Prevalence and risk factors of chronic kidney disease among patients with type 2 diabetes mellitus at a tertiary care hospital in Nepal: a cross-sectional study

OBJECTIVE

To estimate the prevalence of chronic kidney disease (CKD) among patients with type 2 diabetes mellitus (T2DM) and determine the sociodemographic and clinical risk factors associated with CKD.

DESIGN AND SETTINGS

Cross-sectional study among diabetic outpatients of a tertiary hospital in Nepal.

PARTICIPANTS

201 patients with T2DM above 18 years of age.

INTERVENTION

Participants completed a questionnaire regarding their socioeconomic information and underwent pertinent physical and haematological examinations.

PRIMARY AND SECONDARY OUTCOMES MEASURE

The prevalence and risk factors of CKD among patients with T2DM.

RESULTS

The prevalence of CKD in T2DM was 86.6%. In univariable analysis, the variables like age (p=0.026), hypertension status (p=0.002), duration of diabetes (p=0.009) and haemoglobin levels (p=0.027) were significantly associated with CKD among the participants with T2DM. Kruskal-Wallis H test showed that age was significantly different between various CKD stages. Multivariate analysis demonstrated a significant relationship between CKD with age (Adjusted odds ratio (AOR) 3, 95% CI 1.1 to 8.8) and literacy status (AOR 5.8, 95% CI 1.4 to 24.6) CONCLUSION: Advancing age, concomitant hypertension, increasing duration of T2DM and presence of anaemia were found to be important risk factors of CKD. Age is the most important predictor of CKD showing increasing prevalence in the elderly population. Periodic screening tests are essential at an early age to identify kidney diseases at incipient stages, thereby preventing progression to end-stage renal disease.

Knowledge of point-of-care ultrasound and management of deep vein thrombosis patient in resource limited setup: A case report

Introduction

and importance: Deep vein thrombosis (DVT), frequently encountered in an emergency setting, if not identified and managed early, leads to pulmonary embolism that may be life threatening to the patient. The use of point-of-care ultrasound (POCUS) can be used as an effective and time saving tool for diagnosis of such life threatening conditions.

Case presentation

We present a case of a 53 years old male who presented to the emergency department (ED) with complaints of swelling and pain in the left lower limb for one week and redness of overlying skin for the same duration. Following a point-of-care ultrasound scan, a diagnosis of DVT was made. The condition was quickly identified and promptly treated preventing possible complications.

Discussion

Use of point-of-care ultrasound to diagnose DVT has been shown to decrease the need for comprehensive scans, decrease time to diagnosis and length of stay at the emergency department. To improve medical care by increasing early detection, lowering costs, and improving overall patient care, more training of emergency physicians in ultrasound technique and standardized use of ultrasound to screen for DVT in the ED is required.

Conclusion

This case report highlights how, despite the unavailability of sophisticated diagnostic procedures, a skill of using POCUS can prove to be lifesaving in a resource-limited setting.

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Deep vein thrombosis is a life-threatening condition requiring prompt diagnosis and treatment.

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DVT, if not managed timely can lead to complications like pulmonary embolism.

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Point-of-care ultrasound (POCUS) can help detect DVT timely.

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Use of POCUS can prove valuable in resource limited setting where sophisticated tools to diagnose conditions such as DVT are unavailable.

Spectrum of coronary angiographic findings in patients with ST Elevation Myocardial Infarction (STEMI) undergoing primary PCI in a tertiary care center of Nepal

BACKGROUND

Even in developing countries like Nepal, prevalence of ST-elevation myocardial infarction has been shown to be increased with rise in prevalence of conventional risk factors like diabetes, Hypertension, smoking, dyslipidemia and obesity. Our aim is to retrospectively analyze for various risk factors and angiographic patterns of coronary artery disease in patients with ST-elevation myocardial infarction undergoing Primary Percutaneous Intervention.

