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Silver-lining in the Time of Mayhem: The Role of Local Governments of Nepal During the COVID-19 Pandemic
(Nepal Medical Association, 2020) Adhikari, Biplov; Budhathoki, Shyam Sundar
Abstract: The COVID-19 pandemic has not only affected health systems but also has had deep socio-economic effects. The lockdown enforced in Nepal, had people running out of means to make ends meet, the public in fear of an unknown disease, and challenges for leaders to deliver better. Local governments of Nepal, established under the federal system, have the closest ties to the community. They have powers entrusted by the constitution to enact laws according to the needs of the community. During the 83 days of lockdown, the local governments came through for their inhabitants by managing quarantines and isolation centers, taking care of diagnostics, providing food and rations, and arranging facilities to bring back their locals stranded in other cities. The local governments improved awareness and helped maintain the lockdown. These undertakings by the local governments of Nepal highlight the importance of a community-based approach to dealing with pandemics.
Parenting during the COVID-19 Pandemic
(Nepal Medical Association, 2020) Karki, Utkarsh; Dhonju, Gunjan; Kunwar, Arun Raj
Abstract: Parenting is both an art and science of nurturing a child that comes very naturally to some. In todayâ€™s world, the fundamentals of parenting are getting challenged but it has been even more magnified during the coronavirus 2019 (COVID-19) pandemic. The mental health of children is bound to be affected by the stress related to COVID-19 owing to loss of usual routine, unpredictability, uncertainty. Various other social, economic, and environmental factors also threaten their mental well-being. Parents are the childâ€™s first and longest-lasting context for development Positive parenting that involves sensitivity, responsivity, caring, communicating, and empowering would ensure positive developmental outcomes in children and adolescents. Positive parenting and self-care of parents would serve as a promotive and preventative intervention for child and adolescent mental health, especially during this crisis.
Effective Way of Studying and Learning in Medical School
(Nepal Medical Association, 2020) Niroula, Shreya; Niroula, Aliska
Abstract: Medical knowledge is growing. We struggle a lot to retain most of the studied information, but we forget it. Most of us are unaware of how to study effectively and improve memory.Understanding the neurobiology of learning and knowing some of the productive study techniques backed up by the researches can help us to study as well as learn effectively. This article may help medical students to study productively and motivate them to search for effective ways of studying actively.
Multiply Broken Metallic Hardware Removal for United Patella Fracture Applied Twenty Years Before: A Case Report
(Nepal Medical Association, 2020) K.C., Kapil Mani; Acharya, Parimal; Pangeni, Bandhu Ram; Niroula, Ankit; KC, Amuda
Abstract: Breakage of tension band wires, used to treat the patella fracture, is not uncommon several years after the fracture fixation. Broken wires may migrate to surrounding neurovascular structures, other vital organs like heart and may cause potentially fatal complications. Once the wires have been broken, it is very difficult to remove the broken pieces of metal wires. We report a 50 years old male patient with broken tension band wires at multiple sites for patella fracture. The broken wires were removed 20 years after the initial surgery without any undue complications, however patient sustained significant soft tissue damage to remove all the pieces of broken wires that would otherwise have been removed without any undue complications immediately after fracture union.
Colonic Duplication Cyst in an Adult Woman: A Case Report
(Nepal Medical Association, 2020) Shrestha, Sundar; Adhikari, Subodh Kumar
Abstract: Intestinal duplications are rare congenital anomaly found in pediatric age group. Although, ileum is the most common site, there are cases of colonic duplications even in the adult. We report a case of 43 years woman presented with chronic constipation, intermittent colicky abdomen pain and a cystic lump in left abdomen diagnosed as tubular duplication cyst of descending colon. Colonoscopy is a good investigation tool for diagnosis of colonic duplications; however, it may not be true in all cases. She was managed with left hemicolectomy and excision of cyst with uneventful post-operative days. This case has been reported because of rarity of this condition.
Operative Treatment of Fixed Flexion Deformity of Elbow by Anterior Release: A Case Report
(Nepal Medical Association, 2020) Thakur, Abhishek Kumar; Pradhan, Nabees Man Singh; Devkota, Pramod; Gyawali, Bidur; Pokhrel, Prabhav Majgaiyan
Abstract: A 20-year-old male presented to our OPD with stiffness in his right elbow. He gave a history of sustaining a fracture around the same elbow when he was 4 years old. He was treated operatively for the same. In the post-operative period, he did not undergo any physiotherapy. On examination, he had a fixed flexion deformity in his right elbow with a range of motion between 90 and 110 degrees. X-ray did not show any bony abnormalities and MRI revealed susceptibility artifacts in posterior aspect. The elbow was approached anteriorly releasing all the soft tissue contractures. The elbow was immobilised in extension in a plaster cast for 4 weeks. The patient was under regular physiotherapy after plaster removal in the post-operative period. At one year follow up, he has an elbow range of motion between 20 and 120 degrees.
