Journal of Nepal Medical Association

Altered Passive Eruption among Patients Visiting Dental Outpatient Department in a Tertiary Care Center: A Descriptive Cross-sectional Study

Simant Lamichhane — 2024-04-30

Introduction: The eruption of teeth is considered to be a continuous phenomenon. Two types of eruption are possible namely, active and passive eruption. Failure in passive eruption (by the apical movement of gingiva from the enamel surface) generally results in a clinical condition known as altered passive eruption. It can result in the shortened crown height of a tooth and an esthetically unpleasant situation i.e., excessive gingival display or gummy smile. The main motto of this study was to find out the prevalence of altered passive eruption and associated gingival biotypes in adult patients visiting for dental treatment in tertiary centers along with strategically placed outreach centers.

Methods: A descriptive cross-sectional study was done in the Department of Dentistry, Dhulikhel Hospital, and four outreach centers of the same hospital. The study was conducted from October 2022 to April 2023 after obtaining the ethical approval. Convenience sampling was done. Point estimate and 95% Confidence Interval were calculated.

Results: Among 165 patients, the prevalence of altered passive eruption was 21 (12.72%) (7.62-17.78 at 95% Confidence Interval). Furthermore, among 21 patients, the altered passive eruption was seen in the thick biotype patients in 16 (76.19%) and thin biotype patients in 5 (23.81%).

Conclusions: The prevalence of altered passive eruption appeared to be equivalent when compared with the previous studies.

Job Satisfaction among Medical Doctors in Nepal: A Descriptive Cross-sectional Study

Jeevan Gyawali — 2024-04-30

Introduction: Job satisfaction is an attitudinal variable representing the extent to which people like or dislike their jobs. It is a critical factor influencing healthcare quality, patient outcomes, and overall well-being in medical professionals. This study aimed to determine Job Satisfaction among medical doctors in Nepal.

Methods: A descriptive cross-sectional study was conducted among medical doctors of Nepal between June 2023 and August 2023 after obtaining ethical approval from the Ethical Review Board of Nepal Health Research Council. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval.

Results: Among 380 participants, 63 (16.58%) (12.84-20.32 at 95% Confidence Interval) expressed satisfaction. The number of satisfied participants above 40 years were 10 (16%) and less than 40 years were 53 (84%). Out of 63, 46 (73.02%) were male and 17 (26.98%) were females.

Conclusions: Job satisfaction among doctors practicing in Nepal was found to be lower than the studies conducted in similar settings.

Burnout among Nurses and Doctors Working at a Tertiary Care Government Hospital: A Descriptive Cross-sectional Study

Sunil Kumar Shah — 2024-04-30

Introduction: Work environment related feelings of dissatisfaction, exhaustion, decreased interest and isolation is common. Burnout among health professionals has been on rise at every stage of professional growth affecting wellness of service providers, patient care and health care organizational efficiency. Assessment of burnout among health care workers from government setup in the current context in this post COVID era in our socio-geographical context has become essential. The aim of this study was to find the prevalence of burnout among nurses and doctors working at a tertiary care government hospital in Nepal.

Methods: This descriptive cross sectional study was conducted among nurses and doctors working at a tertiary level government hospital from May 2022 to Nov 2022 after approval from Institutional Review Committee of the same institute. Nurses and doctors available on duty, from all ages were included. Trainees and students, those unable to participate due to their illness, on leave, known cases of mental illness were excluded. The point estimate was calculated at 95% Confidence Interval.

Results: Among 180 participants, the prevalence of moderate burnout was 94 (52.22%) (44.92-59.51, 95% Confidence Interval). Among nurses 72 (50%), while in doctors 22 (61.11%) had moderate burnout. Out of those with moderate levels of burnout, the majority of 66 (52.80%) were in the age group 26-50 years.

Conclusions: The prevalence of burnout among nurses and doctors is high, similar to other studies done in similar settings.

