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Ectopic Thyroid Tissue in Submandibular Region in Pediatric Patient: A Case Report
(Institute of Medicine, 2020) Bajracharya, Rohita; Dutta, Heempali
ABSTRACT Normal anatomical location of thyroid gland is anterior to trachea and larynx. Ectopic thyroid is rare presentation. Ectopic thyroid tissue in submandibular region is even more rare. This article reports a case of five year old child who presented with swelling in left submandibular region which was later diagnosed to be an ectopic thyroid gland with no thyroid tissue in thyroid bed. Although rare, physician should consider possibility of ectopic thyroid in patient presenting with submandibular mass. Ultrasonography should always be performed to confirm presence of normal thyroid gland if surgical excision is planned. Keywords: Ectopic thyroid, submandibular region, thyroglossal duct, thyroid gland
Rare Primary Spinal Mesenchymal Chondrosarcoma: A Case Report
(Institute of Medicine, 2020) Paudel, Sushil; Adhikari, Shirish; Adhikari, Sharad C; Pokharel, Rohit K
ABSTRACT Primary extradural mesenchymal chondrosarcoma (MCS) is a very rare intraspinal tumor. Proper clinical evaluation with magnetic resonance imaging (MRI) followed by biopsy of the mass can confirm the diagnosis. Since MCS has a high tendency of recurrence and metastasis, the prognosis is guarded. We report a 52 years old male with primary extradural MCS in the lumbosacral region (L5-S3). Subtotal excision and biopsy were performed which confirmed the diagnosis. The patient received post excisional radiotherapy but expired after four months. Though rare, this tumor should be kept in differentials which helps in early diagnosis and thus can be treated with radical excision of the mass along with postoperative radiotherapy. Keywords: Chondrosarcoma, extradural, mesenchymal, radiation, spine
Relation of Neck Circumference to Central Obesity and Overweight in Patients with Type 2 Diabetes Mellitus Presenting to a Tertiary Center
(Institute of Medicine, 2020) Sharma, Ishwor; Gupta, Sanjay K; Niraula, Kiran
ABSTRACT Introduction: Overweight and obesity with their surrogate anthropometric markers like body mass index (BMI), waist circumference (WC) and waist hip ratio (WHR) have been shown to be strongly associated with Type 2 diabetes mellitus. Neck circumference (NC) though less used can be an equally effective alternative to diagnose overweight and obesity in patients with Type 2 diabetes mellitus in a resource limited setting. Methods: Patients who had Type 2 Diabetes Mellitus for 5 years or more and above 35 years underwent simple random sampling. Weight, height, WC and NC were measured. BMI was calculated and patients were graded into overweight and obesity based on the Asian cutoffs for BMI and abdominal obesity. Results; Among 100 patients enrolled in this study, 45% were men and the mean age was 53.05. Mean neck circumference was 36.55 ± 1.28 cm and 35.27 ± 1.78 cm for male and female respectively. NC was positively correlated with WC and BMI in both men and women (p ˂ 0.001). In the ROC curves, NC presented the largest area under the curve (AUC) for overweight in males (p ˂ 0.001), while NC presented a large AUC for central obesity in both genders. Furthermore, the cut off value of neck circumference for overweight was 35.6 cm in males vs 35.2 cm in females and for central obesity was 36.75 cm in males vs 34.75 cm in females. Conclusion: Neck circumference was positively associated with overweight and central obesity in patients with type 2 diabetes mellitus. Keywords: Anthropometric measure, diabetes mellitus, neck circumference, obesity
Clinical Profile of Patients Presenting with Low Back Pain to Out Patient Department of a Tertiary Level Hospital
(Institute of Medicine, 2020) Thapa, Pradeep; Lakhey, Rajesh B; Shrestha, Binay L
ABSTRACT Introduction: Low back pain is experienced by most of the people at some point of life. In our setting, there are very limited data on low back pain. This study aims to elaborate demographic and clinical profile of patients presenting to outpatient department of Orthopedics, in Tribhuvan University Teaching Hospital with complaints of low back pain. Methods: A descriptive cross-sectional observational study was carried out in 150 patients who presented with complaints of lower back pain in outpatient department of Orthopedics of TU Teaching Hospital from May to November 2019. The demographics including age, gender, occupation, and clinical data- duration of symptoms, body