Browsing by Author "Dhakal, B"
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Publication Clinical Characteristics and Outcomes of Anemia in Critically Ill Patients: A Cross-Sectional Observational Study from a Tertiary Intensive Care Unit in Nepal(Kathmandu University, 2025) Simkhada, N; Pathak, S; Thapa, N; Poudel, P; Dhakal, B; Upadhyay, G; Thapa, J; Regmi, A; Ojha, S; Adhikari, SABSTRACT Background Anemia is a common clinical problem among critically ill patients; however, its prognostic significance remains debatable. In low-resource settings, such as Nepal, data are limited. This study evaluated the clinical, laboratory, and outcome profiles of anemia in a tertiary Intensive Care Unit. Objective To assess the clinical characteristics, laboratory features, and outcomes of anemia in critically ill patients admitted to a tertiary Intensive Care Unit in Nepal. Method This retrospective observational study included 113 adult Intensive Care Unit patients with anemia admitted to Dhulikhel Hospital, Nepal, from October 2024 to March 2025 after obtaining ethical approval from the Institutional Review Committee, Kathmandu University School of Medical Sciences (IRC, KUSMS-156/25). Demographic data, anemia severity, laboratory markers, including peripheral blood smear (PBS), and outcomes, such as mortality and Intensive Care Unit stay, were analyzed using IBM SPSS Statistics version 25.0. Categorical variables were compared with Chi-square tests, continuous variables with independent t-test or Mann- Whitney U test, and correlations were assessed with Spearman’s rank method. Result The median hemoglobin level was 97 g/L (78-112g/L), and mild anemia was the most common (49.5%). Mortality correlated strongly with abnormal peripheral blood smear (p < 0.001, r = 0.52) and moderately with older age (p = 0.012, r = 0.35). Although anemia severity was not statistically significant (p = 0.423), its weak positive correlation (r = 0.15) indicates a potential trend. Conclusion Peripheral blood smear abnormalities and advanced age strongly predict mortality in critically ill patients, while anemia severity alone does not. Routine smear use in resource-limited ICUs may aid early risk stratification and improve care. KEY WORDS Anemia, Critical Illness, Intensive care unit, NepalPublication Endometriosis of Groin Mimicking Neoplasm(Kathmandu University, 2021) Maharjan, PB; Makaju, R; Makaju, S; Dhakal, R; Lama, B; Basnet, D; Dhakal, BABSTRACT Endometriosis is principally a disease of women in active reproductive life. Although it is rare, foci of endometrial tissue may be seen in the bowel, the umbilicus, abdominal surgical scars and in the lungs. Inguinal endometriosis is challenging to the clinicians and pathologist and often diagnosed accidentally. We present a case of inguinal endometriosis mimicking neoplasm. A 40 year old woman presented with a swelling in the right inguinal region associated with cyclical pain. In view of presence of atypical cells in fine needle aspiration cytology, metastatic carcinoma was rendered as diagnosis. Histopathological examination revealed endometrial glands and stroma which was further confirmed by immunohistochemistry. Diagnosis of inguinal endometriosis is difficult and often challenging because of unusual site. The clinician must have high index of suspicion with any patient who has cyclical symptoms. A good history and physical examination can guide clinical diagnosis of endometriosis. KEY WORDS Endometriosis, Groin mass, Inguinal endometriosisPublication Fine Needle Aspiration Cytology with the Assistance of Radiological Tools in the Diagnosis of Deep-Seated Lesions(Kathmandu University, 2021) Dhakal, R; Makaju, R; Karki, S; Dhakal, BABSTRACT Background Fine needle aspiration (FNA) with radiological assisted tools such as ultrasonography (USG) and computed tomography (CT) are effective in obtaining high yield aspiration of tissues located in technically difficult places such as deep-seated. It is a simple outpatient procedure with low cost as compared to surgical biopsies. Objective To study the cytomorphological features of deep-seated lesions according to the site of occurrence, and to categorize them with respect to age, sex and behavior of lesions. Method This was a descriptive cross-sectional study of 125 patients who underwent image- guided fine needle aspiration cytology of deep-seated lesions. The study was conducted in the Department of Pathology and Department of Radiodiagnosis, Dhulikhel