Functional Outcome of Solid Interlocking Nail in Open Tibial Fracture at a Tertiary Care Center: A Descriptive Cross-sectional Study

Vijayendra Adhikari — 2024-04-30

Introduction: There is a high incidence of open fractures accounting 23% of all tibial fractures. The minimal soft tissue and precarious blood supply of the shaft of tibia make these fractures vulnerable to complications. The treatment should be decided through thoughtful analysis for personality of injuries and the status of the soft tissue. Intramedullary nailing allows stable fixation with minimal soft tissues dissection and preserve the soft tissue and allows early joint motion with higher rate of union. The purpose of our study was to find the outcome of open tibial fractures lower than Gustilo type IIIb, that were treated by unreamed solid interlocking intramedullary nails.

Methods: A descriptive cross-ectional study was conducted from December 2021 to June 2023 after taking approval from ethical committee. All 34 patients treated with solid interlocking intramedullary nail, without reaming for open tibial fracture during 18 months period were included in the study. Final follow up was done at one year and the outcome was assessed by Modified Ketenjian’s criteria.

Results: The mean time of union rate was 15.82±3.95 weeks. Complications were: superficial infections in 4 (11.76%) patients and deep infection in 1 (2.94%) patient. Using Modified Ketenjian's Criteria, 26 (76.47%) patients had an excellent result followed by good in 7 (20.59%), fair in 1 (2.94%) and there was no case with poor outcome.

Conclusions: Solid intramedullary interlocking nail is an effective treatment with minimal soft tissue dissection for open tibia fracture less than GA III B as it provides stable fixation with early mobilization and provides a high rate of union, less complication and early return to function.

Multidetector Computed Tomography Used in Evaluation of Olfactory Fossa Depth in a Tertiary Hospital in Eastern Region of Nepal: A Descriptive Cross-sectional Study

Ajay Kumar Yadav — 2024-04-30

Introduction: Olfactory fossa (OF) is a depression in most infero-medial portion of anterior cranial fossa formed by cribriform plate, crista galli and lateral lamella of cribriform plate (LLCP). LLCP being thinnest and extremely variable parts, more prone for iatrogenic injury during sinus surgery in case of asymmetric and deep OF. Multidetector computed tomography (MDCT) is frequently used imaging modality in the evaluation of paranasal sinus. The objective of the study is to classify the OF depth according to the Keros classification.

Methods: In this ethically approved prospective, cross-sectional descriptive study, CT scan was done in 530 consecutive patients from February 2022 to July 2023. Coronal CT images of paranasal sinuses and nose were used to measure the OF depth. The data collected was analyzed using SPSS.

Results: Out of 530 patients included in this study, 310 (58.49%) were male and 220 (41.51%) were female with mean age of 40.46±11.56 years. Total of 1060 olfactory fossa were analyzed with mean depth of 4.96±1.88 mm. In our study, 310 (29.24%) had type I, 730 (68.88%) had type II and 20 (1.88%) had type III according to Keros classification.

Conclusions: Keros type II OF is more common. The dangerous type III OF having low prevalence, more commonly seen on right side and in males.

High Risk Pregnancy and its Outcome in a Tertiary Care Hospital: A Descriptive Cross-sectional Study

Sunita Bhandari — 2024-04-30

Introduction: High-risk pregnancy is defined as one which is complicated by factors or factors that adversely affect the pregnancy outcome (maternal, perinatal or both). Early detection and effectivemanagement of high risk pregnancy helps in achieving favorable maternal and perinatal outcomes. This study aimed to find the prevalence of high risk pregnancy and its outcome among pregnant women admitted for delivery in the obstetrics and gynecology department of a tertiary care hospital

Methods: A descriptive cross sectional study was conducted in a tertiary care hospital among high risk pregnant women admitted for delivery using structured proforma, from April 2023 to September 2023 after obtaining ethical approval from the Institutional Review Committee. Convenience sampling was used among pregnant women who met the inclusion criteria. Data was entered in excel and analysis was done using IBM SPSS Statistics. Point estimate was calculated at 95% Confidence Interval