mass index, VAS score and radiculopathy along with Body Mass Index of each patient were recorded in a proforma separately. Results: Out of total 150 patients, male: female ratio was 1:1.9. The average age of patients was 42.1 years The average height, weight and body mass index of patients were 157 cm, 61.81kg and 24.83kg/m2 respectively. The mean visual analogue score of patients was 5.41. Occupationally, predominant number of patients were housewives (41.3%). Seventy nine patients (52.7%) had low back pain alone. Seventy one patients (47.3%) had low back pain associated with radicular symptoms, out of which 74.6% had unilateral radiculopathy. Conclusion: Low back pain is most commonly seen in fourth decade of life. More females as compared to males are affected with low back pain. The radiculopathy associated with low backache is mostly unilateral. Keywords: Body mass index, low back pain, radiculopathy, visual analogue score
Assessment Of Third Ventricular Parameters in Computed Tomography of Head: A Pilot Study in Tertiary Level Hospital
(Institute of Medicine, 2020) Khanal, Umesh P; Sah, Keshav; Chand, Ram B
ABSTRACT Introduction; Measurement of ventricles of the brain is important for evaluating changes due to growth, ageing, intrinsic and extrinsic pathologies. The aim of this study was to determine the various parameters of the third ventricle and to assess their association with gender and age using computed tomography (CT) scans of head. Methods: This retrospective, quantitative, cross sectional study was performed in the Department of Radiology and Imaging, Tribhuvan University Teaching Hospital from July to October 2019 (4 months) on images of 100 patients (50 males and 50 females) whose age group were 18-87 years, who underwent non-contrast and contrast enhanced CT scan of head. Results: The total mean of width of third ventricle was found to be 0.33±0.09 cm, 0.35±0.10 cm in male and 0.31±0.06 cm in female. Third ventricle width (TVW) showed statistically significant correlation with male and also with Age. Mean of third ventricle sylvian fissure distance index was 0.41±0.67 cm, 0.42±0.65 cm in male and 0.39±0.06 cm in female respectively. Mean of third ventricle ratio was 0.03±0.09 cm, 0.03±0.09 cm in male and 0.02±0.09 in female respectively. The value were slightly higher in male. Conclusion: The third ventricle width in CT in this study was 0.33±0.09 cm. CT was very useful to determine the upper limits of normal value and its variation with age. Keywords: CT, Third ventricle width (TVW), Third ventricle ratio (TVR)
Prevalence of Stunting among 6-59 Months Children and its Association with Water, Sanitation and Hygiene Practice in Urban Slums of Kathmandu, Nepal
(Institute of Medicine, 2020) Singh, Sarswoti; Dhital, Nil P; Paudel, Rajan; Sah, Dipak K; Hamal, Arjun; Shrestha, Junu
ABSTRACT Introduction: Childhood malnutrition is a critical public health concern in Nepal. Slums are supposed to have poor water, sanitation and hygiene practices. This study has aimed to examine association between water, sanitation and hygiene (WASH) variables and stunting among 6 to 59 months children of slums of Kathmandu metropolitan city. Methods: Descriptive cross-sectional study design was employed where 335 households were included in the study. Data were collected using standard questionnaire and observation checklist. Weight and height of children were taken using seca digital weighing scale and wooden height board of UNICEF respectively. Anthropometric analysis was done using WHO Anthro version 3.2.2 software and other statistical analysis was conducted using SPSSversion 22 software. Results: The prevalence of stunting was 23%. Four out of five household (80%) in slum used to drink water from unimproved source. Absence of handwashing station (AOR=2.109, 95% CI:1.05-3.27) and absence of water storage covering (AOR=2.46, 95% CI: 1.16–5.23) were found to be significantly contributing to stunting status. Conclusion: This study highlights the importance of good WASH practices, and the potential of WASH interventions, to contribute for the improved childhood stunting living in urban slums in Nepal. Also, the findings recommend the need of strategies on purification of water, improvement of toilets, behaviour change and awareness related activities to improve the stunting among children. Keywords: Hygiene, sanitation, slum, stunting, water
Assessment of a Scoring System to Predict Difficult Laparoscopic Cholecystectomy
