Left Atrial Enlargement as a Predictor of Atrial Fibrillation in Rheumatic Mitral Valve Disease: An Echocardiography-based Retrospective Cross-sectional Study

BACKGROUND

Rheumatic heart disease is a major cause of cardiovascular morbidity and mortality in developing nations and is a leading cause of hospital admission due to cardiac problems in our country. This study will evaluate the association between left atrial size and the occurrence of atrial fibrillation and describe the clinical characteristics along with complications related to Rheumatic Mitral valve disease.

METHODS

A retrospective cross-sectional study was conducted at a tertiary care center from January 2018 to December 2019. Reports of 207 patients admitted to medical and/or surgical wards with echocardiographic diagnosis of rheumatic mitral valve disease with or without atrial fibrillation were reviewed. Data were collected, entered, and analyzed using the Statistical Package for the Social Science version 25.0.

RESULTS

Among 207 patients, atrial fibrillation was present in 90 (43.5%) patients. Atrial fibrillation was higher in patients with mixed mitral valvular lesions compared to isolated mitral stenosis or mitral regurgitation. Univariate and multivariate analysis revealed left atrial size [aOR=1.067, 95% CI: 1.023 - 1.113, P= 0.002] and age [aOR = 1.073, 95% CI: 1.042 - 1.105, P<0.001] as an independent predictor of atrial fibrillation.

CONCLUSIONS

Larger left atrium was an independent predictor of atrial fibrillation. Besides this, atrial fibrillation was associated with increasing age, mixed mitral valvular lesion, and moderately reduced left ventricular ejection fraction, but not associated with gender and mitral stenosis severity. Left atrial clot was significantly higher in patients with atrial fibrillation than in sinus rhythm.

Myocardial infarction with nonobstructive coronaries (MINOCA) following rabies postexposure prophylaxis: A case report

Key Clinical Message

This case underscores the importance of considering myocardial infarction with nonobstructive coronary arteries (MINOCA) in patients experiencing acute chest pain following rabies vaccination, emphasizing the need for heightened awareness and further research into the association between MINOCA and Rabies vaccination.

Abstract

Rabies is a vaccine-preventable deadly viral disease prevalent in Asia and Africa that causes thousands of deaths annually. Rabies pre (PrEP) and postexposure prophylaxis (PEP) is highly effective in annulling rabies-associated deaths. The adverse reactions following rabies vaccination are typically mild. Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a rare condition, and its association with rabies vaccination is unprecedented. We present a case of a 43-year-old male with MINOCA following Rabies PEP. A 43-year-old male, nonsmoker and nonalcoholic, presented to the ER with complaints of acute onset left sided chest pain following the completion of the third dose of intradermal rabies vaccine, whose clinical features, ECG changes and lab reports were suggestive of acute presentation of inferior wall MI. Coronary angiography was performed, which however revealed normal coronaries with only slow flow being noted in the left anterior descending (LAD) artery. Echocardiography later showed a normal study with no other relevant diagnosis unveiled on further investigations. Hence a diagnosis of vaccine-induced MINOCA was made. Treatment included antiplatelet therapy, statins, and beta-blockers. MINOCA following rabies vaccination is an unprecedented finding. The clear etiology behind this couldn't be ascertained. The patient's treatment was conventional, emphasizing the need for further research and clinical trials in MINOCA diagnosis and management. This case highlights the need for clinicians to consider MINOCA in patients with acute chest pain post-rabies vaccination. Further research is essential to unravel the association between MINOCA and rabies vaccination, paving the way for optimal management strategies.

Induction of Brugada electrocardiogram pattern with aluminum phosphide poisoning: a case report

Introduction and importance

Aluminum phosphide (ALP) is a commonly used suicidal agent in an agrarian country like Nepal. The unmasking of the Brugada pattern in the electrocardiogram (ECG) associated with ALP poisoning is a rare phenomenon, and studies pertaining to it are scarce in the medical literature.

Case presentation

An 18-year-old female presented to the emergency department with multiple episodes of vomiting, headache, blurring of vision, and abdominal pain after 4 h of consumption of ALP with suicidal intent. A 12-lead ECG revealed a coved ST-segment elevation and T-wave inversion in leads V1-V3 with right bundle branch block suggestive of a type 1 Brugada pattern. Her past medical and family history was not significant. The patient made an uneventful recovery with the required supportive treatments.

