Ocular evaluation in patients with chronic renal failure--a hospital based study

Chronic renal failure affects every organ system including eye. The aim of this study is to conduct thorough ocular examination in the patients of chronic renal failure and to analyze the findings. 119 cases were collected from Nephrology unit of Tribhuvan University Teaching Hospital between 1st June 2002 to 15th December 2003. This was a cross sectional, descriptive type of study. Sampling technique was consecutive and stratified. Severity of renal disease was classified as mild, moderate, severe and end stage renal disease. Twenty-three percent of total 238 eyes had vision < 6/18. The causes for visual impairment were maculopathy 23 eyes, cataract 14 eyes followed by proliferative diabetic retinopathy, 9 eyes. Twelve percent of total eyes had vision < 6/60. Lid edema was present in 63.0%, conjunctival pallor in 75.6% and corneal calcification in 1.6%. Retinopathy was the most important finding. Hypertensive retinopathy was present in 56 out of total 119 cases (47.1%). It was more prevalent and tended to be more severe as renal disease progressed. This was statistically significant. Diabetic retinopathy was present in 38 out of 43 diabetic cases (88.3%). Although statistically not proven, more severe grades of diabetic retinopathy were detected with increasing severity of the renal disease. There was one case of bilateral serous detachment of the retina relating to chronic renal failure. In this study, 47 out of 56 cases of hypertensive retinopathy and 19 out of 38 cases of diabetic retinopathy were detected for the first time, thus showing the importance of ocular evaluation of the patients of renal insufficiency.

Unusual mode of firearm injury from the recoiled rear end of a gun barrel

Atypical gunshot wounds are caused by a diverse set of parameters relating to weapons and ammunition. We report a previously-unreported and atypical mode of gunshot wound produced by a detached rear end of the barrel of a gun following accidental gun fire, and discuss the difficulties in the management. A 36-year-old man presented to the emergency department with an alleged history of injury on the forehead with the rear end of a gun barrel following accidental gunfire while cleaning the nozzle. Since the time of injury, the patient was in an altered sensorium and had weakness on the right side of the body. There was minimal but continuous bleeding from the wound, with extrusion of brain matter. Skull radiograph showed that the rear end of the barrel had entered the left frontal bone, with associated depressed fracture of the frontal bone. The patient underwent a bicoronal, bifrontal craniotomy with a T-shaped extension towards the barrel to facilitate the reflection of the scalp flap and to avoid any movement of the barrel as it might further injure the brain. Necrotic brain, dura and bone pieces were removed. The patient was doing well at follow-up except for mild residual motor deficits. This case illustrates that while working with limited facilities, particularly in underdeveloped countries, a careful clinical assessment, interpretation of available images and a judicious operative approach can help to save the patient.

Use of rK39 for diagnosis of post kala-azar dermal leishmaniasis in Nepal

A recently developed nitrocellulose-based dipstick test, rK39, has been widely used for the diagnosis of kala-azar. In this study, we evaluated its use for the diagnosis of post kala-azar dermal leishmaniasis (PKDL). We also investigated the time taken by patients to develop PKDL after apparent cure of kala-azar (visceral leishmaniasis, VL) and the time taken by patients to come to the hospital after the appearance of symptoms of PKDL. A majority of patients developed the disease within three years after the apparent cure of kala-azar (KA). A majority of patients sought treatment within five years after the onset of PKDL. The amastigotes of Leishmania donovani bodies (LDBs) were demonstrated in 70, 20, and 20% of slit-skin smears (SSS) prepared, respectively, from nodular, papular, and macular forms. The presence of highest density (6+) LDBs in the SSS of 20% of nodular PKDL patients indicated that they may have acted as reservoir in the community. Other reservoirs are not known in Nepal. Only 8% cases were detected by aldehyde test. Although this test is obsolete it is still used in rural parts of Nepal. The dipstick (rK39) was 96% sensitive and 100% specific to diagnose PKDL. Its positive predictive value, negative predictive value, and diagnostic efficacy were 100, 91, and 97% respectively. Due to the advantage of cost compared with the direct agglutination test (DAT), and being easy to use and store in field conditions, rK39 is a good tool to diagnose PKDL in rural situations. All the PKDL patients were cured of the disease after treatment by SAG.

Role of mid-trimester transvaginal cervical ultrasound in prediction of preterm delivery

The objective of this study was Transvaginal Ultrasonography (TVS) to examine the potential of routine measurement of cervical parameters by TVS at mid-trimester to predict preterm delivery. Cervical parameters measured by TVS at 20-24 weeks were critically analyzed for their ability to predict spontaneous preterm birth. The risk of spontaneous preterm delivery increased steeply as cervical length decreased. At a cut off value of d<2.5 cm, the cervical length measurements had sensitivity, specificity, positive predictive value and negative predictive value of 77%, 95%, 56% and 98% respectively. Our data suggests that the duration of pregnancy is directly related to length of the cervix, the shorter the cervix, the greater the chance of preterm delivery.

Association of systemic diseases with retinal vein occlusive disease

Retinal vein occlusion (RVO) is the second commonest vascular disease of the eye, second only to Diabetic Retinopathy. The association of the retinal vein occlusion with other systemic disease likes hypertension, diabetes mellitus and others has been well documented. With the increase in persons being affected from these disorders, patients with retinal vein obstruction are also increasing. Hence, a study was designed to evaluate all cases of RVO to find out its association with systemic disorders. A total of 100 patients (106 eyes) were enrolled in the study. Out of which, 66 cases reported to have Brach Retinal Vein Occlusion (BRVO) and rest 34 cases with Central Retinal Vein Occlusion (CRVO). Among the associated systemic diseases, hypertension and diabetes mellitus accounted for 84% cases. Isolated hypertension (54%) was most commonly seen followed by diabetes mellitus (8%). The prevalence of BRVO was almost twice as compared to CRVO. The high association of various systemic disorder especially Hypertension and diabetes further supports the need of early and periodic eye examination for those suffering from these disorders.