(Institute of Medicine, 2020) Sigdel, Prem R; Subedi, Nirajan; Phuyal, Suman; Pokharel, Ashik; Ghimire, Bikal; Singh, Yogendra P
ABSTRACT Introduction: Laparoscopic cholecystectomy (LC) has become the procedure of choice for management of symptomatic gallstone disease. It would be useful to have some reliable predictive factors for conversion in LC. Our aim is to predict difficult laparoscopic cholecystectomy preoperatively by using a scoring system. Methods:A total of 136 patients were included. The parameters considered for this study were old age, male sex, history of hospitalization, obesity, abdominal surgery scar, palpable gall bladder, gall bladder wall thickness, pericholecystic collection and impacted stone. Results: Among 136 cases, 70.6% were easy, 24.3% were difficult and 5.1% were very difficult intraoperatively. The factors like age >50 years, history of hospitalization for acute cholecystitis, previous abdominal surgery, palpable gall bladder, wall thickness >4mm and impacted stone were found statistically significant in predicting difficult LC. The preoperative scoring is statistically and clinically a good test for predicting the difficult LC (area under the curve = 0.824) with sensitivity of the test being 82.3% and specificity 72.7%. Conversion rate was 3.67%. Conclusion: The factors like age >50 years, history of hospitalization for acute cholecystitis, previous abdominal surgery, palpable gall bladder, wall thickness >4 mm and impacted stone are the preoperative predictors of difficult LC. Keywords: Cholecystitis, difficult, laparoscopic cholecystectomy, open cholecystectomy, symptomatic gall stone disease
Outcome of Extracranial Carotid Pseudoaneurysm Surgery: A Retrospective Study
(Institute of Medicine, 2020) Bhandari, Nikesh; Shrestha, Uttam K; Shrestha, Kajan R; Gurung, Dinesh
ABSTRACT Introduction: Extracranial carotid pseudoaneurysm (ECPA) is commonly associated with blunt or penetrating trauma and can result in thromboembolic event, cranial nerves palsies, rupture and hemorrhage. Due to the limited number of large studies, safety and efficacy of surgical and interventional management of ECPA is not well characterized. Open surgery with resection of pseudoaneurysm with end-to-end anastomosis or interposition graft is currently the preferred method of management. The aim of this study is to study the demographics, etiopathogenesis, presentation and outcome after surgical intervention of ECPA at our center. Methods: All patients who underwent surgery for carotid pseudoaneurysm form June 2012 to December 2019, at Department of Cardiothoracic and Vascular Surgery were included in this retrospective chart review study after evaluation of the hospital record book and electronic medical record. Patients who had stroke or cranial nerve injury before surgery, were excluded from this study. Results: Fifteen patients met the inclusion criteria. Male to female ratio was 11:4. Mean age of presentation was 38.17±18.98 years. All patients presented with tender and pulsatile neck swelling. Common carotid artery involvement was more common. Three patients suffered from stroke postoperatively, and all of these patients died, however, one patient with stroke died due to reasons not related to pseudoaneurysm. Two patients suffered cranial nerve injury and ten patients had no other disabling complications. Conclusion: ECPA is an uncommon but a serious disease and ischemic stroke after surgery is associated with high mortality. Keywords: Carotid, extracranial, outcome, pseudoaneurysm
Post-Transplant Erythrocytosis in Live Donor Kidney Transplant Recipients: A Retrospective Single Center Study
(Institute of Medicine, 2020) Maharjan, Suresh; Chhetri, Santosh; Khatri, Bikash; Sapkota, Nisha; Sigdel, Mahesh R
ABSTRACT Introduction: Post-transplant erythrocytosis (PTE) is defined as persistently elevated hemoglobin>17 g/dl and/or PCV>51% in kidney transplant recipients. The incidence of PTE varies from 5% to 17%, with occasional life-threatening thromboembolic complications. We aimed to study the prevalence, risk factors and complications of PTE. Methods:We conducted a retrospective single center study in 132 kidney transplant recipients who had undergone live donor kidney transplantation at Tribhuvan University Teaching Hospital, Nepal, between October 2017 and March 2019. Prior approval was obtained from Institutional Review Committee of Institute of Medicine. Patients with hemoglobin>17 g/dl were defined as PTE group, and others as non-PTE group. The pattern of hemoglobin, serum creatinine, pre-transplant hemoglobin, native kidney