Clinical discussion

Cardiac arrhythmias are the major cause of death in ALP poisoning. Unmasking of the Brugada ECG pattern is a rare but potentially fatal complication implicated in various pharmacological toxicities, including tricyclic antidepressants, cocaine, procainamide, disopyramide, flecainide, and rarely with ALP.

Conclusions

ALP poisoning can unmask the Brugada ECG pattern, which can lead to ventricular fibrillation and/or sudden cardiac death.

Evaluation of patient dose during a digital breast tomosynthesis

INTRODUCTION

When the patient dose in mammography is assessed, it is important to evaluate both average glandular dose (AGD) and entrance surface dose (ESD). A dose survey on both AGD and ESD in mammography has never been studied in Sri Lanka. Therefore, the present study aimed to evaluate the patient dose received during a full-field digital breast tomosynthesis (DBT) examination by determining both AGD and ESD.

METHODS

The study was performed on 140 patients who underwent DBT examination. The AGD, ESD, compression breast thickness (CBT), half-value layer (HVL), target/filter combination, kVp, and mAs values were obtained from the machine, and AGD for each projection was calculated using the equation proposed by the Dance 2011.

RESULTS

The measured mean AGDs and ESDs of both the breasts were statistically significantly lower than the reference values given by European protocol (p < 0.05). There were no statistically significant differences in both AGDs and ESDs between the right and left breast, between right craniocauidal (RCC) and left craniocaudal (LCC), and between right mediolateral oblique (RMLO) and left mediolateral oblique (LMLO) examinations (p > 0.05). The measured median AGDs and ESDs received for MLO projections of both breasts were statistically significantly higher than that of CC projections (p < 0.05).

CONCLUSION

The patients receive a low radiation dose during their DBT examination with both lowered AGD and ESD than the recommended values.

IMPLICATIONS FOR PRACTICE

The results can be used as a baseline to optimize the radiation dose in mammography in Sri Lanka.

Prevalence of Myocardial Bridging in Angiography Study

BACKGROUND

Myocardial bridging is a congenital anomaly in which a segment of epicardial coronary artery takes an intramyocardial course, the systolic compression of which could be asymptomatic or may lead to major hemodynamic changes such as myocardial ischemia, arrhythmias or sudden cardiac death. The prevalence is highly variable depending upon different investigational modalities to diagnose it. Here we have aimed to study the prevalence through invasive coronary angiography.

METHODS

This retrospective study was carried out at Manmohan Cardiothoracic Vascular and Transplant center, Kathmandu, Nepal. The invasive coronary angiography of 5096 patients were studied from March 2018 to April 2021 done for various indications.

RESULTS

Among all the patients, the myocardial bridging was identified in 257 (5.04%) patients. About 177 (68.9%) were males and 80 (31.1%) were females. The mean age of the patients having myocardial bridging was 54.52 ± 10.31years. Diabetes mellitus was found in 33(12.8%) and hypertension was found in 77(29.9%) patients with myocardial bridging. Stable angina (29.2%) was the most common clinical presentation. Treadmill test was positive in about 70 (27.2%) patients. Majority of patients had myocardial bridge in left anterior descending artery alone (89.9%) and located mostly in mid-part (74.9%).

CONCLUSIONS

The myocardial bridging is not an uncommon finding on invasive coronary angiography in middle aged people who present with typical angina.

Two-decade trends and factors associated with overweight and obesity among young adults in Nepal

Background

Young adults are vulnerable to obesity due to different life stresses and challenges, leading to risks of cardiovascular and metabolic disorders. Studies on the long-term trends of overweight and obesity, especially among young people in Nepal are scanty. The problems among this productive age group should be checked and prevented at the earliest. The study aimed to assess more than two decades of trends from 1996 to 2019 of overweight and obesity among Nepalese young adults (18-29 years) and the socio-demographic factors associated with it.

Methods

We utilized data from the nationwide Demographic and Health Survey (DHS) and WHO STEPwise approach to surveillance (STEPS) survey. These surveys adopted multistage stratified cluster sampling techniques and used house-to-house structured interviews for data collection. We assessed the prevalence of overweight (BMI 25-29.9 kg/m2) and obesity (BMI≥30 kg/m2) in 1996, 2001, 2006, 2011, 2012, 2016, and 2019 among 18,714 young adults in total, and evaluated the associated socio-demographic factors from the 2016 survey, using logistic regression model.