The economic burden of visceral leishmaniasis for households in Nepal

Visceral leishmaniasis (VL) affects persons from the lowest socioeconomic strata of the community, but its economic impact is not precisely known. An exploratory survey to document the economic costs of VL to households was conducted in an endemic focus in eastern Nepal. Data were collected from the 20 households in this cluster. Cases of VL over the last 3 years were elicited and information on direct and indirect costs incurred due to the disease as well as income of the households over the last year was estimated. It was reported that 15.0% (16/107) of the residents had suffered from VL and that almost all of the patients had preferred, in the first instance, to visit the private services or local faith healers instead of visiting the local public health facility. Average total costs incurred per episode of VL were above the median annual per capita income, and six of the seven affected households either had to sell part of their livestock or to take a loan to cover the costs. Direct costs consisted of 53% of the total cost, with 75% of this cost incurred before the patients actually received any treatment for VL. This study demonstrates how VL can lead to catastrophic expenditure for affected households.

Treatment of visceral leishmaniasis in south-eastern Nepal: decreasing efficacy of sodium stibogluconate and need for a policy to limit further decline

Sodium stibogluconate (SSG) is the first-line therapy for visceral leishmaniasis (VL) in south-eastern Nepal. Recent studies from the neighbouring state of Bihar, India, have shown a dramatic fall in cure rates with treatment failure occurring in up to 65% of VL patients treated with SSG. A prospective study was conducted at a tertiary-level hospital located in south-eastern Nepal from July 1999 to January 2001. Parasitologically proven kala-azar patients with no previous history of treatment for VL were treated with SSG 20 mg/kg/d for 30 d which was extended to 40 d in those with persistent positive parasitology. Of the 110 patients who completed SSG therapy and were assessed at 1 and 6 months, definite cure was achieved in 99 patients (90%) and SSG failure occurred in 11 patients (10%). Except for the presence of hepatomegaly and a lower platelet count there was no clinical or laboratory baseline characteristic associated with treatment failure. A significantly lower cure rate (76%, P = 0.03) was observed in patients from the district of Saptari, which borders the antimony-resistant VL areas of Bihar. The efficacy of SSG as a first-line treatment for VL in south-eastern Nepal was still satisfactory, except for the patients living closer to the antimony-resistant VL areas of India. These findings indicate that the spread of resistance to antimonials is already taking place in Nepal and that a policy to control further spread should be urgently implemented.

Evaluation of a urinary antigen-based latex agglutination test in the diagnosis of kala-azar in eastern Nepal

BACKGROUND

We evaluated the diagnostic accuracy as well as the reproducibility of the urine latex agglutination test 'KAtex' in the diagnosis of kala-azar in patients recruited at a tertiary care centre in Dharan, Nepal, between November 2000 and January 2002.

METHODS

All patients presenting with fever of 2 weeks or more and splenomegaly were consecutively enrolled. Bone marrow and--if negative--spleen aspirates were examined for Leishmania donovani. Serum and urine samples were taken in duplicate for the Direct Agglutination Test (DAT) and KAtex. The reference laboratory determined sensitivity and specificity of KAtex. Reproducibility between both laboratories was assessed.

RESULTS

KAtex was performed on urine from 155 parasitologically confirmed kala-azar and 77 non-kala-azar cases (parasitology and DAT-negative). KAtex showed a sensitivity of 47.7% (74/155, 95% CI: 39.7-55.9) and a specificity of 98.7% (76/77, 95% CI: 93.0-100.0). Reproducibility of KAtex showed a kappa of 0.684 (P < 0.001, n = 232).

CONCLUSION

KAtex evaluation showed high specificity, low sensitivity and moderate reproducibility. A urine test for kala-azar could become a real breakthrough in kala-azar management if its reproducibility and sensitivity could be further improved.

Cardiac and electrocardiographical manifestations of acute organophosphate poisoning

INTRODUCTION

To study the extent, frequency and pathogenesis of the cardiac and electrocardiographical manifestations of acute organophosphate poisoning.

METHODS

37 adult patients admitted over a three-year period with a diagnosis of acute organophosphate or carbamate poisoning were studied prospectively. The clinical features and electrocardiographical finding were recorded.

RESULTS

Cardiac complications developed in 23 patients (62.2 percent). These were: non-cardiogenic pulmonary oedema in eight cases (21.6 percent), electrocardiographical abnormalities including prolonged Q-Tc interval in 14 cases (37.8 percent), ST-T changes in 11 cases (29.7 percent), and conduction defects in two cases (5.4 percent). Sinus tachycardia occurred in 15 patients (40.5 percent) and sinus bradycardia in seven patients (18.9 percent). Hypertension developed in five patients (13.5 percent) and hypotension in four patients (10.8 percent). Five patients (13.5 percent) needed respiratory support because of respiratory depression of which two patients developed intermediate syndrome. Out of 14 patients with prolonged Q-Tc interval, only one had polymorphic ventricular tachycardia of the torsade de pointes type. Two patients died from non-cardiogenic pulmonary oedema and one from ventricular fibrillation, giving a hospital mortality of 8.1 percent.

CONCLUSION

Cardiac complications usually occur during the first hour after exposure. Hypoxemia, electrolyte derangements and acidosis are major predisposing factors for the development of these complications. Intensive supportive treatment, meticulous respiratory care and administration of atropine in adequate doses vary early in the course of the illness will reduce the mortality.

