Whole Blood Viscosity and Cerebral Blood Flow in Acute Ischemic Stroke

Existing effective treatments for ischemic stroke restore blood supply to the ischemic region using thrombolysis or mechanical removal of clot. However, it is increasingly recognized that successful removal of occlusive thrombus from the large artery-recanalization, may not always be accompanied by successful restoration of blood flow to the downstream tissues-reperfusion. Ultimately, brain tissue survival depends on cerebral perfusion, and a functioning microcirculation. Because capillary diameter is often equal to or smaller than an erythrocyte, microcirculation is largely dependent on erythrocyte rheological (hemorheological) factors such as whole blood viscosity (WBV). Several studies in the past have demonstrated elevated WBV in stroke compared with healthy controls. Also, elevated WBV has shown to be an independent risk factor for stroke. Elevated WBV leads to endothelial dysfunction, decreases nitric oxide-dependent flow-mediated vasodilation, and promotes hemostatic alterations/thrombosis, all leading to microcirculation sludging. Compromised microcirculation further leads to decreased cerebral perfusion. Hence, modulating WBV through pharmacological agents might be beneficial to improve cerebral perfusion in stroke. This review discusses the effect of elevated WBV on endothelial function, hemostatic alterations, and thrombosis leading to reduced cerebral perfusion in stroke.

Bacteriology of endotracheal tube biofilms and antibiotic resistance: a systematic review

Bacteria commonly adhere to surfaces and produce polymeric material to encase the attached cells to form communities called biofilms. Within these biofilms, bacteria can appear to be many times more resistant to antibiotics or disinfectants. This systematic review explores the prevalence and microbial profile associated with biofilm production of bacteria isolated from endotracheal tubes and its associations with antimicrobial resistance. A comprehensive search was performed on databases PubMed, Embase, and Google Scholar for relevant articles published between 1st January 2000 and 31st December 2022. The relevant articles were exported to Mendeley Desktop 1.19.8 and screened by title and abstract, followed by full text screening based on the eligibility criteria of the study. Quality assessment of the studies was performed using the Newcastle-Ottawa Scale (NOS) customized for cross-sectional studies. Furthermore, the prevalence of antimicrobial resistance in biofilm-producers isolated from endotracheal tube specimens was investigated. Twenty studies encompassing 981 endotracheal tubes met the eligibility criteria. Pseudomonas spp. and Acinetobacter spp. were predominant isolates among the biofilm producers. These biofilms provided strong resistance against commonly used antibiotics. The highest resistance rate observed in Pseudomonas spp. was against fluoroquinolones whereas the least resistance was seen against piperacillin-tazobactam. A similar trend of susceptibility was observed in Acinetobacter spp. with a very high resistance rate against fluoroquinolones, third-generation cephalosporins and carbapenems. In conclusion, endotracheal tubes were associated with colonization by biofilm forming bacteria with varying levels of antimicrobial resistance. Biofilms may promote the occurrence of recalcitrant infections in endotracheal tubes which need to be managed with appropriate protocols and antimicrobial stewardship. Research focus should shift towards meticulous exploration of biofilm-associated infections to improve detection and management.

Antidiuretic hormone deficiency secondary to inactive hydrocephalus: a case report

BACKGROUND

Diabetes insipidus is a syndrome characterized by polyuria, which is almost always associated with polydipsia. The most frequent cause is central diabetes insipidus, which is the result of an inadequate secretion of the antidiuretic hormone, and diagnosis involves differentiating it from other causes of polyuria and polydipsia.

CASE PRESENTATION

Here, we present a clinical case of a previously healthy 13-year-old Nepali boy, who, in December 2022, was found to have intense polydipsia accompanied by polyuria. He had bilateral lower limb weakness at the time of presentation. Biochemical evaluation demonstrated raised serum sodium (181 mEq/L), serum creatinine (78 μmol/L), and serum uric acid (560 μmol/L) with suppressed serum potassium (2.7 mEq/L), which was the major concern to the clinicians. Further laboratory workup revealed an increased serum osmolarity (393.6 mOsm/kg) with reduced urine osmolarity (222.7 mOsm/kg). On contrast magnetic resonance imaging of the brain, a thick-walled third ventricular cyst with bilateral foramen obstruction, thin membrane-like structure at top of aqueduct of Sylvius with gross obstructive hydrocephalus (inactive), and compressed and thinned pituitary gland with no bright spot was observed. The laboratory findings, radiological findings, and case presentation provided the provisional diagnosis of diabetes insipidus due to hydrocephalus and third ventricular cyst.

CONCLUSIONS

Central diabetes insipidus due to hydrocephalus, though rare, can have serious complications including the predilection to develop a deficit of other pituitary hormones. Thus, even if hydrocephalus is dormant with normal intracranial pressure, it must be addressed during investigations of central diabetes insipidus.

High Serum Homocysteine among Women with Polycystic Ovarian Syndrome Visiting an Infertility Clinic of a Tertiary Care Centre

Introduction

Polycystic ovary syndrome is a common hormonal disorder that affects women of reproductive age which is characterized by hyperandrogenism, polycystic ovarian morphology, ovarian dysfunction, and hyperinsulinemia. Increased prevalence of cardiovascular disease and higher cardiovascular morbidity is seen in women with polycystic ovary syndrome. This study aimed to estimate the prevalence of high serum homocysteine levels among women with polycystic ovarian syndrome visiting an infertility clinic of a tertiary care centre.

Methods

This was a descriptive cross-sectional study conducted among women with polycystic ovarian syndrome visiting an infertility clinic at the Department of Obstetrics and Gynaecology of a tertiary care centre from 1 June 2023 to 1 September 2023. The study was conducted after obtaining ethical approval from the Institutional Review Committee. Biochemical analysis of gonadal hormones, serum homocysteine and lipid profile was done. A convenience sampling method was used. The point estimate was calculated at a 95% confidence interval.

Results

Among 76 women, the prevalence of high serum homocysteine level was found in 54 (71.05%) (60.86-81.25, 95% Confidence Interval). The mean age of patients was 27.46±6.18 years.

Conclusions

The prevalence of high homocysteine levels among women with polycystic ovarian syndrome is higher than other studies done in similar settings.

Keywords

body mass index; homocysteine; polycystic ovary syndrome; prevalence.

Association of Low Vitamin D and Intact Parathyroid Hormone (iPTH) in Nepalese Population: When Does iPTH Exactly Rise?

Vitamin D deficiency is a global public health concern that provokes bone demineralization and weakening. In response to the decreased vitamin D level, calcium stores wear out. The homeostatic effect of compensatory hyperparathyroidism in vitamin D deficiency incites variable discrepancies in different populations. This study intends to decipher the transition point of PTH in relation to levels of vitamin D in a Nepalese population. A cross-sectional study was carried out at Tribhuvan University Teaching Hospital, Nepal. Serum calcium, phosphorus, intact PTH, and 25-hydroxy vitamin D levels were assayed in an Abbott ARCHITECT Integrated System. A correlation plot of PTH and vitamin D was analyzed in Statistical Package for Social Sciences version 22.0. Using a locally weighted scatter plot smoothing method, the relation between these variables was presented graphically. Among 281 individuals, 30.2% had vitamin D levels below 20 ng/mL. There was an archetypical transition in the PTH levels in concert with the decrease in vitamin D level marked by 2 inflection points (ie, 18.5 and 42.0 ng/mL). Our findings suggest that to augment overall health and avert weakness due to vitamin D deficiency, the levels of vitamin D should be maintained above 42.0 ng/mL in our population.