Results: Among 350 deliveries, high risk pregnancy was seen in 91 (26%) (16.15-32.00, 95% Confidence Interval). The high risk factors were previous history of cesarean section 25 (27.47 %) followed by hypothyroidism 19 (20.87%) and gestational diabetes mellitus 15 (16.48%). Out of 90 high risk pregnancy, 84 (92.30%) had term delivery. Lower segment cesarean section was done in 69 (75.82%) patients of which 26 (28.57%) underwent emergency cesarean section. The total number of births among high risk preganancies were 93 with two sets of twin births. A total of 13 (13.97%) of the babies had low-birth weight.

Conclusions: The prevalence of high risk pregnancy was found to be similar as compared to studies done in similar settings.

Cranial Autonomic Symptoms in Migraine Patient Presenting in the Department of Neurology of a Tertiary Care Center: A Descriptive Cross-sectional Study

Parash Rayamajhi — 2024-04-30

Introduction: Cranial autonomic symptoms (CAS) are typically associated with trigeminal autonomic cephalagias (TACs) and are also a part of TACs' diagnostic criteria. However, they have also been commonly reported in migraine patients. This study aimed to find the prevalence of CAS in Migraine patients who presented to the Department of Neurology in a tertiary care center.

Methods: This descriptive cross-sectional study was conducted among migraine patients who visited the Department of Neurology of a tertiary care center from September 2023 to December 2023 after obtaining ethical approval from the Institutional Review Committee. Neurologists used ICHD-3 beta criteria to diagnose migraine and the presence of cranial autonomic symptoms in patients with migraine through face-to-face interviews using a structured questionnaire. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval.

Results: Among 119 migraine patients, at least one cranial autonomic symptom was seen in 76 (63.86%) (55.23-72.51, at 95% Confidence Interval). Lacrimation 34 (44.73%) and conjunctival injection 27 (35.52%) were the two most commonly reported symptoms. Bilateral CAS was present in 60 (78.94%) patients.

Conclusions: The prevalence of at least one CAS in migraine patients was found to be similar to other studies done in similar settings.

Assessment of Smoking Behaviour of Adolescents in Two Districts of Nepal and Implications of the MPOWER Policy Measures: A Mixed Method Study

Jemish Acharya — 2024-04-30

Introduction: Tobacco use is the single most preventable cause of death and disease worldwide. This study aimed to assess the smoking behaviour of adolescents in two districts of Nepal and examine the implications of the MPOWER policy on their smoking behaviour.

Methods: An explanatory, mixed-method study was conducted in two districts of Nepal. Qualitative in-depth interviews were conducted among nine participants aged 35-50, representatives of the Ministry of Health, academic institutions, and managers of organisations working in tobacco control, using snowball sampling method. A total of 306 students of age 13-15 years, from six government schools were recruited through simple random sampling method using an adapted version of the Global Youth Tobacco Survey (GYTS). Findings of the qualitative and quantitative study were explained for concurrence and relevance to present overall study findings. Ethical approval was received from the Nepal Health Research Council and Mahidol University.

Results: Findings from the survey reported that a total of 25 (8.10%) of respondents were smokers, from which 13 (4.20%) were current smokers and 12 (3.90%) were ever smokers. Socio-economic status played a crucial role in the smoking behaviour. Although the survey among adolescents indicated an awareness of the policies, there was a lack of cessation services, which was concurrent with the qualitative findings. The interviews recommended improvements in the implementation of policy ban on public smoking, taxation, and availability of cessation services.

Conclusions: The MPOWER policies are not regulated strictly, especially in areas of the ban on public smoking, regulating the selling of cigarettes to adolescents <18 years, and availability of cessation services.

