Klippel-Trenaunay Syndrome: Case series from a university hospital of Nepal

Introduction

Klippel Trenaunay Syndrome (KTS) is a rare congenital malformation with capillary and venous malformations and soft tissue/bony overgrowth with or without lymphatic malformation. Cutaneous vascular stain, varicosities and tissue hypertrophy represent its main clinical features. Besides, the patient can develop thromboembolic pathologies, recurrent bouts of infection, stasis eczema, limb length discrepancy and intolerable pain typical of intraosseous involvement.

Methods

Here, we report a case series of seven patients aged 10–45 who presented to our centre with clinical features suggestive of KTS. Out of them, six patients had involvement of unilateral lower limb, while only one had involvement of bilateral lower limb. They all had typical cutaneous vascular stains and underlying venous malformation, while one patient had developed complications with multiple ulcer formation.

Outcomes

An interdisciplinary team of vascular surgeons, dermatologists, interventional radiologists, orthopaedics, and physiotherapists managed the cases. We performed an individualized treatment as per the patient's presentation, which included a combination of supportive, medical, interventional radiologic, and surgical interventions. The follow-up outcomes of all the patients revealed significant resolution of symptoms.

Conclusion

Patients with KTS can have diverse presentations. Therefore, clinicians should ensure an individualized treatment with the involvement of a multidisciplinary team for proper management and prevention of complications.

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Compilation of eight cases of lower limb Klippel-Trenaunay Syndrome (KTS) successfully managed by a multidisciplinary approach.

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Primary complaints include pain, geographic vascular stain and, prominent dilated veins.

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Demonstration of individualized management algorithm, which yields a good outcome.

Vascular Injury to the Neck by a Bamboo Stick: A Case Report

Penetrating neck injuries causing rupture of sternocleidomastoid muscle along with transection of major vessels of the neck have significant morbidity and mortality due to the risk of severe hemorrhage and cerebral infarction. However, there are no universal guidelines for the management of penetrating neck injuries. Here, we report a case of a 67-year-old female with a lacerated wound on the left side of the neck with a complete transection of the left sternocleidomastoid muscle along with transection of internal jugular vein and two superficial branches of internal carotid artery following penetrating injury to the neck by a bamboo stick. It was managed by emergency wound exploration with ligation of the injured vessels with repair of sternocleidomastoid muscle. Post-operatively the hemorrhage was controlled and the patient was discharged on the fourth postoperative day. Thus, in a case of penetrating injury to the neck, prompt surgical wound exploration is beneficial.

Efficacy of Eutectic Mixture of Local Anesthetic Cream and Vibrator Device in Pain Reduction during Peripheral Venous Cannulation in a Tertiary Care Center of Central Nepal

Background Venous cannulation is a commonly performed procedure which often leads to patient anxiety. Application of a vibrator device and or prior use of topical anesthetics are proven methods to decrease associated pain. Objective To compare the clinical efficacy of prior use of Eutectic Mixture of Local Anesthetic (EMLA) cream and vibrator device in pain reduction during peripheral venous cannulation. Method A true experimental study was conducted in November 2019 among 78 patients aged 20-60 years receiving peripheral cannulation at operation theatre. They were included using consecutive sampling and sorted to interventional and noninterventional group using simple random sampling lottery method. Participants in the non-interventional group received peripheral cannulation using routine technique whereas participants in the interventional group received topical Eutectic Mixture of Local Anesthetic cream or vibrator device prior to cannulation. Perceived post cannulation pain intensity was measured using numerical pain rating scale. Kruskal-Wallis test was used for data comparison. Result The mean age of the participants was 40.57 ± 12.5 years. The median pain score of Eutectic Mixture of Local Anesthetic cream, vibrator and no intervention was 3, 3 and 6 respectively. The reduction in median pain intensity was significantly greater with topical anesthetic cream and vibrator device when compared to the noninterventional group (p < 0.05). Conclusion Prior interventions with Eutectic Mixture of Local Anesthetic or vibrator device are useful in reducing pain intensity during peripheral venous cannulation. Routine use of these in day to day practice could be a part of standard nursing care practice.