Liver abscess in the tropics: an experience from Nepal

Thirty-six consecutive cases of liver abscess seen at the BP Koirala Institute of Health Sciences Hospital, Dharan, Nepal, from 1995 to 1998, were reviewed. Twenty-one cases were male and 15 female, with a mean age of 42 years. Twenty-four cases (66.7%) were amebic, 7 (19.4%) pyogenic, 3 (8.3%) indeterminate and 2 (5.5%) tuberculous. The most frequent clinical features included fever (88%), leukocytosis (66.7%), abnormal level of serum albumin (44.4%) and alkaline phosphatase (38.9%). The liver abscess was single in 61.1%, multiple in 27.8%, and in 66.7% of cases the abscess was present in the right lobe of the liver. Ultrasonography was diagnostic in all cases. A positive culture of the abscess was obtained in 7 cases (19.4%). The most frequent bacteria found were Klebsiella pneumoniae (4;11.1%), followed by Escherichia coli (3;8.3%). Two cases were due to Mycobacterium tuberculosis and none had malignancy. Percutaneous drainage was performed in 27 patients (75%). Mortality attributable to the abscess was 5.5%. We found percutaneous needle aspiration of liver abscess helpful in confirming diagnosis, as it provides a better bacteriological culture yield, gives a good outcome, and may uncover clinically unsuspected conditions like malignancy and tuberculosis. These two conditions should certainly be considered possible causes in our part of the world when an abscess fails to respond to standard treatment. In developing countries like Nepal, the clinical presentation of liver abscess has not varied over time. At present, rapid diagnosis and image-guided percutaneous drainage offer a better prognosis for liver abscess. We also recommend routine cytological examination of aspirated abscess materials, as well as stains and cultures for acid-fast bacilli.

Epidemiological study of kala-azar by direct agglutination test in two rural communities of eastern Nepal

We conducted a sero-epidemiological study of kala-azar in two endemic communities (Kasaini and Gidhaniya) situated in the Terai (plain) of eastern Nepal. Direct agglutination test (DAT) was used as a serological test for screening. Capillary blood samples were collected by filter paper method from 601 (96%) people of a total population of 628 in Kasaini and from 482 (94%) people of 515 in Gidhaniya. Positive DAT titres (1:2000) were found in 66 (6.09%) of 1083 sera tested. The male-female sero-prevalence ratio was 1.44:1 and the age group of 15 years and above was most affected. Among the bone marrow aspirates collected from 66 DAT seropositive cases, only 19 were positive for Leishmania donovani (LD bodies). Of the 47 DAT seropositive but LD bodies' negative cases, three were clinically active cases of kala-azar. Another nine developed clinical symptoms of kala-azar during 6 months follow-up and 23 were cases that had received prior treatment for kala-azar (within 1 year). The results of this study show the potential of the DAT on filter paper as a screening test for the surveillance of kala-azar at a community level.

The Parasight -F Test use in malaria Epidemic in Nepal

A field based trial to compare microscopy and a rapid diagnostic antigen capture detection dipstick(ParaSightTM-F) to diagnose malaria was conducted in 2 village development committees (VDCs) of Nepalduring epidemic (1996/97). 57 and 273 subjects were tested from Parasan and Guthiparsauni VDCrespectively yielding 15 (26.3%) and 152 (55.7%) positive by ParaSightTM -F who were given radical treatmenton the spot. Compared to thick blood film (TBF), the ParaSight F (PSF) test was 93.8% and 94.4% sensitivityrespectively in Parasan and Guthiparsauni for the detection of P. falciparum malaria. There were 10 falsenegative results with the PSF test from the two villages; 6 samples with <100 parasites / ? l, 1 sample with240 parasite/? l and 3 samples having only gametocytes. In this population, the PSF was found to be highlyaccurate simple and rapid suggesting that it is suitable to be used in remote areas and/or epidemic situationfor prompt treatment. However microscopy is good to prevent transmission of the parasites from gametocytecarriers.Key Words: Malaria, diagnosis, ParaSightTM - F, An. fluviatilis, epidemic, Nepal.

Students’ perceptions of the pre-clinical integrated medical curriculum in a Health University in Nepal

Abstract

AN OVERVIEW OF INTEGRATED MEDICAL AND DENTAL UNDERGRADUATE PRE-CLINICAL CURRICULA AT B. P. KOIRALA INSTITUTE OF HEALTH SCIENCES, NEPAL: A MULTIPROFESSIONAL APPROACH

Curricular innovations such as multiprofessional education (MPE) sensitise healthprofessionals towards the role of other health professionals and inculcate team spirit.This is a preliminary report on MPE in practice in the preclinical phase of dental andmedical undergraduate courses at B.P. Koirala Institute of Health Sciences, Nepal.The preclinical curriculum of the undergraduate courseis integrated, organ systembased and partially problem based. There is an emphasis on early exposure of studentsto patients and to community. The undergraduate course in medicine started in 1994and in dental surgery in 1999 based on the core curriculum developed at variousworkshops. The course duration and structure is similar in bot

Sodium stibogluconate cardiotoxicity and safety of generics

Between April 9 and May 5 2000, an outbreak of fatal cardiotoxicity occurred in Nepal amongst visceral leishmaniasis patients treated with a recently introduced batch of generic sodium stibogluconate (SSG) from GL Pharmaceuticals, Calcutta, India. Eight (36%) of 23 patients treated with this batch died, and in 5 (23%) death was attributed to the cardiotoxicity of the drug. This contrasts with the low total death rate (3.2%) and death rate due to cardiotoxicity (0.8%) observed among 252 patients treated between August 1999 and December 2001 with generic SSG from Albert David Ltd, Calcutta, India. These data show that every batch of generic SSG should be subject to rigorous quality control prior to use.