Results

The preliminary study findings showed that from 1996 to 2019, overweight in women increased from 1.5% to 17.0%, and obesity from 0.1% to 3.4%. For men, overweight rose from 14.4% to 16.6%, and obesity from 1.3% to 2.5% from 2012 to 2019. Higher age was associated with higher odds of overweight and obesity compared to a younger age. Men were less likely to have overweight (AOR: 0.68, CI: 0.53-0.88) and obesity (AOR: 0.42, CI: 0.23-0.78) compared to women. Moreover, urban residents had higher odds of having obesity (AOR: 2.35, CI: 1.25-4.44) compared to rural residents.

Conclusions

Overweight and obesity have rising trends among young adults in Nepal. Older age, female and urban residence were associated with higher odds of overweight and obesity. Therefore, the interventions targeted to the risk groups can help in curbing the increasing obesity trends in Nepal.

Key messages

• The information on trends and the factors associated with overweight and obesity may help to identify needs and opportunities to halt the rising obesity trend and prevent risk factors.

• The study findings can guide in formulating a national strategy to combat overweight and obesity among Nepalese youths.

Comparison of Hearing Result and Graft Uptake Rate between Temporalis Fascia and Tragal Cartilage in Endoscopic Myringoplasty

Background There are different methods to repair the perforation of the tympanic membrane. Recently cartilage has been used for the repair and results are comparable to temporalis fascia. For surgical procedure endoscope had added good assistance in middle ear surgery. Though the one hand technique the image quality and results are on par with the use of a microscope. Objective To compare the graft uptake rate and hearing results between temporalis fascia and tragal cartilage in endoscopic myringoplasty. Method This is a prospective, longitudinal study conducted among 50 patients who underwent endoscopic myringoplasty using temporalis fascia and tragal cartilage with 25 patients in each group. The hearing was assessed by comparing pre with post-operative ABG (Air bone gap) and ABG closure in speech frequencies (500Hz, 1 KHz, 2 KHz, 4 KHz). The status of graft and hearing results was evaluated on 6 months of follow up in both the groups. Result Out of total 25 patients enrolled for study in both (temporalis fascia and cartilage) groups, 23 (92%) patients in each group had graft uptaken. The audiological gain in the temporalis fascia group was 11.37±0.32 dB whereas in the tragal cartilage group it was 14.56±1.22dB. The audiological gain between the two groups did not show any statistically significant (p = 0.765). However, the pre and post-operative hearing difference was statistically significant in both temporalis fascia and tragal cartilage group. Conclusion Tragal cartilage has similar graft uptake rate and hearing gain when compared with temporalis fascia in endoscopic myringoplasty. Hence, tragal cartilage can be used for myringoplasty whenever required without any fear of deterioration in hearing.

Ultrasonographic Evaluation of Inferior Vena Cava: Aorta Index with a Cut-off Value of 1.0 as a Predictor for Hypotension after Induction of General Anesthesia; An observational study

Background Hypotension after induction of general anesthesia (GA) is common due to pre-existing hypovolemia and has adverse effects on organ function. Out of several methods to predict post-induction hypotension, nowadays Inferior Vena Cava: Aorta (IVC: Ao) index has been studied with different cut-off values. However, limited studies have been performed in our part of the world. Objective To evaluate the efficacy of pre-induction Inferior Vena Cava: Aorta index with a cutoff value of 1.0 for predicting the occurrence of post-induction hypotension after general anesthesia in the Nepalese population. Method A total of 100 patients of ASA I and II, aged more than 18 years posted for elective surgeries under general anesthesia were enrolled in this cross-sectional, observational study. Ultrasonographic guided Inferior Vena Cava: Aorta index was calculated and based on a cut-off value of 1.0, two groups were formed. Seventy patients in group A with Inferior Vena Cava: Aorta index less than 1.0 and 30 patients in group B with Inferior Vena Cava: Aorta index more than 1.0 were enrolled. Vitals parameters were recorded every minute for five minutes after induction of general anesthesia. Incidence of hypotension was the primary outcome. Statistical analysis was done using student t-test, ANOVA test and Chi-square test. Result Inferior Vena Cava: Aorta index with cut-off value of 1.0 predicted post-induction hypotension with excellent efficacy. Total 65 patients developed post-induction hypotension, out of which 63 patients had Inferior Vena Cava: Aorta index less than 1.0. Conclusion We concluded that pre-induction Inferior Vena Cava: Aorta index with cut-off value of 1.0 have high diagnostic accuracy with high degree of sensitivity and specificity to predict hypotension after induction of general anesthesia.

