Showing papers in "Kathmandu University Medical Journal in 2005"

Honey--a remedy rediscovered and its therapeutic utility.

Abstract: Honey is a common household product with many medicinal uses described in traditional medicine. Modern system of medicine is also finding the honey efficacious in various medical and surgical conditions. Antimicrobial, antioxidant and wound healing properties of honey are being evaluated with successful outcome. Prevention and treatment of various infections due to a wide variety of organisms and promoting surgical wound healing are some of the areas where honey is making its mark.

Intensive care unit drug utilization in a teaching hospital in Nepal.

Abstract: Objectives: The intensive care unit (ICU) is a setting where a large number of drugs are administered to patients and the costs of hospitalizati on and drug treatment are high. Information on drug utilization in intensive care units (ICUs) are lacking in western Nepal. The present study was carried out to obtain information on the basic demographic pattern of the respondents , drug utilization during the study period, the antibiotic sensitivity patterns of isolated microorganisms and measure drug consumption in define d daily dose (DDD)/ 100 bed-days. Methods: A retrospective analysis of patients admitted to the ICU of the Manipal Teaching hospital, Pokhara, Nepal during the time period from 01/02/2002 to 31/05/2002 was carried out. The ICU mortality rate, length of sta y greater than 7 days and median length of stay were calculated. Results: A total of 259 individuals were admitted. The ICU mortality rate was 15.4%; median length of stay was 4 days. E.coli, H.influenzae, K.pneumoniae, S.aureus and P.aeruginosa were the common organisms isolated and were found to be resistant to some of the commonly used antibiotics. Mean ± SD number of drugs and cost of drugs were 5.1 ± 2.7 and 1958.5 ± 1267.8 Nepalese rupees (25.1 ± 16.2 US$). Total drug consumption was 356.4 DDD/100 bed-days. Consumption of intravenous fluids was 25.8 litres/100 bed-days. Conclusions: An antibiotic use policy should be framed. Formation of a multidisciplinary team to oversee drug use and periodically review microbial sensitivity patterns will be helpful . Longitudinal surveillance of ICU drug use should be carried out.

A study of sensitivity and resistance of pathogenic micro organisms causing UTI in Kathmandu valley.

Abstract: A retrospective study was conducted in five hospitals to observe the prevalence of organisms causing UTI and their sensitivity to antibiotics. Methodology: Altogether, data from five hundred samples of urine from five hospitals in Kathmandu was collected for this study from January 2005 to April 2005. Result: A total of 244 samples were found to be positive. Altogether six types of organisms were isolated as the causative factors. E. coli (49%), S. aureus, (coagulase positive) (23%), Proteus species (3.6%), Klebsiella (9.71%), Pseudomonas (0.8%) and Citrobacter (2.8%). Analysis of the samples showed that UTI was more common in females of younger age group as comp ared to males. The common age group for females was 21-30 years, whereas that for males was 31-40 years in all the hospitals except in hospital A, where the maximum number of females was from 31-40 years and males were between 71-80 years. The most common organism to cause UTI was found to be E. co li (49%), followed by S. aureus (23%) and Klebsiella (9.71%). All the organisms causing UTI were sensitive to nitrofurantoin and amoxycillin and ciprofloxacin was found to be least effective. Similarly, in three hospitals, B (88.2%), D (64.7%) and E (65.3%), amoxycillin was found to be most effective, amikacin and gentamycin (92.5%) was most effective in hospital C, and nitrofurantoin in hospital A (78%). The second commonest organism, i.e., S. aureus (23%) was most sensitive to cephalosporin (88.8%) of second generation, followed by nitrofurantoin (77.7%), amikacin (80.6%) and norfloxacin (65.5%). The third common organism, Klebsiella (9.71%) was most sensitive to norfloxacin (75%) and nitrofurantoin (75%). Lastly, Pseudomonas was resistant to all the antibiotics in hospital A, D and E, nil in hospital B and sensitive to amikacin (100%) in hospital C.

Anatomic variations of foramen ovale.

Abstract: Objectives Foramen ovale is of great surgical and diagnostic importance in procedures like percutaneous trigeminal rhizotomy for trigeminal neuralgia, transfacial fine needle aspiration technique in perineural spread of tumour and electroencephalographic analysis for seizure. This study presents the anatomic variations in dimensions, appearance and number of foramen ovale. Methods We studied 35 dried human skulls available in the Department of Anatomy, Manipal college of Medical Sciences, Pokhara, Nepal. Variations in appearance and number of foramen ovale were noted. Length and width of foramen ovale was measured. Comparison with other races and differences between right and left sides were also discussed. Results Out of 70 sides in 35 adult skulls, mean length and width of foramen ovale was 7.46+/-1.41 mm and 3.21+/-1.02 mm on right side and 7.01+/-1.41 mm and 3.29+/-0.85 mm on left side. Shape of foramen ovale was typically oval in 43, (22 on right, 21 on left) almond shape in 24 (Fig.1, arrowhead; 11 right, 13 left), round in 2(1 right, 1 left) and slit-like in 1(Fig.1, arrow). Bilateral oval foramen was observed in 15 and bilateral almond was in 7. Out of 70 sides in 35 adult skulls 3 (2 left, 1 right) sides had spine on the margin of the foramen (Fig.2, arrow), 3 (2 left, 1 right) had tubercle protruding from the margin (Fig. 3, arrow), 2 (1 left, 1 right) sides had bridge like bony spur dividing the foramen into two compartments(Fig. 2, arrowhead), 9 (5 left, 4 right) had bony plate on the margin of foramen ovale (Fig. 4, arrow). Variant foramen ovale was observed in 24.2%. Conclusion Anatomical variations in size and shape of foramen ovale could be explained by developmental reasons. Considering the immense surgical and diagnostic importance of foramen ovale, this study was worthwhile.