Patterns of Skin Disease among Prisoners in Central Prison in Nepal: A Descriptive Cross-sectional Study

Bikrant Dhakal — 2024-04-30

Introduction: Skin diseases pose a significant health challenge globally, especially within prison settings where overcrowding and inadequate sanitation create a breeding ground for infections. Prisons, as part of society, exist in a dynamic equilibrium, serving as potential sources of infections that can spread beyond their confines. Despite facing similar challenges, there is a dearth of research focusing on skin diseases among inmates in Nepal. This study aims to assess patterns of skin diseases among prisoners.
Methods: This was a descriptive cross-sectional study at the central prison, Kathmandu from December 2023 to March 2024. All patients with skin disease visiting the consultant Dermatologist and giving consent were included in this study. Ethical approval was obtained from the Nepal Health Research Council. Data were entered in Microsoft Excel 2010 and analysis was done by the Statistical Package for the Social Sciences software. Data were presented in the form of frequency and percentage.
Results: A total of 253 patients visited the consultant Dermatologist for skin conditions. Out of which, eczema was 67 (26.50%), fungal infections 57 (22.50%), and bacterial infections 51 (20.10%). The mean age of the respondents was 34.21±12 years.
Conclusions: The fungal and bacterial infections were common among the prisoners.

Knowledge on First Aid Management of Epistaxis among Medical Students of a Medical College: A Descriptive Cross-sectional Study

Shiva Bhushan Pandit — 2024-04-30

Introduction: Epistaxis, a global Otorhinolaryngology emergency, often requires hospital admission, posing health concerns for all ages. Evaluating medical students' knowledge helps identify strengths and areas for improvement, ensuring future healthcare providers are well-prepared. Our study aimed to assess knowledge on first add management of epistaxis among medical students of a medical college.

Methods: This descriptive cross sectional study was conducted among medical students in Birat Medical College Teaching Hospital after ethical approval was obtained. Data was collected electronically using google form from 109 medical students from 15 January 2024 to 15 March 2024.

Results: The mean age of students was 20.71±1.44 years. The mean knowledge score of first aid management of epistaxis was 11.33± 5.24. Out of all students, 68 (62.38%) students had above-average knowledge on first aid management of epistaxis.

Conclusions: The study emphasizes the varied knowledge levels among first and second-semester medical students regarding epistaxis. While more than half demonstrated above-average understanding, targeted educational interventions are warranted.

Vol. 62 No. 273 (2024): JNMA: Published Monthly

Journal of Nepal Medical Association — 2024-04-30

Healthcare System Sustainability Challenges in Nepal and Opportunities Offered by Alternative Healthcare Delivery Arrangements

Pramila Rai — 2024-04-30

The burden of chronic diseases in Nepal is increasing due to demographic and epidemiological transitions; alongside the persistent impact of communicable, maternal, newborn, and child health diseases, this critical situation acts as the precursor to rising healthcare costs. Nepal struggles to sustain its healthcare system amidst political instability, pandemics, natural disasters, and slow economic growth, particularly when healthcare funding is mainly dependent on out-of-pocket payments. Nepal requires lower-cost alternative healthcare delivery arrangements to provide high-value care while relieving economic sustainability pressures. Alternative healthcare delivery arrangements have a broad potential scope; they can involve strategic changes in how care is delivered and by whom, or they can also involve the application of information and communication technologies, e.g., telemedicine. This paper highlights the specific challenges to healthcare system sustainability in Nepal and the potential for high-value, lower-cost alternative healthcare delivery models to improve system performance in the longer term.

Intraosseous Lipoma of Calcaneus An Uncommon Cause of Heel Pain: A Case Report

Dilip Kumar Yadav — 2024-04-30

Intraosseous lipoma of calcaneum is a rare cause of heel pain. Calcaneum is a typical site of involvement of IOL. There are only a few published articles regarding calcaneal intraosseous lipoma and one has been reported from Nepal. We report a case of 35 years female who presented with left heel pain for 1 year. The pain was gradually increasing in intensity and was severe enough to refrain her from activities of daily living. She was surgically operated with curettage and filling the defect with bone cement. There is no residual pain at 2.5 years follow up. We briefly review the postulated pathogenesis, clinical manifestations, diagnosis and various modalities of treatment of intraosseous lipoma. An orthopedic surgeon should have high degree of suspicion regarding the uncommon cause of heel pain and its possible management. When conservative methods do not relieve symptoms, surgical excision and filling the defect with bone cement provides long term relief.

