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Paroxysmal Nocturnal Haemoglobinuria (classic category)
(Institute of Medicine, 2016) Bhandari, P; Shrestha, A
Abstract Paroxysmal nocturnal haemoglobinuria (PNH) is a rare disease. The prevalence of clinically significant PNH (i.e. classic PNH) plus patients with relatively large clones that arises in the setting of another marrow failure syndrome is likely in the order of less than 1 case per 200,000 population. Here we present a case of classic PNH who presented with acute kidney injury (AKI) requiring haemodialysis secondary to intravascular haemolysis and haemoglobin of 3.6 gm %. Her diagnosis was suggested by positive HAMS test and confirmed by Flow Cytometry. Patient recovered from AKI after starting danazol and her haemolysis was reduced but not controlled fully. Patient is awaiting treatment with either eculizumab or allogenic bone marrow transplantation. Keywords: Paroxysmal Nocturnal Haemoglobinuria, hemolysis, oliuguria, flow cytometry, eculizumab
Neuropsychiatric presentation of Wilson's disease
(Institute of Medicine, 2016) Dhungana, S; Ojha, SP; Chapagain, M; Tulachan, P; Pant, SB
Abstract Wilson's disease is a rare autosomal inherited disorder with various manifestations. Initial manifestations could be hepatic, neurological or psychiatric and there is invariable delay coming to the correct diagnosis. Exact frequency of children and adolescents presenting with psychiatric complaint as the initial manifestation is not known. It is recommended that detailed medical evaluation be done in any child presenting with psychiatric complaints. We hereby present a case of an eight-year old girl who presented with anxiety and subsequently diagnosed to have Wilson's disease. Keywords: children, neuropsychiatric presentation, Wilson's disease
Manual Vaginal Reversion of Acute Puerperal Uterine Inversion: Learning by Doing
(Institute of Medicine, 2016) Katuwal, N; Pokharel, M; Subedi, K; Baniya, J; Sherchan, K; Rawal, S; Baral, J; Gurung, G; Rana, A
Abstract Uterine inversion is the folding of the fundus into the uterine cavity in varying degrees. Acute uterine inversion is a rare and unpredictable obstetric emergency. Here we report a case of a woman who had vaginal delivery complicated by postpartum hemorrhage. Diagnosed as acute puerperal uterine inversion; reposition was tried in the labor room which failed ensuing shock. Simultaneous fluid resuscitation and manual vaginal reversion under general anesthesia was done in Operation Theater, also needing blood transfusion, 5 units in total. Therefore, this case is described herein to illustrate the importance of early recognition and prompt reversion of inverted uterus vaginally,as delay can render replacement progressively more difficult and also increase the risk of hemorrhage.
Allergic Bronchopulmonary Aspergillosis with massive hemoptysis mimicking pulmonary tuberculosis
(Institute of Medicine, 2016) Paudel, K; Adhikari, S; Pant, P
Abstract Allergic bronchopulmonary aspergillosis (ABPA) is a type II hypersensitivity lung disease induced by bronchial colonization of fungus, Aspergillus fumigatus that commonly occurs in patients with asthma or cystic fibrosis. We present a case of 65year-old Brahmin man, non smoker and non atopic who presented with increasing hemoptysis, initially suspected as pulmonary tuberculosis and later diagnosed as ABPA. He was managed with oral prednisolone 0.5mg/kg/day for 14 days followed by gradual tapering over the period of 6 weeks with remarkable response.