RESULTS

During the period of 1 year (January 2019 to December 2019), 816 patients presented to our ER with acute STEMI, among them 437 (53.6%) patients underwent primary PCI strategy and among them 22 (5.3%) patients were died. Thirty-six (4.4%) patients received thrombolysis, among them 5 (13.9%) patients were died while remaining 343 (42.0%) patients were managed conservatively and among them 20 (5.8%) were died. The mean age of patient who underwent primary PCI was 58.5±12.7 years range from 25 years to 99 years. Among them 55-75 years old 217 (49.6%) were highest in number followed by<55 years old 180 (41.2%). Males 318 (72.8%) were predominant. Among those who underwent primary PCI, hypertension 214 (49%) was the most common risk factor, followed by smoking 198 (45.3%), diabetes mellitus 123 (28.1%), dyslipidemia 53 (12.1%) and family history of premature coronary artery disease 18 (4.1%). Among those patients, 292 patients (66.8%) had single vessel disease, 99 patients (22.7%) had double vessel disease, 41 patients (9.3%) had triple vessel disease and 5 patients (1.1%) had non-significant coronary artery stenosis. Left anterior descending (53.3%) was the most frequently found culprit artery, followed by right coronary artery, left circumflex, ramus intermedius and left main artery.

CONCLUSION

Fifty percent of patients presented with acute ST-elevation myocardial infarction and underwent primary PCI were between 55-75 years of age. Hypertension and smoking were the most common risk factors present in those patients. Single vessel disease was most prevalent with left anterior descending found to be the most commonly involved coronary artery followed by right coronary artery and left circumflex.

Digital Subtraction Angiography a Door Opener for Neurosurgical Residents who want to Perform Neurointerventional Procedures

Digital subtraction angiography (DSA) has been a fluoroscopic golden investigative tool to know the vascular angiography of the brain and spinal cord. The technique in performing this procedure exposes residents in accessing the major vessels, branches of the arch of aorta, selective angiography and diagnosing different vascular anomalies of brain and spine. They are also exposed to the knowledge of different diagnostic catheters, its manipulation, use of dye and radiation exposure and safety. We would like to share our experience in training and disseminating the knowledge of digital subtraction angiography to the residents.

Menopausal Health Status of Nepalese Women

INTRODUCTION

Menopause is an unavoidable and sometimes problematic condition in which women may suffer from a number of health problems. Knowledge of the major symptoms associated with menopause helps reduce the burden and stress associated with the condition. In this context, a study was conducted to establish baseline data regarding menopausal health problems among Nepalese women.

METHODS

A descriptive cross-sectional study was conducted among 2000 women aged over 40 years to identify their knowledge, attitude and practice related to menopausal health problems. Data was collected by interviewing the women and doing physical examination. Analysis was done using descriptive statistics and SPSS software was used for data analysis.

RESULTS

A cohort of 2073 women (ages 40-60 years) participated in the research, among them 2000 yielded complete response. The study revealed that 820 (41%) women had reached menopause. The average age of menopause was 48.7 years. Majority of the women 1183 (59.2%) in the study did not know about menopausal health problems. Abnormal bleeding 353 (17.65%), sweating 315 (15.75%), hot flushes 299 (14.95%), joint/muscle pain 285 (14.25%) were the most common menopausal symptoms known by the women. Joint pain 736 (36.8%), hot flushes 584 (29.2%), irregular bleeding 582 (29.1%) were the most common experienced symptoms of menopause and only 586 (29.3%) consulted the health workers to alleviate menopausal symptoms. Moreover, most of the women 926 (46.3%) accepted menopause as a part of life.

CONCLUSIONS

The research has tried to establish the baseline of menopausal health problems in the Nepalese women. The average age of menopause was 48.7 years. Majority did not know about menopausal health problems. Further researches with nationally representative sample are recommended to further explore the menopausal health problems of Nepalese women.

