Progress and prospects of C4 trait engineering in plants

Incorporating C₄ photosynthetic traits into C₃ crops is a rational approach for sustaining future demands for crop productivity. Using classical plant breeding, engineering this complex trait is unlikely to achieve its target. Therefore, it is critical and timely to implement novel biotechnological crop improvement strategies to accomplish this goal. However, a fundamental understanding of C₃ , C₄ , and C₃ -C₄ intermediate metabolism is crucial for the targeted use of biotechnological tools. This review assesses recent progress towards engineering C₄ photosynthetic traits in C₃ crops. We also discuss lessons learned from successes and failures of recent genetic engineering attempts in C₃ crops, highlighting the pros and cons of using rice as a model plant for short-, medium- and long-term goals of genetic engineering. This review provides an integrated approach towards engineering improved photosynthetic efficiency in C₃ crops for sustaining food, fibre and fuel production around the globe.

Conchopexy Suture versus Bolgerization in preventing middle turbinate lateralisation following FESS

Background: Middle turbinate lateralisation is the most common minor post-operative complication following functional endoscopic sinus surgery. This study aimed to compare the outcome between Conchopexy suture and Bolgerization method in preventing middle turbinate lateralisation. Methodology: This was a prospective, comparative and interventional study conducted from May 2018 to November 2019 at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. A total of 68 patients were divided equally into two groups. Following functional endoscopic sinus surgery, the middle turbinate was medialised either by Conchopexy suture or Bolgerization technique. Postoperative assessment was done on the second and 12th week of surgery, where the position of the middle turbinate and status of the sinus cavity were assessed using perioperative sinus endoscopic (POSE) score. Chi-square test and unpaired t test were used for comparison of postoperative results between two groups taking p value of < 0.05 as statistically significant. Results: Lateralised middle turbinate and mean POSE score was 5/34 (14.8%) and 2.1±1.25, respectively, in Conchopexy group whilst in Bolgerization group it was 6/34 (17.6%) and 2.5±1.46. However, the observed differences were not statistically significant. Conclusion: Conchopexy suture and Bolgerization techniques were equally effective in preventing middle turbinate lateralisation. Hence, either of these techniques could be used as an adjunct to FESS to avoid middle turbinate lateralisation.

Comparison of Outcomes of Conventional Septoplasty Versus Endoscopic Septoplasty using Freer's Incision in Symptomatic Deviated Nasal Septum

Background Septoplasty techniques have evolved over the years with endoscopic septoplasty gaining popularity in the recent times. Objective To compare the outcomes of conventional septoplasty with endoscopic septoplasty using Freer's incision in symptomatic deviated nasal septum. Method It was a prospective, randomized and comparative study done at Department of ENTHead and Neck Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal from July 2018 to August 2019. A total of 70 patients with symptomatic deviated nasal septum were allocated randomly into two groups. Group A underwent conventional septoplasty whilst Group B underwent endoscopic septoplasty using Freer's incision. Sino-nasal outcome test (SNOT-10) score was recorded pre-operatively and post -operatively between four to six weeks of surgery. Paired and independent 't' test for mean was used as a statistical tool. Result Out of 70 patients, 57(81.43%) were males and 13(18.57%) females. The age group mostly affected was in the third and fourth decades with total 47 patients (67.14%). In the conventional group, the pre-op mean SNOT-10 score was 11.46 (SD±3.6) while post-op mean SNOT-10 score was 2.60 (SD±1.9), the difference being statistically significant (p value 0.00001). Similarly, in the endoscopic group, pre-op mean SNOT10 score was 12.06 (SD±4.88) and post-op mean SNOT- 10 score was 3.37 (SD±2.71) with the difference being statistically significant (p value 0.00001). Comparison of post-operative mean SNOT-10 score between two techniques was not statistically significant (p value 0.17). Conclusion Both conventional and endoscopic septoplasty techniques using Freer's incision were equally effective in improving symptoms due to deviated nasal septum.

Comparison of outcomes of triamcinolone versus normal saline soaked polyvinyl alcohol pack following bilateral endoscopic sinus surgery

BACKGROUND

Steroids have been proven to be beneficial in improving post-operative outcomes following sinus surgery. The ideal mode of delivery is to increase local concentration in the sinuses with minimal systemic side effects. In this study, we used triamcinolone soaked polyvinyl alcohol packs immediately following sinus surgery, and assessed the effects on post-operative outcomes.

METHODOLOGY

This was a prospective, interventional, and comparative study. Following endoscopic sinus surgery, a polyvinyl alcohol pack was placed in both nasal cavities and 4 ml triamcinolone was infiltrated in one side and 4 ml of normal saline was infiltrated in the other. The pack was removed on the second post-operative day and nasal cavities and paranasal sinuses were evaluated using a flexible endoscope in the third post-operative week using Lund-Kennedy and Peri-operative sinus endoscopic scores.

RESULTS

There was a reduction in the average Lund-Kennedy score and Peri-operative sinus endoscopy score in the treatment site compared to the control site which was statistically significant. There was a greater reduction in crusting, oedema and scarring in the treatment site compared to the control site. However, only the reduction in oedema was statistically significant.

CONCLUSIONS

Triamcinolone soaked polyvinyl alcohol pack following endoscopic sinus surgery improves post-operative outcomes.