Trends of acute poisoning in south Karnataka

Abstract: Background: In recent times poisoning with agricultural chemicals either accidental or suicidal has become common due to easy availability and low cost. So it has become essential to find out the burden of poisoning to the victims, family and to hospital and morbidity and mortality among the victims. Aims: To determine the trends of poisoning along with various parameters such as mode of poisoning, type of poison used, outcome of the poisoning, the most vulnerable age group, occupation of the victim, and the marital status. Method: A 5 year retrospective study in which all the patients of acute poisoning admitted to Govt. Wenlock Hospital, Mangalore during the period from 1 st Jan 1999 to 31 st December 2003 were included. A total of 546 cases were admitted due to acute pois oning during the study period. Results: Three hundred and eighty (69.6%) males and one hundred and sixty six (30.4%) females were admitted to the hospital due to poisoning. Organophosphates were the most commonly used suicidal poison irrespective of age, sex and occupation of the victim. There were two hundred and thirty five cases of male suicidal poisoning and one hundred and twenty six female cases of suicidal poisoning. Majority of poisoning cases were seen in manual labourers. The increasing trend of poisoning was observed for the period of 1999 to 2003 except for the year of 2003. Conclusion: The study highlights about the problem of poisoning in the region. Since the majority of the victims of the poisoning are from low socio economic status. There is economic burden on the family members of the victim of poisoning as the earning member of the family becomes ill (for treatment), dies (loss of earning member) and also emotional setback and disturbance.

A study of poisoning cases in emergency Kathmandu Medical College Teaching Hospital.

Abstract: Objective: - To determine the pattern and severity of poisoning cases in emergency Kathmandu Medical College Teaching Hospital. Design: - Retrospective observational study. Materials and Methods: - All the poisoning cases due to various agents who attended Emergency from 1 st of April

Two faces of major lower limb amputations.

Abstract: Objectives: To review the indications for major lower limb amputations in adults and children in our patient population and to compare our experience in prosthetic rehabilitation with that of other published information. Material and Methods: We retropectively reviewed charts of patients who underwent amputation between 1997 to 2004 at the Orthopaedic Department of B& B Hospital (BBH ) , Gwarko and Hospital and Rehabilitation center for Disabled Children ( HRDC), Banepa. There were 113 patients at BBH & 89 patients at HRDC . Major amputation was defined as any amputation at or proximal to wrist and ankle. Results: Major lower limb amputations constituted 73.58 %(39/53) of all major amputations at BBH and 97.77% (44/45) at HRDC.Road traffic accident was found to be number one cause for major lower limb amputations (74.29%) in adult population. In children postburn contracture was the leading cause for amputation (29.54 %) folowed by Congenital limb conditions (22.72%) ,Spina bifida with trophic ulcers ( 20.45 %), Tumor (13.63%), Chronic Osteomyelitis (6.81%), Trauma (4.54%) and Arthrogryposis (2.27%). Prosthetic fitting and rehabilitation is as yet far from satisfactory in the adult population but all the children who had amputation at HRDC were fitted with prosthesis. Conclusion: Main causes of major lower limb amputation in both population is largely preventable by instituting safty measures and conducting awareness program. There is a need for an effective prosthetic fitting center for adults.

Correlation of cervical cytology with cervical histology.

Abstract: Objective: To correlate cervical cytology with Cervical histology. Methodology: A hospital based prospective study was carried out in consecutive total forty-three patient attending oncology clinic of Kathmandu Medical College Teaching Hospital, Sinamangal, Nepal from 1 st Bhadra 2061 to end of Falgun 2061 (18 th in terms of their age, parity, age at marriage, age at 1 st child birth, smoking habit, contraceptive use, and symptom of vaginal discharge was taken. Reports of Pap smear and cervical biopsy of these patients were collected from oncology clinic during their follow up visit and all these information and finding were entered in structured questionnaire. The reporting of Pap smear was done in Bethesda system. The average duration between performing Pap smear and biopsy was of one month. Statistical analysis was carried out by EPI - INFOS6 system. Result: Of forty three patients who underwent cervical cytology 22 cases were of Benign lesion, 8 cases of LSIL, 9 cases of HSIL, 3 cases of invasive carcinoma and 1 of ASCUS. Sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy and p-value in benign grade was 76%, 83.3%, 86.4%, 71.4%, 79.1%, 0.0004 respectively. Similarly sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy and p-value in LSIL was 60%, 93.9%, 75%, 88.6%, 86%,0 .0008 respectively. For HSIL it was 100%, 89.5%, 55.6%, 100%, 90.7 0.0001 respectively. Respectively for carcinoma it was 100% for sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy p-value was0 .00008. Conclusion: Pap smear significantly correlated with cervical histology.