Hepatitis E induced severe myositis
(Institute of Medicine, 2016) Nepali, R; Shah, DS; Sigdel, MR
Abstract Hepatitis E is one of a rare cause of viral myositis in immunocompromised patients. Presentation in immunocompetent patient is even rarer. We present a case of 26-year-old female patient who presented with viral myositis secondary to hepatitis E with rhabdomyolysis with acute kidney injury with right leg foot drop due to compartment syndrome in an immunocompetent patient. Keywords: Hepatitis E, viral myositis, Rhabdomyolysis
Co-relation between Non-specific Knee Joint Pain and Osteoarthritis
(Institute of Medicine, 2016) Humagain, M; Paudel, S; Hengwoju, S
Abstract Introduction: Osteoarthritis (OA) is a degenerative joint disease. Pain is the worst and most frequent problem in OA patients that leads to disability. The rate of knee joint pain has been found to be correlated with OA in many studies. The association of knee pain with OA differs by gender, with advancing age and nature of occupations. Knee radiograph is preferred by most of the physicians for the initial assessment of the knee joint pain. This study was carried out to see the relation between knee joint pain and OA along with age, sex and occupation. Methods: In this prospective cross-sectional study, knee radiographs of 200 patients performed in the Radiology Department of T.U. Teaching Hospital for nonspecific knee joint pain were reviewed. Pain was considered as non specific pain when there was no history of trauma or any known disease affecting the joint and no significant abnormality related to any disease entity was found during clinical examination. The study was conducted over a period of three months between July to September 2015. The proforma was filled and then collected data were analyzed using SPSS software to show the relation between knee joint pain and OA. Results: Among total of 200 knee x-rays, 63% (126) were female and 37% (74) were male. The highest number of population was in the age group of 50-59 year, which comprised 26% of total population and lowest population was in >80 year group comprising 0.5% of total population. Housewives were highest in number comprising 39.5% (79) followed by farmer 19% (38), physical worker 15.5% (31), people in service 12.5% (25), business 7.5% (15) and student 6% (12). Of the total population, 59% (118) had radiographic features of OA changes. Most affected people were older than 50 years and all patients older than 70 years had OA changes. No OA was seen in people younger than 20 years. Highest percentage of OA was found in housewives accounting 51.7% followed by farmers (18.6%) and business people (4.2%. No OA was found in students involved in the study. Conclusion: The study demonstrated that the occurrence of OA is more common finding in population with non-specific knee joint pain. OA is more common in females and population of age ≥50 years. OA is most common in housewives and least in students. Keywords: knee, pain, osteoarthritis, x-ray
Depression and its association with glycemic control in Nepalese adults with diabetes mellitus
(Institute of Medicine, 2016) Pant, SB; Ojha, SP; Chapagain, M; Tulachan, P; Dhungana, S
Abstract Introduction: Depression is reported more common among people with diabetes mellitus which if not addressed, may lead to poor diabetes outcomes. The purpose of the study was to explore depression among people with diabetes mellitus attending endocrinology outpatient department of Tribhuvan University Teaching Hospital and to find its association with glycemic control. Methods: Patients with diabetes mellitus (n=158) attending endocrinology OPD of Tribhuvan University Teaching Hospital were chosen by simple random sampling technique. A self- designed semi structured proforma was devised to obtain the socio- demographic characteristics of the study population. 'General health questionnaire -12' was applied and those with a score of three or more considered as achieving 'psychiatric caseness and among them depression was diagnosed with ICD-10 DCR criteria and HAM-D scale was used to verify it objectively. Results: Among the patients, 122(77.2%) belonged to type 2 diabetes and 36 (22.8%) belonged to type 1 diabetes. Estimate of depression was found to be 29.11% (n=46) which was almost similar in both types of diabetes. The duration of diabetes were less than 5 years in 38% of patients. Level of depression showed significant associationand a positive correlation with glycemic control. Conclusion: This study concluded that depression is common in both type 1 and type 2 diabetes patients and calls the need for screening of depression for comprehensive diabetes management. Keywords: Depression, diabete smellitus, General Health Questionnaire-12, glycemic control, HAM-D, ICD-10 DCR