Therapeutic Drug Monitoring of Antiepileptic Drugs at a Tertiary Care Hospital of Eastern Nepal

Background Therapeutic drug monitoring (TDM) is the process of measuring drug level in body fluids. It is done to maintain plasma concentration of the drug under therapy within a specific target range for maximum therapeutic efficacy without unnecessary exposure to adverse effects. Objective This study aims to evaluate necessity of therapeutic drug monitoring in Phenytoin, Carbamazepine and Lamotrigine therapy among epileptic patients. Method A prospective, cross-sectional study was conducted for a period of one year at BP Koirala Institute of Health Sciences, Dharan, Nepal. After taking detailed history, blood samples were collected from epileptic patients on monotherapy with the selected drugs. Plasma levels of these drugs were analyzed using High Performance Liquid Chromatography technique (HPLC). Out of total 42 selected patients, 21 were tested for phenytoin, 17 for carbamazepine and four for lamotrigine. The result was categorized into therapeutic, sub-therapeutic and above-therapeutic groups based on reference range. Result Out of total 21 samples tested for phenytoin, 15(71.4%) had plasma drug level within therapeutic range, 5(23.8%) had within subtherapeutic range and 1(4.8%) had above therapeutic range. Analysis of carbamazepine plasma level showed 14(82.3%) at therapeutic level, 1(5.9%) at sub-therapeutic level and 2(11.8%) at above-therapeutic level. Lamotrigine testing in four samples showed 2(50% in) both within therapeutic range and above-therapeutic range. Conclusion Therapeutic drug monitoring of phenytoin, carbamazepine and lamotrigine showed variation in plasma level irrespective of the therapeutic dose. It is suggested that dose adjustment of antiepileptic drugs should be done after establishing 'individual therapeutic range' following regular plasma monitoring.

Clinico-epidemiological Profile of Extra Hepatic Portal Vein Obstruction: A Tertiary Care Hospital Based Retrospective Study

Background Extra hepatic portal vein obstruction (EHPVO) is a common cause of portal hypertension in the developing countries (up to 30% of all variceal bleeders) and is second to cirrhosis in the West (up to 5-10%). Our understanding of the disease is poor compared with other illnesses. Objective To undertake a retrospective study of the clinicoepidemiological profile of Extra hepatic portal vein obstruction in a tertiary care hospital in eastern Nepal. Method All consecutive adult patients whose features were consistent with the diagnosis of extra hepatic portal vein obstruction from June 2014 to June 2016 were retrospectively analyzed to explore the various clinico-epidemiological parameters. Result A total of 58 patients were enrolled in the study with a median age of 24 years (20.5- 40). Portal vein thrombosis was the most common cause of extrahepatic portal vein obstruction. Hematemesis followed by melena were the most common presenting symptoms. All patients had splenomegaly on examination. None of the patients had clinical, biochemical or radiological evidence of chronic liver disease. Conclusion The diagnosis of extra hepatic portal venous obstruction and differentiation from cirrhosis can be easily made by characteristic clinical features, normal liver function tests and doppler ultrasound. Portal vein thrombosis (PVT) is the predominant cause of extra hepatic portal vein obstruction in Nepali patients, as seen at this tertiary care hospital in Nepal.

Acute Total Uterine Inversion: A Life Threatening Obstetrics Emergency

Acute total uterine inversion is a rare and life threatening obstetric emergency. Prompt diagnosis and aggressive management reduces maternal mortality and morbidity .We report a case of 28 year old primi, who had total uterine inversion immediately after normal delivery of full term baby weighing 3150gm. Immediate manual repositioning was done by Johnson’s maneuver under general anesthesia. She recovered well and was discharged after 5 days.

Epidemiological Study of Tobacco Smoking Behaviour amongst Residents of the Hill Region of Nepal

Background Tobacco use is still a serious public health problem in the world and represents a major cause of morbidity and mortality in most parts of the world. Objective To measure the prevalence of tobacco use and to identify the factors associated with tobacco use among the residents of Dhankuta Municipality. Method The cross-sectional study was conducted among the residents of the Dhankuta Municipality where 205 households were taken as subjects. Pretested semistructured questionnaire was used for data collection and face to face interview was conducted. Univariate and multivariate logistic regression was used to see the association between various factors and tobacco use and identify the predictor variables. Result Overall prevalence of tobacco consumption in Dhankuta Municipality was found to be 57.1%. Prevalence of tobacco consumption among the male was significantly higher (67%) than female (47.1%) (p<0.05). Most of the respondents (56.4%) started consuming tobacco due to peer pressure and for recreation (24.8%). The multivariate logistic regression showed that the people with illiterate have higher chances of consuming tobacco than above School Leaving Certificate (OR 38.395, 95% CI=3.209- 459.417). The respondents below poverty line (<1.25 US$) was consuming tobacco more than above poverty line (> 1.25 US $) (OR 6.814, 95% CI= 1.255-36.986). Conclusion The aims of this study was to measure the prevalence of tobacco use and to identify the factors associated with tobacco use among the residents of the Dhankuta Municipality. We conclude that the prevalence rate of tobacco consumption in the Dhankuta Municipality was found to be moderately high. Factors like male in gender, Brahmin/Chhetri in ethnicity, lack of education, poor occupation like farmer and housewife, poor economic status were associated with tobacco use.

Megakaryocytic alterations in thrombocytopenia: A bone marrow aspiration study

Background: Megakaryocyte morphology plays an important role in thrombopoiesis. A defect in any stage of megakaryocytopoiesis can lead to dysmegakaryocytopoiesis and thrombocytopenia. This study was conducted to understand megakaryocytic alterations and their contribution in the diagnosis of cases of thrombocytopenia.Materials and Methods: This was a cross-sectional study was conducted on all consecutive cases of bone marrow aspirates of thrombocytopenia over a duration of one year in BPKIHS. Megakaryocyte morphology was studied with a 100X objective. Data were entered into Microsoft excel 10 and analysed with SPSS version 11.5. Descriptive statistics charted and Chi-square tests were done for inferential statistics to find any association at 95% Confidence Interval.Results: Among the 38 subjects, megakaryocytic thrombocytopenia (44.7%) was the most common cause of thrombocytopenia.  Hypolobated megakaryocytes (63.2%), bare megakaryocytic nuclei (57.9%) were the common morphological changes in megakaryocytes. Odds of increased megakaryocyte count in megakaryocytic thrombocytopenia was found to be 12.5 times than for other causes of thrombocytopenia and the presence of bare megakaryocytic nuclei in MTP was statistically significant. (p –value<0.05)Conclusion: Many similarities were observed in megakaryocytic morphology among different hematological diseases. However, increased megakaryocyte count and presence of bare megakaryocytic nuclei, hypolobated forms were significant in megakaryocytic thrombocytopenia.