Cephalic index of Gurung community of Nepal--an anthropometric study.

Abstract: Cephalic Index (CI) is useful in differentiation of racial and sexual differences. There is no published literature about CI of Gurung community in Nepal. Hence, we under took this study to document the cephalometric characteristics and gender differences in CI of a Gurung community. Head length, head breadth and CI were determined for 267 subjects of Gurung village. The mean CI for male was 83.1 and for female 84.6 which was statistically significant. On comparison with the existing literature the Gurung community can be categorized as brachycephalic and the data presented can be useful for experts in forensic science.

An outbreak of El Tor cholera in Kavre district, Nepal.

Abstract: Outbreak of cholera still remains major public health problem in most of the developing countries including Nepal. A prospective study was carried out at Dhulikhel Hospital, Kathmandu University Teaching Hospital, Kavrepalanchok during 1st May 2004 to 31st October 2004. A total of 148 stool samples from patients with acute diarrhea were collected and further investigated for cholera. The study was conducted to establish the causes of the outbreak of acute diarrheal disease, antimicrobial profiles of the stool isolates and parasitic co-infection in cholera cases. The samples were subjected to standard recommended microbial procedures and confirmation of the isolates was done by seroagglutination using V.cholerae polyvalent O1 and 0139 antisera and monovalent Ogawa and Inaba antisera. Out of the 148 stool samples, 46 cases (31%) were found to be positive for V.cholerae serogroup O1, biotype ElTor, serotype Ogawa. Both sexes were equally affected. Young age group of less than 30 years were mostly affected. Brahmin was the most affected ethnic group. The isolates were sensitive to all the antibiotics tested except co-trimoxazole. Among the laboratory confirmed cholera cases 30% exhibited co-infection with other parasites among which Giardia lamblia and Ascaris lumbricoides were the most common.

HIV/AIDS and STI related knowledge, attitude and practice among high school students in Kathmandu valley.

Abstract: Objective: To assess the knowledge, attitude and practice of high school students regarding HIV/ AIDS and STI and to determine if a school education programme would bring about statistically significant positive change in the knowledge, attitude and practice regarding HIV/AIDS and STI. Methods: The study was conducted among 1012 students of various schools in Kathmandu Valley (Kathmandu, Bhaktapur and Lalitpur). The tool for assessment was confidentially administered closed questionnaire both before and after the education programme of 45 minutes single class, standardized education package. Results: Knowledge on some aspect of the disease was quite low in the study group. 45.8% had prior knowledge of HIV, 65.2% knew that HIV/AIDS could be transmitted by sharing same needle, 46.2% knew that vaccine is not yet available for HIV/AIDS. Knowledge about STI was also quite low, 41.5% knew that pus in the urine is a symptom of STI and 41.7% knew that STI is curable. 4.2% of the study group had previous sexual intercourse, 64.2% had sexual intercourse with friend and 35.17% had sexual intercourse with commercial sex workers. 1.8% would commit suicide if they contracted HIV/AIDS. According to sex wise distribution of the sample, female’s knowledge about HIV was low 43.2% as compared to male 48%, male’s knowledge about transmission of HIV/AIDS from pregnant mother to child was low; 89.7% as compared to female’s knowledge 94.2%. Female’s knowledge about commercial sex worker as high risk group was low (87.8%) as compared to male’s knowledge 90.6%.

Antimicrobial utilization pattern in out patient services of ENT department of tertiary care hospital of Eastern Nepal.