Effect of ABCA1-R219K Polymorphism in Serum Lipid Parameters in Patients under Statin Therapy Visiting Tertiary Cardiac Center of Nepal

Introduction  ATP-binding cassette transporter A1 (ABCA1) encoded by ABCA1 gene is one of the important protein involved in lipid metabolism. The effect of statin therapy on dyslipidemia varies among individuals and it may be due to different genetic polymorphism. The R219K polymorphism of ABCA1 gene is found to have a significant role in the response of statin. Objective  This study was designed to evaluate the effect of R219K polymorphism in lipid-lowering action of statin in patients with dyslipidemia. Material and Methods  This study was conducted in 88 patients. Blood samples were taken from patients before and at the end of 3 months of statin use and were analyzed for lipid profile. Whole blood was analyzed for R219K Polymorphism using polymerase chain reaction-restriction fragment length polymorphism. Results  R219K polymorphism was associated with significant percentage reduction of serum triglyceride/high-density lipoprotein (TG/HDL) ratio and total cholesterol/high-density lipoprotein (TC/HDL) ratio in atorvastatin users. However, there was no significant association of polymorphism with change in serum TC, HDL-C, LDL-C, TG, and very low-density lipoprotein (VLDL). Among KK genotype individuals, value of TG, VLDL, TG/HDL, and TC/HDL were significantly lower than in RR genotypes. Also, TG/HDL and TC/HDL were significantly lower in RK genotype than in RR. Treatment of dyslipidemia with statin was found to be comparatively better in patients having the genotypes KK and RK. Conclusion  Our study demonstrated association of R219K polymorphism with the significant reduction of TG/HDL and TC/HDL and particularly the KK genotype was associated with significant improvement of lipid parameters following atorvastatin treatment.

Positive Thyroid Peroxidase Antibody among Women with Polycystic Ovarian Syndrome Visiting an Infertility Clinic at a Tertiary Care Centre

Introduction

Polycystic ovarian syndrome is the most common endocrine-metabolic disorder, affecting women of reproductive age groups, which shares various symptoms with thyroid dysfunctions. Despite it predisposition of aforesaid cohorts to autoimmunity, these etiologies have not adequately been studied in them. This study aimed to find out the prevalence of positive thyroid peroxidase antibodies among women with polycystic ovarian syndrome visiting an infertility clinic at a tertiary care centre.

Methods

This was a cross-sectional study conducted at a tertiary care centre among patients visiting the infertility clinic at the Department of Obstetrics and Gynaecology from 21 September 2022 to 21 February 2023. Biochemical analysis of thyroid hormones, gonadal hormones, anti-mullerian hormone and thyroid peroxidase antibody were done in Abbott ARCHITECT ci4100 and SNIBE Maglumi 800 autoanalyzer. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval.

Results

Among 70 participants, thyroid peroxidase antibody was positive in 16 (22.86%) (13.02-32.69, 95% Confidence Interval). The mean age of the patients was 28.25±5.26 years. In the individuals with thyroid-stimulating hormone below 2.5 mIU/l, 5 (31.25%) had positive thyroid peroxidase antibody titre.

Conclusions

The prevalence of positive thyroid peroxidase antibodies among women with polycystic ovarian syndrome is similar to other studies done in similar settings. Regular monitoring of thyroid peroxidase antibodies is recommended in these women to guide conception in order to evade inevitable adverse pregnancy outcomes.

Keywords

anti-thyroid autoantibodies; autoimmunity; infertility; prevalence; polycystic ovary syndrome.

Autoimmune thyroid status in subclinical thyroid disorders in patients attending a tertiary care center in Nepal: a hospital-based cross-sectional study

BACKGROUND

Thyroid dysfunction is the leading endocrine disorder worldwide. Iodine deficiency disorders, which were once the major etiology of thyroid dysfunctions, now have been succeeded by autoimmune thyroid diseases with the rise in aberrant salt ionization protocols. This study endeavors to access the level of thyroid autoantibodies viz. anti-thyroid peroxidase (anti-TPO), anti-thyroglobulin (TGA), and anti-thyroid stimulating hormone receptor (TRAb) in individuals with subnormal thyroid profiles.

METHODS

This hospital-based cross-sectional study was conducted at the Department of Clinical Biochemistry, Tribhuvan University for a period of six months. Using non-probability (purposive) sampling method, a total of 60 patients were enrolled with subnormal thyroid profiles to include the population who have not yet started medication. Thyroid hormones (free T3, free T4, TSH) and thyroid antibodies (anti-TPO, TGA, and TRAb) were measured. For non-parametric data, Chi-square test and Kruskal-Wallis test were used. Spearman's correlation was done to determine the association between variables.

RESULTS

Out of 60 participants, the majority of the population between 25 and 44 years were diagnosed with thyroid dysfunction with female preponderance. Among all, 40% (n = 24) had subclinical hyperthyroid states while, 60% (n = 36) had subclinical hypothyroid states, and 75% (n = 45) of the total exhibited positive thyroid antibodies. In subclinical hypothyroid patients with TSH above 10 µIU/ml, anti TPO (58.5%) and TGA (66.7%) positivity were highly prevalent. On the other hand, TRAb was exclusively positive in hyperthyroid condition (50% among the group) which is by far the first of its kind reported in Nepal.

CONCLUSION

The rise in autoimmune thyroid disease among the Nepalese population infers that addressing iodine deficiency simply through salt iodinization may not be adequate to deal with the rising burden of thyroid disorders, especially in iodine-depleted areas. Also, the increasing prevalence of thyroid autoantibodies positivity in subclinical hypothyroidism in the Nepalese population accounts for the arduous screening and monitoring of autoimmune thyroid disorders in Nepal.

Bilateral thalamic infarct involving artery of Percheron: a case report

Introduction and importance

The thalamus and the midbrain have marked variations and overlapping in their blood supply; one of those variations is the artery of Percheron. Artery of Percheron occlusion is a rare cause of infarction in the bilateral thalamus and midbrain.

Case presentation

In this case, a 60-year-old female with chronic hypertension presented with unconsciousness, motor impairments, and oculomotor disorders.

Clinical discussion

Due to highly variable clinical manifestations and possible negative findings during initial imaging, these conditions are often overlooked, causing delays in therapeutic intervention and leading to bad patient prognosis. Various imaging techniques can be used for diagnosis and treatment should be started early. The treatment aims to promote recanalization as soon as possible and prevent future episodes. The involvement of the midbrain is unfavourable.

Conclusion

Early clinical assessment and neuroimaging are vital for timely diagnosis and early administration of therapeutic measures for better patient prognosis.

Biochemical spectrum of parathyroid hormone disorders in patients attending Tribhuvan University Teaching Hospital, Kathmandu, Nepal

Objectives

This study intends to determine the association of parathormone with vitamin D and other biochemical parameters (calcium and phosphate) and evaluate the relationship between low vitamin D and parathormone levels.