Puerperal Sepsis and its Cause in Patan Hospital

Aims: This study was done to find out morbidity related with puerperal pyrexia/sepsis and its risk factors. Methods: This was retrospective study conducted from January 2011 to December 2012 at Department of Obstetrics and Gynaecology, Patan Hospital, Kathmandu, Nepal. All women who delivered in this hospital within 42 days of delivery with puerperal pyrexia/sepsis diagnosed on clinical examination and relevant investigations were included in the study. Women with malaria, typhoid fever and ??other fever were excluded. The data was recorded in predesigned proforma and analyzed. Results: During this period, there were 122 cases of puerperal pyrexia. Puerperal pyrexia accounted for 6.28% of 1945 admissions. Most of the women were aged between 20-29 years, primiparous and booked cases with absent membranes. The causes of puerperal pyrexia in our study were urinary tract infection (47.5%), wound infection (20.5%), endometritis (19.7%) retained product of conception (8.2%), pyoperitoneum (2.5%) and septicemia (1.6%). Conclusions: Puerperal pyrexia/sepsis is one of the causes of preventable maternal morbidity and mortality though in our study it was not proved to be very high in number. Optimal aseptic measures during labour can prevent most of the cases. 

The Study of Prevalence of Helicobacter Pylori in Patients with Acne Rosacea

Background Acne rosacea is an inflammatory disease affecting the central part of the face characterized by erythema, papules, papulo pustules and telangiectasias of unknown etiology. More recently numerous studies have described an association with Helicobacter pylori (Hp) and the extra gastric symptoms of cutaneous origin. Objectives To establish the prevalence of Helicobacter pylori (Hp) infection in the stomach in patients with rosacea based on standard Hp serological test. Methods All patients with the clinical staging of 2, 3 and 4 rosacea attending the Dermatology Out Patient Department from May 2009 – April 2010 were included in the study. Quantitative serological test using the SERION ELISA classic Helicobacter pylori IgG was done. Result A total of 26 patients were enrolled in the study with the age ranging from 26- 82 years. There were 14 males and 12 females and the male: female ratio was 1.6:1. Three (11.53%) patients presented with Grade IV rosacea, a severe clinical presentation and symptoms suggestive of acid peptic diseases were found in 14/26 (53.8%) patients. A positive serology to H. pylori was found in 17/26 (65.4%) of patients. A statistically significant correlation was found when association of H.pylori positivity in patients of rosacea compared with the seropositivity in controls. However correlation in the seropositivity was not found amongst the patients having gastritis and rosacea. Conclusion There still proves to find a correlation of Hp infection with patients with rosacea but it can still be hypothesised as a cutaneous manifestation of an internal peptic ulcer disease . DOI: http://dx.doi.org/10.3126/kumj.v10i4.10995 Kathmandu Univ Med J 2012;10(4):49-52

Risk factors for stunting among children: a community based case control study in Nepal

BACKGROUND

Stunting, a chronic condition, is an underlying cause of child morbidity and mortality in Nepal. This study intends to identify the factors causing stunting among children that will help to prioritize the strategies at the district level.

OBJECTIVE

The objective of the study was to identify the risk factors for stunting among children of age between 6 to 59 months.

METHODS

The study was based on community-based case control design in the mid-west, Surkhet Nepal from August to September 2010. The cases were stunted children and controls were the children without stunting. Data was collected by interviewing those children's mothers and measured length/height of 118 children as cases and 236 children as controls. Logistic regression analysis was performed to identify the best model of factors leading to stunting. Odds ratio and 95% confidence interval were used as a measure of association.

RESULTS

Socio-economic risk factors for stunting comprised mothers without earning (OR=3.11, 95% CI 1.26-7.65), food deficit families (OR=4.26, 95% CI 1.73-10.45) and care taker of the children other than mother (OR=3.02, 95% CI 1.19-7.70). Environmental risk factors for stunting consisted of kitchen without ventilation and children exposed to pesticide. Inappropriate exclusive breast feeding (OR=6.90, 95% CI 2.81-16.97), complementary feeding less than four times a day (OR=3.60, 95% CI 1.32-9.95) and dietary diversity below WHO standard (OR=4.06, 95% CI 1.70-9.67) were factors of stunted children. Diarrhea was found significantly associated with stunting (OR=7.46, 95% CI 2.98-18.65).

CONCLUSIONS

Stunting was found to be as a result of multiple factors such as socio-economic, environmental and inappropriate feeding practices.

Chondrosarcoma of posterior nasal septum

Chondrosarcoma is a rare non-epithelial tumor comprising of 10-20% of primary bone tumor. The nasal septum is a rare site for its occurrence. We present one such case of chondrosarcoma of the nasal septum who was treated with endoscopic removal followed by post operative radiotherapy and discuss the relevant clinical presentation, diagnosis and treatment and review the literature also.

Child-Turcotte-Pugh versus model for end stage liver disease score for predicting survival in hospitalized patients with decompensated cirrhosis

BACKGROUND

Short term and medium term survival predictive value of the Child-Turcotte-Pugh (CTP) and Model for End Stage Liver Disease (MELD) score has been established but their usefulness in predicting survival of hospitalized patients with decompensated cirrhosis is lacking. We compared the survival predictive value of these scoring systems in hospitalized patients of decompensated cirrhosis and other associated factors.