Abstract: Objective The objective of this study was to monitor the antimicrobial utilization in ENT out patient services in a tertiary care hospital of Nepal. Materials & Methods A total of 191 prescriptions were randomly audited at varying time interval from the department of ENT in the year2003. The data was collected in customized Performa in the form of antibacterial audit questionnaires. It also contained Patient particulars, diagnosis, investigations, drug details and information from the prescriber regarding the indication for prescribing antimicrobial agent, suspecting organism underlying infection, duration of therapy and details of any concomitant medications. Results The incidence of use of antimicrobial agents (AMA) in 191 prescriptions was analyzed from the enrolled prescriptions, a total of 218 antimicrobials i.e.1.4 antimicrobial agent per patient were prescribed. .The AMAs were indicated therapeutically in 73.29% of patients & 19.37% patients for prophylaxis. The AMAs were advised for more than 72 hours for prophylaxis in 86.48%. In the concomitant medications antihistaminic were prescribed in 32.62% and NSAIDS in 21.98% cases. Most of patients reported with upper respiratory tract infections (URTI32.56%), Chronic Suppurative otitis Media (CSOM-18.3%), sinusitis (6.28%), tonsillitis (5.75%),. Pharyngitis (3.66%), Acute Suppurative Otitis Media (ASOM-2.61%) and others. The diagnosis was established clinically in 42.40% and confirmative in 35.60%. In 21.46% the diagnosis was not disclosed. Out of 191 patients, culture sensitivity tests were performed for only 31 patients and 13 patients depicted a positive culture sensitivity tests. The common microbes isolated from the culture were staphylococcus aureus (69.2%). Streptococcus (7.7%), Enterobacteriacae (7.7%), Pseudomonas auroginosa (7.7%) & psendomanas mirabilis (7.7%). Clinically suspected organism were mentioned in only 32 prescriptions and most prescriber presumed the infections due to staphylococci & pseudomonas (43.75%), streptococci (21.8%),Gram negative organisms (12.5%) and H influenza (9.3%).The use of a single drug was abundant (89.52%), two drugs (9.94%), and three drugs (0.52% )prescriptions. Ciprofloxacin (23.85%) was preferred, followed by amoxycillin (20.06%), combination of ampicillin + cloxacillin( 9.17%), doxycyclin (5.96%). Erythromycin (4.58%) and cotimoxazole (4.58%). Expensive drugs i.e azithromycin (2.75%), roxithromycin (1.37%) and cephalosporins (3.21%) were also prescribed. The causative microbes were sensitive to amoxycillin (53.84%), cloxacillin (53.84%) ciprofloxacin (46.15%), gentamicin (46.15%), and cephalosporin (46.15%). But resistant to erythromycin, tetracycline, cotrimoxazole and norfloxacin) Conclusions-Majority of patients were prescribed drugs irrationally with misleading indications without confirming the bacteriological culture and sensitivity.

Situation of antenatal care and delivery practices.

Abstract: Objectives: The study aims to assess the situation of antenatal care usage and delivery practices in the study area. (i) To study the coverage rate for ANC and hospital delivery in different age group, parity, educational status and economic status. (ii)To study the relation of ANC visit and hospital delivery. Materials and method: The study design is descriptive cross sectional study. The study was carried out in ward no. 9 of Mahankal VDC, Kathmandu. 50 women of reproductive age group who had delivered live birth five years preceding the survey were selected. A semistructured questionnaire was administered through informal interview. For the women with more than one child, the information was gathered for the last birth. The data were analyzed through the SPSS software. Results: Antenatal visit was a success story. Seventy eight percent of women were using the services. More notable fact was that the 62% of the respondents made antenatal visits for four or more than four times. Seventy two percent of the respondents y received the tetanus toxoid shots. Sixty six percent of the deliveries were hospital deliveries assisted by the doctors. However, 34% of deliveries occurred at home. The difference in ANC visit in different age groups and parity was not much obvious. The educational effect was clear as nearly double women who attained SLC or above, made four or more ANC visit as compared to illiterates. ANC seen as pathway to the institutional deliveries, once again proved its potential. Around 90% of women who made four or more ANC visits delivered in hospital as compared to 18.18% of women who never made any ANC visit. Conclusion: The rate of antenatal care use and hospital deliveries in the study area is found good in percentage. The rapid urbanization is taking place in nearby VDCs of Kathmandu. The hospitals in the Kathmandu are accessible to these VDCs. This could be the reason behind increased antenatal care usage and hospital delivery in the study area.

Dose-dependent effect of copper chloride on male reproductive function in immature rats

Abstract: Background: Copper is essential as a trace element for metabolic processes. Exposure to copper in industries develops toxicity among the workers. Previous findings on adverse effects of copper on male reproductive function in adult albino rats led to investigate the effects of this metal on reproductive function of maturing male rats in the present experiment. Methodology: To study these effects, immature (30 to 35 days old) Wistar strain albino rats weighing about 50-60 g were treated intraperitoneally with copper chloride at doses of 1000, 2000 and 3000 µg/kg body weight/day for 26 days. Result: Significant fall in accessory sex organ weight and inhibition of testicular 17β-hydroxysteroid dehydrogenase activity along with degeneration of testicular growing spermatogenic cells and reduction in serum testosterone, FSH and LH level were observed at the doses of 2000 and 3000µg/kg/day. On the other hand, at the dose of 1000 µg/kg/day significant increase in testicular steroidogenic enzyme activity and stimulation of testicular spermatogenesis along with rise in serum testosterone and LH level were observed, though no significant change was observed in serum FSH level. This suggests that copper has got a dose-dependent effect on testicular steroidogenesis and spermatogenesis and serum testosterone and LH level in maturing male rats.

Ectopic pregnancy - two years review from BPKIHS, Nepal.