Orally effective drugs for kala-azar (visceral leishmaniasis): focus on miltefosine and sitamaquine

Currently there are no effective orally administered drugs or visceral leishmaniasis or kala-azar, a parasitic disease affecting about 0.5 million people a year, majority of whom are in India and adjacent areas of Nepal. Symptoms of affected patients are fever, cachexia, hepatosplenomegaly and pancytopenia. The disease is usually fatal, if left untreated. Traditionally kala-azar is treated with four weeks of injections of sodium stibogluconate, a pentavalent antimonial. However, this treatment has not only shown resistance in 37-64% patients of the current Indian epidemic in Bihar (the epicentrre) but also life-threatening cardiotoxicity in 7-10% and treatment-related deaths in 5-10% cases, besides being unsuccessful at times. Parenteral amphotericin B is used as a secondary agent that shows 95% effectiveness but its toxicity and high cost of even the well tolerated liposomal complex precludes its wide use in the developing countries, where the disease is present in epidemic proportions. Recently, miltefosine (hexadecylphosphocholine), a compound originally developed as an antitumour agent has been shown to be an orally effective drugs against kala-azar. All clinical trials with this drug are conducted in India in patients of visceral leishmaniasis. A regimen of 100 mg per day or 50 mg twice daily for 3-4 weeks was observed to produce a cure rate of 100%. Gastrointestinal side effects were frequent (62%) but no patient discontinued the therapy. A phase III trial involving 300 HIV-negative adults and adolescents is underway in India and the drug is hoped to be licensed in the next 2-3 years. Few studies of phase II clinical trials mainly conducted in Kenya with another drug, sitamaquine or kalazaquine (WR 6026), an 8-aminoquinoline has also shown promise as an orally effective agent (in a dose of 1 mg/kg/day for two weeks) for visceral leishmaniasis. These Studies with two orally effective compounds, it appears, will open new vistas for orally effective, affordable and acceptable drugs in the armamentarium for the treatment of kala-azar. It is expected that in future we would have effective ways to prevent and treat all forms of leishmaniasis without discomforting the patient.

HAEMODIALYSIS IN B. P. KOIRALA INSTITUTE OF HEALTH SCIENCES, DHARAN - AN INITIAL EXPERIENCE

Dialysis supports life, in spite of complete cessation of renal functions. Haemodialysis(HD) service became available in B. P. Koirala Institute of Health Sciences, Dharansince September 1999. Six hundred and sixty one sessions of HD in 50 patients werecarried out in one year. End stage renal disease (ESRD), acute renal failure (ARF),acute on chronic renal failure constituted 54%, 26% and 20% of the patientsrespectively. Majority of the patients (72%) were between 15 to 50 years of age. Chronicglomerulonephritis, chronic interstitial nephritis, and diabetes nephropathy were themost common causes of ESRD. Recovery following HD was 70% in ARF,whileallpatients of acute on chronic renal failure improved following few sessions of HD.Drop out rate on maintained haemodialysis (MHD) was 52%. The increasing demandof dialysis service in this region is difficult to fulfill due to restricted facilities fordialysis, lack of renal transplantation in Nepal, and economic constraint in the part ofpatients. Primary and secondary prevention of renal diseases by community education,awareness and participation needs emphasis. Key Words: Haemodialysis, End stage renal disease, Acute renal failure,Acute on chronic renal failure.

Ocular morbidity in schoolchildren in Kathmandu

BACKGROUND/AIMS

Any information on eye diseases in schoolchildren in Nepal is rare and sketchy. A programme to provide basic eye screening to schoolchildren with an aim to provide services as well as gather information on ocular morbidity has been started.

METHODS

All the children in the schools visited are included in the study. This programme is targeted at poor government schools, which are unable to afford this service. A complete eye examination is given to all the children including slit lamp examination, fundus evaluation and retinoscopy, and subjective refraction.

RESULTS

A total of 1100 children from three schools are included in this report. 11% of our schoolchildren have ocular morbidity, 97% (117 out of 121) of which is preventable or treatable. Refractive error is the commonest type of ocular morbidity (8.1%). Myopia is the commonest type of refractive error (4.3%) as opposed to hypermetropia (1.3%). 12.4% of children with refractive error have already developed amblyopia. Strabismus is the second commonest type of ocular disability (1.6%). Alternate divergent squint is the commonest type of strabismus (1.4%). Traumatic eye injuries (0.54%), xerophthalmia (0.36%), and congenital abnormalities (0.36%) are much less common.

CONCLUSION

A school eye screening cum intervention programme with periodic evaluation seems to be appropriate for countries like Nepal as most of the eye diseases found are preventable or treatable.

Post kala-azar dermal leishmaniasis (PKDL): a first case report from Nepal

Post kala-azar dermal leishmaniasis (PKDL) is a non-ulcerative lesion of the skin caused by Leishmania donovani, which is usually seen after completion of treatment of the kala-azar. The condition is yet to be reported from Nepal. We document and report for the first time a case of PKDL in Nepal.

Post-kala-azar dermal leishmaniasis (PKDL): the first case report from Nepal

Post-kala-azar dermal leishmaniasis (PKDL) is condition characterized by non-ulcerative lesions of the skin caused by Leishmania donovani that is usually seen after the completion of treatment of kala-azar (visceral leishmaniasis). We document the first case report of PKDL in Nepal.

Serum level of low-density lipoprotein cholesterol in hypertensive retinopathy

Increased serum level of low-density lipoprotein is associated with coronary artery disease. There are, however, no reports on whether the same is true in hypertensive retinopathy. A cross-sectional comparative study was carried out to evaluate the serum level status of low-density lipoprotein in hypertensive retinopathy, including 30 randomly selected subjects with hypertensive retinopathy; age and gender matched 26 hypertensives without fundus changes. Serum low-density lipoprotein cholesterol (LDL-C) levels were assessed in all subjects. Results showed statistically significant (p < 0.0196) higher serum levels of LDL-C in hypertensive patients with retinopathy (mean +/- SD = 2.45 +/- 1.76 mmol/l, SE = 0.33 and 95% CI = 1.79-3.11 vs mean +/- SD = 1.6 +/- 0.4 mmol/l, SE = 0.08 and 95% CI = 1.44-1.76). An increased serum level of LDL-C is associated with hypertensive retinopathy.

