Journal of Nepal Medical Association <p>Journal of Nepal Medical Association is an internationally peer reviewed, MedLine/PubMed indexed,&nbsp;general medical journal of Nepal Medical Association. JNMA is the first and oldest medical journal from Nepal since 1963 AD. JNMA is available at <a href="">PubMed</a>, <a href=";query&quot;%3A%7B&quot;filtered&quot;%3A%7B&quot;filter&quot;%3A%7B&quot;bool&quot;%3A%7B&quot;must&quot;%3A%5B%7B&quot;term&quot;%3A%7B&quot;index.issn.exact&quot;%3A&quot;1815-672X&quot;%7D%7D%2C%7B&quot;term&quot;%3A%7B&quot;_type&quot;%3A&quot;article&quot;%7D%7D%5D%7D%7D%2C&quot;query&quot;%3A%7B&quot;match_all&quot;%3A%7B%7D%7D%7D%7D%2C&quot;from&quot;%3A0%2C&quot;size&quot;%3A100%7D">DOAJ</a>, <a href=";btnG=&amp;hl=en&amp;as_sdt=0%2C5">Google Scholar,</a>&nbsp;Index Copernicus, EBSCO, EMBASS and other repositories.&nbsp;</p> <p>The JNMA abide by:<br>1. 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Committee on Publication Ethics for practising good publication ethics</p> <p>&nbsp;JNMA is included and associated with</p> <p><a href=""><img src="" alt="Member of OASPA" height="75"></a>&nbsp;,<img src="" alt="Search JNMA article in DOAJ">&nbsp;,&nbsp;&nbsp;<a href=";as_epq=&amp;as_oq=&amp;as_eq=&amp;as_occt=any&amp;as_sauthors=&amp;as_publication=jnma&amp;as_ylo=&amp;as_yhi=&amp;hl=en&amp;as_sdt=0%2C5"><img src="" alt="Search JNMA article in Google Scholar" height="75"></a>,<img src="" alt="Member of OASPA" width="121" height="75">,<img src="" alt="" height="75">,</p> <h1><a href=";Full=journal%20of%20nepal%20medical%20association" target="_blank" rel="noopener">Science Citation Index</a></h1> Nepal Medical Association en-US Journal of Nepal Medical Association 0028-2715 <p>JNMA allow to read, download, copy, distribute, print, search, or link to the full texts of its articles and allow readers to use them for any other lawful purpose. The author(s) are allowed to retain publishing rights without restrictions. The JNMA work is licensed under a <a href="" rel="license">Creative Commons Attribution 4.0 International License</a>. More about <a href="">Copyright Policy</a>.</p> Effects of Intrathecal Dexmedetomidine as an Adjuvant to Hyperbaric Bupivacaine for Spinal Anaesthesia in Adults Undergoing Elective Infra-umbilical Surgery <p class="p1"><span class="s1"><strong>Introduction: </strong></span>Various adjuvants to local anaesthetic are used to improve quality and duration of spinal anaesthesia. Dexmedetomidine, a novel alpha-2 adrenergic agonist, has been proposed to augment local anaesthetic effects. This study aims to investigate effects of intrathecal Dexmedetomidine on duration of analgesia and duration of sensory block during spinal anaesthesia.</p> <p class="p1"><span class="s1"><strong>Methods: </strong></span>In this randomized double-blind study 38 patients were allocated into each of two groups. Otherwise healthy patients (18 to 75 years) scheduled for inguinal hernia repair or vaginal hysterectomy were included. For spinal anaesthesia, Group A received 2.5 ml hyperbaric Bupivacaine 0.5%, whereas Group B received five micrograms intrathecal Dexmedetomidine in addition. Characteristics of sensory and motor blocks, duration of analgesia, analgesic requirements, and side effects were studied for 24 hours. Student’s t-test for quantitative variables and Chi- squared test for qualitative variables were used for statistical analysis.</p> <p class="p1"><span class="s1"><strong>Results: </strong></span>Duration of analgesia was prolonged in Group B (326 min ±91) as compared to 217 min ±98 in Group A (P value &lt;0.05). Sensory and motor block durations were significantly prolonged in Group B. Time taken to reach significant peak sensory block level was earlier in Group B. Significant reductions in incidence of visceral pain, shivering and analgesic requirements were observed in Dexmedetomidine group, without increased need of medications for altered hemodynamic parameters.</p> <p class="p1"><span class="s1"><strong>Conclusions: </strong></span>Dexmedetomidineas an intrathecal adjuvant to hyperbaric Bupivacaine in spinal anaesthesia prolongs duration of analgesia and sensory block with minimal adverse effects.</p> <p class="p1"><strong>Keywords:</strong><em> Bupivacaine; Dexmedetomidine; intrathecal adjuvant; spinal anaesthesia. </em></p> Binod Gautam Sujata Niroula Mona Sharma Sushila Moktan Lama ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 379 87 Loading Dose only versus Standard Dose Magnesium Sulfate Seizure Prophylaxis in Severe Pre-eclamptic Women <p><strong>Introduction</strong>: Magnesium sulfate is the drug of choice for prevention of seizures in the pre-eclamptic woman. There is no agreement in the published randomized trials regarding the optimal time to initiate magnesium sulfate, the dose to use (both loading and maintenance) as well as the duration of therapy. The objective of this study is to determine whether magnesium sulfate (MgSO4) prophylaxis is needed for up to 24 hours postpartum in all patients with severe pre-eclampsia for the prevention of seizure.