Visible light communication using InGaN optical sources with AlInGaP nanomembrane down-converters

We report free space visible light communication using InGaN sources, namely micro-LEDs and a laser diode, down-converted by a red-emitting AlInGaP multi-quantum-well nanomembrane. In the case of micro-LEDs, the AlInGaP nanomembrane is capillary-bonded between the sapphire window of a micro-LED array and a hemispherical sapphire lens to provide an integrated optical source. The sapphire lens improves the extraction efficiency of the color-converted light. For the case of the down-converted laser diode, one side of the nanomembrane is bonded to a sapphire lens and the other side optionally onto a dielectric mirror; this nanomembrane-lens structure is remotely excited by the laser diode. Data transmission up to 870 Mb/s using pulse amplitude modulation (PAM) with fractionally spaced decision feedback equalizer is demonstrated for the micro-LED-integrated nanomembrane. A data rate of 1.2 Gb/s is achieved using orthogonal frequency division multiplexing (ODFM) with the laser diode pumped sample.

Risk Factors and Outcome of Neonates Born through Meconium Stained Amniotic Fluid in a Tertiary Hospital of Nepal

Introduction: The incidence of meconium aspiration syndrome is still high in the developing world contributing significantly to the neonatal mortality. The study was aimed to know the risk factors contributing to meconium aspiration syndrome and neonatal outcome in a tertiary government hospital of the country.Materials and Methods: It was a hospital based cross sectional study done over a period of three months. All live newborns born through meconium stained liquor were enrolled and all the details regarding mother, neonate were recorded. Odd’s ratio and bivariate analysis was done to assess the risk factors for meconium aspiration syndrome.Result: Out of all the deliveries 14.6% were meconium stained amniotic fluid and meconium aspiration syndrome developed in 6.6% of the neonates. Low Apgar score and premature rupture of membranes was significantly associated with the risk of occurrence of meconium aspiration syndrome. Neonates who developed meconium aspiration syndrome had mortality of 11.3%.Conclusion: Perinatal asphyxia and premature rupture of membranes were significantly associated with the development of meconium aspiration syndrome and neonates who developed meconium aspiration syndrome had high mortality.J Nepal Paediatr Soc 2015;35(1):44-48

10 Mb/s visible light transmission system using a polymer light-emitting diode with orthogonal frequency division multiplexing

We present a newly designed polymer light-emitting diode with a bandwidth of ~350  kHz for high-speed visible light communications. Using this new polymer light-emitting diode as a transmitter, we have achieved a record transmission speed of 10  Mb/s for a polymer light-emitting diode-based optical communication system with an orthogonal frequency division multiplexing technique, matching the performance of single carrier formats using multitap equalization. For achieving such a high data-rate, a power pre-emphasis technique was adopted.

Human genital myiasisin extremes of age

Genital myiasis is a very rare entity associated with poor personal hygiene, restricted mobility, and immunosuppressed status and ulcerating lesions. With the reported incidence of only 0.7%, only a few cases have been published so far in literature but none from Nepal. Despite such rare occurrence, we present here two such cases which we encountered in an interval of three days; one in an unmarried teenager and another in a postmenopausal lady with fungating ulcerative growth of vulval carcinoma. Both were successfully managed.

Diagnostic dilemma of an unusual pelvic mass in a young girl

Dysgerminoma of ovary is the most common germ cell tumor, accounting for 50% of all germ cell tumor cases. About 20% of cases are diagnosed during pregnancy, and 80% occur in women under 30. It is rare to find both ovaries to be involved in germ cell tumors. The prognosis of patients with malignant germ cell has improved significantly over the last two decades after the introduction of chemotherapy specially cisplatin. The only exceptions are stage 1, grade 1, immature teratoma and stage 1A dysgerminoima who are followed up after surgery without adjuvant chemotherapy. Normal ovarian functions and fertility can be retained in most patients by following the conservative surgery.

INTRACARDIAC ELECTROPHYSIOLOGICAL STUDY AND ABLATION IN NEPAL

Cardiac electrophysiology study (EPS) is one of the most advanced, challenging and a complex branch ofinvasive cardiology. It involves placement of large sized multipolar catheters in various chambers of theheart. They are used to map and also to ablate the culprit focus of arrhythmia generation. When done byexperts, the procedure can be curative. Three electrophysiology workshops were conducted in ShahidGangalal National Heart Centre. 44 patients underwent the procedure, among which 38 had radiofrequencyablations done and 8 had electrophysiological study. Of the ablated cases all were successful except onehad recurrence of tachycardia. Overall success rate was 93% and no major complications were notedduring or after procedure.Key Words: Electrophysiology, Radiofrequency ablation.