disease, immunosuppression medications, rejection episodes, and new onset diabetes after transplantation were analyzed and compared between two groups. Results: Out of the 132 kidney transplant recipients, PTE was diagnosed in 28 (21.2%) patients, out of which 27 patients (96.4%) were male and 1 (3.6%) were female with the mean time of onset at 7 months after transplantation. Patients with erythrocytosis had a relatively shorter duration of pre transplant dialysis (p=0.001). The mean pre transplant Hb and Hct in PTE group was 9.72g/dl and 30.35% whereas in non PTE group 10.02 g/dl and 31.31%. Thromboembolic and any other PTE related complications were not observed. Seventeen patients of PTE (60.7%) were treated with ACE Inhibitors and 11 (39.9%) patients did not require any treatment. Conclusion: Post-transplant erythrocytosis was seen in nearly one fifth kidney transplant recipients at mean time of seven months post-transplantation; was more common in male with good graft function, and short duration of pre transplant dialysis. Response to ACE inhibitors was good. Keywords: Erythrocytosis, recipient, renal transplant
Correlation of Body Mass Index with Handgrip Strength and Endurance of Dominant Hand in Medical Students
(Institute of Medicine, 2020) Shrestha, Lava; Gurung, Sanyukta; Bhat, Neeti; Mahotra, Narayan B; Bajimaya, Mahesh M; Malla, Neha; Kandel, Sabita; Shakya, Aman; Aryal, Vibina; Gyawali, Bigyan R; Rayamajhi, Nirmala; Pradhan, Sait
ABSTRACT Introduction: Hand grip strength is used in evaluation of muscle strength and is also increasingly being used as an indicator for nutritional status. The maximum force applied voluntarily by the subject is called maximum handgrip strength, which is measured in kilograms. Muscular endurance is the ability of a muscle or muscle group to perform against a load for an extended period of time, measured in seconds. This study aims to correlate body mass index with handgrip strength and handgrip endurance in medical students. Methods:This is a cross sectional, observational study which included 74 undergraduate students of Maharajgunj Medical Campus by convenient sampling method. Body mass index was calculated by Quetelet’s formula. Camry digital hand dynamometer was used to measure handgrip strength in the dominant hand in kilograms. Participants were instructed to hold dynamometer with maintained pressure of 30% of maximum handgrip strength for as long as possible to determine the handgrip endurance. Statistical analyses were performed with SPSS Statistics software. Results: The handgrip strength was more in males than females with a mean of 43.09±3.72 kg, while handgrip endurance was more in females with a mean of 123.60±50.65 sec. Positive correlation was seen between body mass index and handgrip strength (r=0.23 and p=0.045). Body mass index and handgrip endurance also showed positive correlation (r=0.34 and p=0.003). Conclusion: Significant correlation of body mass index with handgrip strength and handgrip endurance was seen in medical students. Keywords: Body mass index, correlation, handgrip endurance, handgrip strength, medical students
Admission Profile and Outcome of Patients in a Level III Intensive Care Unit: A Two-Year Comparative Study
(Institute of Medicine, 2020) Pathak, Sunil; Acharya, Subhash P; Acharya, Pragya; Bhattarai, Binita
ABSTRACT Introduction: An Intensive Care Unit (ICU) is an area where critically ill patients are admitted and the highest level of care is provided with close intensive monitoring and management. Clinical audit is a must to measure indicators of the quality of care in ICU and benchmarking outcome. The main aim of the study was to evaluate the profile of patients admitted to ICU and assess their outcome of two consecutive years. Methods:A single-institutional, descriptive cross-sectional study was conducted on all adult patients admitted to the ICU of Tribhuvan University Teaching Hospital, Kathmandu, between April 2018 and April 2020 (Baisakh 2075 to Chaitra 2076). Results: With an average of 1.98 admissions per day, a total of 1447 patients were admitted to TUTH ICU over the period of two years. A male preponderance was noted with a male to female ratio of 1.19:1. Most of the patients admitted were neurosurgical cases 429 (29.6%). A total of 884 (61%) were shifted out of ICU in stable condition while the overall mortality was 458 (31.6%). Conclusion:This study shows that there is a higher severity of illness at admission as well as a comparatively high mortality rate. More number of patients were male, of age group of 15-65 years, with medical and neurosurgical conditions. This study of profile and outcome of patients admitted in ICU can serve as a quality indicator as well as evidence on which planning and policymaking can be based upon in the future. Keywords: Intensive care unit, medical audit, outcome