</p> <p><strong>Methods:</strong> It is a randomized controlled trial done on 60 pregnant women with severe preeclampsia randomized into standard dose regimen and loading dose only regimen.</p> <p><strong>Results:</strong> Out of 30 cases in each group 1 (3.3%) patient in standard regimen and 2 (6.7%) patients in loading dose only developed seizure. The occurrence of seizure is not significant statistically. In both regimens there was no maternal mortality. Total of 3 patients needed MICU care and 12 patient developed maternal complications. MgSO4 toxicities were seen only in standard dose regimen that is in 17 (56.7%) of the patients. The median number of IM injections of MgSO4 received in standard dose regimen was 8±2.176. In standard dose regimen 73.3 percent baby were alive whereas in case of loading dose only regimen 93.3 percent of baby were alive after 48 hours of delivery.</p> <p><strong>Conclusions:</strong> Single dose of magnesium sulfate is equally effective as standard dose regimen in terms of seizure prophylaxis in severe pre eclamptic women, with added advantage of reduced maternal toxicity and better neonatal outcome.</p> <p>Keywords:&nbsp; <em>severe preeclampsia; MgSO4; magnesium sulfate; loading dose; eclampsia</em>.</p> Surya Prasad Rimal Pappu Rijal Rabindra Bhatt Kriti Thapa ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 388 94 Prevention of Shivering during Spinal Anesthesia: Comparison between Tramadol, Ketamine and Ondansetron <p class="p1"><span class="s1"><strong>Introduction:</strong></span> Shivering is an unpleasant experience after spinal anesthesia. We conducted this study to evaluate the efficacy of ondansetron, ketamine and tramadol for prevention of shivering.</p> <p class="p1"><span class="s1"><strong>Methods: </strong></span>In this prospective, randomized controlled study, 120 patients aged 18-65 years of American Society of Anesthesiologist (ASA) physical status I&amp;II undergoing various surgical procedures were included and allocated alternately to one of the 4 groups; Normal saline (Group1), Ondansetron 4mg (Group2), Ketamine 0.25mg/kg (Group3) and Tramadol 0.5mg/kg (Group4). Incidence of shivering, effect on hemodynamics, nausea, vomiting, sedation and emergence reactions were recorded. Data was analyzed using SPSS (The Statistical Package for Social Sciences) version 20.0 software.</p> <p class="p1"><span class="s1"><strong>Results: </strong></span>The patients were comparable in terms of demographic variables, baseline temperature, type of surgery, median level of sensory blockade, duration of surgery and anesthesia. Shivering was present in 17 (56.7%), 5 (16.7%), 3 (10%) and 3 (10%) patients respectively in Group 1, 2, 3 and 4 which was statistically significant when compared to Group 1 (P=0.00) The odds of NS and ondansetron, NS and ketamine, NS and tramadol was 6.53, 11.76 and 11.76 respectively which showed that study drugs were effective in preventing shivering. None of the patients were sedated in Group 1 and 2. Mild to moderate sedation was present in Group 3 and 4 (P=0.00). None of the patients had drug related adverse reactions.</p> <p class="p1"><span class="s1"><strong>Conclusions:</strong></span> Prophylactic use of ondansetron, low doses of ketamine and tramadol is effective in preventing shivering post spinal anesthesia without untoward effects.</p> <p class="p1"><span class="s1"><strong>Keywords:</strong></span><em><span class="Apple-converted-space">&nbsp; </span>Anesthesia spinal; Ketamine; Ondansetron; Shivering; Tramadol.</em></p> Gajal lakhe Krishna Murari Adhikari Kiran Khatri Anil Maharjan Akriti Bajracharya Himdip Khanal ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 395 400 Demographic and Clinical Profile in Patients with Liver Cirrhosis in a Tertiary Care Hospital in Central Nepal <p class="p1"><span class="s1"><strong>Introduction</strong></span>: Liver cirrhosis is an important health problem worldwide and is a common disease in Nepal. The profile of cirrhosis may vary due to different factors. This study was undertaken to see the demographic and clinical profiles of patients with cirrhosis of liver attending a tertiary care hospital in Central Nepal.</p> <p class="p1"><span class="s1"><strong>Methods: </strong></span>Six hundred patients with clinical features, laboratory and sonological findings suggestive of chronic liver dysfunction and endoscopic evidence of portal hypertension were included in the study. Their demographic and clinical profile, endoscopic findings, outcomes during hospitalization were studied. Ethical approval was taken from Institutional Review Committee of College of Medical Sciences. SPSS 20 was used for statistical analysis.