Methods

A hospital-based cross-sectional study was conducted among 310 study participants over the period of 1 year. Patients who underwent laboratory investigations for vitamin D, parathormone, calcium, and phosphate in the Clinical Biochemistry Laboratory at the Institute of Medicine, Tribhuvan University Teaching Hospital were included. Serum intact parathyroid hormone, vitamin D, calcium, and phosphate were measured in Abbott Architect (ci4100) integrated system autoanalyzer.

Results

Among the 310 study participants, 177 (57%) were males and 43% were females. The mean age of the patient was 47.09 ± 19.01 years. High intact parathyroid hormone (>68 pg/ml) was observed in 73% of the patients. Low vitamin D (<20 ng/ml) was present in 30.2% of the patients. The findings from our study depict that there is a negative significant correlation between intact parathyroid hormone levels, vitamin D, and calcium levels and a positive correlation between intact parathyroid hormone and phosphate levels (p < 0.001).

Conclusions

The findings from our study illustrate that there is a swapping drift in the profile of hyperparathyroidism in the Nepalese population. We report the presence of hyperparathyroidism in the middle age group than in the older age group contradictory to that reported in the literature.

Metabolic and biochemical profile in women with polycystic ovarian syndrome attending tertiary care centre of central NEPAL

BACKGROUND

Polycystic Ovarian Syndrome (PCOS) is a common endocrinopathy in women of reproductive age group and is highly associated with an increased risk of diabetes, hypertension, cardiovascular disease, and hyper estrogen-related malignancies in women with PCOS. This study was intended to assess the metabolic and hormonal profile of the patients with polycystic ovarian syndrome attending a tertiary care hospital.

METHODOLOGY

A descriptive cross-sectional study was conducted among 107 women diagnosed with polycystic ovarian syndrome from the Department of Clinical Biochemistry of Tribhuvan University and Teaching Hospital. Descriptive analysis was performed to determine the socio-demographic characteristics of the participants. Bivariate analysis was conducted to determine using a t-test for comparing means between two groups and ANOVA for comparing the hormonal and metabolic parameters.

RESULTS

The mean age of the participants was 27 ± 4 years. This study showed that blood pressure was significantly higher in overweight and obese women (p = 0.001). The obese group had significantly higher serum TSH than the normal group (10.04 vs. 2.73, p = 0.001). Abnormal glucose and hyperinsulinemia were present in 4% of the patients, while 40% had Vitamin D deficiency. Hypothyroidism (TSH ≥ 4.5 mIU/ml) was found in 11% of the PCOS participants with a mean value of 6.65 ± 21.17 mIU/ml. Hyperprolactinemia ≥ 26.8 ng/ml was depicted in 21% of the study population with a mean value of 37.25 ± 21.86 ng/ml.

CONCLUSION

Our study demonstrated that PCOS is most commonly prevalent in young women of the reproductive age group which can lead to reproductive, metabolic, and oncological complications in the long term. LH/ FSH ratio was found to be significantly deranged indicating that PCOS should be diagnosed and treated early in the adolescent age group.

Intraglandular Foreign Body - Unusual Aetiology of Submandibular Gland Sialadenitis

Obstructive sialadenitis of submandibular gland is commonly due to sialoliths and strictures in the Wharton's duct. Other endogenous pathologies include mucous plugs and polyps. Foreign bodies of Wharton's duct and submandibular gland are rare. Retrograde migration of foreign bodies via ductal orifice, traversing the ductal system to its final intraglandular location is an even rare entity. These often present with painful swelling of the gland and at times with a purulent sialitis. Diagnostic modalities include plain radiography, ultrasonography, sialography, as well as computed tomography and magnetic resonance imaging. Treatment includes antibiotics, incision and drainage of abscess, and removal of foreign body either surgically (intra-oral approach or sialadenectomy) or more recently via sialoendoscopy. This is a case report of 30 years male with accidental cannulation of Wharton's duct with grass that eventually got lodged in the deep lobe of the gland, and was managed with sialadenectomy.

Porphyria: a case report

BACKGROUND

Prompt diagnosis of metabolic disorders in a resource-limited country like Nepal is daunting. Acute intermittent porphyria is a rare but common hepatic porphyria mostly seen in females of the reproductive age group. As its incidence is quite uncommon, conjectures about porphyria diagnosis are often duped into a diagnostic conundrum.

CASE PRESENTATION

Here we unravel a case of a 15-year-old Hindu Nepalese girl distraught by the myriad of symptoms in the setting of severe abdominal pain accompanied by constipation and limb pain as the chief complaints. She presented with acute severe hypertension with marked persistent hyponatremia (up to 109 mEq/L). Despite conservative management of hypertension and electrolytes, unresolved electrolyte imbalance led us to the speculation of disturbance in the renin-angiotensin-aldosterone system. Due to her exacerbating neurovisceral status, she also required intensive care during the disease course. After thorough investigations and exemption of presumed provisional diagnoses, based on sustained symptomatic presentation, the clinical suspicion was driven towards a diagnosis of porphyria-related disorders. Positive Watson-Schwartz test substantiated the diagnosis of acute intermittent porphyria. Her symptoms gradually abated after the consumption of high carbohydrate diets.

CONCLUSION

This case highlights the baffling amalgamation of symptoms that simulate common diseases of concern yet are buried in the realm of porphyric disorders. Porphyria can be diagnosed using simple screening tools and timely treatment can diminish serious consequences.

Mean Serum Creatine Kinase among Organophosphate Poisoning Cases in a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction

Major cases of poisoning are associated with organophosphates. Cholinergic effects and an intermediate phase seen with organophosphate poisoning may implicate myopathy. Creatine kinase is a marker of muscle tissue damage. This study aimed to find out the mean serum creatine kinase among organophosphate poisoning cases in a tertiary care centre.

Methods

A descriptive cross-sectional study was carried out among organophosphate poisoning cases in a tertiary care hospital from 13 October 2017 to 30 March 2018. Ethical approval was taken from the Institutional Review Committee [Reference number: 117(6-11-E) 2/074/075]. Blood samples were assayed for serum acetylcholinesterase in the pharmacology laboratory and for serum creatine kinase and lactate dehydrogenase in the biochemistry laboratory. Low serum acetylcholinesterase was taken as the basis for the establishment of organophosphate poisoning. A convenience sampling technique was used. Point estimate and 95% Confidence Interval were calculated.

Results

Among 103 organophosphate poisoning cases, the mean serum creatine kinase was 931.35±446.60 IU/l (845.10-1017.60, 95% Confidence Interval).

Conclusions

The mean serum creatine kinase level among organophosphate poisoning cases was higher than in other studies done in similar settings.

Keywords

acetylcholinesterase; creatine kinase; organophosphate poisoning; rhabdomyolysis.

