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Spectrum of Biopsy Proven Glomerular Disease in Children at Kanti Children’s Hospital
(Nepal Paediatric Society (JNPS), 2014) Khatun, N; Bista, KP; Mahaseth, C
Abstract: Introduction: Glomerular disease is one of the most common forms of renal disease and can have many different clinical presentations. However there is variation in the prevalence in the type of glomerular disease according to geographical location and race of population. The aim of the study was to find the overall distribution pattern of glomerular disease based on renal biopsies. Material and Methods: The medical records of all children who underwent kidney biopsy (n=29) between January 2012-june 2014 were analyzed. In this retrospective study we review children from Kanti Children’s Hospital, Nephrology Department. Demographic data including age, sex and indication of kidney biopsy as well as complication of the procedures were recorded. Result: A total number of thirty one biopsies were done. Two children were excluded from the study due to inadequate tissue and artifacts defects in preservative. The remaining twenty nine biopsies were included in the study and analyzed. Renal disease was found nearly equal in both male and female (51.72% vs. 48.27%).Mean age was 10.95±3.30 years. Maximum number of biopsies (75.86%) was performed between 10- 15 years. The most common indication of the kidney biopsy was nephrotic syndrome (steroid resistant nephrotic syndrome and steroid dependent nephrotic syndrome, 31.02% followed by lupus nephritis 27.58%.The most common glomerular disease were focal segmental glomerulosclerosis and lupus nephritis both contribute 27.58%. Among lupus nephritis class III was found more common (44.44%) in children. IgA nephropathy was also contribute (17.24%) in all glomerular disease. Regarding the kidney biopsy complication gross hematuria was observed in 6.89% of children which was self-limited. Conclusion: FSGS and lupus nephritis is becoming the most common glomerular disease in children attending the Kanti Children Hospital. IgA nephropathy was also contribute the glomerular disease in the children.
Postinfective Glomerulonephritis (PIGN) in Children Attending a Tertiary Care Centre in Nepal
(Nepal Paediatric Society (JNPS), 2014) Poudel, DR; Basnet, S; Gami, FC
Abstract: Introduction: Post infectious glomerulonephritis (PIGN) is one of the common paediatric kidney disease in developing countries. This study was undertaken to describe the common clinical features, biochemical findings and complications in children with PIGN. Materials and Methods: This was a retrospective descriptive study in which 30 patients admitted with a diagnosis of PIGN at Tribhuvan University Teaching Hospital (TUTH) in a six month period (July 2014 to Dec 2014) were included. Hospital medical records were reviewed for the data collection. Results: Out of 30 patients, 24 (80%) were between 5 to 15 years of age (mean age of 11.5±3.3) with male to female ratio of 2.3:1. Pedal oedema and hypertension were the clinical features seen in 29 (97%) and 28 (93%) patients respectively. Hypocomplementemia was found in 29 (97%) patients. Recent past history of sore throat seen in 10 (33%) patients and skin lesions in 12 (40%). The complications noted were congestive cardiac failure in 5 (17%) patients, rapidly proliferative glomerulonephritis in 3 (10%) and encephalopathy in 1(3%). Conclusion: The most important clinical and biochemical profile observed in nepalese children with PIGN are the hypertension, pedal edema and hypocomplementemia.
Nutritional Status of Children Seeking Medical Treatment in a Rural Hospital in Ilam District, Nepal
(Nepal Paediatric Society (JNPS), 2014) Paneru, C; George, SM
Abstract: Introduction: Childhood malnutrition is a leading cause of mortality and morbidity in children under five years in Nepal. There is evidence to show that childhood malnutrition varies from region to region, within Nepal. But there is no data available about nutritional status of children in the 75 districts in Nepal. The aim of this study was to evaluate the nutritional status of children less than five years of age in Ilam district. Material and Methods: We analysed the anthropometric data for the children of Ilam district who visited Dr. Megh Bahadur Parajuli Community Hospital in Ilam district. Results: Our data showed that 15.7% of girls and 21.2% of boys under-five years suffered from moderate malnutrition. Severe malnutrition was present in 6.7% of girls and 9.6% of boys. Stunting was seen in 32.6% girls and 30.16% boys. Moderate stunting was present in 19.6% of girls and 19% of boys; while severe stunting was present in 11% of the boys and 13% of the girls. Conclusion: Our data shows that stunting among under-fives in Ilam is less as compared to that reported for Nepal, but underweight is comparable to the national data. However, a systematic study needs to be carried out in Ilam before drawing firm conclusions.