</p> <p class="p3"><span class="s1"><strong>Results: </strong></span>The mean age of subjects was 54±11.84 years with 435 males (72.5%) and 165 (27.5%) females. Majority of 203 (33.8%) patients were from Mongol ethnicity followed by 127 (21.2%) Khas. Two hundred and twenty (36.6%) were farmers followed by 169 (28.2%) retired personnel. A total of 338 (56.4 %) patients were from rural areas. The commonest aetiology of cirrhosis was chronic alcohol consumption and seen in 552 (92%) patients. Abdominal distension was commonest presenting sign and observed in 561 (93.5%) patients. Ascites seen in 555 (92.5%) patients was the commonest complication followed by UGI bleed in 326(54.3%) patients. Gastro-oesophageal varices observed in 345 (57.5%) patients, was the most common endoscopic finding followed by portal gastropathy, peptic ulcer and erosive mucosal diseases. In patient mortality was noted in 92 (15.3 %) patients.</p> <p class="p1"><span class="s1"><strong>Conclusions: </strong></span>This study highlights the burden of cirrhosis, usually caused by chronic alcohol consumption in Central Nepal. Majority of subjects were male, middle aged, farmers, from rural areas and predominantly observed in some ethnicity like Mongols. Cirrhotic patients usually present late with varied complications and have high mortality.</p> <p class="p5">&nbsp;</p> <p class="p5"><span class="s2"><strong>Keywords:</strong></span><em> cirrhosis of liver; complications; endoscopy.</em></p> Subash Bhattarai Merina Gyawali Khus Raj Dewan Gaurav Shrestha ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 401 6 Nerve Conduction and Heart Rate variability in Patients with Hypothyroidism at a Tertiary Care Centre in Eastern Nepal <p class="p1"><span class="s1"><strong>Introduction:</strong></span> Thyroid hormone effects on many organs including central and peripheral nervous systems. However, these hormones do not affect all systems/organs to a similar extent. Thus, we conducted this study to explore the effect of thyroid hormones on somatic nervous system assessed by Nerve conduction study and cardiac autonomic activity assessed by heart rate variability.</p> <p class="p1"><span class="s1"><strong>Methods: </strong></span>The study included newly diagnosed hypothyroid patients and healthy controls. In all subjects NCS were performed in median, ulnar, tibial and sural nerves using Nihonkohden machine Cardiac autonomic control was assessed using Short-term Heart Rate Variability and parameters were analyzed by Time Domain and Frequency Domain methods.</p> <p class="p1"><span class="s1"><strong>Results: </strong></span>Both the groups were comparable in term of age, Body Mass Index, Pulse Rate, Systolic Blood Pressure and Diastolic Blood Pressure. Sensory parameters of NCS showed significant decrease in left median nerve SNAP amplitude (38.24±10.23 Vs 31.59±14.06, P=0.048) and nerve conduction velocity of bilateral median nerve in hypothyroid patients. In motor parameters of NCS, onset latencies of bilateral median nerves and right ulnar nerve were significantly increased in hypothyroid patients.<span class="Apple-converted-space">&nbsp; </span>All Time Domain measures of HRV and Frequency Domain measures; LF Power, HF Power and Total Power were significantly decreased (P&lt;0.05) in hypothyroid patients. These HRV parameters are indicators of parasympathetic activity.</p> <p class="p1"><span class="s1"><strong>Conclusions: </strong></span>In newly diagnosed hypothyroid patients, especially median nerve functions (both sensory and motor) and parasympathetic activity were decreased.<span class="Apple-converted-space">&nbsp; </span>It reflects that in hypothyroidism both autonomic nervous system and other somatic nerves are not affected in a similar extent.</p> <p class="p2"><span class="s2"><strong>Keywords:</strong></span><em><span class="Apple-converted-space">&nbsp; </span>hypothyroidism; heart rate variability; nerve conduction study.</em></p> Shital Gupta Rita Khadka Dilip Thakur Robin Maskey K D Mehta Bishnu Hari Paudel ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 407 11 Significance of Non-Invasive Markers as Predictor of Esophageal Varices in Liver Cirrhosis <p class="p1"><span class="s1"><strong>Introduction: </strong></span>Upper gastro-intestinal endoscopy remains the gold standard for screening for esophageal varices but it has its own limitations. It is an invasive, expensive and uncomfortable procedure and needs clinical expertise. Accordingly, this study was conducted to establish the role of non-invasive markers for prediction of esophageal varices in liver cirrhosis.</p> <p class="p1"><span class="s1"><strong>Methods: </strong></span>A hospital based descriptive cross-sectional study was carried out in Liver unit of National Academy of Medical Sciences, Bir Hospital, from October 2016 to September 2017. Complete blood count, liver function test, liver ultrasound and upper gastro-intestinal endoscopy were done for all patients to detect esophageal varices and to correlate with different non-invasive markers.