Hospital- Kathmandu University Hospital, between January 2017 and December 2018. Under radiological guidance, aspiration was performed under negative pressure, and adequate material was obtained. Smears were stained with Giemsa and Papanicolaou stain. The prepared slides were examined under a microscope. Result Of the 125 patients who underwent USG and CT-guided fine needle aspiration cytology (FNAC), 68(54.4%) were female and 57(45.6%) were male. The age of the patients ranged from 13 to 84 years. The maximum number of patients was above 50 years. The nature of lesions was categorized as malignant 78(62.4%), followed by 23(18.4%) inflammatory and benign 1(0.8%). Conclusion Image-guided fine needle aspiration cytology is a safe diagnostic procedure, as it provides real-time visualization of tip insertion in anatomical structures. It provides high yield and a better representation of the samples. KEY WORDS Computed tomography, Fine needle aspiration, UltrasonographyPublication Hashimoto’s Thyroiditis with Squamous Metaplasia(Kathmandu University, 2024) Dahal, S; Makaju, R; Basnet, D; Dhakal, B; Shrestha, B; Maharjan, PBABSTRACT Hashimoto’s thyroiditis is an autoimmune inflammatory disease. Although rare, squamous metaplasia can be seen in Hashimoto’s thyroiditis. We present a case of 19 years female who presented with chief complaint of anterior neck swelling for three months. Thyroid Stimulating Hormone (TSH) was 3.93 mIU/L. Ultrasonography neck showed TIRADS (Thyroid Imaging Reporting and Data Systems) 5 lesion. Fine Needle Aspiration Cytology showed Papillary Thyroid Carcinoma. Histopathological examination revealed numerous lymphoid follicles of variable size with clusters of squamous metaplastic cells within the germinal centers of lymphoid follicles and surrounding fibrosis. Some cells showed nuclear clearing. Diagnosis of Hashimoto’s thyroiditis with squamous metaplasia was further confirmed by immunohistochemistry. The case presented here is rare and there are very few cases reported in literature so far. KEY WORDS Hashimoto’s thyroiditis, Squamous metaplasia, Thyroid glandPublication Incidence and Diagnosis of Ampullary Carcinoma in Dhulikhel Hospital, Kathmandu University Hospital(Kathmandu University, 2021) Dhakal, B; Makaju, RABSTRACT Background Endoscopy from a suspected ampulla of vator may establish an early preoperative diagnosis of ampullary carcinoma. However, information regarding the diagnostic accuracy of this procedure is limited and variable. Objective To study the preoperative diagnostic accuracy of Endoscopic/ERCP appearance of ampullary tumors with that of endoscopic biopsy. Method Among patients who were performed endoscopy during a one year period; a suspicious ampulla of vator was seen in 44 cases. Endoscopic biopsy specimens were classified into four groups based on the degree of epithelial atypia: group 1 (no evidence of malignancy), group 2 (presence of dysplasia), group 3 (suspicious of malignancy) and group 4 (positive for malignancy). In each case comparison was made between the pre-endoscopic biopsy clinical diagnosis and endoscopic appearance. Result Endoscopic biopsy diagnosis of malignancy (group 4) were seen in 22 cases, Suspicious of malignancy (group 3) in 3 cases, dysplasia (group 2) in 9 cases and no evidence of malignancy (group 1) in 10 cases. Pre-endoscopic diagnostic accuracy of endoscopy/ ERCP was 50% compared to the diagnosis by biopsy. Conclusion Diagnostic accuracy of endoscopy/ERCP was 50% compared to the diagnosis by biopsy. A diagnosis of non malignancy in the forceps biopsy material does not rule out the presence of cancerous foci in ampullary neoplasms. KEY WORDS Ampulla of Vator, Ampullary carcinoma, Diagnostic accuracy, Dysplasia, Endoscopic biopsy, ERCPPublication Outcomes of Treatment of Thoracolumbar Burst Fractures with Intact Neurology Treated in Karnali Academy of Health Sciences, Nepal(Kathmandu University, 2025) Kathayat, TS; Rokaya, PK; Rawal, M; Karki, PD; Dhakal, B; Thapa, S; Maharjan, AABSTRACT Background The vulnerability of the thoracolumbar junction for a higher incidence of fracture with neural injury is mainly due to its anatomical peculiarity. The management of thoracolumbar burst fractures remains controversial due to the potential for further neurological deterioration and vertebral collapse at the thoracolumbar junction. Objective To investigate the outcomes of treatment of thoracolumbar burst fractures with intact neurology treated in Karnali