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Publication An epidemiological study on acute zink phosphide poisoning in Nepal(2002) Adhikari, R P; Lohani, S P; B.C., R KPublication Spectrum of Liver diseases in Liver clinic at Bir hospital(Nepal Health Research Council, 2002) Pradhan, B R; Mishara, A K; Shrestha, J KPublication Neurocysticercosis- a review(Kathmandu University, 2003) Ansari, JA; Karki, P; Dwivedi, S; Ghotekar, LH; Rauniyar, RK; Rijal, SNA.Publication Epilepsy in children: an epidemiological study at Kathmandu Medical College Teaching Hospital Kathmandu(2003) Shakya, KN; Shrestha, R; Baral, MRObjectives: To analyze the relative frequencies of various epileptic seizures and to study the age at onset of different seizure types in Nepalese children. Design: Prospective study. Setting: Hospital outpatient based in Kathmandu, Nepal, between November 2001 to October 2002. Participants: 50 children diagnosed as epilepsy excluding neonatal and febrile seizures. Main outcome measure: Diagnosis and classification of cases according to the International Classification of Epilepsy of the International League Against Epilepsy [ILAE] and number of patients in each category with various ages at first seizure. Result: Generalized seizures (78%) were 3.54 times commoner than partial seizures (22%). Most frequent seizure types were generalized tonic clonic (36%), tonic (16%), complex partial (14%), atonic (12%) and absence (10%). Generalized clonic, simple partial and partial with secondary generalization, each had less than 5% frequencies. In 40% cases the first seizure occurred when aged between 2-5 years. In partial seizures the peak age at onset was observed below 6 years while primary generalized seizure was more frequently seen in age group 2-10 years. Conclusion: More paediatric patients with primary generalized seizures (78%) were observed than with partial seizures (22%). In this age group, the most frequent seizure type was generalized tonic clonic (36%) with the peak frequency of age at onset of seizures in 2-5 years. Key words: Epilepsy, Frequency, Age at onset.Publication Visual outcome of vitrectomy in Seasonal Hyperacute Pan Uveitis(Kathmandu University, 2003) Byanju, RN; Pradhan, E; Rai, SC; Sapkota, YDIntroduction: Seasonal Hyper Acute Panuveitis ( SHAPU) is a sight threatening condition often affecting children. Its management as yet is a challenge in ophthalmic practice. Most of the eyes even after treatment end up in pthisis bulbi. Materials and methods: A retrospective hospital based analysis of 18 patients with SHAPU managed with vitrectomy at Himalaya Eye Hospital (HEH) Pokhara over a period of two years was carried out. Results: Out of 18 patients 10 were males. Majority of them were bellow the age of 15 years. Best corrected visual acuity (BCVA) at presentation was less then 3\60 in 72% of them. BCVA was better then 6/60 in 7 (50%) out of 14 patients, who underwent vitrectomy. Conclusion: Vitrectomy is a useful procedure in management of SHAPU. Key words: Seasonal Hyper Acute Panuveitis, Visual acuity, Vitrectomy.Publication Painless delivery – a short experience(Kathmandu University, 2003) Maharjan, SK; Karki, CBPurpose: To determine efficacy and safety a randomized comparison of continuous infusion versus intermittent injection of epidural bupivacaine for labor analgesia was performed in the Maternity Hospital, Thapathali Kathmandu. Methods : Twenty healthy parturient received a loading dose of 10 ml of epidural 0.1% bupivacaine with 25 mg of pethidine. They were then randomized to receive continuous infusion of 0.1% bupivacaine 10 ml/hour with the help of infusion pump or intermittent injection of 0.1% bupivacaine 10 ml hourly. For breakthrough pain 10 ml of 0.1% bupivacaine top ups given in both groups. The two groups were compared for analgesic efficacy, mode of delivery, patient assessment of analgesia, motor block and other complications. Data analyzed in Pentium III version with SPSS and statistical significance test is done with independent samples t-test. Results: The 10 patients in each group were comparable in age but not in parity. Analgesic efficacy was excellent in 10 cases and comfortable in another 10 cases [excellent / comfortable 6:4 with infusion and 4:6 with intermittent injection]. There were no statistically significant differences between groups in pain scores or duration of active first or second stage of labor. Fifteen women had spontaneous vaginal deliveries, one caesarian section (infusion group) and four instrumental deliveries (intermittent injection group). Four women in the infusion group had hypotension and motor block, but none in the intermittent injection group. APGAR scores in both groups were 7-8/10 at 1 minute and 9- 10/10 at 5 minutes. Conclusion: Both continuous infusion and intermittent injection of low dose bupivacaine are very good methods of relieving labor pain in our context. Analgesic efficacy was similar in both groups and there was no prolongation of second stage of labor. Key words : painless delivery, parturient, bupivacaine, epidural analgesia.Publication Management of Typhoid fever in the Department of Medicine at Kathmandu Medical College(Kathmandu University, 2003) Dhakal, M; Neopane, A; Subedi, N; Dhakal, R; Karki, DBAim 1. To assess the ongoing management strategy of typhoid fever in department of medicine at Kathmandu Medical College, Sinamangal, Kathmandu. 