years period from 2002 to 2014 were included in this study. Their clinical characteristics,laboratory data, tumor histopathology reports were obtained and analyzed using SPSS17.
Result: Total of 47 patients who met inclusion criteria were included in the study. Male to Femalratio was 1:1.8. Age ranged from 32 to 72 years with mean age of 54. Most common presenting
symptom was Pain abdomen (93.6%) followed by weight loss (51.1%) and Jaundice (46.8%).Most common finding on examination was Icterus (42.6%) followed by palpable gall bladder
(34%) and Hepatomegaly (29.8%). Gall Stones were seen in 37 (72.3%) patients. Most commonhistopathology was Adenocarcinoma (93.6%).
Conclusion: Most of the patient with gall bladder cancer remained asymptomatic until late. Painabdomen was most common presenting symptom and icterus was most common findings. There
was strong association between gall bladder cancer and gallstones. There should be high index ofsuspicion if patient with gallstones has constant pain in right hypochondrium and has jaundice.
Key words: Gall bladder cancer, Gallstones, Nepal

Utility of Intracerebral Hemorrhage Score for Predicting Prognostic Value in Hypertensive Bleed

Fri, 24 May 2019 07:56:40 +0000

Introduction: Intracerebral hemorrhage (ICH) constitutes 10% to 15% of all strokes and thereis no treatment of proven benefit. Despite several existing outcome prediction models for ICH,
there is no standard clinical grading scale for ICH analogous to those for traumatic brain injury,subarachnoid hemorrhage, or ischemic stroke.
Method: Records of all patients with acute ICH presenting to Bir Hospital (NAMS), Mahaboudha,Kathmandu during March 1st to June 29th 2017 were prospectively collected. Independent
predictors of 30-day mortality were identified by logistic regression. A risk stratification scale(the age modified ICH Score) was developed with weighting of independent predictors based on
strength of association.
Result: Factors independently associated with 30-day mortality were Glasgow Coma Scale (GCS)score (P=0.028), age ≥65 years (P=0.001), ICH volume (P =0.02), and presence of Intraventricular
hemorrhage (IVH) (P 0.30). The ICH Score was the sum of individual points assigned as follows:GCS score 3 to 4 (=2 points), 5 to 12 (=1), 13 to 15 (=0); age ≥65years yes (=1), no (=0); infratentorial
origin yes (=1), no (=0); ICH volume ≥30 cm3 (=1), ,<30 cm3 (=0); and IVH yes (=1), no (=0). Nopatient of Age modified ICH score was alive and 83% of the Age modified ICH score of 3 or 4were dead. Other with the score of 0, 1, 2 were all alive.Thirty -day mortality increased with Agemodified ICH Score (P-value< 0.001).
Conclusion: The Age modified ICH Score is a simple clinical grading scale that allows riskstratification on presentation with ICH. The use of a scale such as the ICH Score could improve
standardization of clinical treatment protocols and clinical research studies in ICH.30
Key words: intracerebral hemorrhage, medical management, outcome, prognosis, surgery

A Comparative Study on Oral Clonidine and Gabapentin for Preoperative Anxiolysis and Attenuation of Hemodynamic Response to Direct Laryngoscopy and Endotracheal Intubation.

PR Poudel, A Pokharel, JN Pokharel — Fri, 24 May 2019 07:58:05 +0000

Introduction: Patients under going surgery experience unpleasant anxiety preoperatively thatadversely influence anesthetic induction and patient recovery. Hemodynamic stability is an
essential goal of any anesthetic management. The aim of this study was to compare the effectsof oral Clonidine and Gabapentin in preoperative anxiolysis and attenuation of hemodynamic
response to endotracheal intubation.
Method: This is a prospective, randomized, double blind clinical study. Sixty-six patients aged 18to 60 years of American Society of Anesthesiologist (ASA) physical status I and II, scheduled for
elective surgeries under general anesthesia with endotracheal intubation were included. Patientswere randomized and given oral Gabapentin 800 mg (Group G) or Clonidine 300 mcg (Group C)
or Placebo tablets (Group P) two hours prior to surgery accordingly. Study groups were comparedfor patient characteristics, Visual Analogue Scale (VAS) anxiety score and hemodynamic responseat baseline, before intubation and after intubation at 0, 1, 3, 5 and 10 mins. Collected data wereanalyzed with Chi-square test and ANOVA with Post-hoc comparisons.
Result: VAS anxiety score was significantly decreased in group G and C as compared to Placebo(P = <0.001). But it was comparable between the group G and C. There was statistically significant
difference in heart rate (HR) at 0, 1, 3 and 5 mins (P = 0.023, 0.005, 0.037& 0.037) between groupG and C. Mean arterial pressure (MAP) was statistically significant at 0 min (P = 0.011) and 1 min
(P = 0.036) between group G and C whereas at 3, 5 and 10 mins it was comparable. No significantside effects of study drugs were noted.
Conclusion: Oral Clonidine (300 mcg) given two hours preoperatively can effectively decreasepreoperative anxiety and provide good attenuation of hemodynamic response to laryngoscopy
and endotracheal intubation as compare with the oral Gabapentin (800 mg) and Placebo.
Key words: Clonidine, Gabapentin, Hemodynamic response, Intubation, Laryngoscopy