Neonatal Sepsis: A Profile of a Changing Spectrum
(Nepal Paediatric Society (JNPS), 2014) Venkatnarayan, K; Bej, PK; Thapar, RK
Abstract: Introduction: The clinical features of neonatal sepsis are protean and are based on variety of clinical, demographic and laboratory profile of suspected cases. Objectives: To describe the aforementioned profiles in neonates presenting with clinically suspected sepsis based on pre-defined clinical criteria. Material and Methods: Design: Cross-Sectional Study; Setting: Level-2 NICU, Tertiary Care Hospital; Duration: Jan 2011 to Jul 2012. Subjects: 50 consecutive neonates presenting with any of the predefined clinical criteria were assessed for presence of maternal risk factors and studied with respect to: Gestational age, sepsis screen, clinical profile and antibiotic sensitivity of the organisms cultured. Results: Out of the fifty neonates, 38 (76%) were early onset sepsis. The sepsis screen showed an overall sensitivity of 73%, specificity of 54%; with a positive predictive value of 41% and a negative predictive value of 83%. The most common organism cultured was Staphylococcus aureus followed by E Coli, Pseudomonas, Coagulase Negative Staphylococcus and Group B Streptococcus. Ampicillin and Amikacin fared better than Cefotaxime and Gentamicin for Gram positive and Gram negative organisms, respectively. Overall, 37 babies responded to first line antibiotics and 11 required a change of antibiotics. One required addition of inotropes and two of the neonates died. Conclusion: A clinical diagnosis of sepsis based on predefined clinical criteria along with maternal risk factors, over- treated 27 babies (71%) with EONS and 8 babies (66.6%) with LONS. However, such a clinical diagnosis was supported by a septic screen almost twice as frequently (50% Vs 26.3%) in LONS. Staphylococcus aureus was the most common organism isolated.
Knowledge and Practice of Mother regarding Exclusive Breastfeeding having Infant at a Tertiary Level Hospital, Kathmandu
(Nepal Paediatric Society (JNPS), 2014) Adhikari, TM
Abstract: Introduction: Promotion of exclusive breastfeeding is a cost effective intervention to reduce infant mortality in developing countries. The objective of this study was to identify knowledge and practice of mothers regarding exclusive breastfeeding. Material and Methods: This was a descriptive exploratory study carried out in the immunization clinic of tertiary level hospital in Kathmandu. A total of 323 mothers who came for immunization of six months to one year were selected as the sample for the study by using non-probability purposive sampling technique. Semi - structured interview questionnaire was used to collect the data both on knowledge and practice of exclusive breastfeeding, from 13th July to 8th September 2014. Results: Study findings revealed that 84.5 % of the respondents were aware of the correct meaning of exclusive breastfeeding and 49.5 % of the respondents practiced exclusively breastfeeding to their children up to 6 months. There was statistically significant association of respondent’s level of knowledge regarding exclusive breast feeding with their educational status (p = 0.034, OR = 1.7, 95% CI = 1.03-2.66) and type of delivery (p = 0.005, OR = 1.9, 95% CI = 1.2-3). Likewise, a significant association was seen between respondent’s level of practice regarding EBF and type of delivery (p = 0.005, OR = 1.9, 95% CI = 1.2-3). Conclusion: Study concludes that only about half of the mothers tended to have adequate knowledge regarding exclusive breast feeding. However, practice of exclusive breastfeeding for up to six months tended to be low so there should be efforts on encouraging and counseling for exclusive breast-feeding up to six months in hospital, community and immunization clinic.
Is Iron Deficiency Anaemia, a risk Factor For Wheeze Associated Respiratory Tract Infection in Children?
