Transaminitis among Patients with Dengue Fever Visiting a Tertiary Care Centre

Introduction

Transaminitis is a condition where serum aspartate transaminase and alanine transaminase increase indicating liver dysfunction. One such disease where liver involvement might be observed is dengue, which is a mosquito-borne viral infection. The aim of the study was to find out the prevalence of transaminitis among patients with dengue fever in a tertiary care centre.

Methods

A descriptive cross-sectional study was conducted in a tertiary care centre from 1 November 2022 to 31 March 2023 after obtaining ethical approval from the Institutional Review Committee. Informed written consent was taken before collecting the data. A rapid immunochromatography test was used to confirm dengue infection. Serum aspartate transaminase and alanine transaminase were measured through routine Reitman and Frankel's enzymatic method. Dengue-confirmed patients from the medical outpatient department, fever clinic, and medical ward of the centre were included in the study. Patients with known prior liver diseases or any other chronic diseases, pregnancy, and patients in the hospice unit were excluded. Convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval.

Results

Among 442 dengue infected patients, the prevalence of transaminitis was 188 (42.53%) (37.92-47.13, 95% Confidence Interval). The highest frequency of dengue positive was observed among the 18-35 years age group, which was 97 (51.59%) with male predominance 134 (71.27%).

Conclusions

The prevalence of transaminitis among patients with dengue fever in a tertiary care centre was found to be lower than other studies done in similar settings.

Keywords

alanine transaminase; aspartate transaminase; dengue.

Anxiety, depression, and lower quality of life among Danish women with polycystic ovarian syndrome

Background

Polycystic Ovarian Syndrome (PCOS) is the most frequent hormonal/endocrine disorder in women of reproductive age and is one of the most common causes of infertility. Approximately 20% of Danish women of reproductive age are diagnosed with PCOS, and yet only a little attention has been paid to the psychological symptoms appearing in women with PCOS. The present study investigated anxiety, depression, and lower quality of life among Danish women of reproductive age who are diagnosed with PCOS.

Methods

This was a cross-sectional survey study among 326 Danish women who self-reported as being diagnosed with PCOS. The Hospital Anxiety and Depression Scale (HADS) was used to measure anxiety and depression, and the PCOS-QOL scale was used to measure the quality of life. Chi-square tests and logistic regression analyses were used for analyzing data.

Results

Sixty-six percent of women were found to have anxiety (n = 216), 41% of women had depression and 70% of women had low quality of life The most frequently reported symptoms were irregular menstrual cycle (86%), overweight (73%), and mood swings (65%), and irregular menstrual cycle, overweight and infertility were the were perceived of having higher severity. After adjusting for age, ethnicity, education, and income, the severity of symptoms, namely irregular menstrual cycle, infertility, overweight, and hirsutism, were independently and positively associated with depression, and severity of symptoms, namely irregular menstrual cycle, mood swings, and hirsutism, was independently and positively associated with anxiety. Lower quality of life was independently associated with both anxiety and depression.

Conclusions

Women with PCOS are at higher risk of anxiety, depression, and consequently, lower quality of life. Clinicians and other healthcare professionals should pay attention to the importance of mental health support in women with PCOS and work towards promoting it.

Key messages

• Women with PCOS are at higher risk of anxiety and depression, and lower quality of life.

• Health care professionals working with women with PCOS should be aware of this and be prepared to offer necessary support.

Barriers to HIV testing among transgender women and men who have sex with men in sub-Saharan Africa

Background

Accessing HIV testing services is a challenge for transgender women and men who have sex with men (MSM) in sub-Saharan Africa. Only a little about this issue has been understood and discussed. No systematic review exists that discusses barriers to HIV testing among transgender women and MSM on the regional level.

Methods

We systematically searched databases namely MEDLINE, CINAHL, and Google Scholar to identify qualitative studies that reported decision-making and/or experiences with HIV testing uptake among transgender women or MSM and that were conducted in sub-Saharan Africa between January 2005 and March 2020. Two independent authors performed the selection, extraction, and thematic analysis of data.

Results

Twelve out of 794 studies were found eligible and included for synthesis. The synthesis led to the development of a framework illustrating multi-level, inter-related barriers to HIV testing. Couple-based HIV testing policies, criminalizing same-sex behaviors, and (health) governance being influenced by traditional religious (Islamic or Christianity) belief systems were the barriers at the regional level. Discriminatory practices in the communities and health institutions were the community-specific barriers. Interpersonal barriers included interactions with healthcare providers leading to forced disclosure and/or discrimination, and individual level barriers included fears and depressive thoughts, and poor healthcare access.

Conclusions

We identified policies and practices at the regional and country levels that hindered HIV testing practices among transgender women and MSM, which should be reconsidered while providing HIV prevention services to people of gender-minority backgrounds. We also think that countries from the global west do have a responsibility to question the sovereignty of some African countries for their inability to provide optimal health care to gender minority populations.

Key messages

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.

Perceived clinical challenges when treating patients from another culture: a study among doctors training in psychiatry in Norway

Introduction

There is increased migration of patients and physicians worldwide. In Norway, psychiatry is the medical discipline with highest proportion of foreign doctors (24%). We need empirical studies on transcultural clinical challenges among doctors training in psychiatry.

Objectives

What perceived clinical challenges do foreign and native Norwegian young doctors meet when they treat patients from another culture, and what independent factors are associated with such challenges?

Methods

We developed a new 6-item instrument (alpha=0.80), Clinical Transcultural Challenges (CTC), with items about assessing psychosis, risk of suicide, violence etc. The doctors were recruited at mandatory training courses, and they filled in questionnaires about individual factors (age, gender, foreign/native) and work-related factors (training stage, frequency of transcultural meetings, number of working hours, work stress). Associations with CTC were analyzed by linear multiple regression.

Results

The response rate was 93% (216/233), of whom 83% were native and 17% were foreign doctors, 68% were women. Native doctors reported higher levels of CTC than did foreign doctors, 28.8 (6.2) vs 23.8 (7.2), p<0.001, d=0.73. Both native and foreign doctors rated “assessing psychosis” and “lack of helping tools” as most demanding. Independent factors associated with CTC were being a native doctor, Beta 3.9, p<0.01, and high levels of work-home stress, Beta 0.29, p<0.05.

Conclusions

Native doctors training in psychiatry report higher levels of transcultural clinical challenges than foreign doctors do. Both groups of doctors may need more training in transcultural assessment of psychotic disorders. They also report needs for more helping tools, and we should explore this further.

Disclosure

No significant relationships.

Resilience and its association with post-traumatic stress disorder, anxiety, and depression symptomatology in the aftermath of trauma: a cross-sectional study from Nepal

Introduction

Resilience is a multidimensional construct. Despite being quoted as protective against mental disorders, it remains largely unexplored in our context.

Objectives

We attempted to explore the role of resilience in the development of various psychiatric symptoms as depression, anxiety and post-traumatic stress disorder following trauma in clinical population in a psychiatry outpatient of a university hospital.