</p> <p class="p1"><span class="s1"><strong>Results: </strong></span>Total 191 patients of liver cirrhosis were studied after exclusion. Platelet count of 92082.00±43435.83/mm<sup>3 </sup>and spleen size of 144.21±10.71 mm was found to be good predictors of presence of EV (P≤0.001). Significant association between Child-Turcotte-Pugh class and presence of varices was observed (P≤0.001). AST/ALT ratio with cutoff value of 1.415 showed sensitivity of 82.4% and specificity of 36.4%. APRI at a cutoff value of 1.3 showed a sensitivity of 83.2% and specificity of 50%.</p> <p class="p1"><span class="s1"><strong>Conclusions: </strong></span>Platelet count, spleen size and Child-Turcotte-Pugh class are good predictors of presence of esophageal varices in patients with liver cirrhosis. AST/ALT ratio and APRI score are not good substitutes for upper gastro-intestinal endoscopy.</p> <p class="p3">&nbsp;</p> <p class="p3"><span class="s2"><strong>Keywords:</strong></span><em><span class="Apple-converted-space">&nbsp; </span>esophageal varices; liver cirrhosis; non-invasive markers; portal hypertension; upper gastro-intestinal.</em></p> Dipendra Khadka Sushil Prajapati Sudhamshu KC Jeetendra Kaji Shrestha Niyanta Karki Bikash Jaishi Kiran Regmi Sandip Khadka ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 412 6 Prevalence of Hepatitis D Among Patients with Hepatitis B Viral Infection Attending a Tertiary Care Centre of Nepal <p class="p1"><span class="s1"><strong>Introduction: </strong></span>Worldwide there is variation in prevalence of Hepatitis D viral infection. Superinfection and co infection with hepatitis B viral infection is known to occur in 15-20 million people.</p> <p class="p1"><span class="s1"><strong>Methods: </strong></span>This was a descriptive cross-sectional hospital based study carried out in NAMS, Bir hospital, Kathmandu, Nepal from period of January 2017 to June 2017. Consecutive patients of chronic hepatitis B viral infection of HBsAg positive with more than two-time upper normal limit of ALT were enrolled and tested for HDV IgG.</p> <p class="p1"><span class="s1"><strong>Results:</strong></span> Forty patients were enrolled during study period. Mean age was 30.9±12.2 years. Males were 28 (70%) and females 12 (30%). Most of the patients were asymptomatic for HBV infection 32 (80%). HBeAg negative chronic hepatitis was most commonly present in 31 (77.5%). Family history of Hepatitis B viral infection was seen in 7 (17.5%) and sexual promiscuity in 5 (12.5%) as the mode of acquisition of hepatitis B viral infection. HBcIgM was positive in three patients with mean HBV DNA of 4.97x10<sup>5</sup>±4.5x10<sup>5 </sup>IU/ml in HBeAg positive group. HDV IgG was negative in all patients.</p> <p class="p1"><span class="s1"><strong>Conclusions:</strong></span> Coinfection and superinfection of hepatitis D virus were found to be uncommon at Bir hospital, Nepal.</p> <p class="p2"><span class="s2"><strong>Keywords:</strong></span><em> HbsAg; HDV DNA; HDV IgG; Hepatitis B; Hepatitis D. </em></p> Kiran Regmi Jeetndra Kaji Shrestha Sudhamshu KC Bikash Jaishi Niyanta Karki Dipendra Khadka Sandip Khadka ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 417 20 Prehospital Events in ST- Elevation Myocardial Infarction Undergoing Primary Angioplasty <p class="p1"><span class="s1"><strong>Introduction:</strong></span> Pre-hospital delay includes time from onset of symptoms of myocardial infarction till arrival to emergency room of the hospital. This defines time from symptom onset to first medical contact and first medical contact to emergency room. This study aims to study the prehospital events and determining factors in patients undergoing primary angioplasty.</p> <p class="p1"><span class="s1"><strong>Methods: </strong></span>This was a cross sectional study in Shahid Gangalal National Heart Centre for three months. Timings of chest pain, first medical contact time, transfer time to hospital and overall pre-hospital time for PCI and risk factors were analysed.</p> <p class="p1"><span class="s1"><strong>Results:</strong></span> There were 79 cases with 66 (83.5%) males and 13 (16.5%) females with mean age 56±11.2 years. Risk factors were 60 (75.9%), smoking, 47 (59.5%) hypertension, 25 (31.6%) diabetes, 22 (27.8%) dyslipidaemia and 16 (20.3%) heart failure. Chest pain was <span class="Apple-converted-space">&nbsp; </span>maximum in 5 to 9 AM. The median prehospital delay was 300 minutes (5.0 hours) of which symptom to first medical contact was 165 minutes and first medical contact to hospital was 80 minutes. The longer median prehospital delay for hypertension, diabetes, female and age ≥50 years and the shorter for male, age less than 50 years, dyslipidemia and heart failure, though not statistically significant. Private transport was the preferred from symptom to first medical contact and ambulance for first medical contact to emergency room. Patients received in ER had aspirin 72 (91.1%), atorvastatin 54 (68.4%) and double anti-platelets 45 (57%).</p> <p class="p1"><span class="s1"><strong>Conclusions</strong></span>: Chest pain was common in morning and the prehospital delay can be minimized by improving time from symptom to first medical contact and first medical contact to Emergency room.