Correlation between Estimated Glomerular Filtration Rate (eGFR) and Sonographic Findings in Patients with Chronic Kidney Disease
(Institute of Medicine, 2016) Neupane, NP; Lohani, B
Abstract Introduction: Ultrasound can also be used as a non-invasive modality for the evaluation and grading of the chronic kidney diseases. This study aims to correlate the various sonographic parameters with the various grades of CKD based on the eGFR. Methods: The study was a cross sectional study conducted over a period of one year. Study population was adult patients (between 20 to 60 years) with chronic renal disease not undergoing renal replacement therapy. Patients with liver disease and fatty changes in liver in ultrasound and patient with ascites were excluded from the study. Estimated glomerular filtration rate (eGFR) was calculated by using Cockcroft- Gault (CG) equation and CKD classified according to Kidney Disease Improving Global Outcomes (KDIGO) 2004. Ultrasound was performed for all patients and data were entered in a predesigned proforma. Data analysis was done using SPSS 21.0. Results: A total of 138 patients met the inclusion criteria and were included in the study. The mean renal length in our study was 9.03cm (±0.83) on right and 9.00cm (±0.82) on the left side. The mean renal cortical thickness of right kidney was 1.037±0.20 cm and of left kidney was 1.039-±0.20 cm. Renal length and renal cortical thickness demonstrated a negative correlation with grade of CKD while renal echogenicity grading demonstrated a positive correlation with CKD grade. Conclusions: Renal Ultrasound may be used to grade and monitor progress of chronic kidney disease. Keywords: Chronic Kidney Disease, Estimated Glomerular Filtration Rate (eGFR), Renal Length, Ultrasound, Renal cortical thickness
Risk factors for redisplacement in pediatric distal radius fractures after closed reduction and cast immobilisation
(Institute of Medicine, 2016) Ghimire, N; Uprety, S; Lamichhane, A
Abstract Introducation: Pediatric distal radius fractures are one of the most common fractures that we see in our practice. The primary modality of treatment of the displaced fractures of distal radius in children is closed reduction and immobilization in cast. Loss of alignment in cast after an acceptable reduction is common. Twenty one to fifty percent rates of redisplacement in cast after acceptable initial reduction have been reported in literature. Methods: This prospective study included 58 fractures of distal radius and distal third shaft of radius in 57 children with radiologically open physis. Age, gender, initial displacement, associated fracture of the ulna, adequacy of reduction, cast index and gap index were evaluated as possible risk factors for redisplacement in cast. Results: A redisplacement rate of 34.48%was found in distal radius fractures of children after acceptable initial closed reduction and immobilization in cast. Initial complete displacement, degree of initial translation in coronal and sagittal plane, degree of initial angulation in the coronal plane, associated fracture of the ulna, non anatomical initial reduction and cast index were found to be significant risk factors for redisplacement. Age, gender, initial angulation in the sagittal plane and gap index were insignificant risk factors. Conclusion: Distal radius fractures in children have high rate of redisplacement in cast. Fractures with initial complete displacement, fractures with associated fracture of ulna and non-anatomically reduced fractures should either be treated by primary closed reduction and percutaneous pinning or must be followed very carefully in cast treatment. Cast index rather than gap index is a better predictor of loss of reduction in cast. Keywords: Pediatrc, Distal radius fracture, Close reduction, Redisplacement
Educational Intervention about Awareness of Preconceptional care: on Impact Among Bachelor Students
(Institute of Medicine, 2016) Dhakal, K
Abstract Introduction: Preconception care is just as important as prenatal care to reduce adverse pregnancy outcomes such as maternal and infant mortality, preterm births, and low birth weight infants. Awareness means Possession of information about preconceptional care and its components like diet, avoidance of alcohol and smoking, use of folic acid, prevention and management of risk factor related to pregnancy. The aim of the study was to assess the awareness on preconceptional care among bachelor level students before and after educational intervention Methods: A one group pre-test post-test (pre-experimental) study on "Impact of Educational Intervention on Awareness Regarding Preconceptional care Among Bachelor Level Students" was conducted to find out the effectiveness of educational intervention on awareness regarding preconceptional care dated September 2009 to June 2010. The study adopted one group pre-test post-test (pre-experimental) design. Setting for the study was Pashupati Multiple College, Chabahil, Kathmandu. Total of 40 students from bachelor level 1st year (Arts, Major English) were taken by using purposive sampling. The self administered semistructred questionnaire was administered to measure their awareness on preconceptional care before and after educational intervention. The collected data was analyzed by using descriptive and inferential statistics such as frequency, percentage, mean, standard deviation between pre test and post test. Paired t-test was used to find out the difference in awareness at 0.05 level of significance. Statistical package for social science [SPSS] version 12 was used to manage and analyze data. The respondents were between 18 to 30 years of age groups. Out of 40 respondents 57.5% were male and 42.5 were female. Most of the respondents that is 92.5% respondents were unmarried. Results: Only 27.5% respondents knew the meaning of pre conceptional care in pre-test, after intervention it was increased by 42.5%. Half that is 50% of the respondents answered that diet containing carbohydrate, protein and fat is essential for women for the preparation of being pregnant before intervention; it was reached up to 82.5% after educational Conclusion: Over all study findings reveal that there is a significant increase in the awareness in all components of preconceptional care after educational intervention. Therefore, it is concluded that educational intervention on preconceptional care can bring significant increase in awareness of bachelor level students. Further, it is recommended that similar type of educational package should be incorporatedin college level to increase the awareness on preconceptional care among reproductive age populationintervention. Only 15% of the respondents answered folic acid reduces the risk of physical defect in growing fetus in pre-test, it was reached up to 82.5% after educational intervention in post-test. Nearly half that is 45% of the respondents knew that blood sugar should be in control in diabetes women before conception in pretest, after intervention it was increased by 65% in post test. Out of total respondents, 50% respondents obtained fair awareness score and 50% respondents obtained poor awareness score in pre test, after intervention 55% of the respondents got fair awareness score and 45% of the respondents got good awareness score in post test. The grand mean of the mean awareness on preconceptional care regarding the general concept, health promotion, risk factor assessment was 12.41 with standard deviation 4.82 in pre test. Similarly the grand mean of all above mentioned item was 19.89 with standard deviation 4.20 in post test. Research hypothesis states that there will be a significant difference on awareness on preconceptional care among bachelor level students between pre and post educational intervention was tested using paired t-test which was found significant (p<0.05) at 0.05 levels. Keywords: Preconceptional care, Awareness, Bachelor Level Students, Education Intervention, Impact
Evaluation of Hounsfield Unit in adult brain structures by CT
(Institute of Medicine, 2016) Mishra, D; Ghimire, RK; Chand, RB; Thapa, N; Panta, OB
Abstract Introduction: The purpose of study was to evaluate the Hounsfield unit (HU) values in adult brain structures by computed tomography (CT). Hounsfield units (HU) describe relative densities of structures by CT. Different pathological process causes the change in attenuation by different tissues resulting in change of HU of the tissues so we should know the normal HU values to track the changes. These HU values are correlated with different clinical condition and different slice thickness. Methods: A prospective study was done in 72 patients of age above 18 years. All CT scans were performed using 16 row multi-detector CT (Neusoft New Viz16). Two sets of images were reconstructed first one with 5 X 5 mm and second one with 3 X 3 mm slice thickness. For quantitative analysis, HU measurements were obtained by drawing elliptical/ circular region-of-interests (ROI) on various anatomical structures on both 5mm and 3mm slice images. Statistical analysis was done with t test,one way ANOVA and descriptive analysis. Results: HU values for different anatomical area were: thalamus 34.50±1.92, caudate nucleus 36.64±2.01, internal capsule 31.40±2.16, pons 32.70± 2.39, dentate nucleus 30.70±2.22, cerebellar peduncle 30.90±2.37, hemisphere 39.62±2.38, vermis36.77±2.39, lateral ventricle 9.86±2.60, putamen 36.66±1.65, globus pallidus, 36.68±1.87, juxta 28.28±2.42, periventricular 29.18±2.78, deep 27.13±2.06, cortex 34.26±2.25, subcortical 27.36±2.49, corpus callosum 28.71±1.98. There was significant difference in HU values of genu of internal capsule, caudate nucleus, periventricular white matter, dentate nucleus, cerebellar peduncle & hemisphere for the 5mm and 3mm slice thickness. Conclusion: HU of gray and white matter of brain were 34.54 ± 2.54 and 28.25 ±2.00 respectively Keywords: Attenuation, Brain, Computed Tomography, Hounsfield Unit, Slice thickness