(Nepal Paediatric Society (JNPS), 2014) Agrawal, A; Gupta, R; Sodhi, KD; Raghav, V
Abstract: Introduction: Wheezing is the common in children with cumulative prevalence of almost 50% by the age of 6 yrs. Iron deficiency anaemia is an independent risk factor for lower respiratory tract infections (LRTI), however may also play an important role in wheeze associated respiratory tract infection. The present study aimed at finding a correlation between iron deficiency anaemia and wheeze associated respiratory tract infection. Materials and Methods: This case control study was conducted at a multidisciplinary tertiary care hospital from Jul 2012 to Jun 2013 among children six months to five years and having ≥2 episodes of wheeze associated respiratory tract infections. The clinical presentation and laboratory profile were recorded on a predesigned performa. Iron deficiency anaemia was diagnosed by haemoglobin <11.0 gm%, serum ferritin<12ng/ml and RDW>15%. The statistical analysis was done using SPSS, Version 15.0. Results: A total of 100 children were enrolled in the study, of which 50 cases and 50 matched controls. Majority of subjects in both groups were males (n=31;62%),with male to female ratio of 1.6:1. Proportion of cases with iron deficiency anaemia were higher among cases(32%) as compared to controls(24%) but the difference between two groups was not significant statistically (p=0.373) despite having higher risk(OR=1.49;95% CI=0.62-3.59). Mean monocyte, oeosinophil and absolute oeosinophil count was found to be significantly higher in cases as compared to controls (p<0.05). Conclusion: The present study do not suggest a possible linkage between iron deficiency anemia and wheeze associated respiratory infection, however its role as causative factor needs to be explored through long-term prospective and intervention studies on a large population.
Early Experience With Single-Stage Transanal Endorectal Pull Through For Rectosigmoid Hirschsprung’s Disease
(Nepal Paediatric Society (JNPS), 2014) Shrestha, MK; Sherchan, M; Dhoubhadel, BK; Basnet, RB
Abstract: On 24th August 2015, the spelling of the third author's name was changed from Dhaubhadel TO Dhoubhadel - Editor. Introduction: Recent trends in surgery for Hirschsprung’s disease (HD) have been towards earlier operation and fewer surgical stages. A single-stage transanal endorectal pull through (TEPT) is the latest development and minimally invasive technique for HD. This observational prospective study was designed to evaluate the safety and efficacy of single-stage TEPT technique in the management of rectosigmoid HD. Materials and Methods: Infants and children with biopsy-proved aganglionosis and barium enema (BE) documented rectosigmoid HD were included for single stage TEPT. Twenty children aged 22 days to 7 years (17 boys and 3 girls) underwent one stage TEPT over 5 year period. Median follow up was 18 months (range 6-36 months). These patients were evaluated with regard to age, sex, intraoperative details, postoperative functional outcome and complications and need for secondary surgical procedure. Results: The operating time was 105-180 minutes (mean 120 minutes). The length of resected bowel was 18-30 cm (mean 25 cm). Intraoperative blood loss was 5-40 ml, less in infants compared to older children. Blood transfusion was needed in none out of 12 infants and 2 out of 8 older children. Transient perianal excoriation occurred in 16 patients. Postoperative enterocolitis occurred in one patient. One patient developed constipation with encopresis following anastomotic stricture. None had adhesive obstruction and prolapse of pulled through colon, one required colostomy for anastomotic leakage and peritonitis while another had retained aganglionic segment and re-do pull through was required. Conclusion: Single-stage TEPT can be performed successfully in all age of children. The technique is safe, easily learned and has good clinical results.
Community Based Nutrition Education for Promoting Nutritional Status of Children under Three Years of Age in Rural Areas of Mahottari District of Nepal
(Nepal Paediatric Society (JNPS), 2014) Yadav, DK; Gupta, N; Shrestha, N; Kumar, A; Bose, DK
Abstract: Introduction: Maternal and child mortality have declined significantly in Nepal to the extent that Nepal is on track to meet the Millennium Development Goals for maternal and child mortality. Similar improvements have not been seen in general nutrition status of them. Objective of this study was to evaluate a nutrition-education intervention designed to improve nutritional status (reduce stunting, wasting and underweight) of children. Materials and Methods: It was an intervention with separate sample pretest posttest design. Two groups of Village Development Committee (VDC) from Mahottari district were recruited as interventional and control areas. The intervention was a 12-months nutrition education program and comprised of twelve times with 2-3 hour nutrition lectures and discussion classless conducted by the Female Community Health Volunteers (FCHVs). Results: The Present study found that number of underweight children increased by 7.6% in control group while it decreased by 17.7% in intervention group from baseline to endline in both groups. So, intervention programme was able to decrease the number of underweight children significantly. Study shows that wasting status of children increased by 11.4% in control group from baseline to endline period. While in intervention group wasting status of children decreased by more than 5% from baseline to endline period. Conclusion: Nutrition education intervention was effective to reduce wasting and underweight but did not reduce the stunting status of children. Stunting reflects failure to receive adequate nutrition over a long period of time and is affected by recurrent and chronic illness. Findings suggested that nutrition programme of longer duration should be implemented to control the stunting status of children.