Academy of Health Sciences, Nepal. Method This retrospective comparative study was done at Karnali Academy of Health Sciences, which included patients with thoracolumbar burst fractures classified as AO type A3 and A4, treated conservatively or operatively at 2 years follow-up. Data on demographics, kyphotic angles at injury were collected and at 2 years follow-up, and Patient-Reported Outcomes with the Nepali version (PROST) and Visual Analog Scale (VAS) scores for pain assessment. Result The results showed that 32 patients had a mean age of 43.47 years, with a majority in the 30-49 age group, showed a female predominance (56.3%) and fall injuries as the most common cause (78.2%). A total of 18 cases of AO type A3 and A4 were managed conservatively, while 14 cases were managed operatively of AO type A4. There was a significant difference in the kyphotic angle correction in operative cases (19.57 ± 8.19 vs 13.21 ± 5.57 degree (p-value < 0.001). In addition, there was no statistically significant improvement in functional outcome via PROST scores (p-value = 0.718) and VAS score (p-value = 0.450) in conservative and operative treatment. Conclusion Surgical intervention significantly improved kyphotic angles in AO type A4 patients, but the conservative management in both AO type A3 and AO A4 showed no significant change in kyphotic angle. However, PROST Nepali score and VAS score among conservative and operative cases were comparable and not statistically significant. KEY WORDS Burst fracture, PROST Nepali, Thoracolumbar vertebra, Treatment outcome, Visual analog scalePublication Pitfalls in diagnosing Gallbladder Carcinoma – A Single Center Histopathology Study(Kathmandu University, 2025) Dhakal, B; Makaju, R; Maharjan, P; Basnet, D; Shrestha, BABSTRACT Background Gallbladder carcinoma is a rare cancer with incidence of less than 2 per 100,000 populations worldwide. It is the fifth most frequent gastrointestinal malignancy. Radiological or gross examination of majority of gallbladder carcinoma detects no mass. This may lead to under or over diagnosis of cases in histological examination. Objective To identify pathologic features that contribute to the difficulty in diagnosis of gallbladder carcinoma. Method Between 2018 and 2023, 22 patients with gallbladder carcinoma were identified using the histopathology registry book at the department of pathology. Blocks, slides, reports and history of those cases were retrieved and reviewed. The slides were analyzed by two or more pathologist noting some of the diagnostic difficulties which could have been encountered. The number and percentage with interpretations of the cases were noted. Result Nine of 22 primary gallbladder carcinoma cases had tumor masses. Nine cases in histological examination provided diagnostic challenges. The major pitfalls encountered while diagnosing gallbladder carcinoma was mistakenly making a diagnosis of carcinoma when only deeply penetrating Rokitansky–aschoff sinuses are present. Similarly, pathologists misdiagnose carcinoma with minimal disease as benign disease, Adenomyosis as Adenocarcinoma. Under sampling of specimen, grossly occult disease, misinterpreting extracellular mucin pools were other potential pitfalls. Conclusion Deeply penetrating Rokitansky-aschoff sinus or Adenomyosis can be mistakenly diagnosed as gallbladder carcinoma. Careful attention to any evidence of mural thickening and close examination of deeply situated glandular structures were crucial for proper diagnosis of gallbladder carcinoma. KEY WORDS Adenomysois, Gallbladder carcinoma, Histology, Necrosis, Pitfalls, Rokitansky– Aschoff sinusesPublication Prevalence and Clinical Manifestations of Helicobacter Pylori with Reference to Histopathological Diagnosis(Kathmandu University, 2020) Makaju, R; Dhakal, B; Dhakal, RABSTRACT Background Helicobacter pylori infection is on a steep decline in most of the developed countries; however, in developing countries like Nepal such steep decline is not seen. This may be due to failure of treatment regimens and emergence of drug resistance. Our previous study done in 2004/2005 showed 38% prevalence of Helicobacter pylori. The present study has been conducted to review the prevalence and clinical diagnosis of Helicobacter pylori with reference to histo-pathological diagnosis. Method This was retrospective study done at Dhulikhel Hospital, Kathmandu University Hospital over a period of 13 years from January 2006 to December 2018. Helicobacter pylori