Prevalence of rheumatic and congenital heart disease in schoolchildren of Kathmandu valley in Nepal

BACKGROUND

Rheumatic heart disease remains a major public health problem in developing countries with its very high prevalence. Rheumatic and congenital heart disease are significant causes of morbidity and mortality among Nepalese schoolchildren. The aim of our study was to determine the prevalence of rheumatic and congenital heart disease among schoolchildren of the Kathmandu valley in Nepal.

METHODS AND RESULTS

The study included 9420 students, of whom 4466 were male and 4954 were female, with ages ranging from 5 to 18 years. A clinical survey was conducted by the examining team in selected schools, and involved answering standard questionnaires. A total of 83 children were suspected of having heart disease. Out of these 83 children, 23 were confirmed to have heart disease; 11 had rheumatic heart disease, and 12 congenital heart disease, giving a prevalence of 1.2/1000 and 1.3/1000, respectively. The commonest cardiac lesions were mitral regurgitation in the rheumatic heart disease group, and atrial septal defect in the congenital heart disease group. A higher prevalence of congenital heart disease was detected in females.

CONCLUSIONS

The prevalence of rheumatic heart disease and congenital heart disease among schoolchildren of Kathmandu is 1.2/1000 and 1.3/1000, respectively, with mitral regurgitation and atrial septal defect being the commonest lesions.

Distribution of Risk Factors in Patients with Acute Coronary Syndrome – a Hospital Based Study

A total of 230 patients admitted in coronary care unit of Shahid Gangalal National Heart Centre in betweenNovember 2001 and October 2002 were studied. 157 (68.2%) were male, with mean age of 62.8±11.8 years.Majority of acute coronary syndrome (ACS) events were observed in males with advanced age (> 65 years).About 68% patients with ACS were smoker, the most common modifiable risk factor followed by hypertension,dyslipidaemia and diabetes. A strong trend towards development of coronary artery disease (CAD) wasfound in subjects with positive family history of CAD. Multiple risk factors (2 or more) were present in vastmajority of patients. Modifiable risk factors, with smoking at number one position are more common inacute coronary syndrome patients. Appropriate management of modifiable risk factors is advisable to reducethe incidence of coronary artery disease.Key Words: Coronary Artery Disease, Risk Factors.

Lumbar Disc Injury : A Retrospective Study of 150 cases

Abstract

Effect of anionic polymers on the release of propranolol hydrochloride from matrix tablets

Anionic polymers, namely Eudragit S, Eudragit L 100-55, and sodium carboxymethylcellulose, were incorporated into hydroxypropylmethylcellulose (HPMC K100M) to modify the drug release from HPMC matrices. The effects of changing the ratio of HPMC to anionic polymers were examined in water and in media with different pH. The dissolution profiles were compared according to release rates. The interaction between propranolol hydrochloride and anionic polymers was confirmed using the UV difference spectra method. The drug release was controlled with the type of anionic polymer and the interaction between propranolol hydrochloride and anionic polymers. The HPMC-anionic polymer ratio also influenced the drug release. The matrix containing HPMC-Eudragit L 100-55 (1:1 ratio) produced pH-independent extended-release tablets in water, 0.1 N HCl, and pH 6.8 phosphate buffer.

Neonatal hypoglycaemia in Nepal 1. Prevalence and risk factors

AIMS

To measure the prevalence of hypoglycaemia among newborn infants in Nepal, where classic risk factors prevail, and to evaluate their importance.

METHODS

A cross sectional study was done of 578 term newborn infants aged 0 to 48 hours on the postnatal wards of a government maternity hospital in Kathmandu, with unmatched case-control analysis of risk factors for moderate hypoglycaemia (less than 2.0 mmol /l).