Reliability and Reproducibility of Physiological Cost Index (PCI) as an Energy Expenditure Index among Asian Individuals
(Institute of Medicine, 2016) Rana, B S.J.B
Abstract Introduction: Physical activity and energy expenditure are important markers of wellbeing. Energy expenditure index can be assessed by bicycle ergometer and treadmill test but they are costly and are not suitable for physically challenged ones. Hence, simpler and straightforward tests like Physiological Cost Index can be useful in a broader perspective. However, it is not known whether they are reliable and reproducible in Asian population. Methods: A total of 10 young randomly selected healthy individuals performed 50m, 100m and 150m walking test at their self-selected preferred speed. The test was repeated three times on each distance. The resting measurements were taken and their Physiological Cost Index during exercise was calculated using MacGregor's equation. Results: The mean age was 24.8 years (22-39 years). The mean speed of walking was 65m/min. The mean body mass index was 20.68.Their mean PCI values for 50, 100 and 150m distance walks at self-selected, preferred speed did not show statistically significant difference from each other. On a reproducibility test, irrespective of the distance walked, the first test (Test I) had statistically significant higher PCI values than Test II and Test III (p<0.05) for the respective distance walked. Conclusion: Physiological Cost Index can be estimated using MacGregor's equation with walking varying distances (50m, 100m and 150m) at a self-selected and preferred speed. The first test tends to overestimate PCI as compared to the second and third tests on the same distance. However, the second and third tests (trials) seem consistent. Keywords: Exercise, Energy Expenditure Index, Physiological Cost Index
Breastfeeding practices in an indigenous minority community group in Nepal: a cross-sectional study
(Institute of Medicine, 2016) Subedi, N; Poudel, S; Poudyal, AK
Abstract Background: Promotion of breastfeeding has been identified as one of the effective evidence based interventions to improve health of infants and young children. Various factors play an important role in breastfeeding practices which are not sufficiently explored in communities like Chepang in Nepal. The objectives of the study were to identify the knowledge and practices of Chepang mothers on breastfeeding and its associated factors. Methods: A cross sectional descriptive study was carried out in which 203 Chepang mothers with child under one year of age were randomly selected and interviewed. Quantitative method was applied for data collection. Analysis of association was done using logistic regression. Results: Practice of mothers on breastfeeding was found better than knowledge. About one fourth (23%) of them knew the appropriate time for early initiation of breastfeeding, however, 36% had practiced it. Exclusive breastfeeding practice under 6 months was 88%, although 60% knew about the recommended duration. Literate mothers were more likely to initiate breastfeeding at appropriate time [AOR: 4.24 (95% CI: 2.20-8.19)] than illiterate. Conclusions: Breastfeeding practices like colostrum feeding and exclusive breastfeeding were found better in Chepang communities than national average, however, early initiation of breastfeeding needs to be improved which could be improved through counseling during antenatal and postnatal visits.
Cognizance about menopause among women and its importance, a short descriptive study in Baluwatar
(Institute of Medicine, 2016) Bhattarai, S
Abstract Introduction: Globally with the increasing life expectancy, there is growing population of elderly women living after experiencing menopause and thus exposed to potential long term consequences of menopause. According to literature, at least 60% of women suffer from mild symptoms, 20% suffer severe symptoms and 20% are asymptomatic¹. Literature shows variations in reported symptoms in women across regions; Asian women suffer less vasomotor and psychological symptoms than Western women². This study was conducted to determine knowledge, attitude and practice toward menopause among women in Nepal. The most implication of this finding is to help to develop menopausal care guideline and provide information to health educators to design a course on menopause. Methods: This study was descriptive cross sectional study carried out in Kathmandu metropolitian city, Baluwatar, ward no-4, icchunadi marga, Kathmandu district of Nepal where the respondents (N-380) to assess their awareness