Impact of cadaver training for learning abdominal wall reconstruction: our early experience

PURPOSE

Assess the utility of a hands-on cadaver workshop for teaching abdominal wall reconstruction (AWR) using components separation technique.

METHODS

Over a year, from June 2022 to July 2023, 112 surgeons participated in seven training courses focused on the eTEP technique for inguinal and ventral hernias. The workshops covered theoretical learning sessions followed by hands-on training using frozen human cadavers. An online survey was used to know the influence of our workshop on the clinical practice of the attendees.

RESULTS

Out of 112 total participants, 70% (78) participants completed the survey. Among them, 58% (45) surgeons had over 10 years of experience. The workshop resulted in approximately 85% (66) of participants successfully adapting to eTEP. Confidence levels significantly increased for all steps of the technique after the workshop (p < 0.001, Rank-Biserial Correlation = -1.000). Participants expressed high satisfaction with the course.

CONCLUSION

The cadaver model training program was found to be effective in reducing the learning curve and being replicable. This suggests its potential for widespread implementation as an introductory training model for learning the anatomy of abdominal wall and adapting this for treating hernias requiring AWR.

First-Generation SARS-CoV-2 Vaccines: A Comparative Analysis between Vaccinated and Unvaccinated Hospitalized Patients Infected with SARS-CoV-2

Background Severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) variants, which have emerged due to several mutations in spike protein, have a potential to escape immune protection provided by the first-generation vaccines, thereby resulting in breakthrough infections. Objective To identify the socio-demographic factors, clinical features, and outcomes in both vaccinated and unvaccinated hospitalized patients infected with SARS-CoV-2. Method Socio-demographic details, clinical features, and the outcomes among fully vaccinated (double for Covishield/AstraZeneca and BBIBP-CorV and single for Janssen), partially vaccinated, and unvaccinated hospitalized patients with coronavirus disease of 2019 (COVID-19) were collected and analyzed using SPSS version 17. Result Among the hospitalized COVID-19 patients (n=299), 175 (58.5%) patients received a single-dose, 82 (27.4%) double-dose, and 124 (41.5%) did not receive any dose of the COVID-19 vaccines. The risk of SARS-CoV-2 infection when compared between vaccinated and unvaccinated patients was found to be associated among professional degree holders (23.4% versus 9.7%) (p<0.05), professional workers (43.4% vs. 25.0%) (p<0.05), hospitalization to general ward (76.6% vs. 72.6%) (p<0.05), and presence of multiple symptoms (> or equel 3) (86.8% vs. 75.0%) (p>0.05) and comorbidities (> or equal 2) (15.5% vs. 13.7%) (p>0.05). Despite such approximate incidences, the risk of in-hospital mortality among the vaccinated patients was reduced (0.6% vs. 3.2%) (p>0.05), when compared to the unvaccinated patients. The risk of in-hospital mortality was associated with the older age and the presence of multiple comorbidities including bronchial asthma, diabetes, and hypertension. Conclusion Full or partial vaccination against the SARS-CoV-2 variants of concerns might be effective in preventing in-hospital mortality among COVID-19 patients.

Prevalence of Exclusive Breast Feeding and its Associated Factors among Mothers

Background Breast feeding is the priceless gift given by mother to her newborn. It also has benefits to both mothers and baby. Prevalence of exclusive breast feeding varies from 26.4% in one study to that of 82.2% in another study. Objective To assess the factors associated with exclusive breast feeding among mothers. Method A prospective cross-sectional study using systematic random sampling method, was carried out in Dhulikhel Municipality for two months in November and December 2017 after taking permission from KUSMS IRC and from Dhulikhel Municipality. The study sample was 218 mothers whose infants between 6 months to 1 year were included in the study. A structured and semi-structured interview schedule was used in order to collect the information. Descriptive statistics including frequency and percentage was calculated to summarize mothers' socio-demographic information. Chi-square test was used for non-parametric categorical data in order to find out the association between variables. P-value less than 0.05 were considered significant. Result The prevalence of exclusive breast feeding was 75.7% in the present study. Maternal age found to be varied from 17 years to 40 years. Maternal age, parity of mother and types of family found to be significantly associated with the practice of exclusive breast feeding (p < 0.05). Mothers' occupation and education level was not associated with the practice of exclusive breast feeding. Conclusion Majority of the mothers practice exclusive breast feeding (75.7%). Finding of this study i.e. the factors influencing the practice of exclusive breast feeding will help the health care workers to plan the community awareness program on it.