Abstract: Ectopic pregnancy remains an important cause of morbidity and mortality in early pregnancy. The incidence has increased worldwide with an increase in pelvic infections and improvements in the diagnostic techniques. The objective of this study was to analyse the various aspects of ectopic pregnancy with a view to suggest interventions which would decrease the incidence. Material and methods: The study was carried out in the department of Obstetrics and Gynaecology, B.P Koirala Institute of Health Sciences, Dharan (Nepal). Data were analysed retrospectively using the case sheets and operative notes from the past two years (April 02-April 04). The gynaecological admissions and records of the total births within the period of study were also used in the analysis. Result: The incidence of ectopic pregnancy during this study period was 0.93 of total births and 2.92% of the total gynaecological admissions. The peak age of incidence was in the range of 26-30 years. Majority of patients were in the lower socioeconomic group. Pelvic inflammatory disease and induced abortions were the major risk factors. Their contribution was 61.3% and 38.6% respectively. 70.6% of patients did not use any contraception. 16% used depo provera. Abdominal pain (69.3%), vaginal bleeding (45.3%) and syncopal attacks (21.3%) were the most frequent presenting complaints. 58.6% had amenorrhea of 6-10 weeks. Only 1.3% presented with amenorrhea of greater than 10 weeks. Ampulla (62.6%) followed by isthmus (21.3) were the commonest sites of ectopic implantation. Ovarian and abdominal pregnancies contributed to only 1.3% each. There was no significant difference between the side of the tube involved.82.6% had come with ruptured ectopic but only 12% were in shock. Majority of patients underwent salpingectomy (69.3%) followed by salpingo-oophorectomy (17.3%). Only 2.6% received methotrexate. 70.6% required blood transfusion. Conclusion: Majority of patients attending BPKIHS for ectopic pregnancy were between 26-30 years and had history of PID & induced abortions. Surgery (salpingectomy/salpingo-oophorectomy) was the main stay of treatment.

Anatomic characteristics of foramen vesalius.

Abstract: OBJECTIVES Foramen Vesalius is an inconstant foramen that gives passage to an emissary vein that connects pterygoid venous plexus with cavernous sinus, the importance of which lies in the fact that an infected thrombus from an extracranial source may reach cavernous sinus. This study presents some data on characteristics of foramen vesalius. METHODS We studied 70 sides of 35 dried adult human skulls available in the Department of Anatomy, Manipal College of Medical Sciences, Pokhara, Nepal. Variation in number and incidence of foramen Vesalius were noted. Differences between the right and the left side and between the male and the female sex are discussed. MAIN FINDINGS Foramen Vesalius was present in 23 sides (14 right, 9 left) out of the 70 sides observed, the incidence being 32.85% (20.0% right side, 12.85% left side) of all the sides observed. Incidence of bilateral and unilateral foramen vesalius was 22.85% (8 out of 35 skulls) and 20% (7 out of 35 skulls) respectively. Foramen vesalius was found in 10 sides in males and in 13 sides in females. No remarkable differences were observed in the incidence of foramen vesalius between the sides within same sex but the incidence was more in females compared to male skulls. SIGNIFICANCE OF FINDINGS: Anatomic variations of the foramen vesalius could be explained by developmental reasons. Knowledge about characteristics of foramen vesalius and its incidence is not only important for anatomists but equally essential for an operating surgeon.

Lipid peroxidation and antioxidant enzyme status in oral carcinoma patients.

Abstract: Objective: To measure the lipid peroxidation and endogenous antioxidant enzyme status in oral carcinoma and the protective role of exogenous antioxidants. Meterial and methods: 20 new cases of histologically proven oral squamous cell carcinoma, 20 of leukoplakia and 20 age and sex matched healthy conrols were included. Intra oral pH of patients and controlled were measured by quantitative litmus paper test and serum was analysed for malonialdehyde (MDA), super oxide bismutase (SOD), catalase and glutathione peroxidase (GP). Patients with leukoplakia were treated with exogenous antioxidants for 3 months and the same were reassessed. Results: Oral pH of oral cancer patients was neutral (PH-7) but that of leukoplakia and controls were mildly acidic (6.64 and 6.58 respectively). Serum malonialdehyde levels were highest in oral cancer group. With antioxidant enzymes super oxide bismutase, catalase and glutathione peroxidase different pattern was noticed. Antioxidant enzymes remained almost the same (P > 0.005 each) in patients with leukoplakia after 3 months of vitamin A,C and E. but there was marginal increase in catalase level (P<0.05). Conclusion: This study shows the positive benefit of vitamin (A,C,E) and nutrition supplementation on the antioxidant enzyme defense system hence prevention of oral carcinogenesis in patients with leukoplakia.

Correlation between serum-ascites albumin concentration gradient and endoscopic parameters of portal hypertension.

Abstract: Objective: We sought to determine the correlation between the level of serum-ascites albumin concentration gradient (SAAG) and the complications of portal hypertension (PHTN), manifested by the presence and grade of esophageal varices (EV). Material and methods: Our study included 32 patients with ascites, demonstrated by ultrasonography, who had measurement of the SAAG. All had upper gastrointestinal endoscopy with assessment of the presence and size of EV. High SAAG was considered to be present when SAAG was >= 1.1 g/dl and Low SAAG when it measured = 2.0g/dl (p = 0.037). The size of the esophageal varices had no association with the level of SAAG in patients with High SAAG (p = 0.426). Conclusions: In patients with ascites the presence of esophageal varices is associated only with patients with High SAAG. The presence of EV in patients with ascites and High SAAG is directly related to the degree of SAAG. The size of the EV in patients with ascites and High SAAG is not associated with the degree of SAAG.