RESULTS

Two hundred and thirty eight (41%) newborn infants had mild (less than 2.6 mmol/l) and 66 (11%) moderate hypoglycaemia. Significant independent risk factors for moderate hypoglycaemia included postmaturity (OR 2.62), birthweight under 2.5 kg (OR 2.11), small head size (OR 0.59), infant haemoglobin >210 g/l (OR 2.77), and raised maternal thyroid stimulating hormone (TSH) (OR 3.08). Feeding delay increased the risk of hypoglycaemia at age 12-24 hours (OR 4.09). Disproportionality affected the risk of moderate hypoglycaemia: lower with increasing ponderal index (OR 0.29), higher as the head circumference to birthweight ratio increased (OR 1.41). Regression expressing blood glucose concentration as a continuous variable revealed associations with infant haemoglobin (negative) and maternal haemoglobin (positive), but no other textbook risk factors.

CONCLUSIONS

Neonatal hypoglycaemia is more common in a developing country, but may not be a clinical problem unless all fuel availability is reduced. Some textbook risk factors, such as hypothermia, disappear after controlling for confounding variables. Early feeding could reduce moderate hypoglycaemia in the second 12 hours of life. The clinical significance of raised maternal TSH and maternal anaemia as prenatal risk factors requires further research.

Neonatal hypoglycaemia in Nepal 2. Availability of alternative fuels

AIMS

To study early neonatal metabolic adaptation in a hospital population of neonates in Nepal.

METHODS

A cross sectional study was made of 578 neonates, 0 to 48 hours after birth, in the main maternity hospital in Kathmandu. The following clinical and nutritional variables were assessed: concentrations and age profiles of blood glucose, hydroxybutyrate, lactate, pyruvate, free fatty acids (FFA) and glycerol; associations between alternative fuel levels and hypoglycaemia; and regression of possible risk factors for ketone availability.

RESULTS

Risk factors for impaired metabolic adaptation were common, especially low birthweight (32%), feeding delays, and cold stress. Blood glucose and ketones rose with age, but important age effects were also found for risk factors like hypothermia, thyroid hormone activities, and feeding practices. Alternative fuel concentrations, except FFA, were significantly reduced in infants with moderate hypoglycaemia during the first 48 hours after birth. Unlike earlier studies, small for gestational age (SGA) infants had significantly higher hydroxybutyrate:glucose ratios which suggested counter regulatory ketogenesis. Hypoglycaemic infants were not hyperinsulinaemic. Regression analysis showed risk factors for impaired counter regulation which included male and large infants, hypothermia, and poorer infant thyroid function. SGA infants and those whose mothers had received no antenatal care had increased counter regulation.

CONCLUSIONS

Alternative fuels are important in the metabolic assessment of neonates, and they might provide effective cerebral metabolism even during moderate hypoglycaemia. Hypoglycaemic infants generally had lower concentrations of alternative fuels through either reduced availability or increased consumption. SGA and post term infants increased counter regulatory ketogenesis with early neonatal hypoglycaemia, but hypothermia, male gender, and low infant T4 were associated with impaired counter regulation after birth.

A new minimally invasive technique to show nerve ischaemia in diabetic neuropathy

AIMS/HYPOTHESIS

Experimental studies have shown that abnormalities of nerve microcirculation are important factors in the pathogenesis of diabetic neuropathy but there have been few clinical studies. We have applied microlightguide spectrophotometry to measure intravascular oxygen saturation (HbO2%) and blood flow in human sural nerve.

METHODS

We studied ten patients with mild-moderate sensory motor diabetic neuropathy, nine patients without neuropathy and nine control subjects. We took 300 measurements of oxygen saturation under direct visual control through a 1.9 mm rigid endoscope over three regions of the nerve. Spectrophotometric measurements of nerve fluorescence were taken after an intravenous injection of sodium fluorescein and the rate of increase in nerve fluorescence (rise time) was used as an indicator of nerve blood flow.