Prevalence and Associated Factors of Low Birth Weight among Newborns in a Tertiary Level Hospital in Nepal

Background A United Nations Children's Fund reported that the global low birth weight was 15.5%, more than 95.6% of them being from developing countries. Low Birth Weight is a major factor associated with neonatal deaths in developing countries. Also, birth weight is one of the major factor in determining child survival, growth and development. Objective The objective of the study was to identify the prevalence and associated factors of low birth weight among newborns delivered in Dhulikhel Hospital. Method A cross sectional research design was carried out among all newborns delivered at the maternity ward of Dhulikhel Hospital within a period of one year. Data were collected using delivery record register as well as its electronic version which was available in the ward. The collected data were entered and analyzed using software SPSS 20 version with descriptive and inferential statistics. Result Total 2,798 numbers of newborns delivered in the hospital during the period of one year met the inclusion criteria for the study. Among them, 21.6% had low birth weight. We found that low birth weight of newborns was significantly affected by younger age of the mother and lesser weeks of gestation at birth. There were no significantly affected by antenatal clinic visit, parity, sex of the baby, type of delivery. Conclusion The study found that more than one fifth of babies had Low Birth Weight. The study findings suggest that special emphasis should be given to minimize early pregnancy to avoid low birth weight babies.

Prevalence and Predictors of Incomplete Immunization among Children Residing in the Slums of Kathmandu Valley: A Community Based Door-to-Door Survey

Background Expanded program on immunization is one of the most cost-effective and widely applied public health interventions in worldwide. It is priority program for government of Nepal. Objective To estimate the incomplete immunization and identify predictors of incomplete immunization among age of 12-60 months children residing in the slum areas of Kathmandu Valley. Method This cross sectional, community based door-to-door survey was carried out in slum areas of Kathmandu Valley in months of January to February, 2017. Among nine squatters; having more than 100 households, five were selected by using stratified random sampling. The total 505 children age of 12-60 months was included for study. The face-to-face interview with selected mothers was performed using the structured questionnaire. Mean and standard deviation was calculated for continuous variables and proportions with 95% confidence interval level for categorical variables. The chi-square analyses were used to evaluate association between selected variables with incomplete immunization. The p-value <0.05 was considered as statistically significant. Result The mean age of children was 34.7±17.8 months. Nearly half of the children (43.6%) were within age of 12-24 months. The mean age of mothers was 27.1±5.3 years and more than three quarters (82.2%) were literate. The incomplete immunization was 13.0%; it was found higher among female (14.7%) than male children (11.4%). The incomplete immunization was highly associated with poor knowledge on immunization schedule of mothers (p=0.001). Conclusion The incomplete immunization was higher than national mean. It was found association with poor knowledge on immunization schedule of mothers. So, the immunization program should be more strengthen in slum areas and need to expand the education program focusing on immunization schedule.

Evaluation of Pain Preoperatively and Postoperatively in Patients with Chronic Pancreatitis Undergoing Longitudinal Pancreaticojejunostomy

Chronic pancreatitis is a fairly common condition with pain being the major symptom, and longitudinal pancreaticojejunostomy (LPJ) is performed for symptomatic relief. The aim of the study is to assess relief of pain post-LPJ for chronic pancreatitis and to evaluate the factors influencing relief of symptoms. A prospective observational non-interventional study enrolling 28 patients. This study involved a questionnaire studying various risk factors and pain related to chronic pancreatitis, pancreaticojejunostomy, and postoperative assessment of pain relief at 1 and 6 months from surgery. Pain was assessed using Visual analogue scale (VAS). In chronic pancreatitis, there is a significant relief in symptoms of pain post-LPJ; the degree of relief was less in the alcoholics vs non-alcoholics (p = 0.09) and smokers. There was also reduction in analgesic requirement and frequency of acute attacks of pain. Fifty-seven percent of patients had a complete remission of their pain after LPJ for CP. In chronic pancreatitis, there is a significant relief in symptoms of pain post-LPJ, although the degree of relief is less in the alcoholics and smokers.

Pedicled omental and split skin graft in the reconstruction of the anterior abdominal wall

INTRODUCTION

The POSSG is a pedicled graft based on either the right or left gastro-epiploic arteries. It is used with a dual mesh in reconstruction of full thickness defects of anterior abdominal wall and covered by skin grafts.