A Study of Trauma Patients in the Emergency Department of a Tertiary Care Hospital in Nepal during Lockdown in COVID-19 Pandemic

Background The nationwide lockdown was imposed upon by the Government of Nepal with regards to the COVID-19 pandemic. Even during times of limited mobility and travel, trauma cases were presenting to the hospital. Objective To asses trauma patterns among patients presented to the Emergency department in Dhulikhel hospital during the lockdown period. The assessment of the burden of trauma during the pandemic could aid in planning allocation of resources and improving trauma care. Method A retrospective cross-sectional study design was used to assess all patients with a history of trauma during the period of lockdown announced by the Government of Nepal for COVID-19 from March 24 to June 14, 2020. Result Among 2097 patients that visited the emergency department, 23% were trauma cases. In comparison to the corresponding time-period in 2019, trauma cases reduced by more than half (54.5%). The majority of patients utilized ambulances as a means of transportation; a few patients utilized Dhulikhel emergency medical services. The most common mechanism of injury was fall injury, followed by motor vehicle accident and physical assault. Traumatic brain injury occurred in 30% of patients. Of all patients, 71% were discharged after initial treatment, 26% were admitted to different wards and 3% were referred to other health centres. Conclusion Fall injury is a crucial public health concern followed by motor vehicle accident among trauma patients even during the pandemic condition. Thus, emergency rooms should aid in planning for preparedness, mitigation of trauma during situations like these, in planning the allocation of resources and improving trauma care.

Comparison of Her2/Neu Oncoprotein in Serum and Tissue Samples in Women with Breast Cancer

Background and objectives:

Human Epidermal Growth Factor Receptor 2 (HER2/neu) is one of the most extensively studied proto-oncogens in breast cancer patients. Accurate and timely assessment of the HER2/neu over expression is pivotal for the identification of breast cancer patients that could benefit from HER2-targeted therapy. The present study was undertaken to investigate the diagnostic utility of serum HER2/neu testing by chemiluminescent immunoassay (CLIA) in breast cancer patients and compare it with the immunohistochemistry (IHC) method of HER2/neu expression.

Methods:

Serum sample and tissue/paraffin block was collected from 52 patients with breast cancer before start of any anticancer regimen or hormonal therapy. The tissue specimens were processed in Histopathology lab. Sections were immunostained with anti –estrogen receptor (ER) , anti –progesteron receptor (PR) and anti HER2/neu receptor mouse monoclonal antibodies.) Serum HER2/neu was estimated using the chemiluminiscent immunoassay using 15ng/ml as the cut off.

Results:

Out of 52 patients with breast cancer, serum HER2/neu was found elevated in 25(48.1%) patients and remaining 27(51.9%) showed normal serum HER2/neu concentrations. On IHC HER2/neu score was 3+ in 9(17.3%), 2+ in 10(19.2%), 1+ in 1(1.9%); while 32(61.5%) showed no HER2/neu expression. 31(59.6%) patients were ER positive and 28(53.8%) were PR positive. There was a significant correlation (P<0.001) of serum HER2 concentration with tissue expression of HER2/neu and Histological tumor grade. Serum HER2/neu levels showed a negative correlation with ER status (P=0.047) but no correlation with PR status.

Conclusion:

The result showed that the elevated serum HER2/neu was correlated with the IHC expression of HER2/neu in tissue and the histological grade of the tumor. Findings suggest that post initial tissue diagnosis (IHC HER2/neu), serum HER2 assay may supplement subsequent tissue tests to monitor disease status and response to therapy.

Toothbrush, an Unusual Foreign Body

Accidental consumption of foreign body is a common presenting complain among patients especially in young age group. Majority of patients can be discharged safely after reassurance while a fraction of patient requires observation and further management. Here we report a case of a 35-year-old gentleman who presented to the out-patient department of our hospital in June 2021 for accidental ingestion of toothbrush. After detailed history and physical examination upper gastrointestinal endoscopy was planned for the patient. Failed endoscopic removal was considered the indication for surgery. A supraumbilical midline incision was used to remove the toothbrush. Following the surgical removal, he was managed conservatively and was discharged without significant complications. We describe this case in detail in addition to reviewing the pertinent literature.

Clinical Profile and Diagnosis of Obstructive Sleep Apnea Syndrome using Overnight Polysomnography in a Tertiary Care Hospital

Background Obstructive sleep apnea is a highly prevalent yet largely under-diagnosed disease that poses a significant burden on the healthcare system. Objective To determine the role of predictors for Obstructive sleep apnea syndrome and its severity in Nepalese population. Method Prospective and analytical study conducted in the Department of Otorhinolaryngology and Head and Neck surgery at Kathmandu University Hospital between March 2018 and June 2020. A total of 85 adult patients with Obstructive sleep apnea with an Epworth sleepiness score greater than 10 were included. Overnight polysomnography was done and scoring of sleep associated events were done according to the American Academy of Sleep Medicine criteria. Participants were classified as simple snoring and mild, moderate or severe Obstructive sleep apnea syndrome groups depending on the Apnea Hypopnea Index values. Relationship of Apnea hypopnea index was analyzed with age, neck circumference, body mass index and Epworth Sleepiness score. Result Simple snoring was seen in 18(21.17%) patients, 14(16.47%) had mild Obstructive sleep apnea, 13(15.29%) had moderate Obstructive sleep apnea, whereas the severe group consisted of 40(47.05%) patients. The minimum Epworth Sleepiness Score was 10 and the maximum was 25. The Apnea hypopnea index correlated positively with Body mass index (p=.010) and Epworth sleepiness score (p <.001). However, Apnea hypopnea index had no association with age (p=.437) and neck circumference (p=.118). Conclusion Health professionals need to be extremely vigilant while examining patients presenting with Obstructive Sleep Apnea. Polysomnography is the investigation of choice in the early identification of this treatable disease.

Does Vitamin D has Preventive or Treatment Potential to Covid-19 Illness?: A Brief Review

The world’s health in 2020 was in the grip of the COVID-19 pandemic and its adverse consequences and is still continuing in 2021. Most countries have been locked down or going through different forms of lockdown to prevent the transmission of the infectious virus SARS-CoV-2. To date, there is no specific treatment or vaccination preventive measures. World Health Organization has approved few vaccines for emergency use. Still, the emergence of mutations within SARS-CoV has put forward challenges for vaccine developers. Whether infectious or non-infectious, all diseases have an inflammatory aspect to alarm the body system along with an anti-inflammatory counterbalance mechanism to minimize harmful effects whether through immune modulation or antioxidant reserves. An approach to counteract the novel disease, COVID19, was also sought in enhancing the anti-inflammatory aspect, at the level of prevention and at the level of treatment. One of the methodologies was the recommendation of micronutrient Vitamin D whose immune-modulatory role has been well appreciated in many disease conditions. This short review aims to explore the relationship between vitamin D status through susceptibility and clinical outcomes of COVID-19.