Prospective evaluation and comparison of the direct agglutination test and an rK39-antigen-based dipstick test for the diagnosis of suspected kala-azar in Nepal

The diagnosis of visceral leishmaniasis (kala-azar) remains difficult in rural endemic areas and practical and reliable tests are badly needed. Two serological tests, the Direct Agglutination Test (DAT) and an rK39-antigen-based dipstick test, were compared to parasitological diagnosis in a group of 184 patients presenting at a tertiary care centre in south-eastern Nepal with a history of fever > or = 14 days and splenomegaly; 139 patients had a parasitologically proven kala-azar and 45 patients had a negative parasitological work-up. The rK39 dipstick showed a sensitivity of 97% and a specificity of 71%. The DAT was up to 99% sensitive with a low cut-off titre (1:400) but its specificity did not exceed 82% even with a high cut-off titre (1:51 200). Both tests could be used for screening suspect patients in endemic areas. However, their use as confirmatory tests should be restricted to situations where the proportion of kala-azar among clinical suspect patients is high. The rK39 dipstick is cheaper and easier to use than the DAT and could be used widely provided that both its performance and production remain stable.

MANAGEMENT OF SNAKEBITE – CURRENT CONCEPT

Abstract

STEROID INDUCED CATARACT IN A CHILD WITH NEPHROTIC SYNDROME A CASE REPORT

ABSTRACT

VOGT, KOYANAGI, HARADA (VKH) SYNDROME

ABSTRACT

Thyroid dysfunction in eastern Nepal

Nepal lies in an area of endemic iodine deficiency. Thyroid dysfunction, along with a higher than average prevalence of goiter, is a major public health problem among the local population. The present study was undertaken to investigate the prevalence of thyroid dysfunction among the hill and terai (low land) castes of eastern Nepal that attended the thyroid clinic at the BP Koirala Institute of Health Sciences (BPKIHS), Dharan. A total of 599 cases were studied during a single year. The distribution of hyperthyroid and hypothyroidism was 13.68% and 17.19% respectively. The majority of the thyroid dysfunction was seen in the 21-40 year age group. The prevalence of hypothyroidism was slightly higher among terai castes (17.66%) when compared with hill castes (15.17%). There was a similar distribution of thyroid dysfunction among the male and female populations of the goitrous subjects (n=157), most were euthyroid (58.59%); hyperthyroidism affected (27.38%). Since, it was a hospital-based study, the prevalence of thyroid dysfunction may not be applicable to the general population. Extensive field-based countrywide epidemiological studies are necessary to provide data about thyroid dysfunction in the community.

Schwann cells express active agrin and enhance aggregation of acetylcholine receptors on muscle fibers

To explore novel roles of glial cells in synaptic function and formation, we examined the expression of agrin in frog Schwann cells and tested their role in the aggregation of acetylcholine receptors (AChRs). Using reverse transcription-PCR, we found that Schwann cells along nerve fibers in tadpoles expressed only the inactive agrin isoform B0 but began to also express active agrin isoforms B11 and B19 at approximately metamorphosis. During nerve regeneration in the adult, the expression of these active agrin isoforms in Schwann cells was upregulated, including the appearance of the most potent isoform, B8. This upregulation was induced by regenerating axons but not by nerve injury per se. In muscle cultures, the presence of adult Schwann cells enhanced the number and the total area of AChR aggregates 2.2- and 4.5-fold, respectively, and this enhancement was eliminated by heparin treatment. Furthermore, adult Schwann cells in culture expressed active agrin isoforms and produced agrin protein. Using a novel technique to selectively ablate perisynaptic Schwann cells (PSCs) at the neuromuscular junction, we found that PSCs also expressed active agrin isoforms B11 and B19, and these active isoforms were upregulated, including the appearance of B8, during reinnervation. Observation in vivo showed that extrajunctional AChR aggregates were associated with PSC sprouts after nerve injury and subsequent reinnervation. These results suggest that, contrary to the prevailing view that only neurons express active agrin, glial cells also express active agrin and play a role in the aggregation of AChRs both in vitro and in vivo.

Lymphatic leishmaniasis--first case report from Nepal

We report a case of exclusive involvement of lymph node in leishmaniasis presenting as generalized lymphadenopathy. The diagnosis of lymphatic leishmaniasis was confirmed by the presence of Leishmania donovani body in fine needle aspiration cytology, positive direct agglutination test and anti-rK39 antibodies. The bone marrow aspiration was negative for Leishmania donovani body. This is the first case of lymphatic leishmaniasis reported from Nepal.

The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal

AIMS

To determine the incidence of ocular trauma and corneal ulceration in the district of Bhaktapur in Kathmandu Valley, and to determine whether or not topical antibiotic prophylaxis can prevent the development of ulceration after corneal abrasion.

METHODS

A defined population of 34 902 individuals was closely followed prospectively for 2 years by 81 primary eye care workers who referred all cases of ocular trauma and/or infection to one of the three local secondary eye study centres in Bhaktapur for examination, treatment, and follow up by an ophthalmologist. All cases of ocular trauma were documented and treated at the centres. Individuals with corneal abrasion confirmed by clinical examination who presented within 48 hours of the injury without signs of corneal infection were enrolled in the study and treated with 1% chloramphenicol ophthalmic ointment to the injured eye three times a day for 3 days.

RESULTS

Over the 2 year period there were 1248 cases of ocular trauma reported in the population of 34 902 (1788/100 000 annual incidence) and 551 cases of corneal abrasion (789/100 000 annual incidence). The number of clinically documented corneal ulcers was 558 (799/100 000 annual incidence). Of the 442 eligible patients with corneal abrasion enrolled in the prophylaxis study, 424 (96%) healed without infection, and none of the 284 patients who were started on treatment within 18 hours after the injury developed ulcers. Four of the 109 patients (3.7%) who presented 18-24 hours after injury developed infections, and 14 (28.6%) of the 49 patients who presented 24-48 hours subsequently developed corneal ulceration.