Orofacial Herpes Zoster Infection in Dental practice: A Case Report
(Nepal Medical Association, 2020) Gurung, Deepa; Joshi, Ujjwal; Chaudhary, Bikash
Abstract: Herpes zoster infection, commonly known as Shingles, is caused by reactivation of the Varicella-Zoster virus which may have remained latent in the dorsal root ganglia. HZI is characterized by prodromal symptoms of unilateral deep aching, burning pain followed by a maculopapular rash, vesicular eruptions, ulcers, and scab formations over the affected nerve distribution. The ophthalmic branch of the trigeminal nerve is more commonly involved in HZI than maxillary and mandibular branches; in particular, the maxillary involvement is rare. This is a case report of HZI in a 65-years-old male patient involving the maxillary division of the trigeminal nerve. This case highlights the importance of early diagnosis and prompt use of antivirals in managing orofacial HZI in dental practice.
Symptomatic Hyponatremia following Bowel Preparation for Colonoscopy: A Case Report
(Nepal Medical Association, 2020) Shrestha, Pramesh Sunder; Acharya, Utsav; Karki, Bipin; Pathak, Rahul; Acharya, Subhash Prasad
Abstract: Colonoscopy is considered a gold standard tool for the diagnostic evaluation of colorectal diseases. Bowel preparation, a pre-requisite for colonoscopy, usually involves ingestion of purgatives for the cleansing of the bowel so that visualization is not obscured during the procedure. Commonly used preparations are sodium phosphate-based solutions, sodium picosulphate and polyethylene glycol. The use of such preparations is associated with electrolyte disturbances, commonly hyponatremia. Hyponatremia is usually seen with sodium phosphate based solutions and is rare with polyethylene glycol. Symptomatic hyponatremia, however, is rare following bowel preparation and is attributable to other factors as well, such as the age of patient, non-osmotic release of antidiuretic hormone and the procedure itself. In this report, we discuss a case of severe symptomatic hyponatremia observed in a 71-year-old gentleman who underwent polyethylene glycol based bowel preparation for colonoscopy.
Diagnostic Dilemma in Groove Pancreatitis: A Case Report
(Nepal Medical Association, 2020) Laudari, Uttam; Ghimire, Roshan; Pradhan, Rosi; Maharjan, Dhiresh Kumar; Thapa, Prabin Bikram
Abstract: Groove pancreatitis is uncommon form of chronic pancreatitis common in patients with history of smoking and alcohol abuse. High index of suspicion is required as it may masquerade pancreatic ductal adenocarcinoma and both of these conditions are difficult to differentiate preoperatively. Pancreaticoduodenectomy has good outcome in patient with Groove pancreatitis. Hence, we are reporting a case report of Groove pancreatitis in 40 years gentleman, who was being managed by multiple endoscopic dilatations, later underwent pancreaticoduodenectomy for persistent symptoms. He had no perioperative morbidity and doing well in 24 months follow up.
Takayasu's Arteritis with Subcutaneous Nodules in a 4-year -old Child: A Case Report
(Nepal Medical Association, 2020) Das, Sunil Kumar; Dahal, Aakrit; Shrestha, Nikhil; Tnawanasu, Sajal; Sharma, Subash
Abstract: A 4-year-old girl who presented with pain in the abdomen, subcutaneous nodule, fever and was later diagnosed with Takayasu arteritis . Oral corticosteroid and methotrexate were started. Childhood TA should be kept in differential diagnosis when presented with subcutaneous nodules and increased acute phase reactants.
Primary High Grade Serous Carcinoma of the Fallopian Tube: A Case Report
(Nepal Medical Association, 2020) Dhakhwa, Ramesh; Vaidya, Anshu; Giri, Amrita; Shakya, Archana; Vaidya, Achala
Abstract: A 49-year-old, perimenopausal nulliparous woman with lower abdominal pain and abnormal uterine bleeding. Clinical and radiological findings suggested a right adnexal tumor. CA-125 level was moderately elevated. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was done. Peroperative findings revealed a soft to friable growth arising from right fallopian tube with no involvement of ovaries. Histopathologic examination confirmed it to be a high grade serous carcinoma, FIGO stage IA. The histomorphology resembled high grade serous carcinoma of ovary, however ovaries on both sides appeared unremarkable. Surgery was uneventful and the patient was discharged after seven days of hospital stay. She did not receive postoperative chemotherapy or radiotherapy and is under follow-up. The case is reported for its occurrence in an uncommon anatomic site and preoperative dilemma with relevant review of literature.