METHODS

A prospective, observational study in 216 consecutive cases of decompensated cirrhosis admitted in medical ward, were enrolled if the inclusion criteria were fulfilled. All cases were investigated and treated as per standard guidelines and clinician's judgment. CTP and MELD score were calculated for each case at the time of admission and followed throughout the hospital stay till discharge/death. The accuracy of the different score systems for predicting survival was evaluated through the area under ROC curve.

RESULTS

CTP and MELD score were higher (12.44 ± 1.07, 31.91 ± 4.92) in expired cases than who improved and discharged (11.32 ± 1.28, 23.97 ± 5.36) respectively with significant p-value (<0.001). Area under ROC curve for serum creatinine, MELD score, blood urea and CTP score for predicting hospital survival were 0.887, 0.864, 0.836 and 0.738 respectively.

CONCLUSIONS

MELD score is superior to CTP score in predicting survival at the time of discharge in hospitalized patients with decompensated cirrhosis. Renal failure in patients with decompensated cirrhosis carries poor prognosis and has a good outcome prognostic value, even superior to MELD/CTP scoring.

Clinical profile of diabetic ketoacidosis in adults

Introduction: Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus. Recent epidemiological studies indicate that hospitalizations for DKA in the U.S. are increasing. Epidemiological studies from India are limited. We undertook this observational study to analyse the clinical profiles of DKA in adults in south India.Methods: This study was conducted in at a tertiary care center in Andhra Pradesh for one year from Aug 2010 to July 2011. Diagnosis of DKA was made by the presence of (1) Plasma glucose level of 250mg/dl or higher (2) Serum bicarbonate level of 15mEq/lt or lower (3) Arterial blood pH of 7.3 or lower or a venous blood pH of 7.25 or lower (4) Presence of moderate or large urine ketones. All the patients were treated with institutional treatment protocol.Results: Of 27 patients, 22(81%) had type2 diabetes and 5(19%) had type 1 DM .10 were females and 17 males. Age of the patients ranged between 18 to 70 years, with an average of 45.3 years. Precipitating factors were present in 60% of the admissions. Non-compliance or discontinuation of drug therapy was seen in fifty per cent of patients. Average length of hospital stay was slightly longer in type 1 than type 2 DM patientsConclusion: A significant proportion of DKA occurs in patients with type 2 diabetes and many of these cases can be prevented with proper patient education and effective communication with a health care provider during an inter-current illness.DOI: http://dx.doi.org/10.3126/hren.v10i2.6569 Health Renaissance 2012; Vol 10 (No.2); 80-86 

Isolation and characterization of aerobic culturable arsenic-resistant bacteria from surfacewater and groundwater of Rautahat District, Nepal

Arsenic (As) contamination of groundwater is a serious Environmental Health Management issue of drinking water sources especially in Terai region of Nepal. Many studies have reported that due to natural abundance of arsenic in the environment, various bacteria have developed different resistance mechanisms for arsenic compound. In this study, the culturable arsenic-resistant bacteria indigenous to surfacewater as well as groundwater from Rautahat District of Nepal were randomly isolated by standard plate count method on the basis of viable growth on plate count agar amended with arsenate ranging from 0, 0.5, 10, 40, 80 to 160 milligram per liter (mg/l). With respect to the morphological and biochemical tests, nine morphologically distinct potent arsenate tolerant bacteria showed relatedness with Micrococcus varians, Micrococcus roseus, Micrococcus luteus, Pseudomonas maltophilia, Pseudomonas sp., Vibrio parahaemolyticus, Bacillus cereus, Bacillus smithii 1 and Bacillus smithii 2. The isolates were capable of tolerating more than 1000 mg/l of arsenate and 749 mg/l of arsenite. Likewise, bioaccumulation capability was highest with M. roseus (85.61%) and the least with B. smithii (47.88%) indicating the potential of the organisms in arsenic resistance and most probably in bioremediation.

Postoperative complications of septal quilting and BIPP packing following septoplasty

BACKGROUND

Septoplasty is one of the most common surgeries in otorhinolaryngology. After septal surgery nasal packing is usually done to prevent complications like haemorrhage, septal haematoma. However it is associated with many postoperative complications such as pain, hypoxia, dryness in throat, headache, epiphora, vestibular stenosis, crusting, synaechiae, secondary infection etc. In order to prevent these complications quilting has been developed. No study has been done in our country to compare the postoperative complications after septoplasty.

METHODS

This study was carried out to compare postoperative crusting, oedema, synaechia and infection in patients who underwent septal quilting and BIPP packing following septoplasty from August 2008 to July 2011 in the Department of ENT-Head and Neck Surgery, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal.

RESULTS

There were 44 patients in quilting and 41 patients in BIPP packing group. Out of 44 patients of quilting group, crusting occurred in 3 patients, oedema in 4 patients, synechia in 1 patient and infection in 3 patients. Out of 41 patients of BIPP packing group, 9 patients had crusting, oedema was present in 7 patients, 6 patients had synaechia and 5 patients had infection. Crusting and synaechia was found to be statistically significant while oedema and infection was not significant between two groups.

CONCLUSIONS

Complications like excessive crusting, oedema, synaechia and infection can be minimized by quilting suture following septoplasty.

Multiple drug resistance in bacterial isolates from liquid wastes generated in central hospitals of Nepal

BACKGROUND

Healthcare liquid wastes are the reservoirs of harmful infectious agents such as the pathogens and multiple drug resistant microorganisms. Potential infectious risks include the spread of infectious diseases and microbial resistance from health-care establishments into the environment and thereby posing risks of getting infections and antibiotic resistance in the communities.

OBJECTIVES

The objectives of this study were to assess the bacterial load of healthcare liquid waste generated in central hospitals and to explore the antimicrobial resistance pattern of these bacterial isolates.