Comparison of Two Entry Methods for Laparoscopic Port Entry

Background The first step in laparoscopic surgery is to establish the pneumoperitoneum for which many approaches have been introduced to minimize the complications. Although controversies exist regarding the most efficient technique, till now the best entry technique is still unsettled. Objective To compare the safety, operating time and outcome of Direct Trocar Insertion with a well-established and widely practised Open Access Technique. Method This is a prospective study at Nobel Medical College Teaching Hospital from November 2019 to February 2021. Patients were grouped into either of the two groups, Group 1 for Direct Trocar Insertion and Group 2 for Open Access Technique. They were later analysed for major and minor complications of the technique and a comparison of either method was done at the end of the study period. Result A total of 823 patients were enrolled in the study. Among the study population, 411 patients had Direct Trocar Insertion while 412 patients had Open Access Technique. The majority of the operation that was done during the study period was laparoscopic cholecystectomy. Patients in the Open Access Technique group experienced more complications compared to Direct Trocar Insertion group. Conclusion Despite the fear of adopting the Direct Trocar Insertion, this is a safe, better and quick technique for laparoscopic port entry. However, any surgeon practising laparoscopic surgery should be competent to adopt either technique to overcome failure in either process during port entry.

Pilonidal sinus of the cheek: an extremely rare clinical entity-case report and brief review of the literature

Background

Pilonidal sinus is commonly seen at the sacrococcygeal region and few other sites, usually located at the midline, at areas where hairs collect or near protuberances or some adjacent rubbing surfaces. Its presence elsewhere is uncommon. We share an interesting case of a recurrent discharging sinus from the cheek bulge of a male which turned out to be a pilonidal sinus containing tuft of hairs on exploration and wide excision.

Case presentation

A 37 years old hirsute male presents to us with a non-healing discharging sinus at the bulge of the cheek. Exploration after a course of antibiotics showed 2 subcutaneous cavities with tuft of hairs. The area was excised along with a margin, thorough irrigation and curettage was done and the wound was closed primarily; a Z-plasty was incorporated in the central part to break the resultant suture line. Histopathological examination was done to confirm the diagnosis and rule out an off-midline dermoid cyst or an underlying/coexisting malignancy. Post-operative course was uneventful. The patient has been recurrence free for 1.5 years and is satisfied with the nature of the scar.

Conclusions

Pilonidal sinus of the cheek bulge is an extremely rare entity. Complete excision and clinical suspicion are important for cure of this nagging ailment, especially at unexpected areas.

Thresholds for Spinal Anaesthesia-induced Hypotension During Caesarean Section

Background Spinal anaesthesia is the current standard for caesarean section. Hypotension, a common complication, potentially results in adverse foetal and maternal outcomes. However, hypotension-defining criteria are varied. Objective To identify the blood pressure thresholds for spinal anaesthesia-induced hypotension during caesarean section. Method This is a retrospective cohort study of spinal anaesthesia-induced hypotension that occurred till baby-delivery during caesarean section. Reports on intraoperative hypotension, collected previously from January to December 2019, were reviewed to identify the hypotension-defining thresholds. The thresholds were categorized into systolic blood pressure (SBP) of 80, 90 or 100 mmHg, mean arterial pressure (MAP) of 60, 65 or 70 mmHg, combinations, and others. Parturient and anaesthesia characteristics, and associated hypotensive symptoms were also recorded for descriptive analysis. Result Spinal anaesthesia-induced hypotension was identified in 129 (11.5%) cases among 1116 caesarean sections. Altogether, 12 hypotension-defining thresholds were employed. Thresholds of SBP 90, MAP 60, and SBP 80 mmHg were used in 53 (41%), 28 (21.7%), and 21 (16.2%) cases respectively. Mean maternal age was 28 (±4.22) years and 87 (67.4%) cases underwent emergency surgery. Median sensory blockade level was T4. Nausea-vomiting, bradycardia, and tachycardia were associated during five (3.8%), six (4.6%), and 15 (11.6%) hypotensive incidents respectively. Two cases had unrecordable blood pressure but there was no maternal mortality. Conclusion Systolic blood pressure of 90 mmHg and mean arterial pressure of 60 mmHg included the most common thresholds for spinal anaesthesia-induced hypotension during caesarean section. Identifying the safe and clinically relevant hypotension-defining criteria needs further investigation.

Serum anti-thyroid peroxidase antibody in infertile Nepalese women: a hospital-based study

Background: Infertility is a critical component of reproductive health that can precipitate agony for a couple. Antibodies against thyroid peroxidase can lead to not only autoimmune thyroiditis which is highly prevalent in women, but may also represent a generalized autoimmune milieu in our body that can be associated with infertility. This study aims to assess anti-thyroid peroxidase antibodies in female patients with infertility. Materials and Methods: This is a cross-sectional study carried out in the Department of Biochemistry, Tribhuvan University Teaching Hospital over three months (November 2018 to January 2019). All women undergoing work up at the infertility clinic with reported normal thyroid function and otherwise normal levels of reproductive hormones were recruited for this study. Anti-thyroid peroxidase levels were estimated in their serum samples by enzyme-linked immunosorbent assay. Results: Of the eighty-seven females that were selected for the study, 54 were infertile females, 16 were pregnant women in their first trimester and 17 were non-pregnant females in their reproductive age. Four positive cases of anti-thyroid peroxidase were detected among infertile females (7.4% within the group), 2 amid non-pregnant females (11.76% within-group) while no positive cases were detected within the pregnant group. However, the occurrence was not statistically significant (p=0.4). The pregnant group showed higher mean anti-thyroid peroxidase levels compared to both infertile and non-pregnant females though statistical significance could not be established (p=0.066). Conclusions: Functional autoimmune antibodies, like anti-thyroid peroxidase levels, do not have a significant primary association with infertility.

Higher rates of early initiation of breastfeeding associated with health facility delivery in Nepal

Background

Initiation of breastfeeding within one hour from birth is one of the five key essential newborn care messages, implemented along with birth preparedness package since 2008. This study aimed to determine the trend of early initiation of breastfeeding (EIBF) and to assess the effect of health facility delivery on EIBF in Nepal.

Methods

We analyzed the data from the last four nationally representative Nepal Demographic and Health Surveys (NDHS) conducted in 2001,2006,2011 and 2016. Data on the early initiation of breastfeeding was obtained from the mothers of infants born within 24 months prior to the survey. The explanatory variable was the place of delivery, dichotomized as either the health facility, or home delivery. Survey year had a significant interaction with the place of delivery. Multivariable logistic regression was conducted separately on pooled samples before (NDHS 2001 and 2006) and after (NDHS 2011 and 2016) the program implementation. Adjusted odds ratio (AOR) with 95% confidence interval (CI) for EIBF was calculated after adjusting for predetermined covariates.

Results

The rate of EIBF increased by 26.5% points (from 32.8% in 2001 to 59.3% in 2016) among infants delivered in a health facility, compared to an increase by 17.1% points (from 29.9% to 47.0%) among home born infants. EIBF increased by 32.5% points before, compared to 49.7% points after BPP. Delivery in a health facility was associated with a higher odd of EIBF in later years (AOR2.3, 95% CI 2.0,2.8), but not in earlier years (AOR1.3, 95% CI 0.9,2.0). Delivery by caesarean section, first-born infant, and lack of maternal education were associated with a lower rate of EIBF in both periods.

Conclusions

Higher EIBF was associated with health facility delivery in Nepal, only after programmatic emphasis on essential newborn care messages. This implies the need for explicit focus on EIBF at birth, particularly when mother is less educated, primiparous or undergoing operative delivery.