Knowledge and Practice of Health Care Workers regarding Needle Stick Injuries in a Tertiary Care Center of Nepal

Background Needle stick injuries are common health hazards among health care workers. Considering the increasing prevalence of body fluid borne infectious diseases; knowledge regarding the common errors and universal precautions are vital for the prevention of such accidents. Objective This study aimed to assess for knowledge and practice approaches among health care workers regarding needle stick injuries. Method This is a cross sectional survey was conducted using an anonymous, self-reporting 25-item structured questionnaire at a tertiary care center of central Nepal. A total of 165 health care personnel of working experience of more than 6 months were included in the study. Questionnaire included aspects of prevalence and knowledge on needle stick injury, hepatitis B immunization status and post exposure prophylaxis for HIV. Result Prevalence of needle stick injury was found to be 703 per 1000 health care worker (70.3%) during their working tenure and majority of the injury happened among nurses (p<0.05) besides other professions. Seventy nine (47.9%) participants experienced the injury more than one time in their career and the mean number of injury was 2.06±1.16. The practice of needle recapping is still prevalent and 80% participants often use single handed technique. Vaccination against hepatitis B virus was not completed by 31% health workers. Inadequate knowledge about post exposure prophylaxis for HIV was reported by 46% participants. Conclusion High prevalence of needle stick injury with a high rate of ignorance was noted. These issues need to be addressed, through appropriate education and interventional strategies.

Perception on Informed Consent Regarding Nursing Care Practices in a Tertiary Care Center

Background Consent for care procedures is mandatory after receipt of adequate information. It maintains patient's rights and autonomy to make thoughtful decisions. Poor communication often leads to poor health quality. Objective To assess hospitalized patients' perception on informed consent regarding nursing care practices in a tertiary care center. Method This is a descriptive cross-sectional study among 113 admitted patients conducted in February 2012 at Dhulikhel Hospital, Nepal. Patients of various wards were selected using purposive non-probability sampling with at least 3 days of hospitalization. Close ended structured questionnaire was used to assess patients' perception on three different areas of informed consent (information giving, opportunity to make decision and taking prior consent). Result Among the participants 71.6% perceived positively regarding informed consent towards nursing care practices with a mean score of 3.32 ± 1.28. Patients' perception on various areas of informed consent viz. information giving, opportunities to make specific decision and taking prior consent were all positive with mean values of 3.43±1.12, 2.88±1.23, 3.65±1.49 respectively. Comparison of mean perception of informed consent with various variables revealed insignificant correlation (p-value >0.05) for age, educational level and previous hospitalization while it was significant (p-value < 0.05) for communication skills of nurses. Conclusion Majority of patients have positive perception on informed consent towards nursing care practices. Communication skills of nurses affect the perception of patients' regardless of age, education level and past experiences.

A study of wasp bites in a tertiary hospital of western Nepal

Hymenopterid stings and subsequent allergic reactions including fatal anaphylaxis are common indications for emergency department visits worldwide. Besides that, sting can cause death as a result of multi-system involvement ranging from intravascular hemolysis, rhabdomyolysis, acute renal failure, hepatic dysfunction and occasionally thrombocytopenia and coagulopathy. Eleven cases (all male, age 35.5 +/- 15.2 years) of wasp bites admitted in the Manipal Teaching Hospital (MTH), Pokhara during 01st February, 2006 to 30th October, 2007 were enrolled in this study. Mean wasp bites number was 48.7 +/- 7.1 (11-100) and mean time to reach the hospital from the bite time was 69.1 +/- 149.7 hours (1.5 h-12 days). Nine patients developed acute renal failure (ARF) and secondary hypertension. Eight patients underwent hemodialysis. Two patients stuck by more than 75 stings developed refractory pulmonary edema and died in the course of treatment. Victims with lesser numbers of wasp envenomation, who received quick initiation of alkaline diuresis and intensive dialytic support had shorter hospital stay and less severe complications.