MATERIALS AND METHODS

A descriptive study was carried out in 10 conveniently selected central hospitals of Nepal during the period of May to December 2008. Effluent specimens from each hospital were subjected to total viable count studies by spread plate method in nutrient agar plate and incubated for 24 hours at 37 °C using standard laboratory protocol. Similarly, all the specimens were cultured in Mac Conkey Agar media supplemented with 30 μg/ml of Chloramphenicol and 20 μg/ml of Gentamycin for the enumeration of multiple drug resistant (MDR) bacteria, which were further subjected to in-vitro antibiotic susceptibility test by modified Kirby Bauer disc diffusion technique for resistance patterns.

RESULTS

Total viable counts of hospital effluents significantly exceeded the standard heterotrophic plate count (p=0.000). Similarly, the numbers of multiple drug resistant bacteria were alarmingly high in three (more than 30% in 2 and 50% in 1) hospitals of this study. Drug resistant hospital effluent isolates showed simultaneous resistance for most of the antibiotics including Penicillin, Cephalosporin, Cotrimoxazole, Gentamycin and Quinolones.

CONCLUSION

Healthcare liquid wastes were laden with MDR bacteria and seemed to pose a huge public health threat in the transfer of such resistance to the bacterial pathogens causing community acquired infections, thereby limiting our antibiotic pool.

Health care waste management practice in a hospital

BACKGROUND

Health-care waste is a by-product of health care. Its poor management exposes health-care workers, waste handlers and the community to infections, toxic effects and injuries including damage of the environment. It also creates opportunities for the collection of disposable medical equipment, its re-sale and potential re-use without sterilization, which causes an important burden of disease worldwide. The purpose of this study was to find out health care waste management practice in hospital.

METHODS

A cross-sectional study was conducted in Narayani Sub-Regional Hospital, Birgunj from May to October 2006 using both qualitative and quantitative methods. Study population was four different departments of the hospital (Medical/Paediatric, Surgical/Ortho, Gynae/Obstetric and Emergency), Medical Superintendent, In-charges of four different departments and all sweepers. Data was collected using interview, group discussion, observation and measurement by weight and volume.

RESULTS

Total health-care waste generated was 128.4 kg per day while 0.8 kg per patient per day. The composition of health care waste was found to be 96.8 kg (75.4%) general waste, 24.1 kg (8.8%) hazardous waste and 7.5 kg (5.8%) sharps per day by weight. Health staffs and sweepers were not practicing the waste segregation. Occupational health and safety was not given due attention. Majority of the sweepers were unaware of waste management and need of safety measures to protect their own health.

CONCLUSIONS

Health care waste management practice in the hospital was unsatisfactory because of the lack of waste management plan and carelessness of patients, visitors and staffs. Therefore the hospital should develop the waste management plan and strictly follow the National Health Care Waste Management Guideline.

Chronic Cough in Thymoma

Cough is one of the most common symptom for which patients seek medical attention from primary care physicians and pulmonologists. Although tuberculosis and other lung infections are common throughout the developing world, they are not among the most common causes of chronic cough. We report a case of a 23 years old male who presenting to the outpatient clinic with chronic cough not responding to regular and symptomatic treatment that was diagnosed to have thymoma. After all the common causes for chronic cough have been ruled out, unusual causes should also be considered in the differential diagnosis. KEYWORDS: Chronic cough, Thymoma, Anterior Mediastinum.

Chronic cough in thymoma

Cough is one of the most common symptom for which patients seek medical attention from primary care physicians and pulmonologists. Although tuberculosis and other lung infections are common throughout the developing world, they are not among the most common causes of chronic cough. We report a case of a 23 years old male who presenting to the outpatient clinic with chronic cough not responding to regular and symptomatic treatment that was diagnosed to have thymoma. After all the common causes for chronic cough have been ruled out, unusual causes should also be considered in the differential diagnosis.

Healthcare liquid waste management

BACKGROUND

The management of healthcare liquid waste is an overlooked problem in Nepal with stern repercussions in terms of damaging the environment and affecting the health of people. This study was carried out to explore the healthcare liquid waste management practices in Kathmandu based central hospitals of Nepal.

METHODS

A descriptive prospective study was conducted in 10 central hospitals of Kathmandu during the period of May to December 2008. Primary data were collected through interview, observation and microbiology laboratory works and secondary data were collected by records review. For microbiological laboratory works,waste water specimens cultured for the enumeration of total viable counts using standard protocols.

RESULTS

Evidence of waste management guidelines and committees for the management of healthcare liquid wastes could not be found in any of the studied hospitals. Similarly, total viable counts heavily exceeded the standard heterotrophic plate count (p=0.000) with no significant difference in such counts in hospitals with and without treatment plants (p=0.232).

CONCLUSIONS

Healthcare liquid waste management practice was not found to be satisfactory. Installation of effluent treatment plants and the development of standards for environmental indicators with effective monitoring, evaluation and strict control via relevant legal frameworks were realized.

Spinal anesthesia for cesarean section: comparison of 5.0% lignocaine and 0.5% bupivacaine

Objective of the study was to compare the effect of the drugs, intraoperative hemodynamic variables (heart rate, blood pressure) and associated complications (hypotension, nausea, shivering etc) between the bupivacaine and lignocaine group, when administered intrathecally in patients undergoing caesarean section. This is a randomized prospective study where the haemodynamic changes and the complications following sub arachnoid block either with 5.0% lignocaine or with 0.5% bupivacaine in 52 patients undergoing caeserian section were compared. The patients were randomly divided in two groups, group X (lignocaine group, n=26) or group B (bupivacaine group, n=26), either to receive 5.0% lignocaine 75 mg or 0.5% bupivacaine 12.5 mg. Intraoperatively heart rate, blood pressure (systolic (SBP), diastolic (DBP) and mean (MAP)), oxygen saturation were monitored. Any rescue drugs e.g. mephentermine, crystalloid 200 ml bolus, pethidine, diazepam etc given were noted with the dose and time. Urine output and total amount of fluid given was noted at the end of the surgery. Oxytocin 10 U in infusion was given after the baby was delivered in all the cases. Intraoperative blood pressures, total amount of fluid given, rescue vasopressor (mephentermine) given were compared in both the groups. Groups were also compared with respect to the patients' age, height of sensory block, motor block, duration of surgery, Apgar score and weight of the baby and duration of postoperative analgesia. It was concluded that the drugs were similar with respect to their sensory and motor effects, intraoperative hemodynamic changes like hypotension and bradycardia, and other complications like shivering and can be used interchangeably as spinal anesthetic agent for caesarean section deliveries.