Head Injuries at the Emergency Department of a University Hospital in Kathmandu
(Institute of Medicine, 2020) Henriksson, Thérèse; Kjellberg, Jacob; Shakya, Yogendra; Kurlberg, Göran
ABSTRACT Introduction: Traumatic head injuries constitute a major cause of morbidity and mortality worldwide. The developing world is particularly affected due to a high prevalence of risk factors and difficulties in enforcing preventive efforts. This study was carried out at the Emergency Department (ED), Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal – where head injuries account for five per cent of all emergency visits. The aim was to describe demographics, cause of trauma, type of injury, and severity according to the Glasgow Coma Scale (GCS), as well as the outcome of emergency attendance in patients seeking medical care for traumatic head injuries. Auxiliary aims were to study correlations between age, cause of trauma and injury severity. Methods:Data from 577 cases of head injuries from June to October 2019 were collected retrospectively. Results:Traumatic head injuries accounted for 5.2 % of all emergency visits. The median age was 23 years. Patients were predominantly male. Superficial injuries and concussions were the most common. Most injuries were mild (94.4 %, GCS 13–15) and caused by falls (51.3 %) or road traffic accidents (19.1 %). Fall accidents and mild injuries had the lowest median age. Patients from outside Kathmandu Valley constituted 44.9 % of the cases. Only 12.1 % of the patients were admitted to the hospital. Conclusion:Commonest head injuries are mild and superficial; and are caused by falls and road traffic accidents. Most head injury patients are children. Keywords: Contusion, falls, head injury, traumatic brain injury
Normative Measurement of Orbital Structures in Computed Tomography
(Institute of Medicine, 2020) Rokka, Damodar; Poudel, Sharma; Kayastha, Prakash; Suwal, Sundar; Poudyal, Sudil; Chhetry, Saroj; Lohani, Benu; Shrestha, Shantalall; Karn, Rakesh
ABSTRACT Introduction: Normal orbital dimensions are important for diagnosing orbital pathologies. Computed tomography (CT) of the orbit is an important modality offering high accuracy for precise measurements of orbit. The study was disbursed to ascertain criteria for the normative values of the various orbital dimensions using computed tomography in patients visiting Tribhuvan University Teaching Hospital, Kathmandu. Methods: Orbital volume, ocular diameter, length of the interzygomatic line (IZL), the distance of the posterior extent of the globe from the interzygomatic line, globe position, diameters of extraocular muscles (medial, lateral, superior group, and inferior rectus) and lens density were measured in each eye of 172 patients undergoing CT examination of paranasal sinuses. The correlations with age and sex were also analyzed. Results: Mean values (mean±SD) of orbital volume, ocular diameter, IZL, globe position and lens density were 24.54±2.57 cm3, 2.44±0.22 cm, 94.3±6.2 mm, 12.3±2.4 mm and 141.43±16.62 HU respectively. Mean diameters of extraocular muscles were 3.67± 0.52 mm, 3.36± 0.50 mm, 3.74±0.42 mm and 3.87±0.38 mm for medial rectus, lateral rectus, inferior rectus and the superior group respectively. There was no significant age and gender difference in most of the measurements. There was significant positive correlation of age with lens density, orbital volume and ocular diameter (p<0.05). Conclusion: Normative data of different orbital measurements were obtained. The present result may help radiologists and ophthalmologists to accurately assess various orbital parameters, particularly in Nepalese populations. Keywords: CT, measurements, orbit
Does Drilling Induce Hearing Loss after Modified Radical Mastoidectomy? A Retrospective Study
(Institute of Medicine, 2020) Neupane, Yogesh; Kharel, Bijaya; Dutta, Heempali
