Antibiotics use among residents in Eastern Nepal: a community-based mixed method study

Introduction

According to the WHO, more than two-thirds of all antibiotics are used in the community, of which about 30% are used inappropriately. The antimicrobial resistance (AMR) problem is a growing threat to Nepal because of indiscriminate and inappropriate use. However, exact data on the extent of inappropriate use of antibiotics in the community is scarce in Nepal.

Objectives

To know the extent of inappropriate use of antibiotics among the community and their knowledge and practice towards the usage of antibiotics.

Methods

A community-based cross-sectional study was conducted from 20 December 2017 to 20 March 2018 using a purposive sampling technique. A semi-structured questionnaire was used while conducting face-to-face interviews with 336 respondents to find out the knowledge and practice regarding antibiotic use. Investigators took different antibiotics (in all dosage forms) with them to show participants whether they knew and/or used the antibiotics in the last year.

Results

The mean age of respondents with standard deviation was 39.87±13.67 years ranging from 18 to 84 years. Around 35.42% of respondents were farmers and 34.52% were homemakers. 28.87% of respondents were illiterate, 32.44% had primary education and 33.33% had secondary education. Almost half of them (48.51%) think that antibiotics are safe and can be commonly used. So, 43.15% of them preferred taking antibiotics when they had a common cold. The majority of the participants (81.84%) did not have any idea about antibiotic resistance. 94.6% of the respondents used antibiotics inappropriately.

Conclusion

The results of the present study revealed that inappropriate use of antibiotics is high and associated with low earning wages in both males and females in the age group 18-39 years.

Dorsal Approach for Management of Complex Kaplans Dislocation

Complex metacarpophalangeal dislocation is an uncommon injury where the index is the most commonly involved finger. The most common mechanism involves hyperextension of digits at the metacarpophalangeal joint. Such dislocation needs open reduction as the volar plate becomes entrapped between the metacarpal head and proximal phalanx making close reduction difficult. Approaches for open reduction can be dorsal, volar, and lateral. In our patient, we commenced a dorsal approach for reduction and additional stabilization done with K-wire. An early range of movement was initiated and resulted in good functional recovery. Keywords: Dislocation; metacarpophalangeal; plate; volar.

Nontraumatic spontaneous bilateral intracerebral haemorrhage in a young patient: a rare case report

Spontaneous bilateral intracerebral haemorrhage is a rare surgical occurrence, especially in young populations with poor prognosis. Hypertension is the leading cause but vascular malformations, infections and rare genetic conditions are also responsible.

Case presentation

Twenty-three-year-old male with no prior comorbidities presented to emergency with sudden onset loss of consciousness and 1 episode of seizure. No history of intoxication or trauma was given. Glasgow Coma Scale at presentation was E1V2M2. CT scan head revealed bilateral basal ganglia haematoma along intraventricular haemorrhage.

Clinical discussion

The patient was managed conservatively in the Neurosurgical Intensive care unit. Supportive management was provided. The patient's motor response was improving and a repeat CT scan showed a resolving haematoma. However, due to poor economic conditions, the patient party left against medical advice.

Conclusion

Spontaneous bilateral basal ganglia haemorrhage is a rare surgical emergency with no clear consensus on a management approach. This case highlights the importance of undiagnosed hypertension in causing intracerebral haemorrhage in poor economic groups.

Morphometric analysis of foramen ovale, foramen spinosum, and foramen rotundum of human skull using computed tomography scan: a cross-sectional study

There is limited literature of objective assessments of foramina of skull base using computed tomography (CT) scan. This study was carried out to analyze the dimensions of foramen ovale (FO), foramen spinosum (FS), and foramen rotundum (FR) using CT scan imaging of the human skull and their associations with sex, age, and laterality of the body.

Materials and methods

A cross-sectional study was carried out in the Department of Radiodiagnosis and Imaging at BP Koirala Institute of Health Sciences (BPKIHS), Nepal using a purposive sampling method. We included 96 adult patients (≥18 years) who underwent CT scan of the head for any clinical indications. All those participants below 18 years, inadequate visualization or erosions of skull base foramina, and/or not consenting were excluded. Appropriate statistical calculations were done using the statistical package for social sciences (SPSS), version 21. The P-value of less than 0.05 was considered statistically significant.

Results

The mean length, width, and area of FO was 7.79±1.10 mm, 3.68±0.64 mm, and 22.80±6.18 mm², respectively. The mean length, width, and area of FS was 2.38±0.36 mm, 1.94±0.30 mm, and 3.69±0.95 mm², respectively. Similarly, the mean height, width, and area of FR was 2.41±0.49 mm, 2.40±0.55 mm, and 4.58±1.49 mm², respectively. The male participants had statistically significant higher mean dimensions of FO and FS (P<0.05) than the female participants. There were statistically insignificant correlations of dimensions of these foramina with age and between the left and right side of each foraminal dimensions (P>0.05).

