Browsing by Author "Malla, T"
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Publication A Prospective Study on Exchange Transfusion in Neonatal Unconjugated Hyperbilirubinemia – in a Tertiary Care Hospital, Nepal(Kathmandu University, 2015) Malla, T; Singh, S; Poudyal, P; Sathian, B; BK, G; Malla, KKABSTRACT Background An exchange transfusion involves replacing patient’s blood with donor blood in order to remove abnormal blood components and circulating toxins while maintaining adequate circulating blood volume. Objective To observe the incidence, causes of jaundice requiring Exchange and any adverse event of exchange transfusion in newborns with unconjugated hyperbilirubinemia. Method Prospective study undertaken at Neonatal Intensive Care Unit (NICU) of Manipal Teaching Hospital, Pokhara, Nepal from March 2014 to April 2015. For both mothers and neonates blood group and Rh typing and for all newborns pre and post exchange complete blood count with peripheral smear, serum bilirubin, hemoglobin, calcium, potassium, random blood sugar, C-reactive protein and blood culture and where ever required Direct Coombs test, reticulocyte count, G6PD activity and thyroid function test were done. The incidence, indications, positive outcome, complications and mortality were noted. Result Out of 481 cases of unconjugated hyperbilirubinemia 29(6%) required exchange transfusion. 55.2% Pathological Jaundice [13.8% ABO incompatibility, sepsis and hypothyroidism was commonest causes] and 44.8% exaggerated physiological jaundice [27.6% with no underlying pathology, 10.3% preterms 3.4% cephalhematoma] required exchange transfusion. Post transfusion, bilirubin level decreased significantly (p<0.001). The commonest adverse events noted were anemia (89.7% / p<0.018), hyperglycemia(51.7% / p<0.001), hypocalcaemia (48.3% /p<0.001)), sepsis(10.3%), hypernatremia (13.8%), hyperkalaemia, bradycardia, apnea and feed intolerance (6.9%). None of them had kernicterus and there was no mortalities. Conclusion Exchange transfusion is an effective procedure to decrease bilirubin levels but is associated with many complications. Hypothyroidism was one of the commonest cause of jaundice requiring Exchange transfusion. KEY WORDS Exchange transfusion, hyperbilirubinemia, kernicterus, neonate.Publication Analysis of Post Earthquake Disease Pattern in a Camp at Gyampesal Gorkha(Kathmandu University, 2016) Malla, T; Malla, KK; Singh, SK; Shrestha, SABSTRACT Background A major earthquake occurred in Nepal on 25th April 2015 with magnitude of 7.8 causing mass panic amongst people. Objective To analyze scenario, experience and disease pattern of Post Earthquake camp at Gyampesal, Gorkha. Method A prospective observational study done on 13th and 14th June 2015 in a population who attended the health camp at health post, Gyampesal Gorkha. Analysis was done for age, sex, and disease pattern. Medicines for their health problems was provided by Manipal Teaching Hospital, Pokhara, Nepal Pediatric Society and Children Welfare in Nepal, Kathmandu. Result Total 159 patients [80.5% children and 19.5% adults] had attended the health camp. The mean age of children was 6.18±4.27 SD with maximum between 2-5 years (39%) and mean age of adults was 37.87±14.07 SD. Among the children males were more (50.8%) than females but in adult group females (83.9%) were more. Most common complaints were earthquake related fear (Children- 60.23% / adults -71%), insect bite [children -25.8% /adults -35.5%], pain abdomen (children- 64.1% / adult -38.7%) and decreased appetite (children- 83.6% / adults - 16.1%). Pain abdomen and decreased appetite was significantly high in children with p <0.009 and 0.001 respectively. The common disease patterns noted in children were recurrent abdominal pain (25%), acute gastroenteritis (19.5%), upper respiratory tract infections (15.6%), Impetigo (15.6%), Dental caries(10%), Pityriasis alba (10%). In adults Acid peptic disease (51.6%), Headache (32.5%), hypertension, Upper respiratory infections, scabies and Urinary tract infection (16%), Acute gastroenteritis (13%) was common. Conclusion Earthquake related fear, insect bite and Communicable diseases both airborne and water borne were the commonest findings observed. Therefore basic needs and services like safe water and sanitation, adequate shelter, primary healthcare services and vector-control campaigns are crucial and essential for these displaced populations. KEY WORDS Children, disease pattern, earthquakePublication Enteric Fever: A retrospective 6-year analysis of 82 paediatric cases in a teaching hospital(Kathmandu University, 2007) Malla, T; Malla, KK; Thapalial, A; Shaw, CObjective: To evaluate the clinical and laboratory properties, to see the response to therapy, incidence of antimicrobial resistance