of menopause and its importance and effects on health. In addition, the data were collected by using structured questionnaire with the use of simple Nepali language on consent of respondents. Computer software SPSS version 15 was used to scrupulous analysis of study. Results: 96% participants knew that menopause is the developmental process and every women gets menopause. Majority of respondents (94%) knew that female would not be able to reproduce after menopause, 90% of respondents said the correct age of menopause and 74% of them were agreed regarding the need of education for family member about menopause. The lowest percentage of respondents (32%) knew that smoking may affect menopause. Majority of respondents 56% knew symptoms of irregular bleeding, 30% of respondents had headache, 28% with irritability, 24% with loss of sexual interest and only 22% of respondents knew hot flushes and night sweating. In addition, family is the most effective source of information. In this study, 64% participants had heard about menopause from their family, followed by friends 28%, and lowest sources of information were the school/college 6% and health personnel 2%. Likewise, majority of respondents 74% consulted the doctor for perimenopausal symptoms whereas minority of the respondents 2% consulted friends. Conclusion: Under several myths and taboo relating to menopause in our country, majority of women mainly of rural and even urban areas feel dejected and dispirited and make sometime life miserable with lack of knowledge of menopause. With increasing life expectancy, women spend 1/3rd of life in this phase, thus knowledge and awareness is vital point in every aspect. Thus the present study seems to be of small scale study, but, may have higher impact to invoke the researcher out there to do large scale study, to create new syllabic for students of college or at higher level management policy maker to take it seriously on the health of women who is backbone of family and thus country, Nepal. Keywords: Menopause, Nepal, Women
Study of antifungal activity of amphotericin B-lipid formulations with five lipid carriers
(Institute of Medicine, 2016) Adhikari, K
Abstract Introduction:Invasive pulmonary aspergillosis (IPA) is a prime cause of morbidity and mortality in immunocompromised individuals, who is undergoing lung transplantation.Mortality among infected patients is high. Death rate in excess of 90% has been shown in study by Richardson. Most of these invasive mould infections are acquired through the respiratory tract.An increased incidence of invasive fungal infection has created major challenges for medical practitioners. Amphotericin B(AmB) has been the drug of choice for the treatment of many fungal infections, and it is still used as a gold standard therapy against invasive fungal infection and most commonly used to treat life-threatening conditions such as cryptococcosis, histoplasmosis, and IPA.Currently, lipid formulations are accepted as a less toxic alternative to the traditional colloidal dispersion. Drug toxicity, the nephrotoxicity of AmB is the major clinical problem, which could lead to treatment discontinuation. We designed five lipid formulations of AmB, and compared the dose-response effects of all lipid formulations in-vitro against three different fungal strains including Cryptococcus neoformans, Candida albicans and Saccharomyces cerevisiae. Methods: Five lipid formulations amphotericin B were formulated by lyophilization process. The cylinder plate method performs the relative potency by determining the clear zone of AmB-lipid formulation in the inoculum medium as compared with a clear zone of AmB standard. Broth microdilution method can be used to measure the minimum inhibitory concentration (MIC). The MIC value is based upon predetermined end point, which may be interpreted as an absence of visible growth in a broth containing known concentration of AmB.The minimal inhibitory concentration (MIC) and minimal fungicidal concentration (MFC) were determined using Cryptococcus neoformans ATCC 90113 NS and Candida albicans ATCC 90028. Results: All fiveformulations showed good responses against C. neoformans and Candida albicans, with the MIC and MFC values in the range between 0.16-0.32 µg/ml. The potency of these formulations was equivalent to pure AmB (100%). Conclusions: The results indicate that the investigateded potassium cholate, potassium deoxycholate, sodium deoxycholate sulfate, sodium cholate and sodium deoxycholate may be used as a promising alternative carrier system for amphotericin B. Keywords: Amphotericin B, Cryptococcus neoformans, Candida albicans, Potency, Lipid drug carriers
Outcome of Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction Patients Presenting with Cardiogenic Shock
(Institute of Medicine, 2016) Anil, OM; Sayami, A; Nepal, R; Jaiswal, S; Bhattarai, N