Sertoli Leydig Cell Tumour Initially Misdiagnosed as Polycystic Ovarian Syndrome and Congenital Adrenal Hyperplasia: A Case Report
(Nepal Medical Association, 2020) Paudyal, Pooja; Gurung, Geeta; Baral, Josie; Kharel, Nisha
Abstract: Sertoli-Leydig cell tumor of the ovary is an unusual neoplasm that belongs to a group of sex cord-stromal tumors of the ovary and accounts for less than 0.5% of all primary ovarian neoplasms. They are often characterized by the presence of mass with androgen production and signs of virilization. Due to the substantially low incidence of Sertoli-Leydig cell tumors, information on clinical behavior, prognostic factors, and optimal management arelimited. Here in, we report a case of aprimary ovarian Sertoli-Leydig cell tumor in a 21-year-old student, previously diagnosed to have polycystic ovarian syndrome and subsequently congenital adrenal hyperplasia, who presented with a large abdominal mass and features of virilization along with elevated serum testosterone levels. Fertility sparing unilateral salpingo-oophorectomy was done and adjuvant chemotherapy was given after histopathology showed moderate to poorly differentiated Sertoli-Leydig cell tumor. Following surgery, her features of hyperandrogenism resolved and serum testosterone levels returned to normal.
Recurrent Positivity of SARS-CoV-2 RNA in a Clinically Recovered COVID-19 Patient with End Stage Renal Disease: A Case Report
(Nepal Medical Association, 2020) Nepal, Richa; Sapkota, Kalyan; Gurung, Santosh; Paudel, Pramod; Neupane, Prateek; Sah, Kamlesh Kumar
Abstract: Recurrent or persistent positivity of SARS-CoV-2 RNA in clinically recovered COVID-19 patients have been reported worldwide. However, replication competent live viruses were not recovered beyond two to three weeks from onset of symptoms in mild to severe cases of COVID-19. End stage renal disease is characterized by uremia induced immune dysfunction that increases the risk of infectious diseases including COVID-19. The clinical implications of recurrent or persistently positive SARS-CoV-2 RNA in immunocompromised patients are difficult to be generalized to findings as in immunocompetent patients. We report a case of end stage renal disease with recent history of recovered COVID-19 pneumonia, who again presented with positive reverse transcriptase- polymerase chain reaction (RT-PCR) test for SARS-CoV-2 RNA.
Recurrent Sacral Chordoma: A Case Report
(Nepal Medical Association, 2020) Shrestha, Abhash; Nakarmi, Prami; Vaidya, Animesh; Raut, Sumit; Rajbhandari, Binod; Sharma, Mohan Raj
Abstract: Chordoma is a rare and locally aggressive tumor that arises from the notochordal remnants and has an incidence of 0.1/100000 per year. It has a predilection for the axial skeleton and is the most common primary malignant tumor of sacrum. The mainstay of treatment is wide surgical excision but there is a risk of recurrence due to the infiltrating nature of the tumor. Here, we report a case of a 56-years male who complained of pain over his sacral region for the past two years along with episodic urinary symptoms, constipation, and weakness of both legs. Seven years after undergoing surgery and radiotherapy for his sacral chordoma, he was diagnosed with recurrent sacral chordoma and planned for reoperation. Subtotal excision of the chordoma was done which significantly alleviated his symptoms postoperatively. Timely intervention helps to improve the quality of life in patients with either primary or recurrent sacral chordomas.