CONCLUSIONS

Ocular trauma and corneal ulceration are serious public health problems that are occurring in epidemic proportions in Nepal. This study conclusively shows that post-traumatic corneal ulceration can be prevented by topical application of 1% chloramphenicol ophthalmic ointment in a timely fashion to the eyes of individuals who have suffered a corneal abrasion in a rural setting. Maximum benefit is obtained if prophylaxis is started within 18 hours after injury.

Post-kala-azar dermal leishmaniasis in Nepal

BACKGROUND

Post-kala-azar dermal leishmaniasis (PKDL) manifests as a skin eruption after healing of visceral leishmaniasis (VL), either spontaneously or as a result of treatment. This study was undertaken to describe the demographic, clinical, and histopathologic features of PKDL in Nepal.

METHODS

Demographic, clinical, microbiologic, and histopathologic features and response to treatment were studied in 22 patients with PKDL from April 1998 to March 2000.

RESULTS

PKDL accounted for 0.13% of all new dermatologic cases. There were 13 (59.1%) males and nine (40.9%) females. A past history of kala-azar was present in all but one patient. A family history of kala-azar was noted in eight (36.4%) patients. All patients presented with multiple types of lesion, except for two in whom only macular lesions were seen. Oral lesions in the form of nodules and plaques were seen in four patients. Generalized lymphadenopathy was present in five patients. Slit skin smears revealed Leishman-Donovan bodies (LDBs) in nine (40.9%) patients. In macular lesions, there was a sparse infiltrate of plasma cells, lymphocytes, or histiocytes in the upper dermis. There was a dense chronic inflammatory infiltrate comprising plasma cells, lymphocytes, histiocytes, and epithelioid cells in the entire dermis from papules, plaques, or nodules. Giemsa staining of biopsy specimens revealed LDBs in seven (38.9%) patients only. Fine needle aspiration from epitrochlear lymph nodes in two patients demonstrated LDBs. All patients responded well to treatment with minimal side-effects.

CONCLUSIONS

This study emphasizes the need to be aware of the possibility of cases of PKDL in endemic regions of leprosy, as the conditions may be difficult to distinguish clinically and histopathologically.

A clinico-epidemiological study of organophosphorus poisoning at a rural-based teaching hospital in eastern Nepal

Thirty-seven patients with severe organophosphorus poisoning (OPP) presented to the emergency ward of BP Koirala Institute of Health Sciences between January 1995 and December 1996. The mean age of patients was 26.9 years. There were 17 (46%) males and 20 (54%) females, with male:female ratio being 1:1.2.Twenty-three (62%) patients were unmarried with 16 (46%) of them students. The most common reason for poisoning was suicide--32 patients (86.5%). The most commonly involved compound was Metacid (methyl-parathion)--23 (62%) patients. Ninety per cent of the patients presented within 2 h of ingestion. All patients were managed with intravenous atropine. Pralidoxime was given to patients with nicotinic symptoms and mechanical ventilation initiated in patients with respiratory distress. The mean dose of atropine used in the first 24 h and during the hospital stay was 30.6 mg and 136.7 mg, respectively. The mean duration of treatment was 5.5 days (range 2-20 days). Two patients developed intermediate syndrome and the overall mortality among hospitalized patients was 8%.

Reciprocal interactions between perisynaptic Schwann cells and regenerating nerve terminals at the frog neuromuscular junction

The perisynaptic Schwann cell (PSC) has gained recent attention with respect to its roles in synaptic function, remodeling, and regeneration at the vertebrate neuromuscular junction (NMJ). Here we test the hypothesis that, following nerve injury, processes extended by PSCs guide regenerating nerve terminals (NTs) in vivo, and that the extension of sprouts by PSCs is triggered by the arrival of regenerating NTs. Frog NMJs were double-stained with a fluorescent dye, FM4-64, for NTs, and fluorescein isothiocyanate (FITC)-tagged peanut agglutinin (PNA) for PSCs. Identified NMJs were imaged in vivo repeatedly for several months after nerve injury. PSCs sprouted profusely beginning 3-4 weeks after nerve transection and, as reinnervation progressed, regenerating NTs closely followed the preceding PSC sprouts, which could extend tens to hundreds of microns beyond the original synaptic site. The pattern of reinnervation was dictated by PSC sprouts, which could form novel routes joining neighboring junctions or develop into new myelinated axonal pathways. In contrast to mammals, profuse PSC sprouting in frog muscles was not seen in response to axotomy alone, and did not occur at chronically denervated NMJs. Instead, sprouting coincided with the arrival of regenerating NTs. Immunofluorescent staining revealed that in muscle undergoing reinnervation 4 weeks after axotomy, 91% of NMJs bore PSC sprouts, compared to only 6% of NMJs in muscle that was chronically denervated for 4 weeks. These results suggest that reciprocal interactions between regenerating NTs and PSCs govern the process of reinnervation at frog NMJs: regenerating NTs induce PSCs to sprout, and PSC sprouts, in turn, lead and guide the elaboration of NTs.

Evaluation of new WHO diagnostic criteria for diabetes on the prevalence of abnormal glucose tolerance in a heterogeneous Nepali population--the implications of measuring glycated hemoglobin

AIM OF THE STUDY

The present study was designed to (a) evaluate the implications of revised WHO diagnostic criteria on prevalence of abnormal glucose tolerance, (b) compare glycated hemoglobin level amongst healthy, impaired glucose tolerance (IGT), impaired fasting glucose (IFG) and diabetic subjects and (c) evaluate the assay of glycated hemoglobin in screening IGT, IFG from normal subjects.

METHODOLOGY

Hospital based, cross-sectional study. Plasma glucose and glycated hemoglobin (gHb) were estimated by glucose oxidase and affinity chromatography method respectively.