Methods

We interviewed one hundred patients who sought treatment in psychiatry outpatient in a university hospital in Kathmandu, Nepal. We collected sociodemographic and trauma related information using semi-structured interview format. Other instruments used were the World Health Organization Composite International Diagnostic Interview version 2.1 for trauma categorization, the Post-Traumatic Stress Disorder Checklist-Civilian version to measure the post-traumatic stress disorder symptoms, and the 25-item Hopkins Symptom Checklist-25 to assess the level of depression and anxiety symptoms. We used Nepali adapted resilience scale derived from the original Wagnild and Young Resilience scale to measure resilience. We explored the associations between resilience scores and the scores on depression, anxiety and posttraumatic stress disorder using bivariate and multivariate analysis.

Results

Resilience had negative correlations with depression, anxiety, and post-traumatic stress disorder symptoms after adjusting for other variables such as gender, marital status, employment status, socioeconomic status and trauma types which were observed to have significant association in the bivariate analysis.

Conclusions

There was inverse correlation between resilience scores and depression, anxiety, and post-traumatic stress symptoms. Resilience should be considered in studies involving trauma population.

Disclosure

No significant relationships.

Electrical Cardioversion in Pregnancy: A Case Report

A case of 28 years primigravida with refractory tachycardia at term is reported. She was refractory to medical cardioversion. Electrical cardioversion was applied before and after the delivery of baby. With several cycles of variable joules of electrical cardioversion, the normal rhythm was not obtained. However, patient’s rhythm reverted to sinus with anti-arrhythmic medication after third week of cesearean delivery.

Meniscal Tear at Knee: Repair or Resect? An Early Experience from a University Hospital in Nepal

Background The meniscus plays an important role in maintaining healthy articular cartilage. Meniscus tear, one of the common intra-articular knee lesions, is treated by either debridement or repair. Objective This study aims at identifying the early outcome of meniscus tears treated by debridement or repair. This study also elaborates on the spectrum of meniscal injuries presented in a tertiary care hospital in Nepal. Method A retrospective descriptive cross-sectional study was conducted at Orthopedic Department of Dhulikhel Hospital from February 2018 until January 2020 among patients who underwent knee arthroscopies for meniscal tears treated either by debridement or repair. Patients having intra articular fractures, osteochondral injuries and multi-ligament injuries were excluded. The meniscal tears were classified according to location and type of tear. Those patients who had at least one-year of follow up were evaluated with Lysholm score for functional outcome. Data were compiled and analyzed with Microsoft Excel 2011. Result One hundred and ten cases of meniscal tears were managed over the study period. Ninty-three cases could be traced for outcome evaluation, which included 50 cases of meniscal debridement and 43 cases of meniscal repair. The mean Lysholm score of the patients who received debridement was 81.5 (SD 10.4) and those who received meniscal repair was 84.9 (SD 9.1) (p=0.105). The population distribution was found to be similar in both the groups according to age and sex distribution and associated ligamentous injuries. Conclusion Good functional outcome was seen for meniscal tears managed with debridement or repair in at least one year follow up and could not establish one modality of management better than the other.

Angiographic Severity of Coronary Artery Disease in Diabetic and Non-diabetic Acute STEMI Patients in a Tertiary Care Centre of Nepal

Background Patients with diabetes mellitus have a higher prevalence of atherosclerotic heart disease and a higher incidence of myocardial infarction than the general population. Definitive diagnosis and precise assessment of anatomic severity of Coronary Artery Disease requires invasive diagnostic modality like coronary angiography. Objective To study angiographic characteristics and severity involving coronary arteries in patients with acute ST segment elevation Myocardial infarction and to compare the same in diabetics and non-diabetics. Method Among 150 patients with acute coronary syndrome, 75 diabetics and 75 nondiabetics admitted in Manmohan Cardiothoracic vascular and transplant Centre were selected randomly during a period of one year formed the study group. Random Blood Sugar, Fasting Blood Sugar was done in all 150 patients, HbA1c in all diabetics. All subjects with acute ST Elevation Myocardial Infarction were taken up for coronary angiography intended for primary PCI. Result In our study, 35 (46.7%) out of 75 diabetic patients had triple or multi-vessel disease compared to 10 (13.4%) out of 75 non diabetics. Non-diabetic patients had significantly higher single vessel disease (65.3%). There was a statistically significant association of duration of DM with vessels involved. The occurrence of Triple Vessel Disease/Multivessel Disease was significantly higher in the patients with DM duration > 10 years compared to patients with DM duration < 10 years (64.7% vs. 35.3%, P < 0.001), however there was no significant difference in type of vessel involved. Similarly, a significantly higher proportion of Triple vessel disease was observed in patients with poor glycemic control (HbA1c > 8.5%). 72.2% of the patients with HbA1c > 8.5% had Triple vessel disease/Multi vessel disease, whereas patients with good glycemic control (HbA1c < 7.0%) had predominantly Single vessel disease (90.0%), with no occurrence of Triple vessel disease/Multi vessel disease Conclusion Diabetic patients presenting with ST Elevation Myocardial Infarction are likely to have triple/multiple vessel disease compared to non-diabetic patients. The occurrence of Triple Vessel Disease/Multivessel Disease was significantly higher in the patients with DM duration > 10 years compared to patients with DM duration <10 years.

Assessment and Correlation of Uric Acid Concentration in Saliva and Serum of Patients Attending Tertiary Care Centre

ABSTRACT Background Serum uric acid (UA) is associated with many health conditions, including renal, cardiovascular and metabolic disorders. Diagnosis and monitoring often require painful invasive procedures which will add undue stress to the patients. The aim of this study was to correlate salivary and serum UA, so that, salivary sampling will help to bypass these measures and evaluate the condition of both healthy and the diseased. Methods This hospital based descriptive cross sectional study was conducted in 100 participants between age groups 21 to 82 years. Demographic data including height, weight and blood pressure were recorded. Serum and salivary samples were collected and UA level in both type of samples were estimated and correlation statistics was carried out. Results Total participants are categorized in three groups, 20-40, 41-60 and more than 60 years, among which maximum participants 43% are between 41-60 years of age. Average of body mass index (BMI) was found to be 24.46, where 50% were within normal range. Mean serum and salivary UA(mg/dl) was 4.15 and 1.90 respectively, exhibiting moderate positive correlation. They were correlated with significant “p-value” according to gender, age groups and disease conditions. Paired t- test was done between the measured and calculated salivary UA and no statistically significant difference in mean of these two values was obtained. Conclusions Salivary and serum UA are associated in our study so salivary UA can be used as a biomarker. Salivary UA was found to be more gender specific and specific among adults. Salivary UA can also be used as a screening tools for young and adult population.

Hypocalcemia in Elderly Population in a Tertiary Care Hospital: A Descriptive Cross-sectional Study

Introduction:

As the medical facilities are improving, the life expectancy is increasing which has led to rapid rise in elderly population. The epidemiology of many diseases in elderly has been modified, including calcium imbalance. This study aims to know the prevalence of hypocalcemia in elderly population visiting a tertiary care center of Kathmandu.

Methods:

A descriptive cross-sectional study was conducted in a tertiary care center of Kathmandu from March to July 2020 after obtaining ethical clearance (Ref: 2003202007). Total 402 participants at or above 60 years of age groups visiting outpatient departments were included in the study by convenience sampling method excluding those under vitamin D and calcium supplements. Serum total calcium level was measured using standard routine method and corrected with albumin. The serum calcium value less than 8 mg/dl was considered as hypocalcemia in accordance with the reference range of our laboratory. Data analysis for calculation of frequency and proportion was done in Statistical Package of Social Sciences.