Normal Anatomy and Variants of Renal Vasculature with Multidetector Computed Tomography in a Tertiary Care Hospital: A Descriptive Cross-sectional Study
(Nepal Medical Association, 2020) Regmi, Pradeep Raj; Amatya, Isha; Kayastha, Prakash; Paudel, Sharma; Suwal, Sundar; Ghimire, Ram Kumar
Abstract: Introduction: Variation in renal vasculature is quite common and has important implication in surgical planning. Computed tomography has high accuracy in evaluation of renal vasculature. The study was done to estimate the prevalence and pattern of variations of renal vasculature through contrast-enhanced computed tomography in a tertiary care hospital. Methods: A descriptive cross-sectional study was conducted from 6th April 2016 to 6th April 2017. Ethical approval was taken from Institutional Review Board, Institute of Medicine (reference number 325). Contrast-enhanced computed tomography was performed on 188 patients enrolled through convenient sampling and variations of renal vasculature were evaluated. Data were analyzed based on the types of variations and descriptive statistics such as frequency and percentage using Statistical Package for the Social Sciences, version 16. Results: Out of the 188 patients, 60 (31.9%) had accessory renal arteries. The most common variant was hilar artery comprising 38 (20.2%) cases whereas polar artery was present in 21(11.1%) cases and the capsular artery was present in one (0.5%) case. Eleven (5.8%) cases had single and five (2.6%) had multiple accessory polar arteries. Single and unilateral hilar artery was present in 28 (14.8%) whereas multiple accessory hilar arteries were present in two (1.1%) cases. Early bifurcation of the renal artery was noted in 15 (7.9%) cases. Double right renal vein was the most common venous variant seen in 12 (6.3%) cases. Retroaortic left renal vein was noted in four (2.1%) cases. Conclusions: Significant patients undergoing computed tomography examination had renal vascular variations. Therefore, Computed Tomography plays key role as a noninvasive method for anatomic evaluation of renal vascular variants.
Knowledge of COVID-19 among Health Care Workers at a Tertiary Care Hospital of Nepal: A Descriptive Cross-sectional Study
(Nepal Medical Association, 2020) Bhandari, Sandip; Sharma, Medha; Shrestha, Gentle Sundar
Abstract: Introduction: Health care workers are at higher risk of infection with the coronavirus disease as they are directly involved in the treatment of infected patients and perform aerosol-generating procedures. Proper knowledge of this disease can influence the positive attitude, good practices and enhance their safety. We aim to study the knowledge of COVID-19 among health care workers of the tertiary care hospital of Nepal. Methods: A descriptive cross-sectional study was conducted among health care workers of Shahid Gangalal National Heart Centre from May 20 to June 19, 2020. Ethical approval was taken from the Institutional Review Board (IRB No: 4-2020). Written informed consent was taken from all respondents. Correct answers were summated to reflect the mean knowledge, expressed as a percentage. Data analysis was done using Statistical Package for the Social Sciences version 21. Results: The mean general knowledge score was 95.7%. The mean medical knowledge score was 70.5%. Only 42 (56.8%) of physicians and 103 (53.6%) of nurses had a higher level of medical knowledge regarding COVID-19. Likewise, very few lab technicians 7 (21.9%) and none of the pharmacists had a higher level of medical knowledge. Conclusions: The healthcare workers of this centre have adequate knowledge regarding COVID-19. However, periodic training for all workers, especially the nurses and allied workers, may help to update the knowledge and hence enhance their safety and that of their patients.
Professional Quality of Life among Medical Doctors Working in Kathmandu: A Descriptive Cross-sectional Study
(Nepal Medical Association, 2020) Vaidya, Anju; Karki, Shristi; Dhimal, Meghnath; Gyanwali, Pradip; Baral, Dibash; Pandey, Ashok; Jha, Anjani Kumar
Abstract: Introduction: The practice of medicine is an honorable profession besides being accompanied by a demanding environment. This study aimed to find out the professional quality of life of medical doctors working in Kathmandu valley. Methods: A descriptive cross-sectional study was conducted among 174 Nepalese medical doctors working in different hospitals of Kathmandu valley. Ethical approval was taken from the Ethical Review Board of the Nepal Health Research Council (Reference Number: 830). The data collection tool used in the study was WHO Professional Quality of Life Scale-5 to collect data about Compassion satisfaction, Burnout and Secondary traumatic stress among medical doctors working in Kathmandu valley. Data analysis was done in the Statistical Package for the Social Sciences version 16.0. Results: Out of 174 participants, 101 (58%), 126 (72.4%) and 135 (77.6%) were found to have moderate level of Compassion satisfaction, Burnout and Secondary Traumatic Stress respectively. Conclusions: More than half, nearly two-third, and more than two-third participants had moderate levels of Compassion satisfaction, Burnout and Secondary Traumatic Stress respectively. The overall study findings reflected good balance between Compassion satisfaction and Compassion fatigue (burnout and secondary traumatic stress) among the Nepalese medical doctors. Further assessment of professional quality of life of doctors as well as other health care workers via Multifaceted and large-scale study is recommended.