Bacteriological Profile of Neonatal Sepsis in a Tertiary Level Hospital of Nepal
(Nepal Paediatric Society (JNPS), 2014) Khanal, R; Manandhar, S; Acharya, GP
Abstract: Introduction: Neonatal sepsis is one of the most common reasons for admission to neonatal units in developing countries. It is also a major cause of mortality in both developed and developing countries. This study was done to determine the bacterial profile causing neonatal sepsis and to assess their susceptibility pattern to various antimicrobial agents. Materials and Methods: A cross-sectional prospective study was conducted in Paropakar Maternity and Women’s Hospital, Kathmandu, Nepal among 340 neonates suspected of neonatal sepsis. Blood culture was performed and organisms were identified with Gram staining and conventional biochemical methods. Antimicrobial susceptibility testing was performed by Kirby-Bauer disk diffusion method according to the Clinical and Laboratory Standards Institute (CLSI). Results: The prevalence rate of neonatal sepsis was 20.3%. Among 340 neonates, 52.17% were males and 47.82% were females. Gram positive cocci were the most predominant isolates (88.40%). Among Gram positive cocci Staphylococcus epidermidis was the most common isolates (72.46%) followed by Staphylococcus aureus (7.24%), Staphylococcus saprophyticus (4.34%) and Enterococcus fecalis (4.34%). Gram negative bacilli were found in 11.60% of the growth positive samples of which E.coli and Klebsiella spp were found in 10.14% and 1.44% respectively. Sensitivity to Amikacin was highest among all types of organisms isolated. Vancomycin and Gentamycin sensitivity was highest for Gram positive and Gram negative organisms respectively. Ampicillin resistance was highest among isolates. Among the 69 isolates 48 were Multiple drug resistant. Conclusion: The predominance of Gram positive cocci particularly Coagulase negative Staphylococci is shown. Empirical antibiotic therapy should be reviewed for Multiple drug resistant strains.
Antioxidants in Hypoxic Ischemic Encephalopathy
(Nepal Paediatric Society (JNPS), 2014) Rathee, AVS; Prasad, PL
Abstract: Introduction: Perinatal asphyxia and related injuries are leading cause of morbidity and mortality in India. These babies are at risk to develop hypoxic ischemic encephalopathy (HIE) due to multiple organ including brain damage. The role of malondialdehyde (MDA) as a marker of free radical injury has been well established. Vitamin C and alpha Tocopherols have neutralizing effects on the free radicals. Considering these facts, it was decided to estimate serum MDA level in cases of HIE and the neutralizing effects of Vitamin C and Vitamin E. Material and Methods: The study was conducted in a tertiary care teaching hospital. Neonates with an Apgar score of <6 at 5 minutes and birth weight >2500g were included in the study. They were randomized into two groups. One group was given Vit E and vitamin C and the other was not given any of the anti oxidants. Serum MDA level were measured in both groups. Result: Serum MDA level was found to be increasing in both groups, but the increase was significantly higher in group II where antioxidants were not given. It was also found that serum MDA level was significantly low in antioxidants groups with HIE than those without antioxidants. Conclusion: Antioxidants supplementation in cases of HIE is associated with lesser production of free radicals and their neutralization is affected by antioxidants resulting into lesser damage to brain.
Sacrococcygeal Teratoma: Experience with 36 Patients in a Teritiary Care Hospital
(Nepal Paediatric Society (JNPS), 2015) Kundal, VK; Jadhav, A; Gupta, A; Shukla, A; Chaturvedi, V; Kundal, R
Abstract: Introduction: Sacrococcygeal teratomas (SCT) are the most common solid tumours in the neonatal period, originate from embryonic totipotent cells. Most of them are benign however some that present later in life and have major intra-pelvic component have greater malignant potential. Complete surgical excision provides an excellent prognosis. The aim of this study was to describe the clinical profile, age of presentation, sex distribution, diagnostic evaluation and management of children with a histological confirmed diagnosis of sacrococcygeal teratoma. Material and Methods: Patients with histological diagnosis of sacrococcygeal teratoma during a period from January 2011 to December 2012 were included in this retrospective study. Data collected included age of presentation, sex distribution, symptoms, associated anomalies, diagnostic evaluation, operative approach technique employed, tumour histology, operative complications and outcome. Results: Thirty six patients with diagnosis of sacrococcygeal teratoma were included in the study. Of these children, 58.33% were females and 41.66% were males. The median age at presentation was four days. 69.44% of patients presented during the neonatal period. 77.77% of patients presented with sacrococcygeal mass followed by lower abdominal mass in 11.11%. The tumour was resected by sacral approach in 27 patients and abdomino sacral approach in nine patients. Tumour was resectable in 34 patients and two had incomplete resection. Follow up duration varied from six months to 24 months. Conclusion: Sacrococcygeal teratomas represent a group of benign and malignant lesions of children. Neonates present with benign disease and aggressive lesions are seen as age progresses. Overall survival of SCT is high.