Key messages

The rate of initiation of breastfeeding within an hour from birth is increasing in Nepal, with higher rates in health facility delivery, as shown by the recent four nationally representative surveys. Programmatic focus on essential newborn care messages may have contributed to significant association of higher rates of early initiation of breastfeeding when delivered in health facility.

Child abuse and all-cause mortality in the Canadian population

Background

A history of child abuse is common and is associated with the later occurrence of risky health behaviors, mental disorders, and chronic conditions, strongly suggesting that child abuse may be associated with elevated mortality. However, most of the literature on child abuse has studied psychosocial/behavioral or medical outcomes and have not addressed mortality directly.

Methods

Data from the 2012 Canadian Community Health Survey, linked to the Canadian Vital Statistics Database, were used in the analysis. The CCHS-2012 interview (n = 19,830) retrospectively assessed childhood physical abuse, sexual abuse, and witnessing intimate partner violence before the age of 16. Each type of abuse was analyzed separately using Cox proportional hazards models for all-cause mortality. Hazard ratios (HR) and associated 95% confidence intervals (CI) were estimated with and without adjustment for covariates.

Results

An effect on mortality was observed among men for witnessing interpersonal violence (age-adjusted HR 2.47, 95% CI 1.48-4.12), and severe physical abuse (age-adjusted HR 2.3, 95% CI 1.21-4.36). In each case, the association was not significant for women; the age-adjusted HRs being 0.93 (95% CI: 0.51-1.70) and 0.59 (95%CI: 0.64-2.60) respectively. The association was seen only among those reporting frequent abuse ( &gt; =10 times) and weakened (became not significant) with adjustment for covariates that may mediate the association such as smoking and chronic conditions.

Conclusions

As predicted by a broader literature on childhood adversity, child abuse increases the risk of mortality. The effect was significant for severe physical abuse in men, but imprecision due to a limited number of deaths may have rendered other associations non-significant. The study provides some degree of confirmation that child abuse contributes to later life mortality. Hence public health strategies that prevent child abuse and mitigate the harms of the mediators might prevent mortality.

Key messages

Witnessing intimate partner violence is just as harmful as actually experiencing physical abuse. Preventing children's exposure to violence in family is valuable in preventing mortality in adulthood. Enhancing child abuse prevention programs and mitigating the harmful effects of the mediators such as smoking, substance use, and chronic conditions is important in reducing mortality in adult life.

Solid Variant of Alveolar Rhabdomyosarcoma of Nasal Cavity

Rhabdomyosarcoma comprises about half of the soft tissue tumors. Approximately 40% of the alveolar subtype occur in the head and neck region. Patients present with unilateral nasal mass with/without lymphadenopathy and with/without orbital manifestations. Diagnosis is aided radiologically by CT scan, MRI along with biopsy and is confirmed by immunohistochemistry. Treatment involves surgical resection, chemotherapy, radiotherapy or a combination of these. In spite of treatments, however, the outcome is poor. This is a case report of 14-year-old male who presented with unilateral nasal mass with proptosis of right eye who was eventually diagnosed as a case of alveolar rhabdomyosarcoma of solid variant.

Obligate Myiasis: A Case Series From Nepal

Although maggots are unanonymously linked to carcass or dead tissues, there are reports of its infestation into living tissues as well. Myiasis denotes maggot infestation in living tissue. There are two forms of myiasis namely obligate and facultative. Obligate myiasis denotes maggots feeding on living tissue whereas facultative myiasis represents the opportunistic behaviour of the fly taking advantage of wound or necrotic tissue, laying by eggs which hatch into maggots. Decreased physical activity and poor hygiene leads to maggot infestation. Maggot invasion of living tissues is undesirable occurrence which can best be avoided by improving hygiene. People with low living standards in the developing nations are the occasional victims for maggot infestations. We present cases of obligate myiasis for their uniqueness and rarity.

Galvanic Skin Response as a Simple Physiology Lab Teaching Tool- An Alternative Indicator of Sympathetic Arousal

Background Sympathetic arousal response due to rewarding emotion may not be considered threat to the well-being but such arousal response evoked by fear or punishment can be stressful. When such changes are recorded in lab as biological signals, induced with appropriate stimulus, the observed response may serve as a good indicator of homeostatic alteration. In this study, skin conductance was utilized to record sympathetic response for cognitive load, by application of simple subtraction task. Objective To detect sympathetic arousal by utilization of galvanic skin response during mental arithmetic task. Method Total of eighty two subjects, forty two female and forty male participated in the study. Twenty two subjects were provided mental task to record skin conductance. In sixty subjects, galvanic skin response, pulse rate, respiratory rate and temperature were recorded by appropriate transducers to obtain baseline and task response to detect differential recordings. Subjects performed the mental exercise of arithmetic task (MAT) with transducer placed in upper limbs. Mean of averages for respective variables were statistically calculated from obtained recordings. Result For measured galvanic skin response, 57 subjects showed increased skin conductance (rise in amplitude) whereas, 25 subjects had no rise in amplitude ("A peak") while performing the mental arithmetic task, when compared to control recording. However, in 20 subjects, pulse rate and respiratory rate showed significant rise though, the change in the skin conductance was not significant. Conclusion Galvanic skin response is useful for demonstration of sympathetic activation induced by simple mental subtraction task, and can be utilized along with vital parameters mentioned in this study to discuss in vivo variation that exist as differential for core and superficial sympathetic outflow among individuals.

Ceruloplasmin, a potential marker for glycemic status and its relationship with lipid profile in Type II diabetes mellitus

Background: Type II Diabetes Mellitus (Type II DM) is a metabolic disorder characterized by glucotoxicity and lipotoxicity. Marker of glycemic control are HbA1c, fasting blood glucose and postprandial blood glucose. There is altered lipid parameters in Type II DM which possess significant cardiovascular risk to the patient. Recent studies have shown that ceruloplasmin, an inflammatory marker having antioxidant property,is ideal marker to know the cardiovascular status, degree of insulin resistance and cancer risk.Aims and Objectives: Present study was carried out to determine the relation between glycemic status and serum ceruloplasmin along with lipid parameters which reflects the cardiovascular status in these patients.Materials and Methods: Blood samples were collected from eighty-eight patients with type II diabetes mellitus along with age and sex matched forty-two healthy controls. Fasting lipid profile and blood glucose, postprandial blood glucose, serum ceruloplasmin and HbA1c levels were determined using auto analyser in the department of clinical biochemistry in Institute of Medicine.Appropriate tests of significance were computed by SPSS version 20.Results: Serum ceruloplasmin was found higher in type II DM than non-diabetic group, median 52.0 (95% CI: 49-53) mg/dl versus median 45.0 (95% CI: 41-47) mg/dl, at significant level of 0.001 probability test. Similarly, fasting blood glucose, post prandial glucose, HbA1c and TG/HDL cholesterol ratio correlated significantly with serum ceruloplasmin.The cut off value of 46.5 mg/dL was obtained for serum ceruloplasmin with sensitivity of 87.5% and specificity of 62% which has good discriminating value for type II diabetic patients versus non-diabetic patients.Conclusion: Findings in our study shows that increased glycation coupled with altered lipid profile in type II DM causes enhanced generation of ceruloplasmin which could be used as potential marker for identifying acceleratedglycation and atherogenesis in these subjects.Asian Journal of Medical Sciences Vol.9(2) 2018 13-18

Dyslipidemia and Associated Cardiovascular Risk Factors among Young Nepalese University Students

Introduction

Cardiovascular diseases are one of the main causes of morbidity and mortality worldwide, atherosclerosis being the principal underlying cause of cardiovascular diseases. Early detection of dyslipidemia and long-term prevention of atherosclerosis by controlling risk factors should begin in young age. The purpose of this study was to assess dyslipidemia and associated cardiovascular risk factors among university students of Nepal.