Conclusions

The sex-based difference in dimensions of FO and FS should be clinically considered in evaluating the pathology of these foramina. However, further studies using objective assessment of foraminal dimensions are required to draw obvious inferences.

Superior mesenteric artery syndrome mimicking gastric outlet obstruction: a case report and a literature review

Superior mesenteric artery (SMA) syndrome, an uncommon cause of intestinal obstruction, may present with clinical features mimicking gastric outlet obstruction.

Case presentation

The authors present a case of a 65-year-old gentleman who presented to our institute with complaints of sudden onset abdominal distension and multiple episodes of bilious vomiting for 4 days. On examination, he was cachexic and dehydrated and was diagnosed later with SMA syndrome based on contrast-enhanced computed tomography abdomen findings.

Discussion

After the diagnosis of SMA syndrome was made, the patient was planned for the operation. On exploration, a hugely distended stomach dilated first and the second part of the duodenum with SMA compressing the third part of the duodenum was found for which duodenojejunostomy was done.

Conclusion

The high degree of suspicion is necessary for cachectic patients presenting with features of gastric outlet obstruction to diagnose SMA syndrome. Physical examination supported by radiological investigations can diagnose SMA syndrome to some extent. Treatment should be focused on relieving obstruction along with fluid and electrolyte resuscitation and nutritional supplementation. Some cases may require surgical correction.

Association of geographic distribution and birth weight with sociodemographic factors of the maternal and newborn child of hilly and mountain regions of eastern Nepal: a cross-sectional study

OBJECTIVES

To determine the association of geographic distribution, and birth weight with sociodemographic factors of the maternal and newborn child of hilly region (lower altitude) and mountain region (high altitude) of eastern Nepal as well as the prevalence of low birth weight (LBW) and large for gestational age (LGA) among term singleton deliveries in eastern Nepal.

METHODOLOGY

A cross-sectional study was conducted in the district-level hospitals of Dhankuta, Tehrathum, Solukhumbu and Taplejung districts of eastern Nepal of Province 1. Mothers with preterm or post-term delivery, multiple pregnancies, stillbirth/intrauterine fetal death and incomplete records were excluded from the study with only 1386 term pregnancies (37-42 weeks) delivered at the respective facilities between 17 July 2019 and 16 July 2020 were included. The appropriate data were entered in Microsoft Excel 2019 V.16.0 and statistical analysis was performed by using the statistical package for social sciences, IBM SPSS V.29.

RESULTS

The low maternal age, Dalit ethnic group, low gravidity, low parity, higher antenatal care (ANC) visits (≥4), incomplete deworming and dT vaccination status, breech deliveries and LBW newborns were significantly attributed to hilly region (lower altitude) (p value <0.05). Similarly, the hilly region, lower and/or no ANC visits and early term gestation had significant negative association with birth weight at the lower quantiles only. Meanwhile, the female newborn had significant and negative association with birth weight distribution at all seven quantiles. The prevalence of the LBW, average for gestational age and LGA newborn child among term singleton deliveries in Eastern Nepal is 6.6%, 85.8% and 7.6%, respectively.

CONCLUSIONS

The local organisations should focus on adequate antenatal care visits in mountain region and coverage of dT vaccine and deworming medications in hilly region. Appropriate measures and programmes should be initiated to bring down LBW in hilly region.

Acceptance and hesitancy of COVID-19 vaccine among Nepalese population: A cross-sectional study

Introduction

COVID-19 is an emerging infectious disease with a high transmission rate and substantial deaths. Various vaccines have been developed to combat it. This study is aimed to assess COVID-19 vaccine acceptance and hesitancy among the Nepalese population through a web-based survey.

Materials and methods

This is a web-based cross-sectional descriptive study of Nepalese people 18 years and above from different regions of Nepal who use social media (Facebook, Twitter, Reddit) as well as instant messaging applications (Messenger, Viber, WhatsApp). The duration of the study was 3 months from 1st June 2021 to 31st August 2021. The sampling technique used was self-selected non-probability sampling. A validated questionnaire had been taken to record the data.

Results

A total of 307 participants were included in the study. About three-fourths of participants 231 (75.2%) had not been vaccinated while 76 (24.8%) had been vaccinated with COVID -19 vaccine. Out of 231 non-vaccinated participants, most of participants 213 (92.2%) had shown acceptance of the COVID-19 vaccine. More than two-thirds of participants believed that the vaccine would protect them, their family members, and the community from having COVID-19 in the future. Very few participants 18 (7.2%) were hesitant to receive the vaccine against COVID-19. About two-thirds of participants were being afraid of adverse effects of the COVID-19 vaccine while more than half of participants hesitated due to lack of enough information regarding COVID-19 vaccine.