Results:

The prevalence of hypocalcaemia in elderly was found to be 97 (24.1%). Out of 286 participants of age group 60-74 years, hypocalcemia was seen in 75 (26.2%) and among 116 participants of age group > 74 years, 22 (19%) were hypocalcemic. Among 181 male participants, 44 (24.3%) had hypocalcemia and out of 221 female participants, 53 (24%) had hypocalcemia.

Conclusions:

The finding of present study suggests that hypocalcemia is common among elderly which can be life threatening. Therefore, regular monitoring of serum calcium is recommended for this age group.

Burden of scrub typhus among patients with acute febrile illness attending tertiary care hospital in Chitwan, Nepal

OBJECTIVES

Scrub typhus is an emerging neglected tropical disease, reported from many parts of Asia including Nepal. This study aims to determine the seroepidemiology of scrub typhus among febrile patients attending Chitwan Medical College Teaching Hospital (CMC-TH), Bharatpur, Nepal.

STUDY DESIGN AND SETTING

This was a hospital laboratory-based prospective study conducted in CMC-TH (a 750-bed hospital) located in Bharatpur, Chitwan district of Nepal.

PARTICIPANTS

A total of 1797 patients visiting CMC-TH with acute febrile illness (temperature more than 38°C) were enrolled in this study.

METHODS

A total of 1797 blood samples were collected from patients presenting with acute febrile illness. The samples were processed for detection of antibody for scrub typhus by ELISA for specific IgM antibody and Weil-Felix test.

RESULTS

Out of 1797 serum sample of febrile patients, 524 (29.2%) were scrub typhus positive. Maximum seropositive cases were from Chitwan district, 271 (51.7%) with predominance among women, 314 (35.9%). Scrub typhus was common among age group 51-60 years (37.2%) and farmers, 182 (37.8%). Highest seropositivity was found in July, 60 (57.7%). Fever was common clinical symptom. Thrombocytopenia was seen in 386 (73.7%) and raised transaminase aspartate aminotransferase, 399 (76.1%) among seropositive cases. Weil-Felix test positive were 397 (22.1%) and IgM ELISA positive were 524 (29.2%). The correlation between IgM ELISA and Weil-Felix test showed statistically significant association (r=0.319, p<0.001).

CONCLUSION

High prevalence of scrub typhus implies that patients with acute febrile illness should be investigated for scrub typhus with high priority. There is utmost need of reliable diagnostic facilities at all levels of healthcare system in Nepal. Infection with scrub typhus was found high and this calls for an urgent need to introduce vaccine against scrub typhus. More sustain and vigorous awareness programmes need to be promoted for early diagnosis, treatment and control.

An overview of the main intrauterine pathologies in the postmenopausal period

Hysteroscopy is the gold standard for evaluating the uterine cavity, diagnosing intrauterine pathology, and operative intervention for some causes of abnormal uterine bleeding. The American College of Obstetricians and Gynecologists concluded that, when the endometrium measures ≤4 mm with transvaginal ultrasonography, the likelihood that bleeding is secondary to endometrial carcinoma is less than 1% (negative predictive value 99%), and endometrial biopsy is not recommended. Endometrial sampling in this clinical scenario will likely result in insufficient tissue for evaluation and it is reasonable to consider initial management for atrophy. A thickened endometrium on transvaginal ultrasonography (>4 mm in a postmenopausal woman with postmenopausal bleeding) warrants additional evaluation with endometrial sampling. A negative tissue biopsy following 'blind' endometrial sampling in women with postmenopausal bleeding is not considered to be an endpoint, and further evaluation of the endometrial cavity with hysteroscopy to exclude focal disease is imperative.

AB1023 CARDIAC MRI IN HYPERFERRITINAEMIC DISEASE STATES REVEALS MYOCARDIAL INFLAMMATION NOT IDENTIFIED BY ECHOCARDIOGRAPHY

Background:

Acutely unwell adult patients with hyperinflammatory hyperferritinaemic states are typically challenging to diagnose. Case series suggest that cardiac involvement may be common (up to 20%) but the phenotype has not been well characterised1.

The elevation of cardiac biomarkers suggests cardiac involvement, but are non-specific in acute illness. Cardiac MRI (CMR) offers the ability to characterise the myocardium and identify inflammation, and modern motion-corrected sequences now allow the assessment of patients who may struggle to breath-hold in the recovery from acute illness.

Objectives:

We report 3 patients who underwent CMR in the acute phase of illness with raised cardiac biomarkers.

Methods:

Case records of acutely ill patients with hyperferritinaemia from two major London centres were reviewed and cases who had undergone CMR in the acute phase of illness were identified.

Results:

3 cases were identified from a cohort of 22, we report CMR findings from differing aetiologies of hyperferritinaemic states:

Case 1: A female in her 60s presented acutely unwell with fever, swollen joints and salmon pink rash. Ferritin was raised at 50574ug/L (20-300ug/L), troponin I 384ng/L (<34ng/L) and Brain Natriuretic Peptide (BNP) 324ng/L (<159ng/L). Echocardiography was normal. However CMR with T2 mapping revealed several small areas of raised signal consistent with myocardial inflammation. A diagnosis of systemic Adult Onset Stills Disease (AOSD) was made. She received IV methylprednisolone and anakinra with normalisation of cardiac biomarkers.

Case 2: A male in his 20s with known SLE with associated end stage renal failure requiring transplant. He had a previous prolonged admission secondary to HLH. He presented with chest pain and concave shaped ST elevation on ECG. Troponin peak 2168ng/L, BNP 1334ng/L. Peak ferritin 1300ug/l.

He was initiated on colchicine for likely pericarditis. Echocardiography showed a dilated left ventricle and mildly increased wall thickness, but overall systolic function within normal limits.

CMR reported nodular patchy late gadolinium enhancement in the mid inferoseptum and inferior wall associated with areas of raised T2 mapping values. NM cardiac rest gated PET reported abnormal FDG uptake to the myocardium with sites including the apical inferior wall, apical RV insertion point and basal septal/anterior right ventricular walls. Features were deemed in keeping with active myocarditis.

He responded to colchicine with improved troponin, and was discharged with close follow up.

Case 3: A male in his 20s presented with septic shock attributed to meningococcal septicaemia requiring ITU admission. Troponin was elevated at >9000ng/L. Bloods demonstrated raised ferritin and features consistent with HLH were identified.

CMR reported elevated native myocardial T1/T2 signal of the lateral and mid-anterior walls in keeping with myocardial oedema. Pericardium adjacent to the anterolateral wall had elevated T1/T2 signal with hyperenhancement on delayed enhancement imaging. Tissue characterisation was in keeping with an acute myopericarditis process.

In addition to broad spectrum antibiotics to treat his underlying infection, he received therapy for HLH including methylprednisolone, anakinra and IVIG. He subsequently made a good recovery to treatment.

Conclusion:

CMR in acute illness with hyperferritinaemia reveals abnormal tissue characterisation with myocardial inflammation, even when echocardiography is normal. We suggest CMR may be a useful test to expand our understanding of hyperferritinaemic disease states.