ABSTRACT Introduction: Incidence of sensory neural hearing loss following mastoid surgery varies from 1.2 – 4.5%.There are various causes for postoperative sensorineural hearing loss during mastoid surgery. This study aims to identify whether there is any correlation between drilling and postoperative sensory neural hearing loss. Methods: A retrospective study was conducted in the Department of ENT from January 2018 to June 2019. A total number of 68 patients above five years of age who underwent modified radical mastoidectomy for chronic otitis media squamous were included. Revision surgery, preoperative sensorineural hearing loss, injury to the ossicular chain during surgery, patients with lack of follow up or doubtful reports in mentally challenged were excluded from the study. The average bone conduction threshold was calculated from 500, 1000, 2000, 4000 Hz and compared using the Wilcoxon signed-rank test. Results: There were 43 males and 25 females in the study with a median age of 23.5 years (16-55). The mean preoperative bone conduction threshold in the four frequencies of 500 Hz, 1kHz, 2kHz, 4kHz were -2.06dB, -2.06dB, 3.31dB, 4.63 dB respectively and the mean postoperative bone conduction thresholds were 1.03, 1.32, 5.29, 4.04 respectively. There was a decline of mean of 3.09 dB and 3.38dB only at the low-frequencies (500Hz and 1kHz) BC threshold respectively which were statistically significant, whereas at higher frequency there was no decline in average postoperative BC threshold. Conclusion: There is no definite role of drill in inducing hearing loss and if present other causes of hearing loss should be sought in postoperative sensorineural hearing loss. Keywords: Drill, mastoidectomy, noise-induced hearing loss
Comparative Study on Effectiveness and Safety of Atorvastatin with Rosuvastatin in Hyperlipidemic Patients at a Tertiary Care Hospital in Nepal
(Institute of Medicine, 2020) Raut, Binod; Paudel, Nimesh; Shrestha, Deepti; Bhosekar, Anant
ABSTRACT Introduction: Hyperlipidemia is one of the most contributing factors to coronary heart diseases. Statins have become standard medicine in clinical practice to reduce total cholesterol, low density lipoprotein and to increase high density lipoprotein cholesterol. This study is conducted to compare the effectiveness and safety of atorvastatin with rosuvastatin in hyperlipidemic patients. Methods: This is a prospective observational study involving 150 patients conducted in the Department of Internal Medicine of Kathmandu Medical College and Teaching Hospital from July 2019 to March 2020. Patients newly diagnosed with hyperlipidemia were enrolled. Patients that were prescribed with 10 mg of atorvastatin and 5 mg of rosuvastatin by the treating physician once daily for 6 weeks were divided into two groups. Data was recorded in the customized proforma and the SPSS package version 20 was used for analysis. Results: Patients that were prescribed with atorvastatin were put in group I and those prescribed with rosuvastatin were included in group II with 75 participants in each group. The mean age of the patients were 50.56± 10.08 years in group I and 52.45±10.20 years in group II with male to female ratio of 3:1. The mean BMI of group I was 25.36±1.74 and that of group II was 26.48±2.21 before therapy. There was a significant main effect of duration (F1,74=401.02, p<0.001) on the TG and TC levels (F1,74=1134.23, p<0.001) as well as (F1,74=614.99, p<0.001) on the LDL and HDL levels (F1,74=146.38, p<0.001). Conclusion: Rosuvastatin was significantly more effective than atorvastatin in reducing levels of TG, TC and LDL-C. Rosuvastatin also significantly increased the level of HDL. Keywords: Atorvastatin, hyperlipidemia, rosuvastatin
Management of Postpancreatectomy Hemorrhage Following Pancreaticoduodenectomy at a Tertiary Care Center in Nepal
(Institute of Medicine, 2020) Subedi, Nirajan; Kandel, Bishnu; Ghimire, Bikal; Kansakar, Prasan BS; Bhandari, Ramesh S; Lakhey, Paleswan Joshi
ABSTRACT Introduction: Postpancreatectomy hemorrhage (PPH) is an important complication which significantly increases morbidity and mortality following pancreaticoduodenectomy (PD). This study aims to find the incidence, classification, management, and mortality associated with PPH following PD. This study also describes the changes in management and outcomes between the period of 2004-2014 and 2015-2019 in our institute as in the later time period there was use of CT angiography and interventional radiology (IR) to identify and control the bleeding site. Methods: This is a retrospective study in which medical records of patients having PPH following PD between 2004-2019 were analyzed. The grading and classification were done according to the International Study Group of Pancreatic Surgery (ISGPS). Management and outcomes were analyzed using standard descriptive statistics. Results: A total of 43 patients