Conclusion

This study can aid in the planning of vaccination campaigns and the direction of future public health efforts aimed at increasing COVID-19 vaccine uptake.

Gastric antral vascular ectasia (Watermelon stomach); an unusual cause of upper gastrointestinal bleeding in elderly: A case report

Introduction

Gastric antral vascular ectasia (GAVE) is an unusual cause of upper gastrointestinal (GI) bleeding in an elderly patient.

Case presentation

A 73-year-old female with erosive gastritis, hypertension, and unstable angina arrived at the emergency department with shortness of breath, easy fatigability, and melaena. Physical examination indicated pallor but no signs of distress, with an unremarkable systemic examination. Routine blood testing indicated anemia. The patient underwent upper gastrointestinal endoscopy, which revealed linear red ectatic vessels radiating from the antrum towards the body. A diagnosis of GAVE was made. Blood transfusions and argon plasma coagulation were undertaken.

Clinical discussion

This condition is an uncommon cause of upper GI bleeding with the antrum being the most prevalent site. The pathophysiology of GAVE is yet unknown, however, many hypotheses have been postulated. GAVE is frequently misdiagnosed as gastritis. GAVE treatment comprises initial resuscitation and symptomatic treatment with intravenous fluids and blood products. Endoscopy has increasingly been the first-line therapeutic option for GAVE in recent years, including argon plasma coagulation.

Conclusion

The diagnosis of gastric antral vascular ectasia is frequently overlooked during upper GI endoscopy, despite the fact that it should always be explored, especially in cases of unexplained GI bleeding in the elderly.

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An unusual cause of upper gastrointestinal bleeding in an elderly patient.

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Frequently misdiagnosed as gastritis.

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Linear red ectatic vessels radiating from gastric antrum towards the body.

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Argon plasma coagulation is a good treatment modality.

Atrial Fibrillation among Patients Admitted to the Department of Internal Medicine in a Tertiary Care Centre: A Descriptive Cross-sectional Study

INTRODUCTION

Atrial fibrillation is one of the commonest arrhythmias with an overall prevalence estimated to be 0.4-1% in the general population. The objective of this study was to find out the prevalence of atrial fibrillation among patients admitted to the Department of Internal Medicine in a tertiary care centre.

METHODS

A descriptive cross-sectional study was conducted among patients admitted to the Department of Internal Medicine of a tertiary care centre from 01 March 2021 to 01 March 2022. Ethical approval was obtained from the Institutional Review Committee (Reference number: IRC-478/2021). Convenience sampling method was used. Data were collected from the hospital records using a semi-structured study proforma including demography, clinical presentation, laboratory investigations, electrocardiogram, 2-dimension echocardiography, and CHA2DS2VASc score. Point estimate and 95% Confidence Interval were calculated.

RESULTS

Among 27,980 patients, atrial fibrillation was found in 185 (0.66%) (0.58-0.77, 95% Confidence Interval). Among them 66 (35.67%) were in the age group of 61-70 years and 97 (52.43%) were females. Dyspnea was present in 149 (80.54%), palpitation in 137 (74.05%) and pedal edema in 117 (63.27%). Valvular atrial fibrillation was seen in 101 (54.59%) and non-valvular atrial fibrillation was seen in 84 (45.41%) patients.

CONCLUSIONS

The prevalence of atrial fibrillation was found to be similar when compared to other studies conducted in similar settings.

Giant occipital encephalocele complicated with obstructive hydrocephalus: A case report

Introduction

and importance: An encephalocele is a type of congenital neural tube defect defined by herniation of intracranial contents via a cranial defect. When an encephalocele is greater than the size of the head, it is referred to as a "giant encephalocele." The occurrence of encephalocele has been documented to be 1–4 instances per 10,000 live births. Surgery is challenging.

Case presentation

A 1-month-old baby boy sustained a huge swelling on the back of his head since birth, and it increased gradually over time. On examination, he had a huge occipital swelling measuring about 20 × 15 × 17 cm in size. A diagnosis of giant occipital encephalocele was established. Surgical excision and repair was done. After 1 month, he developed obstructive hydrocephalus and a ventriculo-periotoneal shunting was performed. On regular follow-up, he is in a good state of health.

Discussion

Surgery imposes challenges for the anaesthesiologists and neurosurgeons due to its complex site, enormous size, intraoperative blood loss, and prolonged anaesthesia. A team approach is necessary for its successful treatment.

Conclusions

Based on our experience, we would like to deliver following recommendations in the surgical management of giant encephalocele. Surgery should be done quickly to ensure good prognosis. Proper positioning, efficient intubation, infections and sepsis control should be emphasized. Also, fortification of food with folic acid, as well as increased education and awareness of women on the need for antenatal care may also decrease the risk of this disease.