References:

[1]M Gerfaud-Valentin et al. Myocarditis in Adult-Onset Still Disease. Medicine (Baltimore) 2014 Oct; 93(17): 280-289

Disclosure of Interests:

None declared

0707 “What We’Ve Got Here Is Failure To Communicate”: Apnea Patients And Their DME Suppliers

Introduction

Successful treatment of obstructive sleep apnea requires adherence to positive airway pressure (PAP) therapy. A key factor is the relationship between the DME provider and the patient so that treatment can be initiated and continued in a timely manner. Our quality improvement project aims to empower and enable patients towards active participation in their sleep apnea care. Our goal is to ultimately increase patients’ knowledge of their Durable Medical Equipment (DME) supplies company, and thus improve their treatment. The first step was to determine patients’ familiarity with their DME.

Methods

Forty-one patients with sleep apnea on PAP therapy volunteered to be questioned about their DME company during clinic visits at the Yale North Haven Sleep Center, Connecticut, starting November 2019. Patients were asked if they knew the name or the contact of their DME; whether they received adequate training on PAP therapy initiation; if they were receiving timely and correct PAP therapy supplies. They were asked to rate their satisfaction with the DME on a scale of 1 to 5; one being very dissatisfied and five being very satisfied.

Results

Only 12 out of 41 patients (29.3 percent) knew the names of their DME companies. The average satisfaction rating was 3 (neutral); 44% of patients were dissatisfied, or very dissatisfied with the performance of their DME. Detailed comments were mostly related to poor contact and communication with the DME.

Conclusion

Most apnea patients had difficulty identifying and contacting their DME. As the next step of this quality improvement project we plan to intervene to ensure that the patients have the name and contact information of their DME available and attached to their PAP machine equipment. We plan to repeat this questionnaire after this intervention to study the impact of this quality improvement project.

Support

None

Multi-drug Resistant and Extended Spectrum β-lactamase Producing Salmonella Species Isolated from Fresh Chicken Liver Samples

Background Ductus arteriosus is a vascular structure which connects the roof of main pulmonary artery near the origin of the left branch pulmonary artery to the proximal descending aorta. Patent ductus arteriosus (PDA) closure is indicated for any patient who is symptomatic from left to right shunting. Objective To investigate the hospital outcomes of surgical closure of patent ductus arteriosus over last 19 years starting from the very first case of our center. Method This is a retrospective analysis of all patent ductus arteriosus treated surgically from August 2001 to July 2019. Patients who underwent isolated surgical closure of patent ductus arteriosus were included. Data have been presented in three different eras (Era 1: 2001-2007, Era 2: 2008-2013, and Era 3: 2014-2019) to see the trend of evolution of this surgery. Result A total of 901 patients aged 8.67±8.76 years under went patent ductus arteriosus surgical closure over last 19 years. Patients in the initial era 2001-2007 were significantly older compared with other 2 eras (p=0.000). Males accounted for 35.5% of all cases. Twenty percent had severe pulmonary artery hypertension.Duration of mechanical ventilation was 3.57±9.64 hours with ICU stay of 1.55±1.53 days, and hospital stay of 3.9±2.3 days. Overall in hospital mortality was 0.8%; for isolated patent ductus arteriosus diagnosis, mortality was 0.2%. Chylothorax was noted in 0.4%. Conclusion This is the first report to analyze surgical outcomes of patent ductus arteriosus ligation in our center. We have discussed the evolution of patent ductus arteriosus surgery in our center, and have shown favorable outcomes in terms of morbidity and mortality.

Prediction of shunt dependent hydrocephalus following aneurysmal subarachnoid hemorrhage “algorithm based management”

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating disease with a high rate of mortality and permanent morbidity. An important neurologic complication is hydrocephalus reported to range from 6 to 67% while only 10-20% of them will require permanent CSF diversion. The purpose of this study was to identify predictive factors for the development of shunt dependant hydrocephalus among patients with aSAH. This is a retrospective study conducted in among 72 patients who underwent clipping of aneurysm for subarachnoid hemorrhage in our institute during 2 years. EVD placement done for acute hydrocephalus while VP shunt was done for chronic hydrocephalus or requiring prolonged EVD placement. Various clinical and radiological factors were registered on admission and during the intensive care stay. Multivariate logistic regression analysis was done to predict risk of shunt dependant hydrocephalus. P value less than 0.05 was considered significant. Among 72 patients with aSAH.  Intraventricular extension of blood was seen in 24 (33.3%) patients while hydrocephalus was seen among 19 (26.4%) patients. Eight patients (11.1%) required EVD placement for acute hydrocephalus while 10 (13.9%) patients required permanent shunt placement for chronic hydrocephalus. In univariate analysis, SAH with fisher grade >2, presence of hydrocephalus, intraventricular extension of hemorrhage and need of EVD placement were found to have significant association in shunt dependency. However multivariate logistic regression model showed EVD requirement for acute hydrocephalus as an independent predictor of shunt dependent hydrocephalus at p value 0.006 (OR=21.3; 95% CI=2.38 to 191.51). Hydrocephalus is a common complication following aneurysmal subarachnoid hemorrhage. SAH with fisher grade >2, presence of hydrocephalus, intraventricular extension of hemorrhage and need of EVD placement were found to have significant association in shunt dependency however only EVD requirement is an independent predictor of SDH

Adenosine deaminase activity in type 2 diabetes mellitus: does it have any role?

BACKGROUND

Diabetes mellitus is a group of metabolic disorders of carbohydrate metabolism in which glucose is underused, producing hyperglycemia. Diabetic patients are prone to opportunistic infection, thus serum ADA levels in these patients is very important as a screening test for Tuberculosis and autoimmune diseases. Thus, the present study was conducted to estimate the Serum ADA activity, glycated Haemoglobin (HbA1c), fasting and postprandial glucose level in patients with T2DM and to correlate the serum level of ADA with glycated Hemoglobin (HbA1c), fasting and postprandial glucose level in T2DM.

METHODS

This is a Hospital based cross-sectional study done in BPKIHs, Dharan, Nepal. 204 diagnosed patients (102 males and 102 females) with T2DM and 102 healthy controls were enrolled in the study. Diabetic patients were categorized into Uncontrolled and Controlled Diabetes on the basis of HbA1C; HbA1c > 7% = Uncontrolled Diabetes, HbA1c < 7% = Controlled Diabetes.

RESULTS

Serum ADA levels (U/L) was significantly raised in Uncontrolled Diabetic patients (49.24 ± 16.89) compared to controlled population (35.74 ± 16.78) and healthy controls (10.55 ± 2.20), p value < 0.001. A significant positive correlation was obtained between Serum ADA and HbA1c, Fasting Plasma Glucose and Post-prandial Glucose respectively.

CONCLUSION

There is a significant increase in Serum ADA activity in DM with increase in HbA1c levels which may play an important role in predicting the glycemic and immunological status in these patients.