1. To suggest changes, if required for the benefit of patients and doctors Method Prospective study of clinically suspected enteric fever from 2060/01/29 to 2060/04/25. Assessment and analysis of the rationality of the diagnostic parameters that are being used in the ward for clinically suspected enteric fever in unit one of department of medicine. Treatment outcome of the patients with the commonly used antibiotics. Analysis of the sensitivity pattern of the salmonellae isolated among the study group. Result 1. Only 11 cases (37%) were actually culture proven among the 30 cases suspected to be enteric fever on clinical basis. 2. 19 cases (63 %) of the clinically suspected enteric fever were diagnosed only on the basis of single widal test (titre more than 1:320), blood culture being negative. 3. Bone marrow was subjected to culture for salmonella only in 4 Cases (13%) despite blood culture being sterile. 4. The laboratory could provide sensitivity pattern of salmonellae only in 5 cases out of 11 culture positive cases (45%). 5. Eighteen cases (60%) had to be given 3rd generation cephalosporin after not responding to 5 days course of fluoroquinolones (ciprofloxacin or ofloxacin). On the other hand all the cases in the study group subjected to 3rd generation cephalosporin (injection ceftriaxone or cefixime orally) responded well to the treatment. Conclusion 1. We shouldn’t be relying too heavily on a single titre of widal test for the diagnosis of enteric fever and should be sending blood for culture for salmonella and even bone marrow culture, if necessary. This can be concluded on the basis of lots of literature against single widal test in the diagnosis of enteric fever. 2. Widal test should be positive with clearly significant rising titre (with paired sample) or modified widal test has to be performed if one wants to give gravity to the test for the diagnosis of enteric fever. 3. Laboratory personnel’s need to be more serious in their works so as to try to see sensitivity pattern in all positive cultures, if rational use of antibiotics is really desired in view of increasing antibiotic resistance. 4. Fluoroquinolones, once thought to be super powerful antibiotic & still taken as the drug of choice almost everywhere, has been found to be resistant in most of the cases in this study. Though the sample size is too small and there are lots of limitations in this study to come to a firm conclusion, it has borne one serious question in the minds of our unit doctors: Correspondence Dr. Mahesh Dhakal Dept. of Medicine, Kathmandu Medical College, Teaching Hospital Kathmandu University Medical Journal (2003) Vol. 1, No. 3, 197-204 198 whether we are over-using fluoroquinolones for trivial infections and leading to the emergence of resistant strains of salmonellae?Publication Post-mortem ocular changes: a study on autopsy cases in Bharatpur Hospital(Kathmandu University, 2003) Prasad, BKPost mortem eye changes are important evidences to assess post mortem interval. Present study was conducted at Bharatpur Hospital, Bharatpur over 150 autopsy cases during year 1999-2000. In 140 autopsy cases usual post mortem eye findings were observed, e.g. dull cornea, dilated and fixed pupil and soft eye. Fundus findings like cattle-truck appearance could be observed in 10 cases. Key Words: Death, Autopsy, Ocular, Post Mortem Interval.Publication A Typical Case of Myasthenia Gravis(Kathmandu University, 2003) Poudel, M; Angel, GM; Neupane, A; Karki, DBNA.Publication Publication Publication Study of Pterion in skulls of awadh area-in and around Lucknow(Kathmandu University, 2003) Saxena, RC; Bilodi, AKS; Mane, SS; Kumar, ATwo hundred and three skulls of known sex (100 male and 103 female) were studied to find out the variations of Pterion. Sphenoparietal variety of Pterion was seen predominantly along with frontotemporal and stellate varieties. Key Words: Pterion, Sphenoparietal, frontotemporal, stellate.Publication Eclampsia : a hospital based retrospective study(Kathmandu University, 2003) Choudhary, PAim and objective: This study was done to see the incidence, epidemiology , clinical