An Epidemiological study of orthopaedic Trauma cases attending at Sub regional Hospital, Nepal

R Kushwaha — Fri, 24 May 2019 07:58:59 +0000

Introduction: Physical trauma is one of the major causes of mortality and morbidity among young andactive age group and gradually trauma cases are increasing because of significant urbanization, motorization,industrialization and a change in the socioeconomic values. The aim of the study is to assess the variousepidemiological parameters that influence the cause of injury in the patient and there are only few studyconcerning the spectrum of physical trauma in Nepal.
Method: A retrospective study was done in Narayani Sub-Regional Hospital over a period of one year (January2016 to December 2016) in 2170 trauma cases attending to hospital and epidemiological information, mode,type and pattern of injury were recorded. Obtained data was analyzed in Spps..
Result: In a period of one year 2170 trauma cases presented to the hospital and maximum number ofcases (235) was in the month June. Injuries occurs predominantly in the age group of 15-49 year. Maleincurred more injury with male to female ratio of 5:1. Road traffic accident (RTA) was the commonest modeof injury(70%) followed by fall injury (15%). The lower limb were the most common body region injured (42%)followed by upper limb(38%).
Conclusion: RTA and fall related injuries are the most common mode of trauma involving young adultin their active period of life, so appropriate preventive measure through public health approach, improvedroad condition, proper traffic knowledge with comprehensive trauma management for reducing mortalityand morbidity rates related to physical trauma.
Key words: Orthopaedic, trauma, epidemiology, fractures.

Challenges in the Anaesthetic Management of Congenital Diaphragmatic Hernia in a Tertiary Care Children Hospital of Nepal

S Regmi, BK Baral, S Sapkota — Fri, 24 May 2019 07:59:56 +0000

Introduction: Congenital diaphragmatic hernias (CDH) are complex developmental anomaly. Itresults from anomalous closure of pericardio-peritoneal canal. Consequently, abdominal organs
extrude into the thoracic cavity, impairing the growth of the ipsilateral lung. Surgical correctionis the only treatment modality. There are various challenges faced by anesthesiologists such as
hypoxia and hypercarbia leading to pulmonary hypertension and right to left shunt.This study is carried out to present perioperative complications that we faced during theanaesthetic management of CDH in patients who underwent surgical closure of the diaphragmaticdefect in a tertiary care centre of Nepal.
Method: This is a retrospective study carried over a period of one year. We reviewed the medicalrecords of children with the diagnosis of CDH who underwent surgical correction of diaphragmatic
defect. The perioperative complications were recorded as the appearance of bradycardia, hypoxia,sepsis, DIC, pneumothorax and the collected data were analyzed.
Result: Thirteen children presented to the hospital with the diagnosis of CDH and underwentsurgical repair. Among them, 9 (69.23%) were male and 4 (30.76%) were female. Hospital
presentation on 8 to 30 days of life was noted in 46.15% of the cases, The most commoncomplication during the perioperative period was hypoxia, bradycardia and pneumothorax. Thesurvival rate was 61.53%.
Conclusion: The anaesthetic management of CDH is still a difficult and challenging foranaesthesiologist. Bradycardia, hypoxia, pneumothorax, septicemia and DIC are the majorcauses of perioperative morbidity and mortality. Preoperative optimization and gentle ventilationstrategy makes significant impact on survival in child.
Key words: Congenital diaphragmatic hernia, hypoxia, pulmonary hypertension.

Medical Therapy of Benign Prostatic Hyperplasia: A Review

P Maskey — Fri, 24 May 2019 08:01:18 +0000

Medical treatment of benign prostatic hyperplasia (BPH) has conventionally been based on alpha blockers and5-alpha reductase inhibitors. There has been a paradigm shift in this concept with the introduction of otheragents. The treatment of BPH should be based not only on the size of prostate and severity of symptoms, butalso on the type of symptoms (predominant storage versus obstructive), probability of progression, and thepresence or absence of sexual dysfunction
Key words: benign prostatic hyperplasia, lower urinary tract symptoms medical therapy

Tumors of Hand and Forearm

KK Nakarmi — Fri, 24 May 2019 08:02:05 +0000

Hand is a confined anatomical unit with different types of tissues. It translates to the fact thatthere are variety of tumors arising in this small area. Each tumor has unique presentation and
different treatment modality. It is important to differentiate among them for proper management.This paper tries to present common types of tumors of hand and forearm.
Key words: hand, forearm, tumor

Paediatric Angiosarcoma of Gingivobuccal Sulcus: A Rare Case Report

R Maharjan, AK Shah, S Mainali — Fri, 24 May 2019 08:02:50 +0000

We are presenting a case of 10 years male child with huge left sided facial swelling withintermittent bleeding from oral cavity. He underwent total maxillectomy and wide local excision.
Angiosarcoma is a rare aggressive malignant case of the pediatric population which occur in headand neck region1-8.
Key words: Angiosarcoma, Head and Neck Malignancy, Pediatrics