</p> <p class="p2"><span class="s2"><strong>Keywords:</strong></span><em><span class="Apple-converted-space">&nbsp; </span>cicardian pattern; prehospital delay; ST myocardial infarction.</em></p> Sachin Dhungel Rabi Malla Chandramani Ahikari Arun Maskey Rajib Rajbhandari Diwakar Sharma Man Bhadhur KC Binaya Rauniyar Deepak Limbu Milan Gautam Ajay Adhikari Hari chalise ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 421 5 Fingerprints as an Alternative Method to Determine ABO and Rh Blood Groups <p class="p1"><span class="s1"><strong>Introduction: </strong></span>Blood grouping is conventionally done with invasive method by taking blood samples. The objective of this study is to determine blood group with uninvasive procedure by taking fingerprints of the participants and know the associations between their fingerprints and blood groups.</p> <p class="p1"><span class="s1"><strong>Methods: </strong></span>Seven hundred participants of both genders with no any age limitation from Manipal Teaching Hospital and Manipal College of Medical Sciences were randomly selected. The blood grouping was done by cross reacting blood sample with the antibodies. The fingerprints were taken with the help of stamp pad imprinting the finger ridges over A4 size white papers. The loop, whorl and arch patterns were studied.</p> <p class="p1"><span class="s1"><strong>Results: </strong></span>O+ve blood group 224 (32%) was most prevalent among 700 participants. The loop pattern was highly distributed 3708 (53%) in all blood groups except in A-ve blood group with highest distribution of whorl 20 (40%). The mean comparisons of specific fingerprint in total and also in individual fingers with different ABO and ABO-Rh blood groups showed no any statistical association with P&gt;0.05. However, the loop distribution in individual finger was highest in right middle finger (M) of B-ve blood group 5 (10%). The whorl distribution in individual finger<span class="Apple-converted-space">&nbsp; </span>was highest in right index (I), left thumb (T) and left ring (R) fingers of AB+ve blood group 20<span class="Apple-converted-space">&nbsp; </span>(5.5% each). Similarly, the arch distribution was highest in right index fingers of A-ve blood group 3 (6%).</p> <p class="p1"><span class="s1"><strong>Conclusions: </strong></span>The mean comparison of different fingerprints with ABO and Rh blood groups showed no significant statistical association concluding fingerprints cannot be used for blood grouping.</p> <p class="p3"><span class="s2"><strong>Keywords:</strong></span><em><span class="Apple-converted-space">&nbsp; </span>arch; blood group; fingerprints; loop; whorl.</em></p> Sonam Chaudhary Sajana Deuja Munna Alam Poonam Karmacharya Monami Mondal ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 426 31 Basal Cell Carcinoma in Cases with or without Xeroderma Pigmentosum <p class="p1"><span class="s1"><strong>Introduction: </strong></span>Basal cell carcinoma is the most common form of cancer in humans and comprises the vast majority of skin cancers. It predominantly affects fair-skinned individuals, and its incidence is rapidly increasing. The objective of the study is to identify the epidemiology, its topography and different histological subtypes of basal cell carcinoma in patients with or without Xeroderma Pigmentosum.</p> <p class="p1"><span class="s1"><strong>Methods:</strong></span> A cross-sectional descriptive study was conducted at Manipal Teaching Hospital, Pokhara from Jan 2009 to Dec 2016. Ethical approval was taken from MEMG/IRC/GA. The study included patients with a confirmed diagnosis of basal cell carcinoma irrespective of their age and sex.</p> <p class="p1"><span class="s1"><strong>Results: </strong></span>This study showed 77 individuals with 91 biopsies of BCC including 5 cases of Xeroderma Pigmentosum. The predominant histological subtype was nodular with 41 (53.94%) cases, followed by the 14 (18.42%) cases of pigmented and 10 (13.15%) cases baso-squamous subtype. The most frequent sites of involvement were the head and neck, with predominance in the nasal and orbital region. The mean age was 57.68 years but the basal cell carcinoma in cases of Xeroderma Pigmentosum was seen more in younger age groups. There were 43 (55.84 %) male patients and 34 (44.16 %) female patients with a male to female ratio of 1.26:1.</p> <p class="p1"><span class="s1"><strong>Conclusions:</strong></span> Nodular and pigmented varieties were the most frequent subtypes with nose being the commonest site of involvement. Basal cell carcinomas in cases of Xeroderma Pigmentosum were noted in younger age group with multiple lesions.