PRESENTATION OF CASE

A recurrent malignant peripheral nerve sheath tumor (MPNST) of the anterior abdominal wall was excised leaving a large defect. The POSSG was used for reconstruction. A large dual mesh was placed to close the defect in the abdominal wall by suturing it to the remnant rim of abdominal muscles. The omental pedicle was brought through a keyhole in the mesh, spread out over the mesh, sutured and covered by split skin grafts. The final graft take was 90 percent.

DISCUSSION

The POSSG can be used to reconstruct any size of anterior abdominal wall defects due to the malleable nature of omentum. Its prerequisite however is a dual mesh like PROCEED. The POSSG helps keep the more complex musculofasciocutaneous flaps as lifeboats. It can be used singly where multiple musculofasciocutaneous flaps would otherwise have been required. It can be used in patients with poor prognosis of underlying malignancy. It may be used by general surgeons due to familiarity with anatomy of the relevant structures and lack of need for microsurgical skill.

CONCLUSION

The POSSG can be used in reconstruction of abdominal wall defects of any size by general surgeons.

Distribution and skill mix of health workforce in Nepal

BACKGROUND

Distribution and skill mix of health workforce has always been a challenge in rural Nepal. Workforce surpluses or shortages and inappropriate skill mix, decrease productivity and efficiency, deplete scarce resources and squander worker capabilities. This study was aimed at generating evidences on the current distribution and skill mix of health workforce in Nepal.

METHODS

A cross-sectional study was conducted using both qualitative and quantitative methods.Fifteen districts representing three eco-developmental regions of Nepal were selected using multi-stage cluster sampling method. Out of 404 sampled health institutions, 747 health workers from 375 health institutions were interviewed. Observation was carried out in 256 health facilities.

RESULTS

Currently, the vacant positions are mostly of doctors 74(38%) technicians 28 (21%) nurses 50 (10%) and paramedics 26 (6%)with respect to sanctioned positions. Variations of fulfilled positions occurred in all three ecological belts, with the Hill belt having the highest proportion of vacant posts 116 (16%).On the basis of types of health facilities, ayurvedic centres have the highest fulfilled positions 55 (95%) and the lowest in primary healthcare centres (PHCCs) 162 (81%). Proper skill mix was observed in 6 (43%) of hospitals and 3(18%) of PHCCs.Only 132 (17.7%) of health workers have taken part in orientation on non-communicable diseases (NCDs) despite the increasing trend of NCDs.

CONCLUSIONS

There is scarcity of health workforce with appropriate skills, particularly in rural Nepal. Sanctioned positions and categories of health workers need to be revised on the basis of population growth and epidemiological shifts.

Role of civil society in human resources for health management in Nepal

BACKGROUND

The policy document of Nepal has spelled out commitment to involving civil society organisations (CSOs) in improving human resources for health (HRH). However, lack of empirical evidences, it is very hard to figure out exact situation about the roles and engagement of CSOs in HRH management.

METHODS

A cross-sectional descriptive study was conducted using both quantitative and qualitative methods. Out of 404 sample health institutions, 747 health workforce from 375 health institutions were interviewed (<10% non-response rate) using the probability proportionate to size method as per World Health Organization (WHO) guidelines.

RESULTS

Nearly 75% respondents had opined that the political parties were supporting the health institutions in the grassroots. It was found that the support from the CSO was better in Hill (54.9%) compared to Terai (46.9%) and Mountain (46.7%). The support was significantly different between rural (CI: 0.5063-0.591) and urban (CI: 0.3055-0.4363) (p <0.05, CI 95%). Mean index score of effectiveness of CSOs was found highest in Hills (0.3036) followed by Mountains (0.2669) and Terai (0.2589). Effectiveness of CSOs was found positively correlated with feeling of security by health workers and social prestige.

CONCLUSIONS

The roles of civil society in HRH management still need to be recognized and well documented ensuring their active participation in formulation and implementation of policies, strategies and planning related to HRH for effective and quality healthcare services in Nepal.

Perception of security by health workforce at workplace in Nepal

BACKGROUND

In Nepal, the relationship of health worker and patient or community people is now deteriorating and the security and safety of health worker is becoming emerging issues. The poor relationship between community people and health worker is hampering the health service especially in rural setting. This study was aimed at finding the security perception and situation of health workforce in Nepal.

METHODS

A cross-sectional descriptive study was conducted using both quantitative and qualitative methods. Out of 404 sample health institutions, 747 health workforce from 375 health institutions were interviewed (<10% non-response rate) using the probability proportionate to size method as per World Health Organization (WHO) guidelines.