Phenotypic characterisation and drug sensitivity testing of mycobacteria isolated from extra-pulmonary tuberculosis

BACKGROUND

Tuberculosis (TB) is a major cause of morbidity and mortality globally, with most cases occurring in developing countries. The importance of extra pulmonary tuberculosis (EPTB) among all forms of tuberculosis has not yet been ascertained in developing countries.

OBJECTIVE

To identify and perform phenotypic characterization of clinically important mycobacterium isolates from extra-pulmonary sites along with drug susceptibility testing.

MATERIALS AND METHODS

A total of 513 specimens from patients of (EPTB) with varied presentation were studied. Speciation and characterization of isolates were done on the basis of growth and biochemical characteristics. Drug susceptibility testing for mycobacterium isolates was done by proportion method.

RESULTS

Fifty four patients clinically suspected to have extra-pulmonary tuberculosis were culture positive for mycobacteria. On characterization 48 of the 54 isolates were identified as M. tuberculosis, 4 as M. bovis and 2 were M. avium/intracelulare. Drug susceptibility testing was done for the both M. tuberculosis as well as M. bovis. In single drug resistance, Streptomycin was highest followed by Isoniazid, Ethambutol and Refampicin. Multi drug resistance (MDR) was found in 6 isolates and it was observed only in group I cases.

CONCLUSION

EPTB accounts for 10-15 percent of all cases of tuberculosis. Mycobacterium was present in 10.5 percent samples. 48 isolates out of 54 samples were found to be M. tuberculosis. The maximum numbers of M. tuberculosis were isolated from lymph node aspiration.

Scenario of mushroom poisoning in a tertiary care hospital

INTRODUCTION

Mushroom poisoning is not new to Nepal. Undocumented and unrecorded mushroom poisoning is more common than the published one. We evaluated the pattern and outcomes following toxic mushroom ingestions.

METHODS

We did a retrospective analysis of patients admitted with mushroom poisoning in BPKIHS, a tertiary care hospital in Nepal, from 2002 to 2006. The diagnosis of mushroom poisoning was based on history and clinical presentation.

RESULTS

Twenty seven patients, aged between 7-83 years were studied. Fourteen (51.86%) were male and 13 (48.14%) were female. All (100%) patients had consumed wild mushroom unintentionally. Twelve patients developed symptoms within first hour and 11 patients within one to six hours. The average delay in presenting to our hospital was 23.1 (2-96) hours. In 10 cases, other family members were affected, out of which in two cases the family members had died in other hospitals. Reported symptoms were nausea 27 (100%), vomiting 24 (88.88%), abdominal cramping 8 (29.6%), jaundice 3 (11.1%), diarrhea 17 (62.96%) and altered sensorium in 8 patients (29.65%). All patients were treated conservatively. Three patients with severe hepatitis were admitted in ICU, out of which two recovered without liver transplant. One eight year old boy developed acute liver failure and expired within 24 hours of hospitalization.

CONCLUSIONS

Most of the mushroom poisoning was acute, unintentional and by consumption of wild mushroom. Community based awareness programs will help prevent the instances of poisoning.

Scenario of Mushroom Poisoning in a Tertiary Care Hospital

Abstract

Juvenile angiofibroma and its management

This prospective longitudinal study was done to determine extent of tumor and to highlight the importance of lateral rhinotomy approach for nasopharyngeal angiofibroma. Patients with a diagnosis of nasopharyngeal angiofibroma who underwent surgery in Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu from April, 2004 to Jan 2009 were included in the study. Extent of tumour and surgical approaches were noted in a special form prepared for the study. Fisch Staging system was followed for the extent of tumor. A total number of patients were 23 and all of them were male. Age ranged from 15-30 years with mean age of 18.25 years. All the patients underwent contrast enhanced CTScan. Two patients had stage I tumor, 9 patients had stage II disease, other 12 patients had stage III tumor. Twenty patients were operated by lateral rhinotomy approach. In one patient with the tumour hanging in the oropharynx with a pedical attached to the lateral wall of nasopharynx was removed by peroral route and in another patient with tumour confined to nasopharynx and posterior part of nose was removed by transpalatal approach. One patient who had tumour extention into infratemporal fossa were operated by lateral rhinotomy with inferior sublabial extetention approach. Eleven patients underwent preoperative embolization with gelfoam 48 hours prior to surgery. Most of them had stage III disease and were managed surgically by lateral rhinotomy approach. Lateral rhinotomy approach with or without extention of incision can be used to remove tumours in majority of patients.

Community participation in health: a brief review and the experience of Kathmandu Medical College with the Duwakot community

One of the principles of Primary Health Care (PHC), Community Participation is a process through which the stakeholders influence and share control over development initiatives and the decisions and resources which affect them. It is a complex issue that has been studied widely and continues to be of great interest among community health workers. This paper presents a brief review of various aspects of community participation. It then illustrates how it is practiced at Duwakot Community Hospital, Kathmandu Medical College, Duwakot, Bhaktapur, Nepal in collaboration with the local community.