profile of eclamptic patients and the effect of current intervention strategy for Eclampsia on maternal and perinatal outcome. Methodology: Analysis of case records of all Eclampsia cases from mid-April,2000 to mid-April,2001. Results: Incidence of Eclampsia has was found to be 2.9 per 1000 deliveries. Eclampsia was primarily a disease of young women (97.22%) and nulliparas (80.85%). Approximately half of eclamptic patients had some antenatal care(55.31%)and majority of them had fits before the onset of labor(70.21%). Most eclamptic patients presented with fits at term pregnancy (72.34%).About three fourth of them started fitting at home (74.46%) but one fourth had first fit while already admitted in the hospital(25.53%). Caesarean section was common mode of delivery(55.31%). There was no maternal death. Majority of patients stopped fitting once intervention was started (80.85%) and went home within three weeks (95.73%). One fifth of babies died [stillbirths (14%), neonatal deaths (6%)]. Conclusion: It appears that current intervention strategy for eclampsia in the maternity hospital is effective in reducing maternal mortality and morbidity but perinatal outcome still needs to be improved. Key words: Eclampsia, Maternal outcome, perinatal outcome, magnesium sulphate.Publication Hormone Replacement Therapy in menopause: current concerns and considerations(Kathmandu University, 2003) S, SharmaIt has been estimated that one third of postmenopausal women in the U.S. use Hormone Replacement Therapy (HRT) to treat symptoms of menopause and prevent chronic conditions. In developing countries HRT use is not so common but there is an increasing trend in its use. It has been seen that women with better socio-economic status, higher education and urban population use HRT. It is important that benefits and harms of HRT based on scientific evidence should be considered when prescribing HRT. The health care workers should prepare themselves for a better dialogue with women including information about alternative treatment. Objective: To review the available evidence on benefits and harms of HRT. Methodology: A Medline search was done for papers published in English language between 1990 to 2003, with abstracts available. The limitations set were original articles and reviews. The key words used were Menopause, Hormone Replacement, HRT, and ERT. The local libraries were searched and email requests were sent for full text articles. 10 full text articles were available, mostly review and large studies, which were studied in more detail. Some textbooks and reference books for gynaecology were also reviewed. Results: Beneficial effects of HRT on vasomotor symptoms have been supported by various studies, but HRT to treat negative mood is not recommended. A systematic review of Cochran database showed little evidence regarding the effect of hormone replacement therapy or oestrogen replacement therapy on overall cognitive function in healthy postmenopausal women. Oestrogens and androgens have significant beneficial effects on skin collagen, but do not prevent the effect of aging on elastic tissue and have limited use in the prevention and treatment of skin changes of menopause. Short-term benefits have been shown for urogenital atrophy. Recent evidences suggest that benefits of HRT include prevention of osteoporotic fractures, and colorectal cancer while prevention of dementia is uncertain. Harms include Coronary Heart Disease (CHD), stroke, thromboembolic events, breast cancer, with 5 or more years of use, and cholecystitis. It is recommended that the regimen should not be initiated or continued for primary prevention of coronary heart disease. In women with CHD, it should not be used for secondary prevention of CHD events. Active living, alternative therapies and consumption of food rich in phyto-oestrogens are some areas, which need to be explored in more detail. Conclusion: Patient preferences as well as evidence are important to initiate and/or continue HRT. Benefits and harms need to be re-addressed periodically to apply newly published evidence and to reassess emerging risk, co-morbidities and need of individuals.Publication Study of Antibody Recognition Pattern of HCV by Western Blot Method(Kathmandu University, 2003) Joshi, SHCV is a positive strand RNA virus, and is a member of the Family Flaviviridie. HCV show substantial nucleotide sequence variability distributed throughout the viral genome, particularly the HVR1 region that is suggested to be immunogenic in humans. HVR1 is the most heterogeneous region within the E2 genome and peptide corresponding to this region, can be detected by homologous sera. To study the serum reactivity to peptides obtained from HVR1 region of the E2 region of the HCV genome, western