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An encephalocele is a type of congenital neural tube defect.

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Surgery imposes challenges for the anaesthesiologists and neurosurgeons.

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A team approach is necessary for its successful treatment.

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Proper positioning, efficient intubation, infections and sepsis control should be emphasized.

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Fortification of food with folic acid may also decrease the risk of this disease.

Medical students' attitude towards cultural diversity: a cross-sectional study at a health sciences university in eastern Nepal

OBJECTIVES

To assess the attitude of medical students towards cultural diversity aiming to elucidate our current status in understanding cultural awareness and sensitivity.

DESIGN, SETTING AND PARTICIPANTS

A web-based cross-sectional study was carried out among 601 undergraduate health science students (medical and dental courses) at a health sciences university in eastern Nepal via various modes of social-media platforms like WhatsApp, Messenger, Gmail, etc. OUTCOME MEASURES: Medical students' attitude towards cultural diversity and its association with the sociodemographic profile of the students.

RESULTS

A total of 601 students participated in the study, out of which, 64.2% were men with a sex ratio of 1.8:1 and a mean age of 22.3±1.9 years. More than two-thirds (77.2%) of the students had an excellent to good attitude towards cultural diversity. The proportion of students reporting 'excellent' attitude towards cultural diversity was higher among male students compared with female students (37.8% vs 20.5%) and students aged >22 years compared with younger students (37.1% vs 26.7%). Gender (p<0.001) and age (p=0.009) were significantly associated with the attitude towards cultural diversity.

CONCLUSIONS

Medical students, in general, are aware of the impacts of a cross-cultural society on the delivery of quality healthcare and also about the need to be aware of prejudices doctors may have towards certain cultures. Majority suggest the inclusion of concepts of multicultural awareness and sensitivity in the medical curriculum itself.

Intestinal Obstruction among Patients Admitted in the Department of Surgery of a Tertiary Care Centre: A Descriptive Cross-Sectional Study

Introduction:

Although intestinal obstruction is a very common surgical emergency, there is a dearth of evidence regarding its prevalence at our institute. The objective of this study is to find out the prevalence of intestinal obstruction among patients admitted to the Department of Surgery of a tertiary care centre.

Methods:

A descriptive cross-sectional study on a total of 6735 admitted patients' in Department of Surgery a tertiary care centre was conducted from 1^st January, 2014 to 31^st March, 2015. Data were collected retrospectively with ethical approval from Institutional Review Committee (Reference number: 106/071/072). All patients admitted to the surgery ward of the hospital with an age of 18 and above were included in the study. Convenience sampling was used. The data were recorded and analyzed using Microsoft Excel and Statistical Package for Social Sciences version 16.0. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data.

Results:

Out of the 6735 admitted cases, the prevalence of intestinal obstruction among the admitted patients in the surgery department of the tertiary care centre was found to be 100 (1.48%) (1.19-1.77 at 95% Confidence Interval). The most common presentations were pain in the abdomen 93 (93%), vomiting 74 (74%), and abdominal distension 55 (55%).

Conclusions:

The prevalence of intestinal obstruction in our study was lower than the similar studies done in similar settings.

Dyslipidemia in Acute Non-cardioembolic Ischemic Stroke Patients at a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction: Acute ischemic stroke is the second most common cause of death after ischemic heart disease worldwide and Nepal's top five diseases based on Disability-Adjusted Life Years. Dyslipidemia is a major risk factor for coronary heart disease but has an unclear role in the pathogenesis of ischemic stroke. The objective of this study was to find the prevalence of dyslipidemia in acute non-cardioembolic ischemic stroke patients at a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among 76 patients with acute noncardioembolic ischemic stroke admitted in the Neuromedicine unit of a tertiary care centre from August 2017 to July 2018. Ethical approval was obtained from the Institutional Review Committee of the same institute (Reference number: 478/2020). Patients underwent baseline investigations, including fasting lipid profile and Computed Tomography Scan/Magnetic Resonance Imaging head. Data were analysed using Statistical Package for the Social Sciences version 21.0. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. Results: The prevalence of dyslipidemia among the acute non-cardioembolic ischemic stroke patients was 35 (46.05%) (35.05–57.05 at 95% Confidence Interval) where high total cholesterol was diagnosed in 11 (31.43%), high triglycerides in 25 (71.43%), high low-density-lipoprotein in 10 (28.57%), and low high-density-lipoprotein in 11 (31.43%) patients. Conclusions: The prevalence of dyslipidemia among acute non-cardioembolic ischemic stroke patients at our tertiary care centre is higher than the similar studies done in similar settings.