Seasonal variation in plasma levels of lithium in the Indian population: is there a need to modify the dose?

INTRODUCTION

Lithium still remains an important choice in the therapy of manic-depressive psychosis (MDP), and though there are reports of seasonal variation in lithium levels from a few countries, such studies have not been conducted in India. Variability in the lithium level can lead to lack of efficacy or toxicity, making seasonal variation clinically relevant.

METHODS

A retrospective case sheet audit was performed for 101 MDP patients for recording plasma lithium level, oral lithium dose, age and gender for one year. The overall average oral lithium dose and level were recorded; the monthly average to which it most closely matched was noted as the control month, and values of other months were compared with this control month by Friedman's test followed by Dunn's test.

RESULTS

The mean age of patients was 38.22 (standard deviation 12.07) years, and 72 out of 101 patients were male. The mean lithium dose in November (938.61 +/- 243.40 mg/day), which was the closest to the overall mean dose (938.24 +/- 241.78 mg/day) was taken as the control month, which when compared with other monthly values, did not show any significant difference. The June (0.54 +/- 0.23 meq/L), July (0.55 +/- 0.24 meq/L) and August (0.55 +/- 0.24 meq/L) mean plasma lithium values were significantly high when compared to the October value (0.45 +/- 0.22 meq/L) as control. High-low variability between the plasma lithium values of different months was found to be 25 percent.

CONCLUSION

The present study showed a significant high variability of lithium levels in different months of the year, therefore frequent plasma level monitoring and oral lithium dose adjustment to prevent situations of toxicity and lack of efficacy in MDP.

Midazolam for caudal analgesia in children: comparison with caudal bupivacaine

BACKGROUND

Caudal analgesia is the most popular and commonly used regional anaesthesia technique for post operative analgesia in children undergoing lower limb, anoperineal and abdominal surgical procedures. It is commonly applied in all the paediatric patients undergoing the above mentioned surgery, as the goal of balanced anaesthesia is not only limited to intraoperative period but also good analgesia in post operative period. Many drugs like morphine, Pethidine, Neostigmine etc have been used as analgesic agent via the caudal route but not without their side effects. So Midazolam was used as an alternative drug as it may not be associated with the side effects encountered with the other drugs.

AIMS AND OBJECTIVES

The objective of the study was to see the analgesic efficacy of caudal administration of Midazolam with comparison to Bupivacaine for post operative analgesia, and to observe for side effects if any.

MATERIALS AND METHODS

This was a single blinded prospective observational study in children of age 1 to 6 years of ASA grade I undergoing elective hernia or hydrocoele surgery. The patients were allocated randomly into two groups (n=25) to receive caudal injection of either 0.25% Bupivacaine 1 ml/kg (group A) or Midazolam 50 microg/kg with normal saline 1 ml/kg (group B). In the post operative period heart rate, blood pressure, pain score, recovery to first analgesic time, total number of analgesics required in 24 hours and side effects if any were noted and analysed.

RESULTS

There were no significant differences in quality of pain relief, postoperative behaviour or analgesic requirements between the Midazolam group and the Bupivacaine group. Recovery to first analgesic time though was longer in the Bupivacaine group (9.65 hr) than Midazolam group (7.32 hr); it was statistically not significant (P= 0.9). Any of the side effects such as motor weakness, urinary retention, and respiratory depression were not observed in both the groups. However in both the groups, few of the patients had post operative vomiting.

CONCLUSION

We conclude that caudal Midazolam in a dose of 50 microg/kg provides equivalent analgesia to Bupivacaine 0.25%, when administered in a volume of 1 ml/kg for children undergoing unilateral inguinal herniotomy for hernia or high ligation of processus vaginalis for hydrocoele.

Application of "the Sequential Organ Failure Assessment (SOFA) score" in predicting outcome in ICU patients with SIRS

BACKGROUND

Various scoring systems have been developed to prioritize patient admission and management in ICU. The objective of this prospective, observational cohort study was to evaluate application of one such system, the Sequential Organ Failure Assessment (SOFA) Score in predicting outcome in ICU patients with SIRS.

PATIENTS AND METHODS

Fifty patients admitted to a six bed multidisciplinary ICU with SIRS were consecutively enrolled in the study and SOFA scores were calculated at zero hour, after 48 hrs, and after 96 hrs and patients followed till discharge from hospital.

RESULTS

When compared to outcome, the non survivors had high initial, mean and highest SOFA scores as compared to survivors. (p value = 0.002, <0.001, <0.001 respectively). Delta SOFA was not significantly associated with outcome. (p value= 0.117). The initial SOFA score > 11 predicted a mortality of 90%. (OR 23.72, 95%CI2.68-209.78, p=0.004). Similarly, mean SOFA score of > 7 predicted a mortality of 73.9% (OR 22.7, 95%CI 5.0 - 103.5, p<0.001) and high SOFA score > 11 predicted a mortality of 87.5% (OR 32.66, 95%CI 5.82-183.179, p< 0.001). Area under receiver operating characteristic (ROC) curve for mean SOFA was 0.825, for high SOFA was 0.817 and for initial SOFA was 0.708. Thus mean, high and initial SOFA scores were helpful in predicting between the survivors and the non survivors.

CONCLUSION

The SOFA scoring system is useful in predicting outcomes in ICU and thus help in proper utilization of ICU resources.

Correlation of PAP smear findings with clinical findings and cervical biopsy

OBJECTIVES

Carcinoma of the cervix is the most common cause of the death in Nepal. Cervical carcinoma does not develop suddenly from normal epithelium but is presented by a spectrum of intraepithelial neoplastic changes that are precancerous lesion and were termed as cervical intraepithelial neoplasia (CIN). Cervical cytological screening is designed to detect over 90% of cytological abnormalities. It has also been established that most cervical cancers can be diagnosed at the preinvasive stage with adequate and repetitive cytological screening. Keeping in view of the importance of carcinoma and the precancerous lesion (CIN) of cervix, study of different methods for the early detection of abnormalities in cervix, correlation with the clinical findings and comparison between the techniques was carried out.