Methods

A sample of 280 students aged 17–24 years, were selected randomly from Institute of Medicine, Tribhuvan University. An interview-based questionnaire was designed and information was collected on the basis of age, gender, smoking and alcohol consumption. Body mass index and waist-to-hip ratio of all participants were calculated. Fasting blood samples were collected from all participants and assayed for fasting serum total cholesterol, triglyceride, high-density lipoprotein and low-density lipoprotein.

Results

Overall, dyslipidemia was seen as hypercholesterolemia in 31 (11.1%), elevated low-density lipoprotein in 34 (12.1%), low high-density lipoprotein in 95 (33.9%) and hypertriglyceridemia in 39 (13.9%). Current smoking and binge drinking were significantly associated with hypercholesterolemia. Gender, binge drinking, and current smoking were found to be significantly associated with elevated low-density lipoprotein. All factors were significantly associated with hypertriglyceridemia. There was no statistically significant association between risk factors and the low high-density lipoprotein. Body mass index and waist-to-hip ratio were significantly higher in subjects with hypercholesterolemia, hypertriglyceridemia, and elevated low-density lipoprotein level.

Conclusions

The prevalence of dyslipidemia was high in young Nepalese university students. Screening the levels of lipids in youth, especially those at risk, and accurate follow-up of those with dyslipidemia can be done to reduce morbidity and mortality.

Imaging localized electric fields with nanometer precision through tip-enhanced Raman scattering

Tip-enhanced Raman scattering may be used to image various aspects of plasmon-enhanced local electric fields with extremely high spatial resolution.

Comparison of lipid profile parameters and oxidized low-density lipoprotein between normal and preeclamptic pregnancies in a tertiary care hospital in Nepal

Introduction

Preeclampsia is a pregnancy-specific complication that significantly contributes to maternal and perinatal morbidity and mortality worldwide, even more so in developing countries such as Nepal. The potential contribution of dyslipidemia and elevated levels of oxidized low-density lipoprotein (oxLDL) in the pathogenesis of preeclamptic pregnancies has been observed in several studies. The aim of this study was to compare the maternal lipid profile parameters and particularly oxLDL between preeclamptic and healthy pregnancies and also correlate oxLDL with other lipid profile parameters.

Patients and methods

A total of 54 preeclamptic women were selected as cases for this cross-sectional study. Age and gestational week-matched 60 pregnant women were enrolled as controls. Preeclampsia was defined as per Australasian Society Consensus Statement research definition. The serum lipid parameters were measured using automated enzymatic systems and a competitive enzyme-linked immunosorbent assay was used to determine oxLDL concentrations in the serum. Student’s t-test was used to compare oxLDL levels between preeclamptic and healthy pregnancies, and Pearson’s correlation analysis was carried out to assess the relation between oxLDL and other variables.

Results

The mean values of serum total cholesterol, triglyceride, non-high-density lipoprotein-cholesterol (non-HDL-c) and oxLDL were significantly higher in the preeclamptic cases (P<0.01). However, the levels of low-density lipoprotein cholesterol (LDL-c and HDL-c) did not significantly differ between the two groups. oxLDL had a significant positive correlation (P<0.01) with total cholesterol, triglyceride, LDL-c and non-HDL-c, and a negative correlation with HDL-c.

Conclusion

The atherogenic type of dyslipidemia and high oxLDL levels are associated with preeclamptic pregnancies. The lipid parameters, however, seem to be poor markers of the severity of preeclampsia. Further prospective studies are needed to see if the observed dyslipidemia has a causal role in preeclampsia and imparts a long-term cardiovascular risk.

Management of cysto-biliary communication in hydatid cyst of liver

Introduction: Biliary communication of hepatic hydatosis is one of the important complications. It may be minor or major communication. Minor communication is usually diagnosed during operation by the presence of bile stained hydatid fluid on aspiration or bile leak during surgery. However, in major communication, patients present with obstructive jaundice, abdominal pain and cholangitis. Surgical management of major communication is difficult and is associated with high morbidity and mortality.Methods: This is a retrospective study at Tribhuvan University Teaching Hospital, Kathmandu, Nepal over a period of two year (April 15th 2012 to April 15th 2014) and analyzed the medical records of 30 patients admitted and treated for hydatid cyst of liver in surgical ward during that period. Demography, clinical features, management and outcome were analyzed.Results: Of 30 patients with hepatic hydatid cyst operated over a period of two years, thirteen patients had cystobiliary communication. Amongst them, five minor communications were diagnosed during operation and managed with suture plication and omentopexy. Out of the eight major communications, seven were diagnosed preoperatively and all had cholangitis, and one had hydatid cyst of gallbladder and was diagnosed intraoperatively. Among six cases of major communication, five cases required CBD exploration and bile duct reconstruction while partial cholecystectomy was done for hydatid cyst of gall bladder and one case was managed by ERCP sphincterotomy, evacuation of cyst content and stenting. one case was managed with pigtail drain as the patient had infected hydatid cyst and not fit for surgery.Conclusion: Cystobiliary communication is a common complication of hydatid cyst of liver. Therapeutic options are related to size and location of the cyst and size of communication.Journal of Society of Surgeons of Nepal Vol.17(1) 2014: 31-34

Serum CA 19-9 Levels in Benign and Malignant Diseases Associated with the Gastrointestinal Tract