Trends in packaging material for food products: historical background, current scenario, and future prospects

The commercial demand for food products and dietary supplements has increased drastically in the last few decades. The packed food products and nutritional supplements have made a profound impact on the modern human lifestyle. Since ancient times, storage and long-term use of food products remain a significant challenge for humans. There are different parameters for the evaluation of food products and dietary supplements broadly categorized as quality control and quality assurance. On an average million tons of food, materials get spoiled daily worldwide due to lack of storage and transportation point out packaging systems inequalities. To ensure the quality of packed food products and nutritional supplements among available measures, packaging remained an important event and had been refined from time to time to provide a standard. Over a period, the packaging industry has evolved using modern technology from the conventional methods of new generation packaging, including glass, wood, and paper to most new biodegradable materials. The ancient pattern of packaging; manual packaging has been taken over by an automated system of packing, resulting in enhanced output with minimal chance of damage to valuable products for humanity. The article will emphasize new insights into current packaging system not only provide the quality of these products but also in aiming new heights beyond conventional technologies and consumer opinions. In the present study, we have given more emphasis on novel methods of packaging, the packaging materials, quality of packed products, and their impacts of food products on the environment.

High multidrug resistance in urinary tract infections in a tertiary hospital, Kathmandu, Nepal

SETTING:

Tribhuvan University Teaching Tertiary Care Hospital, Kathmandu, Nepal, May–October 2019.

OBJECTIVE:

1) To describe the bacteriological profile, 2) to identify the antimicrobial resistance (AMR) pattern, and 3) to find the demographic characteristics associated with the presence of bacterial growth and multidrug resistance (MDR) in adult urine samples undergoing culture and drug susceptibility testing.

DESIGN:

This was a hospital-based, cross-sectional study using routine laboratory records.

RESULTS:

Among 11,776 urine samples, 16% (1,865/11,776) were culture-positive, predominantly caused by Escherichia coli (1,159/1,865; 62%). We found a high prevalence of resistance to at least one antibiotic (1,573/1,865; 84%) and MDR (1,000/1,865; 54%). Resistance to commonly used antibiotics for urinary tract infections (UTIs) such as ceftazidime, levofloxacin, cefepime and ampicillin was high. Patients aged ⩾60 years (adjusted prevalence ratio [aPR] 1.6, 95% CI 1.4–1.7) were more likely to have culture positivity. Patients with age ⩾45 years (45–59 years: aPR 1.5, 95% CI 1.3–1.7; ⩾60 years: aPR 1.4, 95% CI 1.2–1.6), male sex (aPR 1.3, 95% CI 1.2–1.5) and from inpatient settings (aPR 1.4, 95% CI 1.2–1.7) had significantly higher prevalence of MDR.

CONCLUSION:

Urine samples from a tertiary hospital showed high prevalence of E. coli and MDR to routinely used antibiotics, especially among inpatients. Regular surveillance and application of updated antibiograms are crucial to monitor the AMR situation in Nepal.

High drug resistance among Gram-negative bacteria in sputum samples from an intensive care unit in Nepal

SETTING

Tribhuvan University Teaching Hospital, Kathmandu, Nepal.

OBJECTIVES

1) To report the number and proportion of Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas (PABS) species among intensive care unit (ICU) patients with sputum culture; and 2) to assess antimicrobial resistance patterns, demographic and clinical characteristics associated with resistance to at least one antibiotic and ICU discharge outcomes among those patients with PABS species admitted to hospital between 14 April 2018 and 13 April 2019.

DESIGN

This was a hospital-based, cross-sectional study using secondary data.