Home Ventilation in Children
(Nepal Paediatric Society (JNPS), 2015) Gupta, D; Sachdev, A; Gupta, N; Simalti, AK
Abstract: Introduction: Home mechanical ventilation (HMV) can prolong survival and improve quality of life. The objectives were to review the challenges, clinical conditions and outcome of children who were discharged from the hospital on respiratory support. Material and Methods: Twenty four patients, who were electively discharged from PICU and had received home ventilatory support for more than 15 days, were enrolled over 11 year study period. Patients were followed up monthly, for two years, for ventilatory requirements, any problems encountered during previous month and for any complication. Results: Twenty four patients with a median age of 3.5 years were discharged home with ventilatory support. HMV was started in 2001 at our hospital. Patents received home ventilation for a median period 5.4 months. Twenty (83.3%) patients received invasive mechanical ventilation via tracheostomy and four (16.7%) patients received non-invasive mechanical ventilation. Twelve (50%) patients received ventilatory support for more than 20 hrs a day and twelve (50%) patients received only during sleep. On follow up for two years for each patient, twenty (83.3%) patients successfully came off from ventilatory support while, two (8.3%) patients died and two (8.3%) lost to follow-up. Conclusion: HMV can be safely applied in selected children with CRF after providing adequate training to the care givers. For its more efficient use, we need to have good social support and medical assistance which can be extended to their homes to meet their complete health care needs.
Differentiating Gilbert Syndrome from Crigler Najjar Syndrome Type 2 by Phenobarbitone Test
(Nepal Paediatric Society (JNPS), 2015) Sinha, R; Dalal, S; Sodhi, K
Abstract: Gilbert syndrome characterized by jaundice with intermittent elevations of indirect bilirubin, in the absence of haemolysis or underlying liver disease, has both autosomal dominant and recessive inheritance. Crigler-Najjar syndrome type II (CNS2) is a hereditary disorder of bilirubin metabolism characterized by unconjugated hyperbilirubinemia due to reduced and inducible activity of hepatic bilirubin glucuronosyltransferase (GT). We report 20 children between age 5 to 15 years with unconjugated hyperbilirubenemia who were given seven days of oral phenobarbitone (5mg/kg/day) and decrease in level of bilirubin was noted. There was only 30-40% reduction of bilirubin in Crigler Najjar Syndrome Type 2 compared to Gilberts Syndrome in which bilirubin level normalised. This case series highlights the importance of simple test to differentiate these two conditions. This test is also very helpful in a place where enzyme level and mutational study cannot be done.
Conducting Qualitative Interviews using Virtual Communication Tools amid COVID-19 Pandemic: A Learning Opportunity for Future Research
(Nepal Medical Association, 2020) Sah, Lalita Kumari; Singh, Devendra Raj; Sah, Rajeeb Kumar
Abstract: The COVID-19 pandemic has threatened the health and wellbeing of the global citizens which has led to a significant change in attitude, lifestyle, and behavior of people from diverse professions, including academics and researchers. Doctoral students and funded researchers with the time limit to their research project have experienced stress and anxiety due to the struggle of negotiating and managing the timeline to complete the fieldwork for their research. In the current circumstances, an increasing number of researchers are looking for alternative methods to conduct the fieldwork and complete the data collection. In this context, the aim of this viewpoint is to provide reflections on the challenges and opportunities experienced by the authors while conducting qualitative research fieldwork during the COVID-19 pandemic.
The Increasing Scope of Teledermatology in Nepal
(Nepal Medical Association, 2020) Paudel, Vikash
Abstract: Teledermatology is a rising subspecialty that uses information and communications technologies to diagnose, prevent, treat, and educate skin health. It is an innovative means for delivering quality dermatological care. It embraces the potentials for revolutionizing dermatologic consultation to remote locations in Nepal, where service by dermatologists is almost impossible. By adopting advances in telecommunication, wider and faster coverage of the internet and smartphones, computers, laptops, and high-resolution cameras, the era of teledermatology is changing even in lower-income countries like Nepal. It has emerged as a boon in skin healthcare to rural and even urban care in the recent coronavirus pandemic but would never replace traditional consultations. The challenges faced by teledermatology are lack of technical expertise and proper implementation of guidelines, diagnostic limitations, and various medico-legal aspects. This article presents a brief review of teledermatology in Nepal.