</p> <p class="p4"><span class="s2"><strong>Keywords:</strong></span><em> <span class="Apple-converted-space">&nbsp; </span>basal cell carcinoma; recurrence; topography; xeroderma pigmentosum. </em></p> Dilasma Ghartimagar Arnab Ghosh Sushil Ram Shrestha Sachet Shrestha Raghavan Narasimhan O P Talwar ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 432 7 Postoperative Outcome in Patients with Pulmonary Hypertension Undergoing Elective Non-Cardiac Surgery <p class="p1"><span class="s1"><strong>Introduction:</strong></span> The impact of pulmonary artery hypertension on post-operative outcome in elective, non-cardiac surgery is incompletely understood. This study was designed to evaluate the post-operative outcome of patients undergoing elective, non-cardiac surgery with and without pulmonary hypertension.</p> <p class="p1"><span class="s1"><strong>Methods:</strong></span> The study was conducted in an inner-city hospital in Bronx, New York. A retrospective chart review was conducted on all patients who underwent elective, non- cardiac surgery from January 2000 to December 2010 and had echocardiogram within 30 days of surgery. Patients with systolic pressure of ≥35mm of Hg as estimated by echocardiogram were enrolled. Case matched peers with normal pulmonary pressures served as controls. Post-operative outcomes were compared between the two groups.</p> <p class="p1"><span class="s1"><strong>Results: </strong></span>A total of 66 patients were analysed, 33 cases and 33 controls. All patients were followed up to 30-day post-surgery. Heart failure, myocardial infarction, arrhythmia, stroke, delayed extubation and deaths were measured in both the groups. There were two deaths in the control group while there were three deaths in pulmonary hypertension group (statistically not significant, P &gt;0.05). A total of three patients in pulmonary hypertension group had adverse outcome (one had a major arrhythmia, one had delayed extubation (&gt;24 hours) and one had stroke). Whereas two patients in control group had adverse outcome (one had delayed extubation (&gt;24 hours) and one had major arrhythmia).</p> <p class="p2"><span class="s1"><strong>Conclusions: </strong></span>Pulmonary hypertension does not affect the post-operative outcome in the first 30 days for elective non-cardiac surgery.</p> <p class="p3"><span class="s2"><strong>Keywords:</strong></span><em> echocardiogram; elective surgery; non-cardiac surgery; post-operative outcome; pulmonary hypertension.</em></p> Vikas Pathak Kriti Suwal ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 438 41 Effects of Bilateral Nasal Packing on Oxygen Saturation and Blood Pressure <p class="p1"><span class="s1"><strong>Introduction: </strong></span>Nasal packing is one of the most common rhinological procedures in ENT practice exerting local in nose and systemic effects. Systemic effects may be due to poor sleep quality, respiratory difficulty, decreased oxygen saturation, circulatory problems and toxic shock syndrome which can threaten the life of a person.The study was done to investigate the effect on bilateral nasal packing on blood oxygen saturation and blood pressure changes.</p> <p class="p1"><span class="s1"><strong>Methods:</strong></span> A cross-sectional prospective study was undertaken in Kathmandu Medical College from January 2017 to June 2017. The ethical approval was taken from institutional review committee of KMC and verbal consent was taken from each patient. Thirty patients were included in the study by simple randomized sampling. The association between nasal packing and oxygen saturation and blood pressure was done using ANNOVA and Fisher Exact test. P value of &lt;0.005 was considered statistically significant. SPSS version 20 for windows OS was used for analysis.</p> <p class="p1"><span class="s1"><strong>Results:</strong></span> Blood oxygen saturation on four different days was compared using ANNOVA and paired sample tests. It showed a significant dip on the day of bilateral nasal packing compared to other readings (P value &lt;0.001). Likewise, systolic and diastolic blood pressures showed a significant rise on the day of bilateral nasal packing compared to readings on other days (P value &lt;0.001).</p> <p class="p1"><span class="s1"><strong>Conclusions: </strong></span>Bilateral nasal packing can lead to significant rise in systolic and diastolic blood pressure and a dip in blood oxygen saturation. Thus care has to be taken while performing bilateral nasal packing in normal patients but much more in high risk patients.</p> <p class="p2"><span class="s2"><strong>Keywords:</strong></span><em><span class="Apple-converted-space">&nbsp; </span>blood pressure; nasal obstruction; nasal packing; oxygen saturation; pulse oximetry.</em></p> Meera Bista ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 442 6 Endoscopic Sinus Surgery for Sinonasal Polyposis: Microdebrider or Conventional Instruments <p class="p1"><span class="s1"><strong>Introduction: </strong></span>Sinonasal polyposis is one of the commonest causes of nasal obstruction. Surgical management is treatment of choice. Microdebrider offers more advantage to conventional instruments. We aimed to find out outcome using microdebrider versus conventional instruments in endoscopic sinus surgery of sinonasal polyposis.