RESULTS

Of 166 who underwent sputum culture, 104 (63%) had bacterial growth, of which, 67 (64%) showed PABS species. Of the positive cultures, Pseudomonas, Acinetobacter, Burkholderia and Stenotrophomonas were present in respectively 32 (30.7%), 31 (29.8%), 1 (1%) and 3 (2.8%). Pseudomonas showed a high level of resistance to levofloxacin (61%), cefepime (50%) and amikacin (50%). Acinetobacter was largely resistant to cefepime (95%), imipenem (92%) and levofloxacin (86%). Of the 67 with PABS infection, 32 (48%) died.

CONCLUSION

The study showed a high prevalence of Pseudomonas and Acinetobacter and the emergence of Stenotrophomonas in sputum culture samples of ICU patients. This highlights the need for monitoring PABS and associated resistance patterns to reduce mortality in ICU patients.

Supraclavicular Brachial Plexus Block: Comparison of Varying Doses of Dexmedetomidine with Ropivacaine

Background Alpha-2 adrenergic receptor agonists have been the focus of interest nowadays as an adjuvant to local anesthesia due to its excellent sedative, analgesic, antihypertensive, anesthetic sparing and hemodynamic stabilizing properties. The ideal dose of dexmedetomidine for brachial plexus block is matter of debate. Objective To find the appropriate minimal dose of dexmedetomidine with desired clinical effects and minimal side-effects, we compared different doses (25 mcg, 50 mcg, 75 mcg and 100 mcg) of dexmedetomidine as an adjuvant to ropivacaine. Method One hundred fifty patients of ASA I and II, aged (18-60) years, weighing (50-60) kilograms undergoing upper limb surgeries under brachial plexus block were enrolled in this prospective, double blind, randomized control study. Patients in all group received 19 ml of 0.5% ropivacaine in common. In addition; group RD25, RD50, RD75 and RD100 received 25 mcg, 50 mcg, 75 mcg and 100 mcg of dexmedetomidine diluted in 1 ml of normal saline (NS) respectively whereas group RD00 received only 1 ml of NS. The duration of analgesia was the primary outcome whereas block characteristics, hemodynamic parameters, oxygen saturation, sedation score and adverse effects were taken as secondary outcome. Statistical analysis was done using ANOVA test, Chi-square test and Scheffe's multiple comparison tests. Result The demographic profile and baseline hemodynamic variables were comparable in all five groups. Increasing dose of dexmedetomidine showed significant improvement in block characteristics but associated with increase in sedation and incidence of bradycardia. Conclusion We conclude that dexmedetomidine 50 mcg would be an appropriate dose as adjuvant to local anesthesia in brachial plexus block.

Effectiveness of Visual Inspection with Acetic Acid and Cervical Cytology in Early Detection of Precursors of Cervical Cancer in Nepal

Background Cervical cancer ranks as the first, most frequent cancer amongst Nepalese women. This can be prevented through primary prevention and early detection using screening techniques. Though cervical cytology is a standard screening tool in most of the developed countries, it fails to be the screening method of choice in low and middle income countries (LMICs) with limited resources due to financial and technical constraints. Objective This study aims at early detection of pre-cancerous lesion in cervix with cervical cytology and visual inspection with acetic acid. Method This is a hospital based, descriptive cross-sectional study. It included 104 women attending Obstetrics and Gynecology out-patient department (OPD) in Dhulikhel Hospital. Visual inspection of cervix with acetic acid (VIA) and liquid based cytology (LBC) was performed followed by cervical biopsy for positive VIA, or having abnormal cytology, or having unhealthy appearance of cervix even after treatment. Result The incidence of positive VIA and cytology screening was 38.5% and 7.7% respectively. The negative predictive value of VIA and cytology were similar whereas VIA was found to be more sensitive than cytology. Conclusion Cytology screening is used as an investigation of choice for screening of cervical cancer. In Nepal, VIA can be a good alternative for early detection of cervical cancer as it is found to be more sensitive than cytology.

Echocardiographic Findings in Patients with Atrial Fibrillation in a Tertiary Care Center of Nepal: A Descriptive Cross-sectional Study

Introduction:

Atrial fibrillation is the most prevalent supraventricular arrhythmia responsible for the large morbidity and mortality burden worldwide. There are various causes of atrial fibrillation that may affect the prognosis of patients. This study was intended to determine different echocardiographic findings in patients with atrial fibrillation in a tertiary care center.