RESULTS

The crude prevalence of IFG, IGT and diabetes were 9%, 18% and 5.29% respectively with no significant difference between Mongol and non-Mongol population. Newly introduced IFG group falsely incorporate 12% diabetic subjects and fails to detect 83% IGT subjects as impaired glucose metabolism. The gHb level is raised in IGT and diabetic group but not in IFG group.

CONCLUSION

The assay of gHb may be used to screen abnormal glucose tolerance but paired estimation of fasting glucose increases the reliability of diagnosis. The level of gHb in mild carbohydrate intolerance mostly depend on the level of rise in post prandial glucose (where the variation is wide, as in IGT) but not on the narrow variance in fasting plasma glucose level as found in IFG.

Prevalence of non-insulin dependent diabetes mellitus in urban areas of eastern Nepal: a hospital based study

Non-insulin dependent diabetes mellitus (NIDDM), which affects millions of people throughout the world, is a widely prevalent chronic debilitating disease that causes short term and long term complications. It is a problem in a developing country like Nepal, where there has been no report of prevalence. Hence this study was undertaken to investigate the prevalence of NIDDM among urban patients attending the outpatient clinic of BP Koirala Institute of Health Sciences (BPKIHS) hospital, and coming from the eastern part of Nepal. A sample of 1,840 subjects was incorporated in the study during a period of one year. WHO diagnostic criteria (1985) were followed to establish the diagnosis of NIDDM. The prevalence of diabetes was 6.3% (1.63% previous and 4.67% new) which is relatively high in comparison to many other countries. The prevalence of NIDDM in females was relatively lower (5.75%) than in males (6.73%). The prevalence showed an increasing trend with increasing age. The high incidence (new cases) of NIDDM in Nepal as found in the study may be due to lack of public awareness regarding the problem and poor medical services in the country.

The South Asian cataract management study: complications, vision outcomes, and corneal endothelial cell loss in a randomized multicenter clinical trial comparing intracapsular cataract extraction with and without anterior chamber intraocular lens implantation

OBJECTIVE

To determine clinical outcomes of primary intracapsular cataract surgery with and without implantation of anterior chamber lenses.

DESIGN

A multicenter randomized clinical trial.

PARTICIPANTS

One thousand two hundred twenty-nine male and female patients 40-75 years of age with senile cataract.

METHODS

Study patients were recruited from screening eye camps and outpatient clinics. Randomization to the two treatment groups was performed after screening for predetermined inclusion and exclusion criteria. Demographics, visual acuity, intraocular pressures, and corneal endothelial cell data were recorded before surgery and at 6 weeks, 12 months, and 24 months after surgery. Monitoring of the study was secured by a standardized image documentation procedure on all patients using the IMAGEnet digital imaging system. Analysis of corneal endothelial cell images was performed with the Cell Soft software (Topcon Corporation, Japan).

MAIN OUTCOME MEASURES

Visual acuity and central corneal endothelial cell loss.

RESULTS

The patients were randomized to intraocular lens (IOL; n = 616) and no IOL (n = 613) implantation. Surgical complications were reported in 177 (14.4%) patients (IOL = 14.8%; no IOL = 14.0%). The most frequent complication observed was vitreous loss which occurred in 10.3% of eyes (IOL = 11.2%; no IOL = 9.5%). At the final examination (2 years after surgery), 88% of the operated eyes had a best corrected vision of 6/18 or better (IOL = 88.8%; no IOL = 86.6%). Analysis of corneal endothelial cell data showed a small but significantly greater cell loss 6 weeks after surgery in eyes with IOL compared with those without IOL, but no overall difference was found between the treatment groups in the long term follow-up.

CONCLUSIONS

The findings indicate that there is a rationale for the use of anterior chamber intraocular lenses in primary intracapsular cataract surgery.

Quest for social accountability: experiences of a new health sciences university in Nepal

CONTEXT

B.P. Koirala Institute of Health Sciences (BPKIHS), a new Health Sciences University in Nepal has taken several steps to respond to the societal needs and has adopted an integrated, partially problem based and community oriented curriculum.

OBJECTIVE

The objective of this study was to measure the school's achievements in responding to societal needs.

METHODOLOGY

A descriptive cross sectional questionnaire survey (N = 46) of the administrators, faculty, students/residents and the community. The questionnaire included statements on relevance, quality, cost effectiveness and equity in the education, service and research domains of a medical school. The data were analyzed by using WINKS 4.5, a statistical package for Windows.

RESULTS

The responders satisfactorily rated BPKIHS. The mean rating (mean 3.11, SD = 1.06) was more than the satisfactory score (3). The responders were satisfied with the education (Mean = 3.26, SD = 1.06) and research (Mean = 3.12, SD = 1.10) but were less satisfied with the service domain (Mean = 2.94, SD = 0.98). The majority believed that the service is based on health care priorities (72%), and includes primary care (80%). A fair proportion felt the need for improvements in quality of care (50%) and cost effectiveness of care (46%). In general the faculty and administrators groups were more satisfied than the community and students/residents groups.

CONCLUSION

The study was useful in identifying the school's strengths as well as weaknesses in responding to the societal needs.

Assay of iodine deficiency status in three ecological regions of Nepal by a microdigestion method

Iodine deficiency disorders (IDD) are a global public health problem. In continuation of the efforts to eliminate the iodine deficiency in different parts of the world, IDD surveys are being conducted to assess the status of iodine nutriture. A survey was conducted in Nepal in 1998 with assistance from UNICEF. We present the status of the iodine nutriture, as assessed from urinary iodine levels of casual samples by a micro-digestion method, in the three ecological regions: Terai (flat region), Hilly region (300-3,000 m altitude) and mountainous regions (>3,000 m altitude) of Nepal. Terai region is more affected, having iodine deficiency in 18.6% of the population. The hilly and mountainous regions were found to have 11.2% and 9% iodine deficient populations respectively. The study shows improvement in iodine deficiency status with respect to previous surveys yet it continued to be prevalent in the country as a major public health problem which requires strengthening of preventive measures.