and complications of Enteric Fever in children. Methods: This is a retrospective study of 82 cases of enteric fever admitted in department of pediatrics, Manipal Teaching hospital, Pokhara, Nepal .Study period was six years from (Jan 2000 to Dec 2005). Results: Total of 82 cases of Salmonella infections were admitted .There were 50 (60%) males and 32 (40%) females. Most of the patients were above the age of five. The leading clinical feature were Fever (100%) , GI symptoms (73%), followed by splenomegaly (60%), hepatomegaly (58%) , chills & rigor (41%), headache(33%),coated tongue(17%), lymphadenopathy (13%), Respiratory signs (13%) , toxic look (7%). The laboratory reports revealed leucopenia in 26% and leukocytosis in 16%. Widal test was positive in 83%, Blood culture was positive in 37 %.Bone marrow was done in 8 cases, out of which 5(62.5%) were culture positive. Out of 35 culture positive cases 32 were Salmonella typhi and 3 were Salmonella paratyphi A. Regarding the treatment 55% were treated with ciprofloxacin, 29 % with ceftriaxone , 7% with ampicillin , 6% with cefotaxime and 2.4 % with chloramphenicol . Response to therapy was assessed by day of defervescence after antibiotics. Best response was observed with ciprofloxacin (4.7 days) followed by ceftriaxone (5days), ampicillin (5.5 days), cefotaximee (6.4 days), chloramphenicol (10 days) respectively. In the antibiogram resistance was 43% with chloramphenicol, 37% with ampicillin, 31% with trimethoprim- sulfamethoxazole, 5.7%with ciprofloxacin and 4% with cefotaxime .Resistance was 0% with ceftriaxone, cefuroxime, and ofloxacin. Gentamycin was found to show high sensitivity (91%). The complications observed were anemia in 10%, 5% had neurologic signs like clouding of consciousness and 3.7% had CNS irritability. Conclusion: It is important to include Enteric fever in the differential diagnosis of febrile patients with abdominal symptoms. Though blood culture is the definite test, Widal test plays supportive role in diagnosis of enteric fever, especially when patients come after a course of antibiotics. Sometimes when both blood culture and Widal tests are negative Bone marrow can be the diagnostic tool for the diagnosis. Based on this analysis ciprofloxacin is still a good drug for the treatment of Enteric Fever. Ceftriaxone, Cefuroxime and Ofloxacin can be considered as first line treatment for Enteric fever since resistance was nil with these drugs on culture reports. Key words: Enteric fever, salmonella infectionsPublication Incidence of Simian Crease in Normal Nepalese Children(Kathmandu University, 2010) Malla, T; Malla, KK; Gauchan, E; Brijesh, S; Sharma, RABSTRACT Backgroud Simian crease is usually associated with some chromosomal anomalies and syndromes but it is also seen in some populations without any chromosomal defects. Objective To see the incidence of simian crease in children without chromosomal anomalies and to detect the Ethnic group variations. Methods A prospective study in children attending the paediatric outpatient department of Manipal Teaching Hospital, Pokhara. –2,067 children were screened randomly from the 1st June 2007 to the 31st December 2007. Palm crease and axial triradius angle were detected in every child. Axial Triradius angle was compared between those who have simian crease to those who do not simian crease.Children who were found with simian crease underwent IQ testing. The exclusion criteria were children with Down syndrome, other chromosomal and minor anomalies, plus or any other chronic disease condition. Results 2,067children (1,084 boys & 983 girls) were screened. Among them four were cases of Down syndrome so were excluded from the study. Finally total of 2,063 (1,082 boys & 981 girls) were the study group. There were a total 14 ethnic groups who attended the outpatient department of Manipal Hospital during a seven months period. Among the seven ethnic groups Brahaman, Gurung, Tamang, Lama, Newar, Chettri and Dalit had single palmar crease. The incidence of simian crease was14.6%.This incidence was highly significant (p<0001) in Lama population (71.2%). In these seven ethnic groups axial triradius angle was compared between those who had simian crease and with those who did not have simian crease. Comparisons were made statistically and found to be significant. Conclusion Incidence of simian crease in Nepalese children was 14.6% and was observed only in certain ethnic groups. It was significantly high in the Lama population (71.2%0. Key Words Simian crease, single palmer crease, incidence, Down syndrome, ATD anglePublication Meckel-Gruber syndrome(Kathmandu University, 2006) Ramachandran, U; Malla, T; Joshi, KSMeckel- Gruber syndrome is a rare lethal, autosomal disorder. It has been linked to chromosome 17. It consists of a