Methods:

A descriptive cross-sectional study was conducted at Manmohan Cardiothoracic Vascular and Transplant Center, Institute of Medicine, among 175 patients with atrial fibrillation admitted in the cardiology department from June 2017 to October 2018. It was approved by the Institutional Review Board of the Institute of Medicine (Ref.:411(6-11-E)2/073/074). Convenience sampling was used. Statistical analysis was done using Statistical Package for Social Sciences version 21.0.

Results:

A total of 175 patients with atrial fibrillation were enrolled where Rheumatic heart disease 68 (38.9%) was the leading cause in which 54 (79.4%) had mitral valve lesion, 1 (1.5%) had aortic valve lesion and rest had a combination of both. The mixed lesion of mitral stenosis and mitral regurgitation was the commonest. The left atrium size was larger in valvular atrial fibrillation (47.29±6.651mm). The left ventricular systolic dysfunction was seen more in non-valvular atrial fibrillation. The commonest site of thrombus formation was left atrium 7 (63.6%).

Conclusions:

Atrial fibrillation was common in rheumatic heart disease, especially mixed lesions of mitral stenosis and regurgitation. Valvular atrial fibrillation had a larger left atrium. The thrombus was seen in mitral stenosis and left ventricular systolic dysfunction. The left atrium size and left ventricular ejection fraction were associated with the occurrence of atrial fibrillation.

Indoor Air Pollution (IAP) Traceable to Household Fuel Consumption and its Impact on Health

Energy is an essential and obligatory prerequisite of life. Indoor air pollution is one of the biggest environmental problems in the world being specifically concentrated in resource limited settings. Inspite of the availability of cleaner fuel technologies, people in resource limited setting still depend on traditional fuel to meet their basic needs resulting even in premature deaths. In Nepal people in rural areas are the pre-dominant users of biomass fuel, there is limited research focusing on rural areas particularly; women as they spend most of their time in kitchen. Reports were extensively searched for literature using preset keywords in English language peer-reviewed journals databases PubMed and Google Scholar published between the years 2005 to 2020. Citation details were examined, titles and abstracts screened for eligibility and if relevant, full text was also reviewed in greater detail. Findings were then presented primarily under two bold themes: Household fuel consumption: existing theories and evidence; and health impact of indoor air pollution. Several health effects were reported of indoor air pollution including respiratory illnesses, cardiovascular diseases, cancer, endocrine system disruption and pregnancy complications. These exposures almost double the health risks predominantly among children and women of rural communities as they are directly involved in household activities causing air pollution. Based on our review of evidence, women and children of rural households were the major victims. Further, determinants of household fuel consumption and health effects should be considered while formulating policies in regard to promoting accessibility of clean fuels and reducing household air pollutants.

Occurrence of the genes encoding carbapenemases, ESBLs and class 1 integron-integrase among fermenting and non-fermenting bacteria from retail goat meat

The present study was planned to detect the genes encoding carbapenemases, ESBLs and class 1 integron-integrase among bacteria obtained from retail goat meat. Fermenting and non-fermenting bacterial isolates (n = 57), recovered from 61 goat meat samples, were identified by 16S rRNA gene sequencing. Antimicrobial susceptibility of isolates was tested by the broth dilution method using ceftazidime, cefotaxime, meropenem and imipenem. Plasmids were isolated and tested for their physical characters. Plasmids were subjected to screening of carbapenemase, ESBL and intI1 gene. Conjugation assay was performed using bla_NDM -positive isolates as the donor, and Escherichia coli HB101 as the recipient. Isolates showed the high rates of resistance to ceftazidime (77·2%), cefotaxime (70·2%), meropenem (22·8%) and imipenem (17·5%). They showed variability in number and size (~1 to >20 kb) of plasmids. Among all, 1, 4, 13 and 31 isolates showed the bla_KPC , bla_NDM , bla_SHV and bla_TEM genes, respectively. The bla_KPC-2 gene was observed in one E. coli isolate. The bla_NDM-1 gene was detected in Stenotrophomonas maltophilia (n = 2), Acinetobacter baumannii (n = 1) and Ochrobactrum anthropi (n = 1) isolates. These isolates co-harboured the bla_TEM and bla_SHV genes. The intI1 gene was detected in 22 (38·6%) isolates, and 16 of these isolates showed the carbapenemase and/or ESBL genes. The conjugative movement of bla_NDM gene could not be proved after three repetitive mating experiments. The presence of genes encoding carbapenemases and ESBLs in bacteria from goat meat poses public health risks.