Clinical Outcome following Intra-articular Triamcinolone Injection in Osteoarthritic Knee at the Community: A Randomized Double Blind Placebo Controlled Trial

Background Knee pain is one of the common complaints patients present with in any community based health camps and Osteoarthritis of knee is a usual diagnosis. Injecting a long acting steroid is a common practice to alleviate the symptoms of osteoarthritic knee. Objective To evaluate the clinical outcome of injecting Triamcinolone acetenoid in osteoarthritis of knee in a community set up over a randomized double-blind placebo control trial. Method A prospective, randomized, double blind, placebo control trial was carried out in community after obtaining the ethical clearance from the IRC. Patients with clinically diagnosed osteoarthritis of knee were injected either Triamcinolone or Placebo after recording the baseline scores of the knee by Knee injury and Osteoarthritis Outcome Score (KOOS) - Physical Function Short form (KOOS-PS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Visual Analogue Scale (VAS). The same tools were used at two, six and at twelve weeks post injection to evaluate the functional outcome and pain. Result One hundred and seventeen patients were available for analysis among which, 55(48.7%) patients received Triamcinolone and 58(51.3%) received placebo. The baseline status of knees of two groups was comparable at the start of study. There was significant pain relief in the group receiving Triamcinolone at two and six week but not in twelve weeks. Group receiving placebo had pain relief only for first two weeks. Functional outcome was significantly improved compared to baseline in both the groups until six weeks however, in the triamcinolone group, it was significant until twelve weeks. No major complications were noted. Conclusion Intra-articular injection of Triamcinolone acetenoid is effective in symptoms control and improving functional outcome in clinically diagnosed osteoarthritis of knees in community set up during health camps.

Improving Knowledge, Skill and Confidence of Novice Medical Doctors in Trauma Management with Principles of ABCDE

Background Trauma is one of the major public health concerns clamming about five million death annually worldwide. Experience and confidence of a doctor in the management of trauma patients have big impact on the overall outcome. Objective This study aims to evaluate the outcome of a trauma course in improving the knowledge, skill and confidence of novice doctors in managing trauma victims. Method A pre/post test analytical study was carried out among novice medical doctors from Kathmandu University School of Medical Science (KUSMS) who participated in a standard two and a half day trauma course, that utilizes the principles of ABCDE, as a part of their regular training. Pre-course knowledge and skill were compared with immediate post-course scores on the same guidelines. Objective structured and subjective written feedbacks from the participants were analyzed qualitatively to identify the perceptions of candidates. Result Sixty-eight males and twenty-nine females completed the course. The average pre-test scores in knowledge and skill were 8.3(33.2%) and 19.6(78.5%) respectively. Similarly the post-test scores were 16.04(64.2%) and 22.45 (89.5%) respectively, showing statistically significant improvements (P 0.000). The mean percentage improvement in knowledge was 48.8% and that in skill was 160.9%. The feedback analysis showed majority of the participants were satisfied with the course and they perceived improved "self-confident" in handling trauma cases. Conclusion All the novice doctors should participate in a standard trauma course hence their knowledge, skill and confidence in handling a trauma can be improved.

First Dark Matter Search Results from the XENON1T Experiment

We report the first dark matter search results from XENON1T, a ∼2000-kg-target-mass dual-phase (liquid-gas) xenon time projection chamber in operation at the Laboratori Nazionali del Gran Sasso in Italy and the first ton-scale detector of this kind. The blinded search used 34.2 live days of data acquired between November 2016 and January 2017. Inside the (1042±12)-kg fiducial mass and in the [5,40]  keV_{nr} energy range of interest for weakly interacting massive particle (WIMP) dark matter searches, the electronic recoil background was (1.93±0.25)×10^{-4}  events/(kg×day×keV_{ee}), the lowest ever achieved in such a dark matter detector. A profile likelihood analysis shows that the data are consistent with the background-only hypothesis. We derive the most stringent exclusion limits on the spin-independent WIMP-nucleon interaction cross section for WIMP masses above 10  GeV/c^{2}, with a minimum of 7.7×10^{-47}  cm^{2} for 35-GeV/c^{2} WIMPs at 90% C.L.

Burden of bacterial upper respiratory tract pathogens in school children of Nepal

INTRODUCTION

Respiratory tract infections are one of the most common human infections in all age group and important cause of mortality and morbidity worldwide. Most bacterial upper respiratory tract infections are vaccine preventable. This study aimed to determine the prevalence of carrier state of bacterial upper respiratory tract pathogens among school children. It also aimed to study their antibiograms.

METHODS

The specimen from posterior pharyngeal wall and tonsils were collected from 204 participants on calcium alginate coated swabs (HiMedia). Isolates were identified by standard microbiological methods and tested for in vitro antibiotic susceptibility testing by modified Kirby-Bauer disc diffusion method.

RESULTS

In this study, Streptococcus pneumoniae (16.6%) was the most common bacterial pathogen recovered, followed by Staphylococcus aureus (14.7%), β-haemolytic streptococci (non-Group A) (8.8%), Streptococcus pyogenes (5.3%) and Corynebacterium diphtheriae (3.4%). The Gram negative bacteria were Klebsiella pneumoniae (4.9%), Haemophilus influenzae (3.4%) and Neisseria meningitidis (1.4%). Important findings in antibiogram include high resistance of Streptococcus pneumoniae to penicillin (91.17%) and resistance of S. aureus to oxacillin (23.3%).

CONCLUSION

Pharyngeal colonisation by S. pneumoniae was found high among school children and this calls for an urgent need to include pneumococcal vaccine in routine national immunisation schedule of Nepal given the high burden of invasive pneumococcal disease. Despite expected universal vaccination, pharyngeal colonisation by C. diphtheriae is possible and there is possibility of transmission of these respiratory pathogens to other healthy children.

Estimation of indirect reference intervals for serum thyrotropin using hospital records

Background: Reference intervals of any biochemical analyte serve as an invaluable tool in clinical decision making. The IFCC (International Federation of Clinical Chemistry) guidelines for determining these values are not feasible in some hospital laboratory setting and have led to the development of alternative approaches.Aims and Objectives: To determine the indirect reference intervals for serum thyrotropin form the hospital records of individuals visiting a tertiary care center.Materials and Methods: In a hospital-record based, observational, cross-sectional study, data of serum TSH levels were collected from the hospital records of participants who underwent this test in the Central Clinical Laboratory, College of Medical Sciences and Teaching Hospital, Bharatpur, Chitwan, Nepal from July 2012 to June 2015. All the individuals, irrespective of their diagnoses of thyroid diseases and other possible comorbid conditions, were included in the study. Prior to the statistical analyses, partitioning was done in relation to gender, age, and ethnicity. The reference intervals for thyrotropin were established by non-parametric method.Results: Reference intervals for serum TSH best agreeing to those provided by the test kit suppliers were determined by combining the two strategies that used Tukey’s method of detection and removal of outliers, prior to the final analyses. Lower limit was best determined from the natural-log-transformed and upper limit from non-transformed TSH values with outliers removed by Tukey’s method in both. As such, for the cases with TSH in the range 0.02-98.8 mIU/L, the reference intervals were calculated as [0.31 (0.30-0.33) to 6.04 (5.97-6.12) mIU/L] and for the TSH in the range 0.102-9.99 mIU/L, [0.35 (0.34-0.37) to 5.81 (5.75-5.90) mIU/L].Conclusion: For establishing the indirect reference intervals from the hospital records, laboratory data can be combined with information stored in clinical databases for selecting subjects fulfilling stated clinical criteria.Asian Journal of Medical Sciences Vol.8(3) 2017 41-48

Orbital lymphoma in an elderly patient

Lymphomas of the orbit and orbital adnexae are rare tumors, comprising only 1% of all non-Hodgkin’s lymphoma. Lymphomas are the most common primary orbital tumor in adults of age 60 years and older. Here we present a case of 49 year male with left upper lid swelling since 1 year who was diagnosed histopathologically as non-Hodgkin’s lymphoma of orbital region. 