RESULTS

Nearly 168 (23%) of health workers felt some level of insecurity at their workplace. Mostly, doctors felt insecure at their workplace 24 (30%) and argued with service users , 26 (32.50%). Feeling of security was highest in central region 160 (83.30%). Nationwide, 121 (16%) of health workers faced some level of arguments with service users, which was highest in Tarai 64 (18.08%). Of the total harassment, both gender based and sexual harassment was higher among female health workers [20 (62.5%) and 13 (56.5%) respectively]. Only, 230 (30.7%) of health workers who suffered from workplace accidents got compensation and treatment.

CONCLUSIONS

Higher proportions of health workers feel insecurity at workplace whereas provision of compensation was minimal. There is a need of strict implementation of Security of the Health Workers and Health Organizations Act, 2066 (2009) for effective health service delivery.

Knowledge and practice of blood donation: a comparison between medical and non-medical Nepalese students

College students form a large and important group of population eligible for blood donation. Studies report that students do not donate much, and medical students' blood donation rate is less as compared to non-medical students. To assess and compare the knowledge, attitude, and practice of blood donation among medical and non-medical Nepalese students. A cross-sectional descriptive study using structured self-administered questionnaire was conducted in students of medical (MBBS) and non-medical programs of different colleges of Nepal. Total 456 students, 177 non-medical and 279 medical, participated; 28.5% students were donors. More medical students donated blood, more often, and were more knowledgeable in all aspects of blood and blood donation related knowledge (p values 0.01 or less). In both groups, proportionately more boys donated than girls. Common reasons for not donating included no request, medically unfit, no information about blood collection services, fear of weakness, and fear related to venepuncture. Moral satisfaction was the commonest reason to donate. Among Nepalese students, medical students donate more and are more knowledgeable than non-medical students. Lack of information and lack of direct requests are important causes of fewer donors in the non-medical group and girls.

Leiomyosarcoma of inferior vena cava

Malignancy arising from the blood vessels is a very rare finding in daily clinical practice. In addition, the finding can often be misdiagnosed and ill-treated. These tumors usually go unnoticed unless it has metastasized to distant tissues. Among these rare tumors, leiomyosarcoma is the most common. It mostly arises in the inferior vena cava (IVC). Clinical signs and symptoms are very vague. Usually it is often misdiagnosed as an abscess cavity in the liver or primary hepatic malignancy (when present at level II) or as a thrombus in the IVC. Radiological investigations are the key to proper diagnosis. Depending upon the exact location, further treatment options vary. Generally, it is believed that level II and level III tumors are amenable to surgery followed by chemo or radiotherapy. We present a rare case of leiomyosarcoma of IVC at level II being diagnosed with proper radiological investigations and its management with further stress on offering chemo-radiotherapy after its surgical removal as compared to only surgery performed earlier. This case report will throw some light on the proper management of such rare tumors in terms of their exact diagnosis and treatment in order to prolong patient survival.

In health--vital capacity is maximum in supine position

Vital capacity, frequently measured clinically as an index of pulmonary function, gives useful information about the strength of respiratory muscles and other aspects of lung functions. It is generally noted in sitting position. As in the supine position, respiratory excursions of diaphragm is highest in normal breathing, this study was planned to note whether there occurred any alteration in vital capacity in supine position in comparison to that noted in sitting position. Young sedentary non smoker healthy medial students (n = 100, age 19-22 years) of Nepal Medical College participated as volunteers in this study. Body mass index (BMI) of each of them was calculated. Vital capacity was noted in sitting position and in supine position with the help of a spirometer, following the standard procedure. Result exhibited greater vital capacity in supine posture than in sitting position in the same individual. Diaphragm is the major muscle of inspiration, responsible for some two-thirds of the vital capacity. Naturally, in supine posture the scope of diaphragmatic movements increased and as a result, vital capacity exhibited greater value in comparison to that recorded in sitting posture.

Immediate effect of a slow pace breathing exercise Bhramari pranayama on blood pressure and heart rate

The study was carried out to evaluate the immediate effect Bhramari pranayama, a slow breathing exercise for 5 minutes on heart rate and blood pressure. Heart rate and blood pressure of volunteers were recorded. The subject was directed to inhale slowly up to the maximum for about 5 seconds and then to exhale slowly up to the maximum for about 15 sec keeping two thumbs on two external auditory canal, index and middle finger together on two closed eyes and ring finger on the two sides of the nose. During exhalation the subject must chant the word "O-U-Mmmma" with a humming nasal sound mimicking the sound of a humming wasp, so that the laryngeal walls and the inner walls of the nostril mildly vibrate (Bhramari pranayama, respiratory rate 3/min). After 5 minutes of this exercise, the blood pressure and heart rate were recorded again. Both the systolic and diastolic blood pressure were found to be'decreased with a slight fall in heart rate. Fall of diastolic pressure and mean pressure were significant. The result indicated that slow pace Bhramari pranayama for 5 minutes, induced parasympathetic dominance on cardiovascular system.