triad of occipital meningoencephalocoele, large polycystic kidneys and post-axial polydactyly. Death is mainly due to pulmonary hypoplasia. We report this rare case which presented with many associated defects. Key words: - MKS syndrome, meningoencephalocoelePublication Modifiable Demographic Factors that Differentiate Bronchiolitis from Pneumonia in Nepalese Children Less Than Two Years – A Hospital Based Study(Kathmandu University, 2014) Malla, T; Poudyal, P; Malla, KKABSTRACT Backgroud Bronchiolitis and pneumonia is an important cause of mortality and morbidity in children. Various risk factors make these children more prone for this illness. There is limited data on the risk factors from this part of the world. Moreover there is a significant clinical overlap between bronchiolitis and pneumonia thus necessitating the need for evaluating their demographic difference. Objective To evaluate the modifiable demographic risk factors for bronchiolitis and pneumonia in children less than 2 years. Method A prospective, comparative hospital based study undertaken during March 2012- March 2013 in Manipal Teaching Hospital, Pokhara. Altogether 200 cases of bronchiolitis and 200 cases of pneumonia, in the age group of 2 to 24 months, were randomly selected for comparison of risk factors as per a predesigned proforma. A ‘p’ value of <0.05 was considered statistically significant. Data was analyzed by using SPPS version 16. Result The significant risk factors for bronchiolitis were age < 6 months (p<0.001), prematurity (p<0.001),male(P<0.04), younger maternal age (p< 0.009), poor maternal knowledge (p<0.013), air pollution and lack of ventilation (p<0.001), exposure to cooking fuel – kerosene (p<0.007), firewood (p<0.001) , tobacco smoke (p<0.001), overcrowding (0.008), winter season (p<0.015), domestic pets (p<0.003), low birth weight (p<003), use of animal milk (p<0.001).The significant risk factors for pneumonia were age 13 months- 24 months, maternal age 26- 35 yrs (p<0.009), female (p< 0.04), malnutrition, lack of Vitamin A supplementation and immunization (p<0.001). Conclusion Most of the risk factors for bronchiolitis and pneumonia identified in this study were modifiable; hence could be prevented to decrease the burden of both the diseases. KEY WORD ALRI, bronchiolitis, pneumonia, risk factorsPublication Prognostic indicators in Haemolytic Uraemic Syndrome(Kathmandu University, 2004) Malla, K; Malla, T; Hanif, MdObjective: This study aims to review the clinical presentations of Haemolytic Uraemic Syndrome (HUS) and to compare the poor prognostic indicators with mortality. Methods and Materials: Prospective study carried out in Renal Dialysis ward of Dhaka Shishu Hospital, Bangladesh from September 2001- November 2003 for a period of 26 months. All children admitted to renal dialysis ward with oliguria or anuria with pallor was included in this study. HUS was confirmed after laboratory investigations showing features of hemolytic anaemia, thrombocytopenia and renal insufficiency. Various clinical presentations were reviewed. Then bad prognostic factors were compared with mortality. Results: There were total 25 cases of HUS in 26 months.17 (68%) were males and 8(32%) females.21 (84%) children were <5 years. Only 4(16%) were >5 years. Before onset of HUS 40% children had bloody diarrhoea, 36% had acute watery diarrhoea and 24% had others symptoms. The other presentations noted were fever 88%, respiratory distress and convulsion 52% and oliguria 40%, anuria 60%, reluctant to feed 40% and cough 28%. The main physical findings noted were irritability 40%, pallor 100%, dehydration 28%, puffy face with oedema 32%, high blood pressure 16%, hepatomegaly 28%, jaundice, sclerema and petechial rashes 8%, lethargic 16%, acidotic breathing 48% and rectal prolapse 12%. 44% children died after HUS and 56% recovered from the illness. Mortality was 66% when duration of illness before onset of HUS was >14 days. With duration of anuria <3 days there was no mortality but it was 91% and 100% with anuria >3-8days and >8 days respectively. Mortality was 78% when age was<18months and it was 75% when age was >5years.Diarrhoea associated HUS had 27% and non diarrhoea associated HUS had 85% mortality. Mortality was 77% and 100% respectively when HUS was associated with convulsion and hypertension. WBC >30,000 had mortality 100% and decreased platelet count <30,000 had mortality 80%. With creatinine level >700μmol/L mortality was 80% and with Serum potassium level 5.6- 7.5mmol/L mortality was 67%.Conclusion: HUS comprised of varieties of presentations. Diarrhoea was the commonest preceding illness before onset of HUS. The bad prognostic indicators carrying high mortality was duration of illness before onset of HUS >14 days, anuria >3days, age < 18 months and >5 years, Non diarrhoea associated HUS, HUS associated with convulsion and hypertension, WBC >30,000/cumm, platelets <30,000/cumm, creatinine level >700μmol/L and serum potassium level 5.6-7.5mmol/L. Since bad prognostic factors may progress rapidly to mortality, consultation with paediatrician and transfer to a tertiary care centre should be done when HUS is diagnosed so that it can be managed appropriately in time. Key words: Haemolytic Uraemic Syndrome-clinical presentation-mortality.Publication Urinary Tract Infection in Asymptomatic Newborns with Prolonged Unconjugated Hyperbilirubunemia: A Hospital based Observational study from Western Region of Nepal(Kathmandu University, 2016) Malla, T; Sathian, B; Malla, KK; Adhikari, SABSTRACT Background Urine culture is usually not a part of work-up for neonatal unconjugated hyperbilirubinemia; hence its prevalence remains unknown. Objective This study was done to determine the incidence of urinary tract infection (UTI) in asymptomatic newborns with prolonged unconjugated hyperbilirubinemia and to evaluate which other laboratory parameters are associated with UTIs. Method A prospective observational study where jaundiced newborns otherwise clinically well, were evaluated for UTI. The study was carried out in neonatal intensive care unit of Manipal Teaching Hospital, Pokhara from June 2012 -April 2013. The babies were divided in two groups group I- late prolonged jaundice and Group II - early physiological jaundice. Serum bilirubin, Septic screening and suprapubic urine sample analysis was performed for all subjects. Data was analyzed using SPSS version 16 and p < 0.05 was considered statistically significant. Result Of the 85 neonates, 33(38.8%) were females and 52(61.2%) males; 68(80%) were of term gestation and 17(20%) were preterms. The age at onset of jaundice for group I (n=53) was 13.6±4.88 days and for Group II (n= 32) was 5.0± 1.04 days. 11 /85 (12.9%) were diagnosed to have UTI [10 (90.9%) in group I and 1 in group II (9.01%] (p=0.04). UTI was more prevalent in group I [OR 7.20, 95% CI (0.87, 59.27)], more prevalent in male [OR 8.40, 95% CI (0.59, 74.13) and term babies of group I [OR 4.39, 95% CI (0.48, 39.82) when compared to Group II. Among other lab parameters only total WBC count was statistically significant (p=0.03). Escherichia coli was the predominant pathogen (45.45%) isolated. The sensitive antibiotics were aminoglycosides, fluroquinolones, nitrofurantoin and vancomycin and resistant antibiotics were most cephalosporins and penicillins for the isolated organisms. Conclusion The present study highlights significant association between late prolonged unconjugated hyperbilirubinemia and UTI. It is suggested that evaluation for UTI may be considered as a screening test for such cases. KEY WORDS Neonatal hyperbilirubinemia, newborn, septic screening, urinary tract infectionPublication Variability of Presentations and CT-Scan Findings in Children with Neurocysticercosis(Kathmandu University, 2011) Gauchan, E; Malla, T; Basnet, S; Rao, KSABSTRACT Background Neurocysticercosis is one of the common neurological morbidities in childhood. Objectives To find the commonest mode of presentation of this disorder in children. The study also aims to find out the age at which it commonly occurs, commonest site affected in the brain and the ethnic group and region most commonly affected in Western Nepal. Methods Retrospective hospital based study carried out in the Department of Pediatrics, Manipal Teaching Hospital, Pokhara from June 2004 to June 2009. Results Over the period of five years, 678 patients were admitted for seizures; out of which 109 patients were diagnosed as having neurocysticercosis (16%). Out of them, 66 (60.5%) were males and 43 (39.4%) were females. The age of presentation varied from 18 months to 16 years, with mean age 9.77 years. The most common age of presentation was between 6-10 years (n=47; 43.1%) and 11-15 years (n=47; 43.1%). Maximum number of patients were from Kaski district (n=41; 37.6%) followed by Syangja (n=34; 31.1%).The commonest presentation was with seizures (n=85; 77.9 %); generalised seizures was present in 45 patients (52%). Psychiatric manifestations were present in 3 patients (2.7%). The lesions were found mostly in the parietal region (n=65; 59.6 %). Most of the lesions were single (n=89; 81.6%). Out of 109 patients, 74 patients (67.8%) improved without any recurrence of symptoms on two years follow-up. Conclusion Neurocysticercosis is a preventable zoonotic disease which results in significant morbidity in children where sanitary measures are inadequate. Any child presenting with a first episode, afebrile seizure should be screened for neurocysticercosis provided other common causes are ruled out. KEY WORDS neurocysticercosis, seizures