MATERIAL AND METHODS

Patients with suspicious cervix attending Gynaecology OPD of TUTH and Western regional hospital (Pokhara) who have undergone for pap smear cytology test along with biopsy were selected. Detail history with clinical examination was performed and the findings were correlated.

RESULTS AND CONCLUSION

Unhealthy cervix with discharge was found to be common even in chronic cervicitis however bleeding and tenderness were associated with more advanced lesions. Pap smear test was found to be equally sensitive to histopathological examination for the early detection of different cervical lesions. However, it is advised to perform biopsy if any abnormalities are detected in pap smear for correlation and confirmation.

Cardiovascular collapse during induction of general anesthesia

Anaphylactic reactions to anesthetic drugs, though rare, may be encountered by anyone involved. The clinical manifestation of the anaphylactic reactions, which may be different from patient to patient, is caused by the histamine released either from the mast cells or basophils or both. Laboratory investigations can determine the source of histamine release. Here, I present a case of anaphylactic reaction to sodium thiopental. The main stay of the treatment is oxygenation, fluids and epinephrine, which was applied in this case also, with successful outcome of the patient.

Combined epidural anesthesia & general anesthesia for aorto-renal bypass: two case reports

Aorto-renal bypass surgery is associated with significant hemodynamic alterations as well as other comorbidities due to necessity of aortic cross-clamping and release during vascular anastomosis. Combined epidural and general anesthesia for the aorto-renal bypass surgeries provides not only hemodynamic stability during aortic cross-clamping but is also associated with increased graft blood flow, graft survival and decreased morbidity and mortality in intraoperative and postoperative period. Two cases of aorto-renal bypass are presented, for which combined epidural and general anesthesia techniques were applied.

Spectroscopic studies on methyl torsional behavior in 1-methyl-2(1H)-pyridone, 1-methyl-2(1H)-pyridinimine, and 3-methyl-2(1H)-pyridone. I. Excited state

The laser induced fluorescence excitation and dispersed fluorescence spectra of three nitrogen heterocyclic molecules 1-methyl-2(1H)pyridone (1MPY), 1-methyl-2(1H)pyridinimine (1MPI), and 3-methyl-2(1H)pyridone (3MPY) have been studied under supersonic jet cooled condition. The methyl torsional and some low frequency vibrational transitions in the fluorescence excitation spectrum were assigned for 1MPY. These new assignments modify the potential parameters to the methyl torsion reported earlier. Some striking similarities exist between the torsional and vibrational transitions in the fluorescence excitation spectra of 1MPY and 1MPI. Apart from pure torsional transitions, a progression of vibration-torsion combination bands was observed for both these molecules. The excitation spectrum of 3MPY resembles the spectrum of its parent molecule, 2-pyridone. The barrier height of the methyl torsion in the excited state of 3MPY is highest amongst all these molecules, whereas the barrier in 1MPI is higher than that of 1MPY. To get an insight into the methyl torsional barrier for these molecules, results of the ab initio calculations were compared with the experimental results. It was found that the conformation of the methyl group undergoes a 60 degrees rotation in the excited state in all these molecules with respect to their ground state conformation. This phase shift of the excited state potential is attributed to the pi*-sigma* hyperconjugation between the out-of-plane hydrogen of the methyl group and the molecular frame. It has been inferred that the change in lowest unoccupied molecular orbital energy plays the dominant role in the excited state barrier formation.

Origin of methyl torsional barrier in 1-methyl-2(1H)-pyridinimine and 3-methyl-2(1H)-pyridone: II. Ground state

To get the insight into the electronic structure-methyl torsion correlation in nitrogen heterocyclic molecules, a comparative study on torsion of the methyl group in 1-methyl-2(1H)pyridone (1MPY), 1-methyl-2(1H)pyridinimine (1MPI), and 3-methyl-2(1H)pyridone (3MPY) was carried out using ab initio calculations. To understand the barrier forming mechanism in the ground state and its consequence on the molecular structure, the ground state torsional potential has been investigated by partitioning the barrier energy using the natural bond orbital (NBO) theoretical framework. The NBO analysis reveals that the delocalization energy is the barrier forming term whereas the Lewis energy is always antibarrier for all these molecules. To get further insight into the effect of local electronic structure on the methyl torsional barrier, the individual bond-antibond interactions and structural energy contributions have been investigated. It was found that when the bond order difference between the vicinal bonds does not change appreciably during the course of methyl rotation, the local electronic interactions with the methyl group do not play any decisive role in barrier formation as observed in the case of 1MPY and 1MPI. In these cases, it is the skeletal relaxation during methyl rotation that plays an important role in determining the barrier. On the other hand, if the bond order change is appreciable as is the case for 3MPY, the local interactions alone suffice to describe the origin of the torsional barrier of the methyl group.

Spirometry in evaluation of respiratory diseases

A hospital based cross-sectional study was conducted from March 2005 to April 2006 to evaluate the distribution of various respiratory diseases by spirometry. A total of 228 consecutive cases referred for spirometry were included of which 65% were male and 35% female. COPD was the commonest referral diagnosis (40%) followed by the diagnosis of shortness of breath (22%). After spirometry the prevalence of COPD was 42%, Asthma 23.5%, Restrictive disease 3.1% and mixed obstructive and restrictive disease 3.5%. 25% of the sample population was smokers and 22% ex-smokers. Hence we conclude that spirometry is a very useful diagnostic tool for preliminary diagnosis of respiratory diseases and should be used more by general practitioners and physicians to make their diagnosis and therapy more scientific.