Genetic variation in the chemokine receptor 5 gene and course of HIV infection; review on genetics and immunological aspect

Chemokines are small protein molecules associated with various physiological events precisely in immune modulation via chemokine receptors. The chemokine receptors are G-protein coupled receptors express mainly on the cell surface of immune cells. Retroviruses, including HIV in the early stage of infection, primarily target chemokines receptors and get internalized easily into immune cells; T cell and escape from immune surveillance. HIV glycoprotein selectively develops an affinity for the extracellular domain of chemokines receptors and allows the pathogen to internalize via CCR-5. Now, CCR-5 remains a crucial signaling pathway that can be translated into the therapeutic target by changing the receptor protein environment. Many populations have a mutation in coding and promoter regions of CCR-5, tuning a resistance for HIV infection. Natively, there are several mechanisms where the human genome remains in the dynamic state by changing its composition and acquiring variations. Single nucleotide polymorphism is spontaneous phenomenon responsible for precise and point mutation at the genome. Several studies have demonstrated that European and African American populations are enriched in significant CCR5 promoter SNP (CCR5Δ32) in the coding and promoter region as well. Now, such SNP can be an early-stage biomarker in studying HIV and other similar infections. Here, in this study, we have elucidated the role of SNP (both the promoter and coding region) and the fate of HIV infections. We also empathized with the genetics of such SNPs, mostly frequency and its immunological impact.

Investigating the Efficacy of Triple Drug Therapy and Sequential Drug Therapy in the Eradication of Helicobacter Pylori with Respect to Antigen Stool test: A Pilot Study

Background Helicobacter pylori is one of the most prevalent infectious disease worldwide. The treatment regimens involve mainly two therapies: Standard Triple drug therapy and Sequential drug therapy. Several studies have shown that the sequential therapy has higher eradication rates of H. pylori than the standard triple drug therapy and since proper study on sequential drug therapy and standard triple drug therapy is still lacking in Nepal, this study is attempted to compare efficacy of Sequential Drug Therapy in the eradication of H. pylori in gastritis with respect to the Standard triple drug therapy. Objective To investigate the efficacy of Triple Drug Therapy and Sequential Drug Therapy in the eradication of Helicobacter pylori with respect to Antigen Stool test. Method This study was the prospective study conducted in 62 patients attending the Department of Gastroenterology, Dhulikhel Hospital, meeting the inclusion criteria who were confirmed as H. pylori positive by histopathology and stool antigen test. Patients were randomized into two groups. One group prescribed with Standard triple drug regimen and another group with Sequential drug regimen. Eradication of H. pylori infection was confirmed by repeating the stool antigen test at least five weeks after the completion of the regimen. Result Among the 62 participants included in this study, 54.5% of them were males. Among the study population, the eradication achieved by standard triple drug therapy was 87.8% and 89.6% with Sequential drug therapy. Higher numbers (82.3%) of patients were compliant to the prescribed medication. Forgetfulness was the main reason for missing the dose (91%) of the non-compliant patients. Conclusion The study revealed an equal efficacy of both Standard Triple drug regimen and Sequential drug regimen in the eradication of H. pylori infection. Further, Stool antigen test can be preferred as a non-invasive test, for diagnosis of H. pylori infection, monitoring the response to treatment and in epidemiological studies.