Ocular side effects of antitubercular drugs - a focus on prevention, early detection and management

Abstract: Given the increasing prevalence of tuberculosis, antitubercular drugs frequently used are also associated with ocular toxicity. Ethambutol is the most commonly implicated drug. It is generally well tolerated, but known to cause optic neuritis, more specifically retro bulbar neuritis causing blurred vision, decreased visual acuity, central scotomas, and loss of red-green color vision. The exact mechanism of toxicity is not understood. Though optic neuritis due to ethmabutol is generally considered to be reversible upon prompt discontinuation of the drug, there are reports of reversible toxicity, particularly in the elderly population. Isoniazid can rarely cause retro bulbar neuritis. Dose relationship is usually not seen. Streptomycin is known to cause pseudo tumorcerebri. Thiacetazone can produce severe cutaneous reactions including Steven Johnson Syndrome affecting the skin and mucosa including conjunctiva. Educating the patients for early detection of the ocular manifestations and regular follow-ups are very essential.

Attitude of women towards family planning methods and its use--study from a slum of Delhi.

Abstract: BACKGROUND: To predict the need of family planning methods family planning managers often rely on unmet need derived from measure of contraceptive demand. However womens intention and her background knowledge of family planning methods not received as much attention as a measure of family planning methods demand. OBJECTIVE: To know the attitude of women regarding use of family planning methods and to find out the factors that restricts its use and the change in pattern of use over a period of one year. METHODS: This was a prospective study. One (Block G) out of eight blocks was selected randomly. Using convenient sample method families were selected starting from a point in the selected block (Block G). 40 women of childbearing age group (15- 49 years) were enrolled. All women were followed for a period of one year. RESULTS: Weakness was narrated as the commonest side effect from all family planning methods. More than 70% women told that irregular menstruation from Oral Contraceptive pills and ill health from tubectomy as the other side effects. Demands for more children and for son preferences were the leading reason for not using any methods followed by afraid of side effects and health problems. There was negligible change in the use of family planning methods during the period of the study. CONCLUSION: Effective family planning methods use should be advocated through adequate counseling about the correct use side effects and their proper management and their benefit in the back ground of custom and belief.

Accidental out-of-hospital deliveries: factors influencing delay in arrival to maternity hospital.

Abstract: OBJECTIVE: To find out various factors influencing delay in arrival to Shree Panch Ratna Rajya Laxmi Maternity Hospital leading to accidental - out - of hospital delivery. METHODOLOGY: This was a hospital based cross sectional descriptive study conducted at maternity hospital, Kathmandu. Women who delivered on the way to the maternity hospital during the time period- 060/9/1 to 060/12/ 31 (4 months) were interviewed using a structured questionnaire. RESULTS: The prevalence of such deliveries was 45 out of 5703 deliveries i.e. 0.78%. Majority of women (n= 37) who had accidental - out - of hospital delivery were of parity 1-2 group (82.22%), whereas 2 of them were primigravida (4.44%) and 6 of them were of group parity 3-4 (13.33%). Economic factor was not responsible for delay for majority of women as they could arrange money immediately in emergency situation (88.88%) and majority of women had personal money saved for use in emergency (71.11%). Accessibility to the hospital was difficult for few women (21.00%) only as many women lived within the ring road of Kathmandu valley (48.88%) or outside the ring road but within municipality area of Kathmandu valley (31.11%). Only 60% of women could get transport easily during daytime only. Eight of them were late due to delay in getting transport (17.77%), whereas five patients were late due to disturbed / diverted traffic (11.11%). In three cases, transport was not available due to Nepal Bundh and delay was due to time taken to arrange ambulance (6.66%). Majority of women came for antenatal visits (84.44%) and most of them came to maternity hospital for antenatal visits (73.33%). Lack of birth preparedness and inadequate counselling during antenatal visits probably contributed towards many A-O-H (65.78%). More than half of patients were not satisfied with health staff during ANC (63.15%). Many women did not have any discussion about place of birth during ANC (73.68%) and many of them had no discussion even in the family (36.84%). Seven patients had probably precipitate labour (15.55%). 4 patients were returned back home with diagnosis of false labour pain (8.88%) and later on they delivered on the way to the hospital. SUMMARY AND CONCLUSION: Lack of birth preparedness that involves adequate counselling during ANC about symptoms and signs of onset of labour pain and prior decision about place of birth together with delay in getting transport or delay due to diverted traffic were important factors leading to A-O-H. In addition, unusually short duration of labour or dismissing the diagnosis of true onset of labour may have accounted for few cases of A-O-H.

Prevalence of Moraxella catarrhalis infections of the lower respiratory tract in elderly patients.