RESULTS

Nerve oxygen saturation was reduced in patients with neuropathy compared with control subjects (67.1 +/- 2.2% vs 76.7 +/- 2.1%, p = 0.006). Fluorescein rise time was prolonged in patients with neuropathy compared with the control group (48.5 +/- 7.0 s vs 14.0 +/- 3.1 s, p = 0.001) suggesting impaired nerve blood flow. There was a correlation between rise time, nerve oxygen saturation, glycaemic control and sural nerve sensory conduction velocity (p < 0.01).

CONCLUSION/INTERPRETATION

The combination of microlight-guide spectrophotometry and micro-endoscopy provides a valuable minimally invasive technique for clinical investigation of nerve microcirculation. We have shown reduced nerve oxygenation and impaired blood flow in diabetic neuropathy and these findings strongly support a central role of microvascular disease in the pathogenesis of diabetic neuropathy.

A study of dermatological disorders in geriatric age group

A total of 320 patients of more than 60 years of age were studied for dermatological changes with aging. The male female ratio of patients was 3:1. Majority of cases (60.6%) were between 60-65 years of age. Pruritus was present in 37.5% cases, wrinkles in 82.1%, senile lentigenes in 57.8%, seborrhoeic keratosis in 48.8%, cherry angioma in 48.1%, idiopathic guttate hypomelanosis in 43%, skin tags in 37%, xerosis in 28%, comedones in 19%, infection and infestation in 40%, eczematous disorders in 36.9%, papulosquamous disorders in 10%, metabolic disorders in 16%, pigmentary disorders in 8.7%, keratinisation disorders in 4.1%, vesiculobullous disorders in 2.8% and associated systemic disorders in 49.7% cases.

Short report: an outbreak of Japanese encephalitis in Kathmandu, Nepal

We report the first proven outbreak of Japanese encephalitis (JE) occurring in the Kathmandu Valley of Nepal. During September and October 1995, we treated 15 patients with meningo-encephalitis. All of the patients were Nepalese, all but one lived in the Kathmandu Valley, and their overall mortality was 53%. Anti-JE virus (JEV) IgM in the cerebrospinal fluid was found in the two cases for whom it was tested. The two tested patients were similar to the other patients in clinical presentation and in home location. We recommend immunization against JEV for those traveling to Kathmandu during the months of August to October.

Puerperal inversion of the uterus in Nepal: case reports and review of literature

Retrospective study of 6 cases of puerperal inversion of the uterus is being presented from 1975 to 1995 and a review of literature for 20 years of the period 1975-1995 has been summarised. In the present series, one case with acute puerperal inversion of uterus were treated by manual reposition, 2 cases of chronic puerperal inversion of uterus was treated surgically by Kustner's vaginal approach. Two cases with subacute puerperal inversion of uterus, 1 case of chronic puerperal inversion were treated by Haultain and Huntington method. Out of 241 cases of uterine inversion obtained from review of literature for last 20 years, 229 (95%) constituted puerperal and 12 (5%) were non puerperal inversions. Among puerperal inversions, 191 (83.4%) cases were of acute type and only 6 (2.62%) cases were of subacute variety. The chronic puerperal inversion constituted 32 (13.9%). Out of 63 cases of uterine inversions in India, maternal deaths were reported as 6 (9.5%) but there was no maternal death in the present series.

Perinatal Mortality At Kathmandu Model Hospital

Total number of 410 deliveries were performed at Kathmandu Model Hospital (KMH)during 33 months (April 96 -Dec 98 ). Among 410 deliveries 107 (26.09%) cases weredone by Lower Segment Caesarean Section (LSCS), 54 cases (13.37%) by forcepsdelivery, 188 (45.85%) cases normal vaginal delivery with epigiotomy and 61 (14.87%)normal vaginal delivery with or without tear.During this period, 6 twin delivery cases were observed. There were 14 cases of perinataldeaths (still birth -10 and neonatal-death - 4). Hence, perinatal mortality rateduring this peroid in this hospital was 34.15.Perinatal mortality was mostly due to severe prematurity, birth asphyxia, ante-partumhaemorrhage (APH), intrauterine growth retardation (IUGR), congenital abnormalitiesand sepsis.KEY WORDS: Neonatal death, Still birth, Perinatal mortality, Antepartum haemorrhage (APH), Sepsis.