Abstract Introduction: Cardiogenic shock is the leading cause of death in patients hospitalized for acute myocardial infarction (MI). Cardiogenic shock can occur in both ST elevated MI (STEMI) and non-ST elevated MI (NSTEMI). In these patients primary percutaneous coronary intervention (PCI) has better outcome and decreased in-hospital mortality compared to thrombolysis, if performed in time. Methods: This is a retrospective observational study conducted at Manmohan Cardiothoracic Vascular and Transplant Centre, Maharajgunj, Kathmandu, Nepal from September 2012 to December 2014. Patients who presented with acute myocardial infarction and cardiogenic shock and underwent primary PCI were enrolled in this study. Records from cath lab, Coronary Care Unit (CCU) and discharge notes were reviewed and analyzed. Results: A total of 22 patients were enrolled in this study. The mean age of the study population was 61.5±11.5 years and 73% of the participants were male. Four patients were intubated in the emergency department, three received cardiopulmonaryresuscitation (CPR) and one patient received electrical cardio version on presentation. Triple vessel disease was the most common finding and left anterior descending (LAD) artery was the commonest culprit vessel. Procedural success was 91%. In-hospital mortality was 31.2% in the entire study population. Ventilator associated pneumonia and severe sepsis was seen in 5 out of 7 cases that died. Conclusion: Initial outcome of primary PCI performed in patients with acute MI in cardiogenic shock at our centre is encouraging. In-hospital mortality in patients with acute MI complicated by cardiogenic is high. Primary PCI improves outcome in these patients and should be performed as an initial strategy. Keywords: Acute Myocardial Infarction, Primary Percutaneous Coronary Intervention, Cardiogenic shock, Outcome
Detection of coliform bacteria in irrigation water and on vegetable surfaces in the Kathmandu Valley of Nepal
(Institute of Medicine, 2016) Shrestha, S; Haramoto, E; Sherchan, JB; Junko, S
Abstract Introduction: Consumption of vegetables irrigated using polluted water is widespread in the Kathmandu Valley of Nepal. However, studies on the microbial analysis of water and vegetable samples from this region are limited. In this study, irrigation water and vegetable samples from farmers' fields in the Kathmandu Valley were examined for the presence of Escherichia coli and total coliforms. Methods: Irrigation water (n = 8) and vegetable (n = 27) samples were collected from November to December 2015. The presence of E. coli and total coliforms in water and on vegetable surfaces was determined by the most probable number (MPN) method using Colilert reagent. In addition, information about vegetable washing and consumption was obtained through a survey to discuss changes in their microbial concentrations before selling and/or consumption. Results: E. coli was detected in 75% (6/8) of the water samples, with concentrations ranging from 8.8 * 10 ^ 3 to 5.2×107 MPN/100 ml, whereas total coliforms were detected in all the 8 water samples, with concentrations ranging from 9.7 * 10 ^ 2 | 7.9 * 10 ^ 7 * MPN / 100 * m . E. coli was similarly detected in 7% (2/27) of the vegetable samples, with concentrations ranging from 0.4 to 10.2 MPN/cm², whereas total coliforms were detected in 59% (16/27) of the vegetable samples, with concentrations ranging from 0.4 to 448 MPN/cm². Well, river, and tap were the predominant sources of water for washing vegetables before selling and/or consumption. Conclusions: Unlike water samples, vegetable samples contained low microbial contamination; however, the level of contaminants was expected to increase because of washing with polluted water. Keywords: E. coli, Kathmandu, total coliforms, vegetable contamination
Failed Back Syndrome: Evaluation with MRI
(Institute of Medicine, 2016) Gurung, GS
Abstract Introduction: One of a major late post operative complication of discectomy is persistent pain and radiculopathy also termed as failed back syndrome. The study aims to evaluate the MRI findings of failed back syndrome. Methods: A retrospective hospital record based study among 53 patients was carried out at multimodality- imaging center associated with a tertiary care neurological center in Kathmandu, Nepal. MRI of patients performed for persistent pain after discectomy were selected for duration of 3 years and reviewed. All MRIs were performed with and without contrast enhancement. Three radiologists reported the MRIs with mutual consensus in disputed issues. All data were entered in SPSS spreadsheet and analysis was done using SPSS version 19. Results: The mean age of the patients was 45.9± 16.1 years. Out of the total 53 cases, the operative site was at cervical spine in 35.8% cases, in lumbar spine in 64.2% cases and none in dorsal spine. Predominant epidural fibrosis without any other cause attributed to radiculopathy in 93.5% patients. Recurrent Disc herniation was noted in 6.5% patients whereas spondylodiscitis was seem in only one (1.9%) patient at C6-C7 level. The most common level operated in lumbar spine was L5-S1 (28.3%) followed by L4-L5 (24.5%) and in cervical spine was C4-C5 and C5-C6 contributing 17% each. Conclusion: The study concluded that the common causes of failed back syndrome were epidural fibrosis, recurrent disc herniation and rarely spondylodiscitis. Keywords: Syndrome, MRI, Failed Back