Assessment of kidney stone and prevalence of its chemical compositions

Kidney stone analysis is the test done on the stone which cause problems when they block the flow of urine through or out of the kidneys. The stones cause severe pain and are also associated with morbidity and renal damage. There is also no clear understanding on the relative metabolic composition of renal calculi. Hence, the study is aimed to find out the chemical composition of it which can guide treatment and give information that may prevent more stones from forming. The study was carried out on the stones that had been sent to the department of Biochemistry (n = 99; M = 61; F = 38; Mean age: 33.6 +/- 14.4 years) Approximately 98.9% of stones were composed of oxalate, 95.9% of Calcium, 85.8% of phosphate, 62.6% of Urate, 46.4% of Ammonium and very few percentages of Carbonate.

Spirometric evaluation of pulmonary function tests in clinically diagnosed patients of bronchial asthma

The present study was undertaken to assess the difference between the normal predicted value and observed value of pulmonary function test (PFT) amongst the asthmatic patients and also to compare the aforesaid observed values between male and female asthmatic patients. Clinically diagnosed cases (male 62, female 75) of bronchial asthma attending medical out patient department of Nepal Medical College Teaching Hospital were assessed. All the pulmonary parameters showed significantly less observed values than the normal predicted values except PEFR in female and FVC in male asthmatic patients. Hence, PEFR in female and FVC in male asthmatic patients might not be considered as a valid parameter to indicate bronchial asthma. Present study also revealed that all the pulmonary variables were significantly higher in males than in females.

Assessment of some pulmonary parameters and cardiorespiratory fitness status in Nepalese medical students

Some pulmonary function tests along with cardio respiratory fitness test were performed to assess the health status of the young (19-21 years) non-smokers Nepalese medical students. Results revealed that the vital capacity was 3.46 liters and 2.40 liters among the boys and girls respectively. PEFR was found to be 597.98 l/min among the boys and 456.53 l/min among the girls. Likewise, VO2 max among the boys and girls were 54.32 ml/kg/min and 44.88 ml/kg/min respectively. It was evident from the result that the health status of the Nepalese medical students ill the present study group was fairly well. It might be due to their health awareness, balanced-nutritious diet and the habits of occasional physical exercise.

Effect of alternate nostril breathing exercise on cardiorespiratory functions

Pranayama (breathing exercise), one of the yogic techniques can produce different physiological responses in healthy individuals. The responses of Alternate Nostril Breathing (ANB) the Nadisudhi Pranayama on some cardio-respiratory functions were investigated in healthy young adults. The subjects performed ANB exercise (15 minutes everyday in the morning) for four weeks. Cardio-respiratory parameters were recorded before and after 4-weeks training period. A significant increment in Peak expiratory flow rate (PEFR L/min) and Pulse pressure (PP) was noted. Although Systolic blood pressure (SBP) was decreased insignificantly, the decrease in pulse rate (PR), respiratory rate (RR), diastolic blood pressure (DBP) were significant. Results indicate that regular practice of ANB (Nadisudhi) increases parasympathetic activity.

Tensional homeostasis in dermal fibroblasts: mechanical responses to mechanical loading in three-dimensional substrates

Many soft connective tissues are under endogenous tension, and their resident cells generate considerable contractile forces on the extracellular matrix. The present work was aimed to determine quantitatively how fibroblasts, grown within three-dimensional collagen lattices, respond mechanically to precisely defined tensional loads. Forces generated in response to changes in applied load were measured using a tensional culture force monitor. In a number of variant systems, resident cells consistently reacted to modify the endogenous matrix tension in the opposite direction to externally applied loads. That is, increased external loading was followed immediately by a reduction in cell-mediated contraction whilst decreased external loading elicited increased contraction. Responses were cell-mediated and not a result of material properties of the matrices. This is the first detailed characterisation of a tensional homeostatic response in cells. The maintained force, after 8 h in culture, was typically around 40-60 dynes/million cells). Maintenance of an active tensional homeostasis has widespread implications for cells in culture and for whole tissue function.