Prevalence of methicillin resistant Staphylococcus aureus in school children of Pokhara

Present study was carried out to find out the prevalence of methicillin resistant Staphylococcus aureus (MRSA) in school children of Pokhara city in western, Nepal. A total of 184 randomly selected children younger than 15 years were included in the study. Nasal swabs collected were subjected to standard bacteriological culture. S. aureus isolates were identified by mannitol fermentation, coagulase positivity and DNase positivity. Antimicrobial susceptibility test was performed on muller-hinton agar (MHA) by modified Kirby-Bauer disc diffusion method. Out of total 184 nasal swabs, S. aureus was isolated in 31.0% (n=57). Among the isolates, 35.1% (n=20) were from male children whereas 64.9% (n=37) were from female. There was no significant sex difference in colonization of S. aureus. Out of 57 isolates, 56.1% (n=32) were MRSA. MRSA isolates indicated relatively high rate of resistance to antibiotic cloxacillin (68.7%) followed by ofloxacin (40.6%), tetracycline (15.6%), erythromycin (9.4%), ciprofloxacin (6.2%) and vancomycin (3.1%).This study showed a high prevalence of MRSA carriage in school children indicating the spread of MRSA in the community.

Parkisonism with Shy-Drager syndrome--a case report

A previously healthy 60 years old female patient presented with bradykinesia, postural instability and increased rigidity of both upper and lower limbs for 2 years and was diagnosed as Parkinsonism for last years. Later on she developed features of autonomic dysfunction including postural hypotension, hyperhydrosis and urinary incontinence so was diagnosed as Shy-Drager Syndrome. She was treated with fludrocortisone and nefidipine for the management of postural hypotension. Patient developed aspiration pneumonia during oral feeding, despite of ICU management for the same cause patient died of respiratory arrest.

When left ventricular failure complicates chronic obstructive pulmonary disease: hypoxia plays the major role

INTRODUCTION

As the chronic obstructive pulmonary disease (COPD) progress, is usually accompanied by involvement of the both left ventricle (LV) and right ventricle (RV), and their systolic and diastolic function. Signs and symptoms of LV failure can be difficult to distinguish from those of COPD.

OBJECTIVE

The study was carried out to determine the prevalence of LV systolic dysfunction in the COPD patients and to assess the possible risk factor behind such development.

MATERIAL AND METHODS

It is a prospective study of 60 cases of COPD patients with or without cor-pulmonale attending Manipal Teaching Hospital.

RESULTS

The prevalence of LV systolic dysfunction was found to be 26.7%, and the findings directly correlate with the severity of COPD i.e., the more the severity of the lung disease more the probability for the incidence of LV systolic dysfunction. These data are in support of the hypothesis that hypoxia and the excess accumulation of toxic metabolic products like lactic acid, significant right-to-left shunting through the bronchial circulation explains the diminished LV ejection fraction in severe COPD patients.

CONCLUSION

Routine echocardiography investigation of the severe COPD patients is required for assessing the status of LV function and to rule out the possible association of LV systolic dysfunction.

Why treat? Better prevent: adult immunization

Immunization is a safe, effective and simple way to prevent life threatening illnesses not only in children but also in adults. Vaccines are some of the safest medicines available which can relieve suffering costs related to these preventable diseases. The reason for underutilization of vaccines in adults are 1) Low prioritization of the importance of vaccines preventable diseases among adults 2) Uncertainty or lack of knowledge about the safety and efficacy 3) Lack of universal recommendations for all adults and 4) Financial constraints, especially in developing countries. Adult immunizations are administered in primary series like previously immunized, booster doses and periodic doses. Agents include Toxoids (Diphtheria and Tetanus), Live Virus Vaccines (Measles, Mumps and Rubella), and inactivated virus vaccines (Influenza), Inactive viral particles (Hepatitis B), inactivated bacterial polysaccharide vaccine (Pneumococcal) and Conjugate / Polysaccharide vaccine (Meningococcal). And also vaccines like Hepatitis A, Polio and Varicella may be recommended in some. Since the economy and literacy rate has shown a steady rise in the South Asia and people are being aware of different health problems through the recently advanced global communication, the education and awareness for immunization not only in children but also in adults need a special consideration. Keeping in view the statistical data of suffering costs related to the non-utilization of immunization in adults, the need of hour has come for utilization of immunization to emphasize its importance.