Unusual Giant Syringomyelia with Neurocutaneous Melanosis
(Nepal Paediatric Society (JNPS), 2014) Shrestha, R; Cohen, AR
Abstract: A two year old male presented with feeding intolerance and lethargy. Mother had normal delivery with term baby. The patient denied previous trauma or recent weight loss. Physical examination revealed neurocutaneous melanosis (NCM) over lower back side of body and no signs of peripheral motor deficit or abnormal reflexes. Hematological investigations showed no abnormality. Magnetic resonance (MR) imaging found a large, cystic cavity that was eccentric in the cervicothoracic spine extending from C3 to L1. Suboccipital decompressive craniectomy, bilateral C1 laminectomy, and occipital duraplasty were done.
Outbreak of bloodstream infection with extendedspectrum ß-lactamase-producing Klebsiella pneumoniae at a Teaching Hospital
(Nepal Paediatric Society (JNPS), 2014) Senanayake, NP; Karunanayake, L
Abstract: Introduction: Klebsiella pneumoniae (K. pneumoniae) is an important hospital-acquired pathogen causing severe infections in neonatal units. Several outbreaks of infection caused by multi-drug-resistant K. pneumoniae isolates have been widely reported among neonates. The aim is to investigate an outbreak of blood stream infection caused by Extended-Spectrum ß-Lactamases (ESBL) producing K.pneumoniae in a Neonatal Intensive Care Unit (NICU) at Teaching Hospital Kandy, Sri Lanka. Materials and Methods: Blood culture samples were collected from the neonates on admission to the NICU and 2 to 3 days later on clinical suspicion of blood stream infection. The blood culture samples were processed according to the standard methods and the antibiotic susceptibility tests were carried out as per Clinical Laboratory Standards Institute (CLSI) guidelines. Results: Of the 140 blood cultures 36 were identified as Extended-Spectrum ß-Lactamases (ESBL) producing K.pneumoniae. All the isolates were susceptible to ciprofloxacin, amikacin, netilmicin, imipenem and meropenem. Twenty eight of the 36 patients responded to treatment with a combination of amikacin and meropenem. Conclusion: ESBL producing K.pneumoniae was responsible for this outbreak at the NICU. Knowing the susceptibility patterns of clinical isolates will allow the rational use of antibiotics, which is important in the treatment of infections with multi-drugresistant bacteria.
Study of Antibiotic Susceptibility among Bacterial Isolates in Neonatal Intensive Care Unit of a Tertiary Care Hospital: A Descriptive Cross-sectional Study
(Nepal Medical Association, 2020) Chaudhary, Brajesh Raj; Malla, Kalpana Karmacharya; Poudel, Sajan; Jha, Brajesh Kumar
Abstract: Introduction: Neonatal sepsis is a major cause of neonatal morbidity and mortality worldwide, especially in developing countries like Nepal. Antibiotic resistance among microorganisms poses new challenges in the treatment of neonatal sepsis. The present study is conducted with the objectives of determining clinico-bacteriological profile and antibiotic susceptibility among isolated bacteria in a neonatal intensive care unit. Methods: A descriptive cross-sectional study was conducted from January 1, 2017, to December 31, 2019, in the neonatal intensive care unit of a tertiary care hospital after obtaining ethical clearance from Institutional Review Committee (Reference Number: 2020-064). The sample size was calculated and 77 neonates with culture-proven sepsis were included in the study. The antibiotic susceptibility tests of the isolates were done by Kirby-Bauer disc diffusion method. Data entry was done in Statistical Packages for the Social Sciences version 20. Results: Of the 841 specimens (blood, cerebrospinal fluid, urine, tracheal aspirate and pus) processed for culture, bacteria were isolated in 84 (10.0%) specimens. Among the 84, gram-negative bacilli were the predominant isolates 76 (90.5%); of which Acinetobacter baumannii was the most common 27 (32.1%). Both the Gram-negative and the Gram-positive bacteria showed high resistance to Penicillin and Cephalosporins. Gram-negative bacteria showed maximum sensitivity to Colistin, Carbapenems, Tigecycline and Fluoroquinolones. Gram-positive bacteria showed maximum susceptibility to Amikacin, Vancomycin and Carbapenems. Conclusions: Judicious use of antibiotics based on the updated knowledge of prevalent organisms in the local hospital setting and their antibiotic sensitivity pattern is of utmost importance for the effective treatment of neonatal sepsis.

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