A clinico-epidemiological study of snake bite in Nepal

Envenoming from snake bite is an important medical condition, frequently encountered at the emergency department of BPKIHS hospital (Dharan, Nepal). This is a retrospective study of 52 cases of suspected snake bite who presented at the department from August 1993 to November 1994. Analysis of the data showed that snake bite was more frequent between the ages of 11 to 20 years (36.7%) and 2.5 times more common in males. Fifty-seven per cent of the bites occurred between 1600 h and midnight with highest incidence (51%) occurring during the monsoon (August-October). Twenty per cent of the patients were able to identify the snake species as venomous and 90% of them presented to the hospital within 3 h of being bitten. Sixty per cent of the bites were in the lower limb. Neurotoxicity due to envenoming was recorded in nine patients (17%). No case of coagulopathy was recorded. The overall case fatality was 3.8% but mortality amongst those exhibiting signs of neurotoxicity was 22%.

Cutaneous leishmaniasis in Nepal

We report an imported case of cutaneous leishmaniasis in a 30 year old adult male from Nepal caused by Leishmania tropica. This case from Dharan is the first such report of imported cutaneous leishmaniasis in Nepal.

A thirty day course of sodium stibogluconate for treatment of Kala-azar in Nepal

Twenty-seven cases of Kala-azar were treated with sodium stibogluconate at a dose of 20 mg/kg/day for 20 days (group A) and an equal number of cases were treated with the same dose but for a longer duration of 30 days (group B). Clinical and laboratory evaluation of these cases were carried out before and after therapy, during a follow up of cases every month, upto 6 months. Renal and liver function tests and electrocardiography were carried out of monitor any toxic effect of the drug during therapy. The cure rates of patients were 77.78% and 92.59% in group A and B cases respectively. Six and two patients in group A and B respectively were unresponsive to the treatment and showed relapse. Results of the study show that treatment of cases of Kala-azar with sodium stibogluconate in a dosage of 20 mg/kg/day for a longer period of 30 days is effective with a higher cure rate and minimum side effects, for treatment of cases of Kala-azar in this eastern part of Nepal, endemic for the disease.

Knowledge, attitudes, and practices about kala-azar and its sandfly vector in rural communities of Nepal

Reported are the results of a study of the knowledge, attitudes and practices (KAP) about kala-azar of the inhabitants of two villages (Titaria and Haraincha) situated in terai (plain) areas of Nepal. The villagers had poor knowledge about the transmission of kala-azar, with most villagers perceiving that mosquitos, instead of sandflies, were responsible for transmission of the infection. Most also failed to recognize the common symptoms of kala-azar. The majority of the respondents, 78.9% in Titaria and 48.4% in Haraincha, were aware that the condition can be treated, while fewer than 2% believed that it cannot be treated at all. More than 58% of villagers in Titaria and 36.8% in Haraincha used bednets. The residents of both villages were highly responsive to a programme to spray houses with insecticides. Fewer than 5% of respondents slept outdoors in farm outhouses and these individuals did not take any personal vector control measures. The results of this study show the importance of understanding the beliefs and practices of communities in the successful planning and implementation of kala-azar control activities in Nepal.

Epidemiologic characteristics, predisposing factors, and etiologic diagnosis of corneal ulceration in Nepal

Corneal ulceration is one of the most frequent causes of blindness in developing countries. Between September 1985 and August 1987, 405 patients with corneal ulceration were examined at Tribhuvan University Teaching Hospital in Kathmandu, Nepal. Males and females were equally affected. The most common predisposing cause of ulceration was corneal trauma, usually with organic agricultural materials. Microorganisms were grown from 324 (80%) of the ulcers. Pure bacterial cultures were obtained from 256 (63.2%) of the patients, whereas pure fungal cultures were obtained from 27 (6.7%) of the patients. In 41 patients (10.1%), corneal cultures yielded a mixed growth of bacteria and fungi. Of a total of 398 bacterial isolates, 124 (31.1%) were positive for Streptococcus pneumoniae, the most commonly isolated organism in the series. Other frequently isolated bacteria included Staphylococcus epidermidis, S. aureus, and Pseudomonas species. Of 68 positive fungal isolates obtained, 32 (47.0%) were identified as Aspergillus species. Candida species and Fusarium species were less commonly seen.

Pattern of Childhood Glaucoma

Glaucoma is one of the important causes of blindness in children all over the world1 .Childhood glaucoma encompasses a wide variety of conditions ranging from primarycongenital glaucoma to different acquired varieties. They may present with only ocularinvolvement or as a part of a syndrome with multiple system involvement. Thevisual prognosis of childhood glaucoma depends upon the structural involvement, stageof presentation, time of intervention and their follow up2. Though all glaucomas areknown to produce blindness, childhood glaucoma unlike the glaucoma in adults havedifferent disease process which enables the optic nerve fibers to regain their functionalintegrity once the IOP is brought down to normal.3 Thus, early diagnosis andearly treatment to achieve normal intraocular pressure can, to some extent, bringback one’s vision. Childhood glaucoma certainly needs to be addressed with muchmore emphasis than that of adult glaucoma, as it may threaten physical as well asmental growth if not tackled at proper time to retain visual stimuli.Most of the literatures on childhood glaucoma have emerged from western world 4,5,6.There has been no literature in this regard from Nepal and profile of childhood glaucomais yet to be determined. This was a retrospective study carried out by GlaucomaUnit B.P. Koirala Lions Center of Ophthalmic Studies with the main intention to seethe profile of glaucoma in Nepalese children.Out of a total of 475 cases of glaucoma seen in a period of 5 years, 27 (5.68%) werefound to be the cases of congenital glaucomas.Primary congenital glaucoma (PCG) was most frequently seen among children. Majorityof the cases of PCG presented late, after 3 years of age, with significant amountof visual loss. Most of them were brought to hospital for the complaint of watering andenlargement of eyeball.