developed PPH out of 336 PDs. Out of 43 patients, 4 (9.3%) had Grade A, 16 (37.2%) had Grade B and 23 (53.5%) had Grade C PPH. Fifteen (35%) patients were managed conservatively, seven (16.2%) with IR procedure and 21 (48.8%) were reexplored. There were 16 (37.2%) mortalities, out of different factors- intraoperative blood loss >500 ml showed the predictability for mortality (p= 0.01). On comparing two time periods it was seen that the PPH rate was almost similar but the mortality decreased from 58.8% to 23.07%. Conclusion: PPH following PD is associated with high mortality. Increased use of IR procedure and CT angiography can decrease the relaparotomy rates and eventually decrease mortality. Keywords: Interventional radiology, pancreaticoduodenectomy, postpancreatectomy hemorrhage
Comparison of Round Window Anatomy between Pediatric and Adult Population: A Perspective from Cochlear Implantation Surgery
(Institute of Medicine, 2020) Pradhananga, Rabindra B; Gyawali, Bigyan R; Rayamajhi, Pabina
ABSTRACT Introduction: The round window is thought to be an ideal port for inserting electrodes during cochlear implantation. Considering its complex anatomy with an individual variation, this study aims to review the anatomy of round window based on the visibility of round window niche and round window membrane via posterior tympanotomy in pediatric and adult population who underwent cochlear implantation. Methods: This was a retrospective observational study conducted at the Department of ENT-HNS, Institute of Medicine, Kathmandu, Nepal. Surgical notes of adult (>15 years) and pediatric cases (<15years) who underwent primary cochlear implantation from January 2015 to January 2018 were assessed for different grading of round window niche and round window membrane visibility via posterior tympanotomy. Cases with revision surgery and with incomplete documentation of intra-operative findings were excluded from the study. Statistical analysis was done using SPSS software version 25. We used Chi-square and Fisher’s exact tests to analyze the statistical association. Results: Type B round window niche (partially visible) was the most common variant seen in the pediatric group while in adults, both Type B (partially visible) and Type C (fully visible) round window niche were common. Compared to the adults, the pediatric group had good visibility of RWM. However, there was no statistical association between these observations. Conclusion: The round window has a wide range of anatomical variations with different levels of visibility of RWN and RWM in the different age groups. Although statistically insignificant, RWM visibility seemed to be better in pediatric cases compared to adults. Keywords: Anatomical variation, cochlear implantation, round window
Preoperative Anxiety Assessment in Adult Patients Undergoing Elective Surgeries: A Cross-Sectional Observational Study
(Institute of Medicine, 2020) Acharya, Santosh; Gurung, Renu; Parajuli, Basudev
ABSTRACT Introduction: Anxiety is the subjective unpleasant feeling of dread over something unlikely to happen. The incidence of preoperative anxiety ranges from 32% to 76.7%. We aimed to measure the preoperative anxiety level using Amsterdam Preoperative Anxiety and Information Scale questionnaire and clinical rating scale given by attending anesthesiologist / anesthesia residents. Methods: It was cross-sectional observational study conducted in wards. We enrolled 110 adult patients planned for elective gynecological and gastrointestinal surgeries. After taking informed written consent, principal investigator interviewed the patient, one day prior to surgery in wards using a structured questionnaire of Amsterdam Preoperative Anxiety and Information Scale. Demographics characters were recorded. The attending anesthesia residents (blinded to patient response) performed preanesthetic assessment, provided their subjective rating about patient anxiety and need for information using Clinical Rating Scale. Results: Out of 110 patient, 57(51.81%) were found to have higher anxiety level. Comparing the APAIS score with various factors, we found younger age, female gender, unemployed status, higher level of education, adverse events in previous surgery and higher grade of surgery was associated with higher anxiety score. Comparing APAIS with Clinical Rating Score, there was poor correlation. Conclusion: The incidence of preoperative anxiety is high (51.81%) in adult patients undergoing elective surgery. During the preoperative anesthetic checkup, APAIS can be used as a screening tool. It provides relevant information on the presence of preoperative anxiety and need for information, which helps to achieve patient satisfaction and better outcome. Keywords: Amsterdam preoperative anxiety and information scale (APAIS), anxiety, clinical rating score, need for information, preoperative anxiety