</p> <p class="p1"><span class="s1"><strong>Methods:</strong></span> The cross sectional descriptive study carried out in patients aged 13 years and above with diagnosis of sinonasal polyposis. Total of 51 patients were operated on the right side with microdebrider and left side with conventional instruments. Postoperatively each patient assessed for nasal obstruction subjectively and by endoscopic examination to look for mucosal oedema, synechiae and recurrence at 4 weeks and 8 weeks postoperatively.</p> <p class="p1"><span class="s1"><strong>Results: </strong></span>The incidence of mucosal oedema in microdebrider and conventional instruments at 4 weeks and 8 weeks was statistically not significant with P value 0.089, 0.322 respectively. The incidence of synechiae in conventional group was more than microdebrider 1 (2%) versus 4 (7.8%) at 4 weeks follow up but the difference was statistically not significant (P value 0.773). There were 2 (3.9%) recurrences in microdebrider group and 3 (5.8%) recurrences in conventional group with P value 0.532.</p> <p class="p1"><span class="s1"><strong>Conclusions:</strong></span> Use of microdebrider offered fewer incidences of synechiae and recurrence. But we couldn’t find statistical advantage over conventional instruments.</p> <p class="p2"><span class="s2"><strong>Keywords:</strong></span><em><span class="Apple-converted-space">&nbsp; </span>conventional instruments; endoscopic sinus surgery; microdebrider; sinonasal polyposis.</em></p> Nabin Lageju Bibhu Pradhan Narmaya Thapa ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 447 50 Limited Open Reduction and Percutaneous Plate Osteosynthesis - Alternative Option to Minimally Invasive Plate Osteosynthesis in Management of Distal Tibia Fractures <p class="p1"><span class="s1"><strong>Introduction: </strong></span>The management of distal tibia fracture is challenging because of the limited soft tissue coverage and poor vascularity around the bone in that area. Minimally invasive percutaneous plate osteosynthesis is a novel technique in this regard but needs fluoroscopy. In unavailability of fluoroscopy or its technical malfunction, limited open reduction percutaneous plate osteosynthesis becomes useful. The aim of this study is to compare the outcomes of distal tibia fractures treated by LORPPO and MIPPO techniques in terms of duration of hospital stay, full weight bearing, union time and complications.</p> <p class="p1"><span class="s1"><strong>Methods: </strong></span>Twenty-two cases of closed distal tibia fractures without articular involvement or comminution operated at Koshi Zonal Hospital, Nepal from March 2014 to May 2016 were included in this study. Total 11cases of which were treated by MIPPO whereas other 11 cases were treated by LORPPO. MIPPO technique was done only when the fluoroscopy was available.</p> <p class="p1"><span class="s1"><strong>Results: </strong></span>In MIPPO, the average age of the patients were 43.72 (range 23-65) years, hospital stay mean duration 8.45 (range 6-12) days, full weight-bearing walking was started in 11.27 (range 9-15) weeks and average radiological union time was 21.25 (range 18-28) weeks. In LORPPO, the mean age was 46.36 (range 25-70)years, hospital stay mean 11.81 (range 10-15) days, full weight bearing walking mean 10.63 (range 9-15) weeks and average radiological union time was 23.0 (range 19-27) weeks.</p> <p class="p2"><span class="s1"><strong>Conclusions:</strong></span> The outcomes are comparatively similar for both the techniques. LORPPO could be an alternative to MIPPO in the management of distal tibia fractures.</p> <p class="p3"><span class="s2"><strong>Keywords:</strong></span><em><span class="Apple-converted-space">&nbsp; </span>distal tibia fracture; limited open reduction; percutaneous plate osteosynthesis.</em></p> Shambhu Sah Bikash KC Sailoj Jung Dangi Rem Kumar Rai Roshan Yadav ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 456 60 Ventilator-Associated Pneumonia and Role of Nurses in Its Prevention <p class="p1">Ventilator-associated pneumonia (VAP) is one of the most frequent nosocomial infections among ventilated patients in ICUs, associated with an increase in days of ICU stay, morbidity, and mortality. Its prevention is a significant concern in every hospital. Most of the interventions and prevention strategies are part of routine nursing care. Nurses have different vital roles such as care provider, manager, educator, coordinator, and evaluator in preventing VAP. Lack of knowledge of infection prevention and proper nursing care among nurses may become a barrier in adhering to evidence-based guidelines for preventing ventilator-associated pneumonia. This study will help nurses to know about VAP and its prevention in detail so that they can apply the knowledge in clinical practice. Understanding pathophysiology of VAP, its risk factors, and care bundle is vital for the proper prevention and treatment of VAP. There must be specific protocols, strategies and active surveillance in every ICU regarding the care bundle.