Spindle cell sarcoma: a case report of diagnostic and therapeutic quandary in a low resource setting

Sarcomas can present differently in different parts of the body and showcase varied histopathological features and tend to recur locally and metastasize to distant sites. We discuss a case of a 37-year-old male with local recurrence of spindle cell sarcoma of the paraspinal muscles of size 20 × 20 cm² with overlying ulceration and discharge with possible pulmonary metastasis. The mass was evaluated using magnetic resonance imaging/computed tomography and the histology was confirmed by biopsy. Wide surgical resection of the mass was done and the patient was referred to another center for radiotherapy and further treatment. The large size of the sarcoma and the possible pulmonary metastasis poses a risk of significant morbidity and mortality in this patient. This case showcases the scenario of many patients in developing countries where the patients are lost to follow-up due to various reasons and present later with grave consequences.

Diffuse proliferative cerebral angiopathy: a case report and literature review on a very rare and misdiagnosed entity

Diffuse proliferative cerebral angiopathy (DPCA) is an uncommon type of cerebral vascular malformation, mostly diagnosed in young females. It is characteristically different from other cerebral arteriovenous malformations and can be differentiated by its peculiar imaging findings. A nidus of normal brain parenchyma is present between the abnormal vascular channels. Therefore, it is crucial to diagnose it as a separate entity because unnecessary treatment of DPCA increases the risk of damage to the normal parenchyma leading to neurological deficits. Here we describe a case of a 60-year-old male who presented with severe neurological deficits and was later diagnosed with DPCA. He was managed conservatively with antiepileptics and almost completely recovered to normal within 2 weeks. A rare case of DPCA confused with other hemorrhagic disorders is discussed here. Rare cases are often overlooked. Correct diagnosis helps to prevent tragic consequences.

Perception of Health Care Practitioners of Government Designated COVID-19 Hospitals of Nepal towards the Management of COVID-19 Pandemic: A Descriptive Cross-sectional Study

INTRODUCTION

Amidst the chaos of COVID-19, health care practitioners are persistently providing services and experiencing many challenges. This study aimed to determine the perception of health care practitioners of government designated COVID-19 hospitals of Nepal towards the management of COVID-19 pandemic.

METHODS

A descriptive cross-sectional study was conducted among the frontline health care practitioners working in the government designated COVID-19 hospitals in Nepal from 21st June, 2020 to 15th August, 2020. Ethical approval was obtained from the Ethical Review Board of the Nepal Health Research Council (Reference number: 347/2020 P). A total of 252 health care practitioners (doctors, nurses, and paramedics) working at the forefront in the emergency ward, general wards, intensive care units, isolation centers, fever clinics, laboratory, quarantine centers, help desks, etc. in the designated hospitals who consented to participate were included in the study. Convenience sampling was used. The data was analyzed using Statistical Package for the Social Sciences version 16.0. Point estimate at 95% confidence interval was calculated along with frequency and proportion for binary data.

RESULTS

Only 41 (16.3%) (11.73-20.86 at 95% Confidence Interval) of the health care practitioners were found to have satisfactory perception towards the management of COVID-19 pandemic in Nepal.

CONCLUSIONS

The satisfactory perception of the health care practitioners in our study towards the management of COVID-19 pandemic in Nepal is lower as compared to the other studies in Nepal and abroad.

OUP accepted manuscript

Intestinal tuberculosis (TB) is a rare condition comprising a majority of the extra-pulmonary TB cases. Owing to a similar clinical presentation, ultrasonographic and biopsy findings of intestinal TB with that of other abdominal pathologies such as carcinoma colon, their clinical delineation is very difficult unless aided with other modalities of investigations such as colonoscopy, culture of the biopsy material, etc. and even advanced methods such as polymerase chain reaction and gene X-pert of the biopsy material. Having all these investigations may not even lead to a correct diagnosis of intestinal TB as evidenced in the reported cases in the literature, advocating the need of diagnostic laparoscopy in the diagnosis of intestinal TB to eliminate extensive and unnecessary surgeries. Here, we present a case of intestinal TB in a 51-year-gentleman who got diagnosed in the course of treatment for a suspected carcinoma colon.

Living with a giant inguinoscrotal hernia for 35 years-a case report

In this modern era, giant inguinoscrotal hernias are very rare to experience in a medical career. We discuss a case of a 65-year-old man with a history of an inguinoscrotal hernia with progressive growth for the past 35 years. On examination, he had a 20 cm × 15 cm non-reducible swelling with multiple ulcers over the skin surface extending to the mid-thigh with otherwise no other bladder and bowel complications. These large hernias pose a different set of surgical problems. Open surgery was performed, hernial sac opened, contents reverted and left orchidectomy were done with scrotal reconstruction. The defect was closed with Vicryl 1-0 over the muscle layer and the skin was stapled. Daily wound care was provided. Besides, this case also compels us to explore possible reasons for the occurrence of such potentially dangerous surgical problems in low-to-middle income countries (LMIC).