Being an Imposter: Growing Out of Impostership
(Nepal Medical Association, 2020) Mainali, Sumina
Abstract: Imposter syndrome is the fear of being discovered as an intellectual fraud. It is an internal experience of believing that you are not as competent as others perceive you to be. It lowers a personâ€™s inner self-confidence, self-esteem that impedes work performance and this phenomenon is more prevalent among medical students. However, talking openly about it with peers, rooting positive thoughts, and building confidence help us to the appropriate reality of our situation and counter our negative self-talk.
Otorhinolaryngological and Ophthalmological Manifestations of COVID-19 in the Pediatric Population
(Nepal Medical Association, 2020) Magar, Sanju Thapa; Gyawali, Bigyan Raj
Abstract: Severe Acute Respiratory Syndrome Coronavirus 2 pandemic has affected several countries throughout the world. Being very contagious, it can affect any individual. So far, the prevalence of Severe Acute Respiratory Syndrome Coronavirus 2 in children amongst the total infected population is very low, ranging from 1-5%. Difficulty in diagnosing the disease clinically in the pediatric population owing to their inability to explain their symptoms often renders a possibility of overlooking this disease. Moreover, new modes of presentation are being reported apart from the classical tell-tale signs. In this scenario, medical professionals dealing with the children should be well aware of different modes of presentation of this disease in the pediatric population. This study thus aims to review otorhinolaryngological and ophthalmological manifestations in the pediatric population affected by Severe Acute Respiratory Syndrome Coronavirus 2.
The First Successful Endovascular Management of Posterior Fossa Arteriovenous Malformations in Nepal: Case Series
(Nepal Medical Association, 2020) Phuyal, Subash; Agrawal, Pooja; Dawadi, Kapil; Paudel, Raju; Lamsal, Ritesh
Abstract: Posterior fossa arteriovenous malformations represent 7â€“15% of all intracranial AVMs. They carry a higher risk of rupture than supratentorial AVMs and are associated with considerable rates of morbidity and mortality. Available treatment options include conservative management, microsurgical resection, radiosurgery, endovascular embolization, or combinations of these modalities. Recent advances in endovascular techniques have revolutionized their management with better clinical outcomes. We illustrate two cases of posterior fossa AVMs treated by endovascular techniques with good clinical outcomes. The first patient also had associated flow-related aneurysms. One of these aneurysms had already ruptured, so it was coiled first followed by AVM nidus embolization using the same microcatheter. The second patient had a diffuse type of posterior fossa AVM for which staged-embolization was planned and the first-stage partial embolization was successfully performed.
Human Poisoning due to Delphinium Species in the Himalayan Region of Nepal: A Case Report
(Nepal Medical Association, 2020) Adhikari, Santosh; Bhandari, Abhishek
Abstract: The Delphinium species herb, common name â€˜Nirmasiâ€™ in Nepal, is one of the community level flower herbs used as medicinal ingredients in various clinical problems in Manang District and other Himalayan parts of Nepal. Roots of the plants from the genus Delphinium have been used for a long time for headache, epilepsy, mania, paralysis, rheumatism, toothache, and various types of pain. However, many species of Delphinium are poisonous and look quite similar in morphology to the beneficial ones. As a result, accidental poisoning is common. Poisoning due to these plants results in symptoms due to gastric irritation, competitive neuromuscular blockade, and cardiotoxicity caused by various alkaloids present in them. We report here a case of poisoning due to Delphinium species ingestion presenting as hypotension and bradycardia managed successfully with symptomatic treatment.
Ureter Quadruplication with Huge Ureteral Cyst
(Nepal Paediatric Society (JNPS), 2015) Joshi, R; Singh, DR
Abstract: Ureteral quadruplication is an extremely rare congenital anomaly. It was first reported in 1975. The patients may present with different features and complications in respect to this congenital anomaly. They may also present with other congenital anomalies. Diagnosis sometimes is difficult and may need to be investigated with Magnetic Resonance Urogram, CT scan apart from routine investigations like ultrasonography and intravenous urogram. Surgical treatment should be based on the operative and investigational finding. We present the twelfth reported case but the first from Nepal. It was associated with a large ureteral cyst with diagnostic dilemma. Surgical exploration was done with a provisional diagnosis of large retroperitoneal cyst.

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