Abstract: Objectives: To determine: • rate of isolation of Moraxella catarrhalis in elderly patients having lower respiratory tract infection • The antibiotic susceptibility pattern of Moraxella catarrhalis isolates. • The predisposing factors responsible for Moraxella catarrhalis infections of lower respiratory tract. Material and Method: This is a prospective study carried out at Manipal Teaching Hospital, Pokhara during May 2002 to April 2003. A total of 716 sputum samples collected from patients with suspected lower respiratory tract infection were investigated. The samples were subjected to Gram stain, culture and sensitivity. Sputum samples were inoculated on blood and chocolate agar and incubated at 37 0 C for 18 to 24 hours in candle jar containing 3-5% Co2. For the identification of bacterial isolates, the cultural and colonial characteristics were recorded and identified with the use of biochemical test. The susceptibility of bacterial isolates to antimicrobial agent was performed following Kirby-Bauer method. Result: Out of the 716 samples, 355 (49.58%) grew normal commensals of the upper respiratory tract. Respiratory pathogens were recovered from 361 (50.41%) samples. The most common respiratory pathogen was H. influenzae (26. 86%), followed by S. pneumoniae (21.16%). Moraxella catarrhalis accounted for 6.90%. Rate of isolation of Moraxella catarrhalis was higher in males than in females. Out of 25 isolates 16 were from males and 9 were from females. Frequency of isolation of Moraxella catarrhalis was more frequently seen in age group 61-70 years. It was most commonly recovered in winter. The most effective antibiotics were amoxicillin-clavulanate and ceftriaxone and least was ampicillin. Conclusion: Moraxella catarrhalis isolation from sputum especially in persons above 60 years of age and in the absence of other well established pathogens should not be disregarded as they can cause lower respiratory tract infection in these individuals.

Study of clinical profile and antibiotic sensitivity pattern in culture positive typhoid fever cases.

Abstract: Objectives: The present study was designed to analyze the clinical profile and antibiotic sensitivity pattern in the cases of culture positive typhoid fever. Method: The study was conducted over a period of 1year. Total of 46 culture positive cases of Typhoid fever were included in the study. The sensitivity pattern of isolates from blood culture was recorded. The modes of presentation, clinical course, lab investigation reports were also recorded. Results: Out of 46 cases, 33 (71.7%) were males and 13 (28.3%) were females. Average age of presentation was 26.17 years. Fever was present in all patients. Resistance of S .typhi to amoxycillin, chloramphenicol and cotrimoxazole were significantly high. Ciprofloxacin showed resistance in 2 (4.3%) cases. Sensitivity to ceftriaxone was 100% in our study. Conclusion: Typhoid fever is one of the most common health problem in Nepal. Various drugs are being used in the treatment of typhoid fever, in the mean time resistance to many of them are emerging. An appropriate antibiotic has to be initiated only after culture sensitivity in typhoid fever.

Analgesia after inguinal herniotomy in children: combination of simplified (Single Puncture) ilioinguinal and iliohypogastric nerve blocks and wound infiltration vs. caudal block with 0.25% bupivacaine.

Abstract: Objective: To assess whether simplified ilioinguinal and iliohypogastric nerve block in combination with minimal wound infiltration with local anaesthetic is better than caudal block with local anaesthetic alone in children undergoing inguinal herniotomy for easy transition to safe oral analgesia. Subject and Methods: Sixty children of both sexes undergoing herniotomy were allocated randomly to receive either simplified (single puncture) ilioinguinal and iliohypogastric nerve block described by Dalens in combination with small volume wound infiltration with 0.1ml/kg of 0.25% bupivacaine (Group I) or caudal block with 1 ml/kg of 0.25% bupivacaine (Group II) at the end of surgery under general anaesthesia using halothane in oxygen and nitrous oxide mixture. Duration of analgesia, complication associated, parents and children’s satisfaction were compared. Results: The mean duration of analgesia was 253±102.6 minutes in group I as compared to 219.6±48.4 minutes in group II. Six (20%) patients in group I and two (6.67%) patients in group II required parenteral analgesic. Complications and parents and children’s satisfaction were comparable in both the groups. Conclusion: Simplified ilioinguinal and iliohypogastric nerve blocks described by Dalens in combination with small volume local anaesthetic wound infiltration with its longer mean duration of analgesia offers better safety margin to start oral analgesics than caudal block with local anaesthetic alone in children undergoing herniotomy. Larger studies may further confirm the findings.

Rupture of the pregnant uterus--a 20 year review.