Open Reduction and Internal Fixation with Mini-plate and Screws for Management of Unstable Metacarpal Fracture among Hand Injuries in a Tertiary Care Center: A Descriptive Cross-sectional Study

Introduction:

Hand injuries metacarpal fractures are common and it accounts about 14 to 28%. Mini-plate fixation in unstable metacarpal fractures provides absolute stability and early mobilization of fingers to reduce complications. The purpose of this study is to find out the prevalence of open reduction and internal fixation with mini-plate and screws for management of unstable metacarpal fracture among hand injuries done in a tertiary care center.

Methods:

This was a descriptive cross-sectional study done from February 2019 and January 2021 in a tertiary care center with unstable isolated metacarpal fracture treated with mini-plate fixation and were followed up for six months duration. Ethical approval and informed written consent were taken from all patients. The outcome was assessed by the American Society for Surgery of the Hand Total Active Flexion Score. Convenient sampling method was used. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. Statistical Package for Social Sciences used for analysis.

Results:

Out of 250 patients who underwent hand surgeries, open reduction and internal fixation with mini-plate and screws for unstable metacarpal fracture were done in 32 (12.8%) (8.66-16.94 at 95% Confidence Interval). The mean time of fracture union was 6.78±1.008 weeks. Functional outcome according to American Society for Surgery of the Hand Total Active Flexion score was excellent in 25 (78.2%), good in 6 (18.8%), and poor in 1 (3%) patient.

Conclusions:

Fixation of metacarpal fracture by mini-plate and screws was required in fewer patients. Mini-plate fixation provides better stability and early mobilization for unstable metacarpal fractures to achieve a good functional outcome.

Clinico-Epidemiological Profile of Patients with COVID-19 in a Tertiary Care Centre of Mid-Western Nepal

Introduction: With little to no research done that sheds light on the COVID-19 pandemic in the Mid-Western region of Nepal, this study attempts to educate the general populace and concerned authorities on the impact of the pandemic in the region.Materials and Methods: Patients presenting at Rapti Academy of Health Sciences between 14 May 2020 to December 21, 2020, diagnosed with COVID-19 were included in the study. These patients were reviewed for age, sex, address, recent travel history, and presenting symptoms.Results: A total of 3895 COVID -19 positive individuals were included in the study. The mean age of the patients was 33.6 ± 13.8 years, a majority (49.5%) of the cases were in the 20-29 years age group. 73.7% were male. 82.9% of the patients were from Dang, 86% of the cases of Dang were from urban areas, and the districts bordering India accounted for 88.5% of cases. Most of the positive patients were asymptomatic (97.1%), Amongst the symptomatic cases, the most frequent clinical manifestation was both fever and cough. 8.5% of the patients also reported travel history, of which a majority had returned from India.Conclusions: The patients were mostly young males belonging to the economically active age group who were mostly affected by COVID-19 in Mid-Western Nepal. It is important to carry out age-group targeted testing to flatten the infection curve. Testing must be done irrespective of observable symptoms to overcome this public health emergency.

Overutilisation of imaging studies for diagnosis of pulmonary embolism: are we following the guidelines?

OBJECTIVE

To evaluate if imaging studies such as CT pulmonary angiography (CTPA) or ventilation-perfusion (V/Q) scan are ordered according to the current guidelines for the diagnosis of pulmonary embolism (PE).

METHODS

We performed a retrospective observational cohort study in all adult patients who presented to the Sparrow Hospital Emergency Department from January 2014 to December 2016 and underwent CTPA or V/Q scan. We calculated the Wells' score retrospectively, and d-dimer values were used to determine if the imaging study was justified.

RESULTS

A total of 8449 patients underwent CTPA (93%) or V/Q scan (7%), among which 142 (1.7%) patients were diagnosed with PE. The Wells' criteria showed low probabilities for PE in 96 % and intermediate or high probabilities in 4 % of total patients. Modified Wells' criteria demonstrated PE unlikely in 99.6 % and PE likely in 0.4 % of total patients. D-dimer was obtained in only 37 % of patients who were unlikely to have a PE or had a low score on Wells' criteria. Despite a low or unlikely Wells' criteria score and normal d-dimer levels, 260 patients underwent imaging studies, and none were diagnosed with PE.

CONCLUSION

More than 99 % of CTPA or V/Q scans were negative in our study. This suggests extraordinary overutilisation of the imaging methods. D-dimer, recommended in patients with low to moderate risk, was ordered in only one-third of patients. Much greater emphasis of current guidelines is needed to avoid inappropriate utilisation of resources without missing diagnosis of PE.