</p> <p class="p2"><span class="s1"><strong>Keywords:</strong></span><em><span class="Apple-converted-space">&nbsp; </span>Mechanical ventilation; Nosocomial infections; Nurses role; Ventilator-associated pneumonia; VAP Prevention.</em></p> Chadani Osti Deepa Wosti Bimala Pandey Qinghua Zhao ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 461 8 Identification of Deceased Children of Nepal Airlines Crash through Dental Age Estimation <p class="p1">Identification of victims in a disaster is a challenging process and requires use of both primary and secondary identifiers. Development of teeth is one of the routinely used methods of age estimation and helps in establishing deceased biological profile. Two children who lost their lives in 2014 in Nepal Airlines crash, were looked for the dental developmental status. One of the children had primary dentition, while the other had mixed dentition. This helped us in estimating age of these individuals reconciled with the chronological age provided by the relatives. This led to the identification of both the children, thus, emphasizing teeth as important means of identification in any disaster.</p> <p class="p3"><span class="s1"><strong>Keywords:</strong></span><em> dental age; dental identification; disaster victim identification; forensic dentistry; forensic odontology.</em></p> Nitin Kumar Agrawal Samarika Dahal Harihar Wasti ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 469 71 Chorioangioma of Placenta <p class="p1">Chorioangioma of placenta is the commonest benign tumour of the placenta. It consists of a benign angioma arising from chorionic tissue. We report a case of placental chorioangioma which was diagnosed in the post partum period in a patient with polyhydramnios who went into preterm labor and delivered a premature baby.</p> <p class="p2"><span class="s1"><strong>Keywords:</strong></span><em> chorioangioma;<span class="Apple-converted-space">&nbsp; </span>placenta; polyhydramnios.</em></p> Rubby Das Nilam Subedi Gahana Gurung ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 472 4 Late Presentation of Post Diphtheritic Myocarditis in a 15-year male <p class="p1">A 15-year old male patient presented to us with dyspnoea for four days. He had a history of fever, pseudo-membranous tonsillitis and cervical adenopathy twenty-five days prior to the presentation. On examination and laboratory investigations, he had features suggestive of myocarditis with biventricular failure. There was no reliable history of immunisation and he had a positive history of contact. He was planned for anti-diphtheria toxin but before the anti-toxin could be initiated, the patient succumbed to refractory cardiogenic shock. This was a rare case of late onset diphtheritic myocarditis in an unimmunised adult. With the advent of universal immunisation, there has been a significant decline in the incidence but there is still some road to cover.</p> <p class="p3"><span class="s1"><strong>Keywords:</strong></span><em> Corynebacterium diptheriae; diphtheria; myocarditis.</em></p> Kutty Sharada Vinod Nitin Gupta Harsh Sahu Naveet Wig ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 475 7 Oral Squamous Papilloma of Edentulous Mouth Interfering with Denture Retention <p class="p1">Soft tissue overgrowths inside oral cavity can present with wide range of clinical manifestations and some of them can be even asymptomatic. Oral squamous papilloma is one of that asymptomatic lesion described in the literature with extremely low virulence and infectivity rate. Soft tissue overgrowths can sometimes interfere with denture retention. Here we report a case of squamous papilloma in a 60 years old edentulous female who presented with loss of denture retention.</p> <p class="p2"><span class="s1"><strong>Keywords:</strong></span><em> denture retention; papilloma; sialadenoma papilliferum.</em></p> Nashib Pandey Shivalal Sharma Ashish Shrestha Vinay Marla ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 478 81 Immune System and Kidney Transplantation <p class="p1">The immune system recognises a transplanted kidney as foreign body and mounts immune response through cellular and humoral mechanisms leading to acute or chronic rejection, which ultimately results in graft loss. Over the last five decades, there have been significant advances in the understanding of the immune responses to transplanted organs in both experimental and clinical transplant settings. Modulation of the immune response by using immunosuppressive agents has led to successful outcomes after kidney transplantation. The paper provides an overview of the general organisation and function of human immune system, immune response to kidney transplantation, and the current practice of immunosuppressive therapy in kidney transplantation in the United Kingdom.</p> Badri Man Shrestha ##submission.copyrightStatement## 2017-12-31 2017-12-31 56 208 482 6