Short Term Outcome of Acute ST Elevation Myocardial Infarction in a Tertiary Care Cardiac Center
(Institute of Medicine, 2020) Shrestha, Hemant; Gajurel, Ratna M; Poudel, Chandra M; Thapa, Sanjeev; Sayami, Arun
ABSTRACT Introduction: Acute ST Elevation Myocardial infarction (STEMI) is a cardiovascular emergency and is associated with significant adverse short and long-term outcome. The objective of this study was to determine the short-term outcome in terms of heart failure, myocardial reinfarction, stroke, hospital readmission and mortality in patients admitted with STEMI Methods: It was a prospective observational study conducted at Manmohan Cardiothoracic Vascular and Transplant Center, Kathmandu from May 2014 to April 2015. All patients admitted with diagnosis of STEMI during study period were enrolled. Patients were treated on the basis of existing guidelines. Mode of management, adverse outcomes and mortality of patients during the study period were evaluated. The discharged patients were followed up for 30 days. Statistical analysis was performed with SPSS version 20. Ethical approval was taken from the Institutional Review Committee of Institute of Medicine. Results: The median duration of presentation was 20 hours, and only 40% of the patients presented within 12 hours of symptom onset. Primary PCI was performed in 50 (33%), thrombolysis was performed in 29(19%) and conservative medical management was done in 72 (48%) patients. Overall outcome occurred in 52 (37.7%) patients. In hospital and 30 day mortality was 14 (9.2%) and 17 (11%) respectively. Heart failure was present in 28(18.5%), myocardial reinfarction 8 (5%), stroke 4 (2.6%), and hospital readmission was 18 (12%). Conservatively treated patients had significantly more adverse outcomes (p=0.02). More patients in conservatively managed group had hospital readmission. (p=0.04) Conclusion: There were more overall adverse outcomes in conservatitley managed group which is mainly due to more hospital readmission. Keywords: Primary PCI, short term outcome, STEMI, thrombolysis
Thyroid Disorders and Prolactin Hormone and Their Association with Obesity in Infertile Women in a Tertiary Hospital of Nepal
(Institute of Medicine, 2020) Maskey, Suvana; Rijal, Hima
ABSTRACT Introduction: Thyroid dysfunction has profound effects on menstrual function and female fertility. Hypothyroidism is often associated with increased prolactin level which again worsens the problem. This study was done to evaluate the prevalence of thyroid disorders in infertile women attending infertility outpatient department (OPD) in Tribhuvan University Teaching Hospital (TUTH) and to determine the association of hypothyroidism and hyperprolactenemia with obesity which is not well studied in our population. Methods: A hospital-based cross-sectional study was conducted in infertility OPD of TUTH reviewing women’s records who underwent infertility workup and relevant history, clinical finding and results of investigations including thyroid function test (TFT) and serum prolactin (PRL) level were documented. Descriptive and inferential statistical analyses were used to identify the prevalence and associations of predictors and outcome variables. Results: Out of 213 participants, the majority of the participants were obese (90; 42.3%) with mean (±SD) body mass index (BMI) being 24.8 ± 4.5 kg/m2. The prevalence of thyroid disorder was 18.4% including hypothyroidism 13.6% and hyperthyroidism 4.8%. There was no significant association of BMI and hyperprolactinemia with thyroid disorder as well as of BMI with hyperprolactinemia however the thyroid stimulating hormone (TSH) had significant positive correlation with prolactin (r=0.23, p<0.001). Conclusion: Thyroid disorders and hyperprolactinemia are commonly observed in infertile women, so they should be routinely screened during initial evaluation of infertility. As majority of the study population were obese, despite no significant association of BMI with thyroid disorder and hyperprolactinemia, the effect of weight gain on infertility cannot be overlooked. Keywords: Hyperprolactenemia, infertility, obesity, thyroid disorders

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