Bilateral Patella Dislocation after Total Knee Arthroplasty: A Report of Two Cases and a Review of the Literature

Patellar instability is a known but catastrophic complication after total knee arthroplasty (TKA). The occurrence of bilateral dislocation of the patella after TKA is exceedingly rare. It may present as anterior knee pain, and diagnosis can easily be made clinically or by plain radiographs. Early diagnosis with surgical realignment and repair of the extensor mechanism can provide good outcomes after this complication.

Radiological and Functional Outcome of Displaced Colles' Fracture Managed with Closed Reduction and Percutaneous Pinning: A Prospective Study

Background: Displaced Colles’ fractures are treated by manipulation and below elbow cast application. Malunion is a common complication, resulting in pain, mid-carpal instability, and post-traumatic arthritis. Fracture stabilization by percutaneous pinning is a simple, minimally invasive technique that helps prevent displacement of the fracture, thereby minimizing complications. This study aims to assess the amount of collapse after closed manipulation and percutaneous pinning with Kirschner wires (K-wires) and its correlation with the functional outcome of the wrist after union.

Methods: A prospective study was conducted from May 2015 to May 2016 in a tertiary orthopedic center. Ninety patients (60 females, 30 males) with an average age of 54.93 years with Type II fractures underwent closed manipulation and percutaneous pinning with crossed K-wires as the primary procedure. Serial radiographs were taken to document the amount of collapse. The functional outcome was assessed using the Cooney Wrist Score.

Results: At the final follow-up at six months, the collapse in the mean dorsal angle was 0.94 and mean ulnar variance was 0.51. Functionally, 48 patients (53.33%) had an excellent outcome, 36 patients (40%) had a good outcome, and six patients (6.67%) had a fair outcome.

Conclusions: Displaced Colles’ fractures should be reduced and stabilized with percutaneous K-wires to achieve an excellent functional outcome.

Arthroscopically Assisted Evacuation of Brodie's Abscess of Distal Femur

Brodie's abscess is a type of subacute osteomyelitis. Opinions differ as to whether treatment should be surgical or medical for these classic lesions. Failure of symptoms to resolve after six weeks of antibiotics or worsening of the condition during treatment should be followed by surgical treatment. Clinical signs of subperiosteal pus or synovitis indicate that the subacute infection has transformed into an acute component, and it must be drained surgically. Surgical treatment is comprised of evacuation and curettage for small lesions and evacuation, packing with cancellous bone chips, for large cavities. When clinical signs of synovitis are present, with a possibility of pus within a joint, arthrotomy is performed. Arthroscopically assisted evacuation of Brodie's abscess from the distal femur has never been reported in the literature. We report a case of a 23-year-old female who presented with pain and swelling over the left knee for four months. There was diffuse swelling in the knee; tenderness was present over medial femoral condyle and range of motion (ROM) of the knee was five to 45 degrees at the time of presentation. X-ray and magnetic resonance imaging (MRI) revealed Brodie's abscess on the lateral aspect of the medial femoral condyle. The patient was treated with the evacuation of pus and curettage of the cavity using an arthroscope. After two weeks, the patient had mild pain with knee ROM from zero to 45 degrees, and at the one-month follow-up, the knee ROM improved to zero to 90 degrees. At the two-year follow-up, the patient had no pain, with knee ROM from zero to 120 degrees.

Radiological and Functional Outcome of Medial Epicondyle Fracture Treated Surgically in Children and Adolescents: A Retrospective Study

Purpose: Fractures of the medial humeral epicondyle represent approximately 10% of all pediatric elbow fractures. Surgically treated pediatric fractures of the medial humeral epicondyle were analyzed retrospectively for their epidemiological, clinical, radiological and surgical parameters. The evaluation includes the Mayo elbow performance score (MEPS).

Methods: Twenty-five surgically treated fractures of the medial humeral epicondyle were analyzed. A valgus stress test was performed under general anesthesia or sedation. All patients underwent open reduction internal fixation using a similar technique. The medial epicondylar fragment was anatomically reduced and fixed in all cases with screws and Kirschner wires. At final evaluation, union was assessed radiologically, and elbow function was assessed by MEPS.

Results: An evaluation of all our patients after a mean follow-up of 8.75 months (SD=4.76) after initial surgery was possible. The mean age of patients at the time of injury was 10.8 years (SD=2.3). Fifteen (60%) dominant elbows were injured in our study and twelve (48%) elbows had an associated elbow dislocation. On examination in the operating room post anesthesia, all the elbow injuries revealed some degree of valgus instability. All our patients (n=25) showed good to excellent results in MEPS. Radiographically, union was achieved in all cases. Three patients developed postoperative ulnar nerve neuropraxia; all recovered at time of final follow-up.

Conclusion: Our results suggest that open reduction internal fixation of displaced medial epicondyle fractures leads to satisfactory motion and function. A valgus stress test in the operating room can reveal the true nature of joint instability that can warrant operative stabilization of medial epicondylar injuries.