Abstract: UNLABELLED Nepal is a land-locked developing country located in between China and India with a population of 2.34 millions. The male: female ratio being 49:51 and very high maternal mortality. (539/100,000 live birth-1996) The geography of the country makes the situation very much divergent and difficult to cater the health services, especially operative procedures in remote places. THE AIMS OF THE STUDY ARE:- 1. To find out the incidence of R.U, distance from where the patients came, age, parity antenatal attendance, type of rupture, type of intervention and foetal outcome. 2. To suggest the concerned authorities to focus their attention to strengthen and expand comprehensive emergency obstetric care service (CEOCS) in remote areas of the country. MATERIAL AND METHOD This is a retrospective study of rupture of pregnant uterus (RU) after 28 weeks of pregnancy for the period of 20 years from 1985 to 2005 A.D. (2042-2061 BS) admitted in the very busy tertiary centre for women (Maternity Hospital, Thapathali, Kathmandu.) with approximately 16000 deliveries and 11% Caesarean section rate per year. Available charts from hospital records of cases of R.U. admitted for the period of 20 years were analysed. During the period, 251 cases of R.U. were admitted. RESULT There were 272245 live births, 25819 Caesarean section, 270 maternal deaths and 11197 perinatal foetal deaths, during the study period. Incidence of rupture of pregnant uterus was (0.09%) 1:1100 live-birth. There were 60% spontaneous, 29% scar rupture and 11% traumatic rupture. Maximum cases were brought from distance of more than 70 kilometres away, between 25-29 years of age, (mean age 28.7), of third and fourth gravida at 36-40 weeks of gestational period with 68% without antenatal attendance. Seventy percent (70%) had complete rupture. Sixty percent (60%) were managed with suture repair with bilateral tubal ligation, 24% had only repair and 15% had hysterectomy. The case mortality of R.U. (n=20) was 7.9%. Two percent (n=5) cases died before intervention due to arrival in moribund condition. Seventy five percent (75%) cases had stillborn babies. Conclusion More cases of RU are coming to the hospital due to better communication and awareness of the people outside the capital, and case- mortality is reduced compared to previous years.

Upper GI endoscopy in children- in an adult suite.

Abstract: UNLABELLED Although Upper GI endoscopy is commonly performed in adults, paediatric endoscopy is not available in many of our referral centres. The efficacy and safety of upper GI endoscopy in paediatric age group performed in adult suite of Kathmandu Medical College is reviewed. PATIENTS AND METHOD A retrospective study of endoscopies performed on children aged up to 15 years in an adult endoscopy suite of Kathmandu medical college over last one year is presented. All cases were the referred cases from paediatric unit for various problems. RESULTS Endoscopy in paediatric group comprises only 6% of total upper GI endoscopies performed during the same year. Sex ratio was almost equal. Most cases (87%) were performed under local anaesthetic and well tolerated by the patients. Recurrent abdominal pain (RAP) was the commonest indication and among them one third of cases had significant positive finding. CONCLUSION Upper GI endoscopy is a useful diagnostic tool in children. Where specialized paediatric endoscopy units are not feasible i.e. developing countries, endoscopic services to children can be safely provided in adult endoscopy suite with or without sedation. Upper GI endoscopy is well tolerated by children even without sedation.

Therapeutic dimensions of ACE inhibitors--a review of literature and clinical trials.

Abstract: In the 1970s, pharmacological therapy interrupting the renin-angiotensin system was considered beneficial for patients with high-renin hypertension. This gave rise to the development of ACE inhibitors. Surprisingly, the ACE inhibitors proved to be effective not only in patients with high renin hypertension, but also in many patients with normal levels of plasma renin activity. At present ACE inhibitors have a significant position in a wide range of chronic illnesses such as atherosclerosis, hypertension, myocardial infarction, diabetic complications, stroke etc. They are combined safely with drugs like angiotensin receptor blockers, calcium channel blockers and thiazides with varying degree of benefits. Though they are safe drugs, patients need monitoring for renal insufficiency, hypotension, hyperkalemia etc. The safety of these drugs in paediatrics patients is not established. It is better to avoid these drugs during pregnancy.

Anthropometric studies on students of the Nepal Medical College: elbow breadth.

Abstract: Background: Body mass index is a valuable tool to assess the nutritional status of an individual. It can be used to identify subjects who are underweight and obese. The present study was conducted with a view to identify the prevalence of underweight and obesity among Nepalese medical students. The study also detects the body frame size of these medical students by elbow breadth measurements. Aim of study: To measure Body mass index and body frame size based on elbow breadth measurements. Materials and Methods: A total of 191 (males, 106) students participated in the study. The ratio of male to female was 1.24:1. The elbow breadth was measured by a vernier caliper (Tajima, Japan) to the nearest 0.1 mm. The body mass index (kg/m 2 ) (BMI) was calculated using the height and weight measurements taken previously 1 . Body frame size was obtained using a table 2 based on elbow width. Data were analyzed using Microsoft excel for Windows 98. Results: The study reveals that the prevalence of underweight and overweight in males of Nepal Medical college Vth batch were 30% and 1% and of IVth batch were 23.2% and 12.15% respectively. Of the females 38.6% and 2.2% of the IVth batch and 36.6% and 4.9% of the Vth batch were underweight and overweight respectively. The body frame size results indicted that 70% of the males and 61% of the females had small body frame. The study revealed a significant degree of under nutrition in male (26.4%) and female (20%) of Nepalese medical students. Conclusion: The present study observed that majority of the medical students of the Nepal Medical College were of small body frame size.