Primary nasal meningioma- a case report

Extracranial meningiomas may be subdivided into primary and secondary types based on absence or presence of intracranial attachments respectively. Primary sinonasal tract meningiomas are rare with unknown etiopathology and non-specific clinical presentation. Of these PEMs only 11.5% are in the nasal cavity and nasal septum. To our knowledge less than 50 cases of PEM of nasal cavity have been reported in the literature. We report a case of a 22 years old male who presented with epistaxis and increasing nasal stuffiness for the last one year.

Pleomorphic adenoma of nasal septum: A case report

Pleomorphic adenomas are the most common benign tumor of the major salivary glands. Other rare sites for the occurrence of pleomorphic adenoma have been described in the larynx, pharynx, nasal cavity, lacrimal glands and trachea. We report here a case of intranasal pleomorphic adenoma arising from the nasal septum causing nasal obstruction which was clinically diagnosed as papilloma. Histopathology confirmed the diagnosis of pleomorphic adenoma.

Correlation study of adenosine deaminase and its isoenzymes in type 2 diabetes mellitus

OBJECTIVE

Adenosine deaminase (ADA) plays an important role in cell-mediated immunity and modulation of insulin activity. Its clinical and diagnostic significance in Nepalese type 2 diabetes is not yet characterized. So, this study's objective was to determine the isoenzymatic activities of ADA (ADA1, ADA2, and total ADA) and show its correlation with demographic, anthropometric, and biochemical characteristics of type 2 Nepalese subjects with diabetes.

RESEARCH DESIGN AND METHODS

This is a hospital-based cross-sectional study including 80 type 2 diabetes mellitus (DM) patients and same number of age-matched and sex-matched healthy controls. Data were collected using preformed set of questionnaires and biochemical data were obtained from the laboratory analysis of the patient's blood samples. Statistical analysis was performed with SPSS V.20.

RESULTS

A significantly higher (p<0.001) mean values of body mass index (BMI), fasting blood sugar (FBS), postprandial blood sugar (PPBS), glycated hemoglobin (HbA1c), and lipid profiles except high-density lipoprotein cholesterol (HDL-C) were found in type 2 diabetic cases compared with controls. Serum ADA activities were significantly higher in cases compared with controls (p<0.001) showing significant positive correlation (p<0.05) with FBS, PPBS, HbA1c, and alcoholism; while no correlation was found with age, sex, ethnicity, BMI, waist-hip ratio, dietary habits, smoking, and duration of diabetes.

CONCLUSIONS

Serum ADA activities were significantly higher in type 2 diabetic patients compared with controls having significant positive correlation with glycemic parameters. Serum ADA and its isoenzymes could be used as biomarkers for assessing glycemic status in patients with type 2 DM.

Clinicopathological Study of Malignant Melanoma at Tertiary Care Centre

INTRODUCTION

Malignant melanoma, which causes three fourth of all deaths related to skin cancer, is more common in Caucasian population compared to Asian population. There is no reliable information about malignant melanoma in Nepal hence an effort has been made to assess the clinical and pathological features of melanoma patients.

METHODS

This was a retrospective hospital based study done in the department of Pathology. All cases of malignant melanoma diagnosed on biopsy during a period of 13 years were retrieved, reviewed and collated.

RESULTS

We had 35 cases with age range from 15 to 84 years with the mean of 51.4 years and M: F of 1.3:1. The predominant site was lower extremities. Most cases were less than 3 cm. Majority of histologic subtypes were nodular melanoma 29 (82.8%) followed by mucosal lentiginous melanoma 3 (8.6%), superficial spreading melanoma 2 (5.7%) and acral lentiginous melanoma 1 (2.9%). Half (50%) of the excisional biopsies were at Clark's level IV and 75% were at high Breslow thickness.

CONCLUSIONS

The most frequent site in males and females were lower extremities and trunk respectively in contrast to Western studies where it is opposite. Nodular melanoma was the commonest histologic subtype while in other Asian studies and in Western studies majority were acral lentiginous melanoma and superficial spreading melanoma respectively.

Histopathological Analysis of Non-Neoplastic Superficial Lymphadenopathies

Background Lymphadenopathies are the clinical manifestation of enlargement of lymph nodes which are a common occurrence and are processes of lymph nodes in response to a variety of exogenous and endogenous stimulants. The vast majority of enlarged lymph nodes are non- neoplastic. Objective The objective of the study is to analyze the spectrum of non-neoplastic lesions of superficial lymphadenopathies with their histomorphological features. Method This was a retrospective hospital based study done in the department of Pathology. All cases of superficial lymph node biopsies received during a period of 7 years were retrieved and divided into 2 broad categories: neoplastic and non-neoplastic. The latter group is the material for the present study. The diagnosis was made on morphological basis. Result Of all the 268 superficial lymph node biopsies, 25.4% (68 cases) were neoplastic and 74.6% (200 cases) were non-neoplastic. The non-neoplastic cases were further categorized into non-infectious 60.5% (121 cases) and infectious 39.5% (79 cases). Neck node (70%) was the most common site of involvement. There were 102 male and 98 female patients with male to female ratio 1.04:1. The age range of the patients was 2 years to 83 years with a mean of 27.16 years and most common being 11-20 years 29% (58 cases). Majority of the cases were non-specific reactive lymphadenitis 84.3% (102 cases) followed by tuberculosis 36.5% (73 cases). Conclusion The major cause for the superficial lymphadenopathy was found to be non-neoplastic etiology with slight male predominance. Reactive lymphadenitis was the leading cause unlike the studies done in other Asian and Tropical countries where tuberculosis was more common.

Prevalence of inducible clindamycin resistance in erythromycin resistant clinical isolates of Staphylococcus aureus and CONS at tertiary care hospital

Background & Objectives: The objective of this study was to isolate and identify Staphylococcus species from different samples clinical samples and to determine the current trend regarding the incidence and distribution of inducible clindamycin resistance in clinical isolates of Staphylococcus aureus and CONS.Materials & Methods: A total of 264 isolates of staphylococcus species were isolated from various clinical samples. Clinical samples were cultured and Staphylococcus species were identified using standard microbiological methods recommended by the American Society for Microbiology (ASM). Methicillin resistance was confirmed using cefoxitin and oxacillin disks. Inducible clindamycin resistance was identified using D-zone test.Results: Among 264 erythromycin resistant staphylococcus species, 213 (80.6%) were S. aureus and 51 (19.3%) were CONS. Out of 213 erythromycin resistant isolates of S. aureus, 140 (65.7%) were MRSA and 73 (34.2%) were MSSA whereas out of 51 erythromycin resistant isolates of CONS, 28 (54.9%) were MRCNS and 23 (45%) were MSCNS. Constitutive MLSB phenotype and Inducible MLSB phenotype was higher among both MRSA and MRCNS isolates. MS phenotype was more predominant among 11 (5.1%) MSSA and 5 (9.8%) MSCNS isolates compared to 9 (4.2%) in MRSA and 2 (3.9%) in MRCNS.Conclusion: The prevalence of constitutive & inducible clindamycin resistance in staphylococcus isolates was high among both MRSA and MRCNS. Hence the implementation of D-test routinely, will reveal the iMLSB & cMLSB phenotype & will guide the clinicians whether to use clindamycin in staphylococcal infections when erythromycin resistance is present.