Outcome of Percutaneous Release of Tennis Elbow: A Non-Randomized Controlled Trial Study

Background

Tennis elbow is a common disorder of the upper extremity. It can be treated conservatively in the majority of patients, but some resistant cases eventually can be treated by percutaneous release with good functional outcome.

Materials and methods

This non-randomized control trial was conducted at the Department of Orthopaedics Surgery in a tertiary care hospital from July 2015 to June 2016 on 50 patients who underwent percutaneous release of the common extensor origin using an 18 gauge hypodermic needle. These patients did not respond to conservative treatment including rest, nonsteroidal anti-inflammatory drugs (NSAIDS) and local steroid injections. The outcome was graded as Excellent, Good, Fair, and Poor.

Results

Fifty patients (50 elbows) were included in the study. Thirty-two patients were female (64%), and 18 were male (36%). The right side was affected in 37 patients (74%) and left side in 13 (26%). The time taken to achieve a completely pain-free elbow ranged from one day to two months (average of 26.2 days). Those who did not achieve a pain-free elbow had a residual pain of 1.5 to six on the visual analogue scale (VAS) (average 2.32). Excellent outcome was noticed in 24 patients (48%); Good result in eight patients (36% ); Fair in four patients (eight percent) and Poor in four patients (eight percent).

Conclusion

Tennis elbow probably results from the degenerative tear of the common extensor origin, and a percutaneous tenotomy using an 18 gauge hypodermic needle is a simple, safe, patient-friendly, efficient, and easily reproducible method of treating tennis elbow in those who are resistant to conservative treatment, and it can be done as an outpatient procedure.

Outcome of Both Bone Forearm Fracture Fixation in Children by Rush Nails

Introduction: Forearm fractures are common upper limb injuries among children and usuallytreated non-operatively. Failure of non-operative treatment, open injuries and multiple fracturesare the indications for surgery in paediatric both bone forearm fractures. Intramedullary nailingis considered as minimally invasive procedure with excellent to fair outcomes but it is not freeof complications. We reviewed the results and evaluated the outcomes of IM fixation of forearmfractures in children by Rush nails to understand the risks and complications associated with theseprocedures.Methods: A retrospective crossectional study of all paediatric patients treated for diaphyseal forearmfractures for period of five years in a tertiary care setup. Complications were classified accordingto modified Clavien-Dindo complication classification system. Outcomes were graded dependingupon complication grade along with range of motion of forearm.Results: A total of 25 patients were included in the study. Mean time for fracture union was 10.56weeks. Outcomes were excellent in 16 (64%), good in 7 (28%), fair in 2 (8%) patients and no pooroutcome was noted. Ten minor complications were seen.Conclusion: Fixation of paediatric forearm fractures by intramedullary Rush nail is minimallyinvasive procedure and outcomes are excellent to fair with acceptable complication rates.Keywords: complication; forearm fractures; intramedullary nailing; outcome; paediatrics; Rush nail.

Outcome of Both Bone Forearm Fracture Fixation in Children by Rush Nails

INTRODUCTION

Forearm fractures are common upper limb injuries among children and usually treated non-operatively. Failure of non-operative treatment, open injuries and multiple fractures are the indications for surgery in paediatric both bone forearm fractures. Intramedullary nailing is considered as minimally invasive procedure with excellent to fair outcomes but it is not free of complications. We reviewed the results and evaluated the outcomes of IM fixation of forearm fractures in children by Rush nails to understand the risks and complications associated with these procedures.

METHODS

A retrospective crossectional study of all paediatric patients treated for diaphyseal forearm fractures for period of five years in a tertiary care setup. Complications were classified according to modified Clavien-Dindo complication classification system. Outcomes were graded depending upon complication grade along with range of motion of forearm.

RESULTS

A total of 25 patients were included in the study. Mean time for fracture union was 10.56 weeks. Outcomes were excellent in 16 (64%), good in 7 (28%), fair in 2 (8%) patients and no poor outcome was noted. Ten minor complications were seen.

CONCLUSION

Fixation of paediatric forearm fractures by intramedullary Rush nail is minimally invasive procedure and outcomes are excellent to fair with acceptable complication rates.

High altitude pulmonary oedema (HAPE) in an Indian pilgrim

Increasing number of Hindu pilgrims visit the Himalayas where some of them suffer from high altitude illness including the life threatening forms, high altitude pulmonary oedema (HAPE) and high altitude cerebral oedema. Compared to tourists and trekkers, pilgrims are usually ignorant about altitude illness. This is a case of a pilgrim who suffered from HAPE on his trip to Kailash-Mansarovar and is brought to a tertiary level hospital in Kathmandu. This report emphasises on how to treat a patient with HAPE, a disease which is increasingly being seen in the high altitude pilgrim population.