blot can be performed in place of Enzyme - Linked Immuno Sorbent Assay (ELISA), if the expressed recombinant protein is insoluble & cannot be extracted or purified from the host cell. Key words: - HCV, serum reactivity, western blotPublication Publication Supraclavicular brachial plexus block with and without dexamethasone - A comparative study(Kathmandu University, 2003) Shrestha, BR; Maharjan, SK; Tabedar, STo compare the analgesic efficacy of local aesthetic with and without dexamethasone in supraclavicular brachial plexus block. Methods: Forty patients undergoing arm, forearm and hand surgeries were randomly selected. The forty patients were divided in two groups of 20 each. In-group one, a brachial plexus block was done with 40-50 ml of local anaesthetic with 1:200,000 adrenaline and in the other group the block was performed with the same amount of local anaesthetics with dexamethasone. The onset of action and duration of analgesia in the two groups were compared and any complications of the procedure were noted. Statistical analysis was done using the independent sample t-test. Results: The two groups were comparable in respect to age, sex, and weight. There was significant faster onset of action and prolonged duration of analgesia in the dexamethasone group than in the other group. There were no complications. Conclusion: Addition of dexamethasone for brachial plexus block significantly prolongs the duration of analgesia without any unwanted effects.Publication Epilepsy in children: an epidemiological study at Kathmandu(Kathmandu University, 2003) Shakya, KN; Shrestha, R; Baral, MRObjectives: To analyze the relative frequencies of various epileptic seizures and to study the age at onset ofdifferent seizure types in Nepalese children. Design: Prospective study. Setting: Hospital outpatient based inKathmandu, Nepal, between November 2001 to October 2002. Participants: 50 children diagnosed as epilepsyexcluding neonatal and febrile seizures. Main outcome measure: Diagnosis and classification of casesaccording to the International Classification of Epilepsy of the International League Against Epilepsy [ILAE]and number of patients in each category with various ages at first seizure. Result: Generalized seizures (78%)were 3.54 times commoner than partial seizures (22%). Most frequent seizure types were generalized tonicclonic (36%), tonic (16%), complex partial (14%), atonic (12%) and absence (10%). Generalized clonic, simplepartial and partial with secondary generalization, each had less than 5% frequencies. In 40% cases the firstseizure occurred when aged between 2-5 years. In partial seizures the peak age at onset was observed below 6years while primary generalized seizure was more frequently seen in age group 2-10 years. Conclusion: Morepaediatric patients with primary generalized seizures (78%) were observed than with partial seizures (22%). Inthis age group, the most frequent seizure type was generalized tonic clonic (36%) with the peak frequency ofage at onset of seizures in 2-5 years.Key words: Epilepsy, Frequency, Age at onset.Publication Study of patients presenting with symptoms of peripheral neuropathy and thickened greater auricular nerve(2003) Neopane, A; Upadhyaya, B; Dungana, S; Karki, DBObjective: To analyze symptoms and make a clinical diagnosis of leprosy in patients presenting with symptoms of peripheral neuropathy and found to have thickened greater auricular nerve. Design: Cross- sectional study Setting: Kathmandu Medical College Teaching Hospital, Sinamangal, Kathmandu. Patients attending the medical out patient department of this hospital were taken in the study. Materials and methods: 40 patients presenting with symptoms of peripheral neuropathy and are found to have thickened greater auricular nerve were included. Results: Thickened greater auricular nerve and sensory symptoms showed male predominance (97.5%). Mean age of involvement was 28.65 years. The symptom most frequently complained of was chest pain (75%), followed by pins and needle sensation 67.5%, burning of the upper extremities, nape of the neck and chest 57.5%, palpitation 45%, disturbed sleep mostly said to be due to burning 35%, sweating 20%, dizziness17.5%, shortness of breath 7.5%, and numbness of the limbs in 2.5%. None of the patients had somatic neuropathy. Autonomic neuropathy was present in 42.5 %. Conclusions: 1. In endemic areas patients with thickened peripheral nerve and sensory symptoms should be diagnosed clinically as primary neuritic leprosy. 2. In absence of objective loss of somatic sensation autonomic neuropathy may be the only early indicator of neuritis. 3. Close follow up of these patients is necessary. Key words: peripheral neuropathy, primary neuritic leprosy, autonomic neuropathy, follow up