BACKGROUND: The diagnostic utility of CA 19-9 has been thoroughly evaluated and revised more than once over the past years in the context of pathological conditions related to the gastrointestinal tract. Our study was conducted to evaluate the diagnostic usage of CA 19-9 levels in the serum of patients affected with various disorders of the gastrointestinal tract, and to assess the diagnostic values in terms of severity and organ system involved in the context of clinical disorders requiring surgical interventions.METHODS: A total of 70 patients admitted to various surgical units and the critical care units were randomly selected and the sera analyzed for levels of CA 19-9. Mean values were compared using independent t-tests and ANOVA, and cut-offs were estimated using ROC Curves.RESULTS: CA 19-9 levels in the serum were found to be elevated in 57%, 50%, 100%, 81% and 63% of patients with Stomach / Upper GI, Liver / Gall Bladder, Pancreas, Colorectal and Lungs/Pleural pathologies respectively, with the normal cut-off values at 35 U/ml. In general, mean values of CA 19-9 in the serum were higher in patients with neoplasms (75.63±34.3 U/ml) compared to patients with inflammatory conditions (44.5±20.5 U/ml), (p<0.001). Similarly, mean values of CA 19-9 were higher in patients with malignant neoplasms compared to benign lesions (56.06±24.5 U/ml, compared to 88.39±34.2 U/ml, p = 0.003). Patients with pancreatic pathologies had the highest mean values of CA 19-9 in their serum 94.43±29.28 U/ml) compared to patients with other organ system pathologies (p< 0.001). When assessed separately, patients with malignant conditions of the pancreas had a higher mean value of serum CA 19-9 compared to patients with non-malignant and inflammatory conditions of the pancreas 121.0±16.7 U/ml compared to 74.5±17.86 U/ml, p<0.001). Mean levels of CA 19-9 were also higher in patients with surgically inoperable stages of malignant cancers of the pancreas in comparison to patients who had a surgically resectable mass in the pancreas (99.36±33.51 compared to 65.91±30.11 U/ml, p = 0.02). Finally, in order to establish a cut-off value for achieving maximal sensitivity and specificity to diagnose malignant conditions of the pancreas, the cut-offs were set at 92 U/ml achieving 100% sensitivity and 90% specificity.CONCLUSIONS: The serum levels of CA 19-9 are practically elevated in all conditions associated with the Gastrointestinal System, and thus, at current cut-off values, this marker is at best, non-specific. Higher values, however, are typically associated with pancreatic conditions, both benign and malignant. Thus, with a higher cut-off value, CA 19-9 serves better as a specific marker for the diagnosis of clinical conditions of the pancreas, at preferably above 90 U/ml.

The Effect of Vacuum on Venous Drainage: an Experimental Evaluation on Pediatric Venous Cannulas and Tubing Systems

Introduction: To observe how vacuum assisted venous drainage (VAVD) may influence the flow in a cardiopulmonary bypass circuit with different size of venous lines and cannulas. Methods: The experimental circuit was assembled to represent the cardiopulmonary bypass circuit routinely used during cardiac surgery. Wall suction was applied directly, modulated and measured into the venous reservoir. The blood flow was measured with a flow-meter positioned on the venous line. The circuit prime volume was replaced with group O date expired re-suspended red cells and Plasmalyte 148 to a hematocrit of 28% to 30%. Results: In an open circuit with gravity siphon venous drain, angled cannulae drain more than straight ones regardless the amount of suction applied to the venous line (16 Fr straight cannula (S) drains 90 ml/min less than a 16 Fr angled (A) with a siphon gravity). The same flow can be obtained with lower cannula size and higher suction (i.e. 12 A with and -30 mmHg). Tables have been created to list how the flow varies according to the size of the cannulas, the size of the venous tubes, and the amount of suction applied to the system. Conclusions: Vacuum assisted venous drainage allows the use of smaller cannulae and venous lines to maintain a good venous return, which is very useful during minimally invasive approaches. The present study should be considered as a preliminary attempt to create a scientific-based starting point for a uniform the use of VAVD. Keywords: cardio-pulmonary bypass; experimental study; vacuum assisted drainage.

Effect of Vacuum on Venous Drainage: an Experimental Evaluation on Pediatric Venous Cannulas and Tubing Systems

INTRODUCTION

To observe how vacuum assisted venous drainage (VAVD) may influence the flow in a cardiopulmonary bypass circuit with different size of venous lines and cannulas.

METHODS

The experimental circuit was assembled to represent the cardiopulmonary bypass circuit routinely used during cardiac surgery. Wall suction was applied directly, modulated and measured into the venous reservoir. The blood flow was measured with a flow-meter positioned on the venous line. The circuit prime volume was replaced with group O date expired re-suspended red cells and Plasmalyte 148 to a hematocrit of 28% to 30%.

RESULTS

In an open circuit with gravity siphon venous drain, angled cannulae drain more than straight ones regardless the amount of suction applied to the venous line (16 Fr straight cannula (S) drains 90 ml/min less than a 16 Fr angled (A) with a siphon gravity). The same flow can be obtained with lower cannula size and higher suction (i.e. 12 A with and -30 mmHg). Tables have been created to list how the flow varies according to the size of the cannulas, the size of the venous tubes, and the amount of suction applied to the system.

CONCLUSIONS

Vacuum assisted venous drainage allows the use of smaller cannulae and venous lines to maintain a good venous return, which is very useful during minimally invasive approaches. The present study should be considered as a preliminary attempt to create a scientific-based starting point for a uniform the use of VAVD.

Prevalence of depression among elderly people living in old age home in the capital city Kathmandu

Background: There has been a considerable increase in the numbers of older people in the world population of both developed and developing countries. These populations are thought to be at greater risk for depression. Many researches are conducted on physical wellbeing of elderly but studies regarding depression among elderly, especially in old age home is lesser in the developing countries. Objectives: To assess depression among elderly residing in an old age home in Kathmandu and its association with some of the socio-demographic variables. Methods: One hundred fifty elderly people residing in social welfare centre elderly home, Pashupatinath, Gaushala, Kathmandu, Nepal were selected randomly. Geriatric depression scale (GDS) was applied in all the individuals to assess the prevalence and degree of depression. Results: This study showed that, 47.33% of population had depression. Among the depressed population, 70.42% had mild depression and 29.58% had severe depression. There was significant association between the prevalence of depression and history of physical illness. Conclusion: Depressive disorder is highly prevalent among the elderly population residing in the old age home in Kathmandu with history of physical illness. DOI: http://dx.doi.org/10.3126/hren.v11i3.9634 Health Renaissance 2013;11(3):213-218

Bacteriology and antimicrobial susceptibility of adult chronic dacryocystitis

INTRODUCTION

Chronic dacryocystitis results in chronic infection and inflammation of the lacrimal sac.

OBJECTIVE

To identify the aetiology of chronic dacryocystitis and to determine their antimicrobial susceptibility pattern.

MATERIALS AND METHODS

A cross - sectional study was undertaken including 120 lacrimal swab materials collected from patients aged above 15 years suffering from chronic dacryocystitis.

STATISTICS

Data analysis was done by using software "Win pepi'' ver 7.9.

RESULTS

The bacteria of eight different species were isolated from 76.66 % (92/120) culture positive samples. 85.86 % showed a single and 14.13 % showed a mixed growth pattern. Coagulase negative staphylococci were the most common bacteria (P= 0.018) accounting for 33.96 % followed by Staphylococcus aureus (25.46 %), Streptococcus pneumoniae ( 19.81 % ), Streptococci viridans (5.66 %), Escherichia coli (5.66 %), Haemophilus spp ( 4.71 % ), Streptococcus pyogenes (3.77 %) and Bacillus spp (0.94 % ). Staphylococcus aureus were the most predominant bacteria in mixed growth. Rate of infection was higher in males 81.39 % than in females 74.02 %. Infection was higher in the age group of above 31 years. In the antimicrobial susceptibility test, except staphylococcus aureus, all the Gram positive isolates were 100 % sensitive to chloramphenicol and were least sensitive to tobramycin, but Gram negative isolates were equally sensitive to Chloramphenicol and Nalidixic acid.

CONCLUSION

Coagulase negative staphylococci are the most frequently isolated bacteria. Staphylococcus aureus is predominantly found in mixed growth. Chloramphenicol is the most effective drug of choice for chronic dacryocystitis.