Thyroid hormone profile in patients with chronic kidney disease: a single centre study

BACKGROUND

Chronic kidney disease (CKD) is a global burden and now recognized as a major public health problem worldwide. Patients with CKD have alteration in thyroid hormone metabolism. This study aims to evaluate the status of thyroid hormone profile in different stages of CKD.

METHODS

The cross-sectional study included 103 CKD patients attending Nephrology and Dialysis unit of KIST Medical College Teaching Hospital, Lalitpur, Nepal. Serum creatinine, free triiodothyronine (fT3), free thyroxine (fT4), and thyroid stimulating hormone (TSH) were measured. Risk factors, duration of illness and physical examination of patients were recorded along with their written informed consent. Patients with history of any thyroid function abnormalities, on medication for hypothyroidism and pregnancy were excluded.

RESULTS

Out of 103 CKD patients, 59 (57.28%) were males and 44 (42.71%) were females. Thirty five (33.98%) CKD patients had low fT3 and 19 (18.44%) had low fT4 with normal TSH. Six (5.82%) CKD patients had increased TSH concentrations with normal fT3 and fT4. The median value of creatinine, fT3 and fT4 were significantly altered at different stages of CKD. Among the risk factors for CKD, diabetic nephropathy (44.66%) was found to be the lead primary cause followed by chronic glomerulonephritis (26.21%) and hypertension (23.30%).

CONCLUSIONS

In our study thyroid hormone profile was altered in CKD patients, mainly in the stage 5 CKD. Most common thyroid dysfunction was low fT3 and low fT4 with normal TSH levels.

Diversity and functional traits of culturable microbiome members, including cyanobacteria in the rice phyllosphere

The diversity and abundance of culturable microbiome members of the rice phyllosphere was investigated using cv. Pusa Punjab Basmati 1509. Both diversity and species richness of bacteria were significantly higher in plants in pots in a semi-controlled environment than those in fields. Application of fertilisers reduced both diversity and species richness in field-grown plants under a conventional flooded system of rice intensification (SRI) and in dry-seeded rice (DSR) modes. Sequence analyses of 16S rDNA of culturable bacteria, those selected after amplified ribosomal DNA restriction analysis (ARDRA), showed the dominance of α-proteobacteria (35%) and actinobacteria (38%); Pantoea, Exiguobacterium and Bacillus were common among the culturable phyllospheric bacteria. About 34% of 83 culturable bacterial isolates had higher potential (>2 μg·ml(-1) ) for indole acetic acid production in the absence of tryptophan. Interestingly, the phyllosphere bacterial isolates from the pot experiment had significantly higher potential for nitrogen fixation than isolates from the field experiment. Enrichment for cyanobacteria showed both unicellular forms and non-heterocystous filaments under aerobic as well as anaerobic conditions. PCR-DGGE analysis of these showed that aerobic and anaerobic conditions as well as the three modes of cultivation of rice in the field strongly influenced the number and abundance of phylotypes. The adaptability and functional traits of these culturable microbiome members suggest enormous diversity in the phyllosphere, including potential for plant growth promotion, which was also significantly influenced by the different methods of growing rice.

Ovarian Tumors: Pattern of Histomorphological Types- A 10 Years Study in a Tertiary Referral Center and Review of Literature

Background Ovarian cancer accounts for 6% of all cancers in females. Among cancers of female genital tract, the incidence of ovarian cancers ranks below only carcinoma of the cervix and the endometrium. Objective To find the frequency of different types of histomorphological types and their association with age, side and size distribution. Method This study is a hospital based retrospective study carried out in the Department of Pathology, Manipal Teaching Hospital over a time period from Jan. 2006 to Sep. 2015. Specimens were received from the Manipal Teaching Hospital and other hospitals within the Himalayan valley of Pokhara. All the clinical and histolpathological data were retrieved from the departmental data bank and were analyzed. Result A total of 409 cases of ovarian tumors have been reported in the same period. Among them, 215 cases were of surface epithelial origin including 172 benign, 07 borderline and 36 malignant cases. Among the surface epithelial tumors, the commonest was serous cystadenoma (119 cases) followed by mucinous cyst adenoma (40 cases). There were 176 cases of tumors with germ cell origin which included 170 cases of teratoma, four dysgerminoma and one each case of choriocarcinoma and yolk sac tumor. Among seven metastatic tumors, one case was of Krukenberg tumor. Age range was 12 to 90 years and the size range from 3 to 36 cm. Conclusion In our study, we analyzed all the spectrum of ovarian tumors diagnosed on morphological bases and most of the findings were similar to other national and international studies. However, we have reported increased percentage of mucinous tumors and less sex cord stromal tumors.

Dipeptidyl-Peptidase IV inhibitors and glycemic control in type 2 Diabetes Mellitus

Background & Objectives: Type 2 diabetes mellitus (T2DM) is a progressive disease, characterized by insulin resistance, impaired glucose-induced insulin secretion, inappropriately elevated glucagon concentrations, and hyperglycemia. Many patients cannot obtain satisfactory glycemic control with current therapies. New and more effective agents, targeted not only at treatment, but also at prevention of the disease, its progression, and its associated complications, are, therefore, required. The dipeptidyl peptidase-4 (DPP-4) inhibitors are a newer class of oral drugs for the treatment of T2DM. They inhibit the breakdown of glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) thereby increasing the incretin effect in patients with T2DM. In clinical practice they are associated with significant reductions in HbA1c, no weight gain and a low risk of hypoglycemia. Since incretin response is markedly diminished in Asian populations, these agents can be used to achieve satisfactory glycemic control in Nepalese T2DM patients.JCMS Nepal. 2016;12(1):28-32.

Streptococcus pneumoniae and Haemophilus species colonization in health care workers: the launch of invasive infections?

Background

Streptococcus pneumoniae and Haemophilus influenzae are important human pathogens. The risk of airborne and droplet-transmitted respiratory tract infections in healthcare workers (HCW) is substantial. The aim of this study was to determine the extent of oropharyngeal colonization with S. pneumoniae and Haemophilus spp. their antibiogram and risk factors of colonization in HCW at a tertiary care center, Western Nepal.

Methods

During 3 month period, 100 oropharyngeal swab specimens were collected from HCW of Manipal Teaching Hospital and 50 from non HCW from community. All the 150 specimens were screened for Haemophilus spp. and S. pneumoniae by standard techniques. Serotyping of H. influenzae type b was done by using specific antiserum. Antibiotic sensitivity patterns of isolates were determined by modified Kirby Bauer disc diffusion method. Association between the groups was analyzed using the Pearson χ² test and Fisher exact test. A forward step logistic regression model was used to identify significant predictors for colonization.

Result

Sixty-five percent of HCW were colonized with S. pneumoniae and/or Haemophilus species compared to 32 % of non-HCW. Health care workers had odd ratio (OR) 3.946 [CI (1.916, 8.128)] times more tendency of colonization compared to non-HCW (P < 0.05). Pneumococcal colonization was observed high among smokers (81.5 %). Amongst HCW, post graduate resident doctors had higher rate of colonization (83.3 %) followed by interns (64.9 %), least being amongst the laboratory workers (58.3 %).