Sarcoidosis--three clinical vignettes with a short review

Sarcoidosis is a multi system disorder of unknown cause most commonly affecting the young and middle age adults and frequently presents bilateral hilar lymph-adenopathy. The diagnosis of sarcoidosis is often delayed following the onset of symptoms. The reason being first, the disease is often sub clinical; second as the disease affects any system, the diagnosis of sarcoidosis may not be considered; third, the symptoms are not disease specific hence often treated as other chronic pulmonary diseases; finally economic issues or barriers to access for further workup may affect the timeliness of the diagnosis. No laboratory diagnosis is specific for diagnosing sarcoidosis but histological confirmation from the lymph nodes accessible for biopsy either direct or by intervention may be more specific.

Two faces of major lower limb amputations

OBJECTIVES

To review the indications for major lower limb amputations in adults and children in our patient population and to compare our experience in prosthetic rehabilitation with that of other published information.

MATERIAL AND METHODS

We retrospectively reviewed charts of patients who underwent amputation between 1997 to 2004 at the Orthopaedic Department of B& B Hospital (BBH), Gwarko and Hospital and Rehabilitation center for Disabled Children ( HRDC), Banepa. There were 113 patients at BBH & 89 patients at HRDC. Major amputation was defined as any amputation at or proximal to wrist and ankle.

RESULTS

Major lower limb amputations constituted 73.58%(39/53) of all major amputations at BBH and 97.77% (44/45) at HRDC. Road traffic accident was found to be number one cause for major lower limb amputations (74.29%) in adult population. In children postburn contracture was the leading cause for amputation (29.54%) followed by Congenital limb conditions (22.72%), Spina bifida with trophic ulcers ( 20.45%), Tumor (13.63%), Chronic Osteomyelitis (6.81%), Trauma (4.54%) and Arthrogryposis (2.27%). Prosthetic fitting and rehabilitation is as yet far from satisfactory in the adult population but all the children who had amputation at HRDC were fitted with prosthesis.

CONCLUSION

Main causes of major lower limb amputation in both population is largely preventable by instituting safety measures and conducting awareness program. There is a need for an effective prosthetic fitting center for adults.

Results of simultaneous open reduction and Salter innominate osteotomy for developmental dysplasia of the hip

OBJECTIVES

To assess the results of simultaneous open reduction and Salter Innominate Osteotomy for developmental dysplasia of the hip in our context where there is a tendency for these cases to present late without having undergone any treatment previously.

MATERIAL AND METHOD

We retrospectively reviewed the record files and radiographs of 22 dislocated hips of 20 patients managed with simultaneous open reduction and Salter osteotomy at Hospital and Rehabilitation Centre for Disabled Children from 1999 to 2001. Only eight patients with 9 hips with purely developmental dysplasia of hip aged one to seven years were included. The acetabular index on the initial and final radiographs was measured. The neck shaft angle was also measured. All radiographs were evaluated to determine the presence of avascular necrosis of the femoral head and position of the head after the operation. Clinical results were determined using modification of the McKay criteria (Pain, ROM, LLD, Containtment and Gait) . Follow-up ranged from a minimum of 1 year to a maximum of 5 years (average 3 years and 1 month).

RESULTS

The results were excellent in 7 hips (77.77%) good in 1 hip (11.11%) and poor in 1 hip (11.11%) according to modified McKay criteria.. No complications related to infection, graft fracture, vascular or neural injury were encountered.

CONCLUSION

When case selection for surgical treatment is appropriate, a reasonable excellent to good result can be expected even in cases such as ours which present late.