Severe Acute Respiratory Distress in a Child with Hypereosinophilic Syndrome: A Case Report

Bipesh Kumar Shah — 2024-04-30

Hypereosinophilic syndrome with respiratory distress and multiorgan involvement is not so common in children. It is essential to identify this entity based on clinical, laboratory, and imaging features. Corticosteroids should be instituted at the earliest to stabilize the patient and prevent organ damage. Tropical infections are a common secondary cause in children warranting the administration of Diethylcarbamazine. We present a case of an adolescent male in respiratory distress with marked eosinophilia and organs involving the lungs (pulmonary infiltrates with effusion), heart (pericardial effusion), and abdomen (ascites with infiltrates in the liver) which was managed with steroids and anthelmintics. The case highlights the importance of identifying patients with Hypereosinophilic syndrome in pursuing thorough evaluation and commencing therapy.

Post-operative Unilateral Visual Loss and Ophthalmoplegia following Cervical Spine Surgery in Prone Position: A Case Report

Samaj Gautam — 2024-04-30

Visual loss following a spine surgery in a prone position is a disastrous and irreversible complication. Moreover, the recommended treatment for such visual loss is lacking and the outcome is not so satisfactory. A 38-year-old gentleman developed profound right sided visual loss after an uneventful cervical spine surgery in a prone position that lasted approximately two and half hours. Immediate
ophthalmic consultation was done and the case was diagnosed as right-sided central retinal artery occlusion. Despite the initiation of vasodilatation, anticoagulation, and adequate fluid infusion, satisfactory improvement was not achieved. Extensive review of pertinent literature highlighted limited efficacy of treatments for postoperative visual loss after prone spinal surgery, further emphasizing the importance of preventive measures as the cornerstone in such procedures.

Paraquat Toxicity Leading to Acute Kidney Injury: A Case Report in an Adult Patient

Newton Ashish Shah — 2024-04-30

Paraquat poisoning poses a significant and emerging public health challenge in developing countries. The distribution and usage of Paraquat, a potent herbicide, remain unrestricted in many regions despite its high fatality rate and absence of a specific antidote. Paraquat mostly involves lungs but can also involve the kidneys and liver. Diagnostic challenges and a lack of available samples at presentation contribute to underreporting and limited awareness among healthcare providers, making paraquat poisoning a neglected toxicological emergency. Herein, we present a case of a 40-year-old male who presented to the emergency department on the fourth day after ingesting paraquat in a suicidal attempt. Upon presentation, he had erosion on the tongue and posterior pharyngeal wall, along with deranged renal function tests and elevated serum creatinine levels. The patient developed acute kidney injury, with serum creatinine levels rapidly rising from normal to 3.85 mg/dl, accompanied by a decrease in daily urine output. He was managed conservatively, and his hospital stay was uneventful.

Touch of Medical Ethics at the Beginning of Medical School

Nova Ghimire — 2024-04-30

There comes a great responsibility to make patients feel better with the title of doctor. Often we meet certain moral and ethical dilemmas that cannot be solved by our medical textbook alone. It requires a certain assistance which can only be provided by medical ethics. Medical ethics is the guiding moral that guides Health Care Workers to provide a holistic approach while treating a patient. Medical ethics is the soul that can not only prevent future dilemmas but can overall make a healthcare worker ‘feel’ and have empathy for the patient. From the story of Paul and the true life stories of patients we encountered during our visit to the Leprosy center, we got a sense of empathy. Ethical practice and empathy are the pillars that can play a vital role in the rapidly increasing level of violence against the Health care professionals. So it is an emerging need to have medical ethics as
a part of the curriculum among medical students.