Clinical and Echocardiographic assessment of Patient's with Rheumatic Heart Disease
(Institute of Medicine, 2016) Dali, B
Abstract Introduction: In developed countries rheumatic heart disease (RHD) have become uncommon health problems. On the contrary, in the developing countries like Nepal they remain the leading cause of heart disease in children and young adults augmenting morbidity and mortality. The prevalence of RHD varies considerably through the world. The global average prevalence rate of RHD was 2.2/1000 ranging between 0.1 and 12.6 according to World Health Organization (WHO). Community based data are not available regarding the prevalence and distribution of RHD whereas recent epidemiological data are limited to school surveys and facility based reports. Because of low enrollment rates and frequent absenteeism, these studies are unlikely to reflect accurately the epidemiology of RHD in Nepal. The aims of this study were to analyze the clinical presentation pattern of the involvement of various valves and complication in established RHD. To assess the accuracy of clinical evaluation of valvular heart disease to compare it with echocardiographic evaluation. Methods: Fifty consecutives cases of RHD, attending the outpatient department (OPD), of Tribhuvan University Teaching Hospital fulfilling the criteria, formed the material for the present study. Cases were examined in detail with record of physical findings made and cardiovascular examination done in each case. All the cases were scrutinized to detail echocardiographic study using Hitachi EUB 555, 12 lead EKG, chest x-ray and laboratory test. Design of the study was carried out in prospective, cross sectional study. Results: The distributions of the various valvular lesions were noted singly and in combination. Females were more commonly affected 80% than males 20%. Majority of the patient studied had past history of rheumatic fever (72%). Mitral stenosis (MS) was noted in 38 (76%) clinically and 45 (90%) were diagnosed by echo. Pure MS were found in 4 cases (8%). Mitral Regurgitation (MR) was the second most common lesion clinically, in 29 (58%) and 44 (88%) by echocardiography. Keywords: Rheumatic heart disease, Doppler echocardiography, Mitral valve
Comparison of preoperative and postoperative corneal astigmatism after phacoemulsification through a 2.8mm clear corneal temporal incision
(Institute of Medicine, 2016) Joshi, SN; Pant, M; Rijal, S; Bhattarai, D
Abstract Introduction: Phacoemulsification with foldable intraocular lens implantation through clear corneal incision has become common surgical approach for cataract surgery because it produces minimal surgically induced astigmatism and provides best postoperative visual acuity. This study thus aims to compare the preoperative and postoperative corneal astigmatism and to compare the postoperative change in keratometric astigmatism between right and left eyes after temporal 2.8 mm clear corneal incision phacoemulsification cataract surgery and implantation of foldable intraocular lenses. Methods: A prospective study included 31 patients with bilateral senile cataract who had undergone sutureless, 2.8mm clear corneal incision phacoemulsification cataract surgery with foldable intraocular lens implantation. Keratometry was recorded preoperatively and weeks postoperatively using Nidek automated keratometry. A paired sample t-test was performed to compare the preoperative and postoperative corneal astigmatism. Results: Mean age of the population was 63.39 plus/minus 9.705 years (range: 49 to 83 years). Before surgery, mean corneal astigmatism in right and left eye was 0.92 plus/minus 0.58 * D and 0.85 plus/minus 0.61 * D respectively. After the surgery, mean astigmatism in right eye was 0.97 plus/minus 0.51 * D and in left eye was 0.97 plus/minus 0.48 * D There was no statistically significant difference in preoperative and postoperative keratometric astigmatism of both eyes. (RE: p-valve 0.427; LE: p-valve 0.188) Conclusion: Temporal clear corneal incision is quite stable and has minimal effect to corneal astigmatism. Keywords: Cataract, Clear Corneal Incision, Corneal Astigmatism, Phacoemulsification

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