Conclusion

The higher rate of colonization amongst HCW raises the possibility of occupational risk as well as horizontal spread of infections.

Non-cancer mortality in workers in the meat and delicatessen departments of supermarkets (1950-2006)

We studied non-cancer mortality in 10,701 workers in the meat and delicatessen departments of supermarkets because they have increased exposure to a variety of microorganisms that infect and cause disease in food animals such as cattle, pigs, sheep, and poultry, to which subjects in the general population are also exposed, albeit to a lesser degree. These workers were also exposed to fumes from the wrapping machine. Standardized mortality ratios were estimated in the cohort as a whole and in race/sex subgroups, using the US population for comparison. Study subjects were followed up from January 1950 to December 2006. Significantly increased deaths from diabetes, ischemic heart disease, pulmonary embolism, chronic bronchitis, peritonitis, intracranial and intraspinal abscess, other bacterial diseases, and significantly decreased deaths from diffuse diseases of connective tissue, functional diseases of the heart, intracerebral hemorrhage, occlusion/stenosis of the precerebral and cerebral arteries, and various types of accidents were observed in certain race/sex subgroups or in the cohort as a whole. The observed increased risks of several infectious conditions suggest that the increased occupational exposure to microorganisms may be responsible for at least some of the observed excess deaths, while exposure to fumes may also contribute to the excess of chronic bronchitis. The findings are important not only for supermarket workers and other workers in the meat and poultry industries, but also because the general population is exposed to these microorganisms found in food animals and their products. Nested case-control studies within cohorts that include both workers in supermarkets and other sectors of the meat and poultry industries, are now needed to examine specific risks from occupational exposures while adequately controlling for confounding factors, so that the role of these infectious agents in the occurrence of these diseases in workers and in general population subjects can be adequately assessed.

Conventional Brain MRI in Carbon Monoxide Poisoning

Carbon monoxide poisoning is a common fatal condition which can have acute or chronic presentation with varying severity. It commonly involves globus pallidus and putamen but can involve other parts of brain. Conventional MRI using T1 weighted,T2 weighted and FLAIR sequences are helpful in determining the extent of damage to the brain. However, appropriate clinical and laboratory findings should supplement findings on imaging.

Clinical Profile and Early Complications after Single and Dual Chamber Permanent Pacemaker Implantation at Manmohan Cardiothoracic Vascular and Transplant Centre, Kathmandu, Nepal

BACKGROUND

Permanent pacemaker implantation is a minimally invasive surgical procedure in the management of patients with cardiac problems. However, complications during and after implantation are not uncommon. There is lack of evidences in rate of complications with the selection of pacemakers in Nepal. Therefore, this study was performed to compare the frequency of implantation and complication rate between single chamber and dual chamber pacemaker.

METHODS

The present study is based on all consecutive pacemaker implantations in a single centre between April 2014 and May 2015. A total of 116 patients were categorized into two cohorts according to the type of pacemaker implanted- single chamber or dual chamber. All patients had regular 2-weeks follow-up intervals with standardized documentation of all relevant patient data till 6-week after implantation. Data were presented as means ± standard deviation (SD) for continuous variables and as proportions for categorical variables. Comparison of continuous variables between the groups was made with independent Student's t-test. For discrete variables distribution between groups were compared with Chi-square test.

RESULTS

The mean age (±SD) of total population at implant was 64.08 (± 15.09) years. Dual chamber units were implanted in 44 (37.93%) of patients, single chamber in 72 (62.06%). Only 14 women (31.81%) received dual chamber compared with 42 women (58.33%) who received single chamber (Chi-square=18, DF=1, P = 0.0084). Complete atrioventricular block was the commonest (56.03%) indication for permanent pacemaker insertion followed by sick sinus syndrome (33.62%), symptomatic high-grade AV block (11.20%). Hypertension (dual chamber 21.55%, single chamber 40.51%) was the most common comorbidity in both cohorts. Complications occurred in 11 (9.48%) patients. More proportion of complication occurred in single chamber group (9 patients, 12.50%) than in dual chamber (2 patients, 4.54%). Complications occurring in dual chamber group include pocket hematoma 1 patient (2.27%) and arrhythmia in 1 patient (2.27%). Similarly, complications occurring in single chamber include RV perforation in two patients (2.77%) and one each (1.38%) had pocket hematoma, pneumothorax, infection, swelling at pocket site, arrhythmia in the form of NSVT, leads displacement, DVT and mortality.

CONCLUSIONS

Women were more likely to receive single chamber systems than men. More proportion of complication occurred in single chamber group than in dual chamber. Future prospective studies on larger number of patients are needed to confirm and support our findings.

Pattern of Pediatric Admissions in a Tertiary Care Hospital of Central Nepal

INTRODUCTION

An understanding of the epidemiological trend in hospital admissions, including morbidity and mortality patterns and the economic impact, is critical for healthcare planning and appropriate resource allocation. As we find very few literature on the pattern of paediatric admissions outside Kathmandu Valley, it is essential to conduct studies in the various parts of the country to determine the paediatric inpatient burden as well resource allocations.

METHODS

A retrospective study was carried out at Department of Pediatrics, College of Medical Sciences-Teaching Hospital, Bharatpur, Chitwan, Nepal over a period of one year. All the admissions were analyzed for age, sex, address, seasonal variation, frequency of diseases according to the organ system involved, duration of hospital stay, and the outcome.

RESULTS

Out of the total 814 cases admitted 68.8% of the patients were younger than five years. There was male preponderance with male to female ratio of 1.9:1. Majority (43.6%) admissions were from Chitwan itself. Respiratory, gastrointestinal and neurologic conditions were the main cause for admission. The mean duration of hospital stay was 5.28 days and the mortality was only 0.1%.

CONCLUSIONS

In this study under five-year patients contributed to 2/3rd of the hospital admissions. Respiratory, gastrointestinal and neurologic conditions were the main cause for admission with pneumonia, URTI and acute gastroenteritis being the most common diseases.

In ovo delivery of Toll-like receptor 2 ligand, lipoteichoic acid induces pro-inflammatory mediators reducing post-hatch infectious laryngotracheitis virus infection

Toll-like receptor (TLR) ligands are pathogen associated molecular patterns (PAMPs) recognized by the TLRs resulting in induction of host innate immune responses. One of the PAMPs that binds to TLR2 and cluster of differentiation (CD) 14 is lipotechoic acid (LTA), which activates downstream signals culminating in the release of pro-inflammatory cytokines. In this study, we investigated whether in ovo LTA delivery leads to the induction of antiviral responses against post-hatch infectious laryngotracheitis virus (ILTV) infection. We first delivered the LTA into embryo day (ED)18 eggs via in ovo route so that the compound is available at the respiratory mucosa. Then the LTA treated and control ED18 eggs were allowed to hatch and the hatched chicken was infected with ILTV intratracheally on the day of hatch. We found that in ovo delivered LTA reduces ILTV infection post-hatch. We also found that in ovo delivery of LTA significantly increases mRNA expression of pro-inflammatory mediators in pre-hatch embryo lungs as well as mononuclear cell infiltration, predominantly macrophages, in lung of post-hatch chickens. Altogether, the data suggest that in ovo delivered LTA could be used to reduce ILTV infection in newly hatched chickens.