proven cases were retrospectively analyzed with clinical features and endoscopy findings. The clinical picture were categorized into antral gastritis, gastroduodenits, erosive duodenitis, acid peptic disease, reflux esophagitis, hiatal hernia, polyp, ulcer (gastric and duodenal), acute abdomen, upper gastrointestinal bleeding and malignancy. Result A total of 1624 upper gastrointestinal endoscopy biopsies were taken during the study period. Helicobacter pylori infection was seen in 618 (38.0%) cases out of 1624 cases. Helicobacter pylori were seen in 349 male and 269 female patients with male to female ratio of 1.29:1. Clinically, gastritis 210 (41.4%), acid peptic disease74 (42.7%), gastroduodenitis 46 (37.7%), reflux esophagitis 38 (52.7%), gastric ulcer 48 (28.4%), duodenal ulcer 34 (53.1%) and acute abdomen 50 (42.3%) cases were seen respectively. Conclusion Most commonly Helicobacter pylori cause chronic gastritis in our context. There is no significant change in prevalence of Helicobacter pylori infection as compared to our previous study (2004/05). This needs proper management of Helicobacter pylori infection to prevent serious complication such as gastric cancer in our part of the world. KEY WORDS Helicobacter Pylori, Histopathological diagnosis, PrevalencePublication The Diagnostic Accuracy of Frozen Section Compared to Permanent Section: Single Center Study(Kathmandu University, 2019) Dhakal, B; Makaju, RABSTRACT Background Intra-operative consultation by frozen section is a procedure which plays a major role in the surgical management of patients with neoplastic and non neoplastic disease. Therefore it is critical to determine efficiency of frozen section performance periodically. Objective To evaluate the accuracy of frozen section tests at different anatomical sites by comparing the frozen section diagnosis with the histological diagnosis. Method We conducted a retrospective study in Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, and compared the results of 47 cases of frozen section with their final permanent section diagnosis during a period of January 2017 to December 2018. Result A total of 47 cases were studied on frozen section while no case was deferred for permanent paraffin section. The indication of frozen section was for presence/ typing of neoplasm in 38 cases (80.75%), clearance of margin in eight cases (17%) and diagnosis of Hirschsprung’s disease in one case (2.1%). The overall accuracy of frozen section was 91.4% (43 cases) with 8.5% (four cases) discordant with the diagnosis, reported as false negative. None of the cases were reported as false positive. Sensitivity, specificity, positive predictive value and negative predictive value of frozen section in comparison with permanent section (as gold standard) were 85.18%, 100%, 100% and 83.33% respectively. Conclusion The accuracy of frozen section diagnosis at our institute was 91.4% which can be interpreted as comparable with most national and international studies. The overall error rate is 8.5% which is higher than previously published studies. Experience and training of the pathologist reduce the error rate. KEY WORDS Accuracy, Discordant, Deferred, Frozen section, Intra-operative consultation, Permanent sectionPublication The Risk of COVID-19 in People Having a Particular Set of Gene(Kathmandu University, 2021) Dhakal, B; Makaju, R; Dhakal, RABSTRACT These risk factors of advancing age, male gender and co-existing health conditions like cancer, cardiovascular diseases, diabetes and obesity do not fully explain why some people have no or mild symptoms whereas others have severe symptoms. Genomewide association study (GWAS) identify a 3p21.31 gene cluster as a genetic susceptibility locus in patients with COVID-19 with respiratory failure. They also found a higher risk among persons with blood group A and protective effect for blood group O than among patients with other blood groups. The particular haplotype in a region of chromosome 3 is contributed to modern humans by neandertals. Another Neanderthal haplotype on chromosome 12 is associated with a 22% reduction in relative risk of becoming severely ill with COVID-19. The ApoE e4e4 homozygous genotype was found to increase the risk of severe COVID-19. Change in angiotensin converting enzyme (ACE) 2 gene was also found to be associated with increased risk of COVID-19, cardiovascular and pulmonary conditions. KEY WORDS Blood group, Chromosome 3, Chromosome 12, Angiotensin converting enzyme