Carbapenemase and ESBL genes with class 1 integron among fermenting and nonfermenting bacteria isolated from water sources from India

The present study was aimed to detect the carbapenemase, extended-spectrum β-lactamase (ESBL), and intI1 gene of class 1 integron among fermenting (n = 61) and nonfermenting (n = 10) bacterial isolates recovered from water samples (n = 128). Isolates were identified by 16S rRNA sequencing. These isolates showed reduced-susceptibility to third-generation cephalosporins and carbapenems. The isolates varied in number and size of plasmids (2 kb to >20 kb). Plasmid DNA screening showed 5·6, 7, 11·2 and 26·7% prevalence of bla_KPC , bla_NDM , bla_SHV and bla_TEM genes respectively. Diverse bla_NDM (bla_NDM-1 and bla_NDM-4 ) and bla_SHV subtypes (bla_SHV-2 and bla_SHV-11 ) were recorded, unlike the single allelic bla_KPC (bla_KPC-2 ) and bla_TEM (bla_TEM-1 ) gene. Of the total 27 bla-gene-producing bacterial isolates, seven isolates co-harboured the carbapenemase genes (bla_NDM or bla_KPC or the both) along with the ESBL genes (bla_SHV or bla_TEM ). The intI1 gene of class 1 integron was detected among 12 (44·4%) of ESBL- and/or carbapenemase-harbouring isolates. Gene transferability was seen among four of the 10 Enterobacteriaceae donors. Carbapenemases and ESBLs with class 1 integron among aquatic environmental isolates raise the serious issue of the biosecurity and health of the ecosystem. SIGNIFICANCE AND IMPACT OF THE STUDY: Anthropologically affected and polluted environment harbours the resistance threats, where a diverse bacterial species maintain, develop and exchange genetic determinants that constitute a risk to human and ecological health. The antimicrobial resistance (AMR) in Enterobacteriaceae and non-Enterobacteriaceae bacteria caused the failure of the therapy of last resort (carbapenems) and thus lead to life-threatening infections affecting public health. Surveillance and monitoring of AMR could be important for epidemiological, diagnostic testing and control of pathogens. This is a point-prevalence study reporting the comparative occurrence and co-occurrence of carbapenemase and extended-spectrum β-lactamase genes among fermenting and nonfermenting bacteria isolated from the aquatic environment in India.

The Trend and Outcomes of Laparoscopic Appendectomy for Complicated Appendicitis in Nepal: A retrospective study from 2014 to 2018 in a University Hospital

Background Globally, appendicitis is the most frequent emergency surgical procedure. Laparoscopic Appendectomy (LA) is recommended as a standard surgical procedure to remove appendix. In Nepal, studies showed improved outcomes of Laparoscopic Appendectomy than Open Appendectomy (OA) in treating acute appendicitis. However, effectiveness of in Complicated Appendicitis (CA) has not yet studied in Nepal. Objective This study aims to assess the temporal trend of Laparoscopic Appendectomy in management of Complicated appendicitis and to compare outcomes with Open Appendectomy. Method The study is a retrospective descriptive study. The outcome measures in the study are age, sex, ethnicity, length of postoperative stay (LOS), and conversion rate. Secondary data of 174 patients with complicated appendicitis were extracted and reviewed from the operation theater records and the discharge summary from the period of 2014 to 2018. Result The mean age of the patients is 33.2 (SD ±19.4). Predominantly increased incidence is observed among male patients (66%). Mean Length of stay was 4.07(SD±2.1) days. Laparoscopic Appendectomy had shorter hospital stays than open and converted cases. The conversion rate was 10.92% for the observation period, and it was in a decreasing trend with the latest of 4.54%. The temporal trend for the percentage of patients who underwent Laparoscopic Appendectomy was increasing in the observation period. Conclusion The utilization of laparoscopic appendectomy in complicated appendicitis is growing in Nepal, and has decreasing conversion rate.

Awake Fiberoptic Intubation in Cervical Spine Injury: A Comparison between Atomized Local Anesthesia versus Airway Nerve Blocks

Background In cooperative patients with cervical spine injury, awake fiberoptic intubation is an excellent option for elective and semi urgent situations. It allows documentation of neurologic examination before and after intubation and surgical positioning. We have compared anesthesia of airway by nerve block and the local anesthesia atomizer undergoing awake fiberoptic intubation in cervical spine injury patients, in terms of the intubation time and discomfort. Objective To compare the intubation time and discomfort in patient with cervical spine injury with anticipated difficult airway potential to aggravate pre-existing injury undergoing awake fiberoptic intubation, based on cough and gag scores, between anesthesia of airway by (transtracheal and bilateral superior laryngeal) nerve block with local anesthetic agent and the local anesthesia atomizer. Method After institutional ethical approval and having informed written consent, 30 patients scheduled for elective surgery who require awake fiberoptic intubation, were included in the study. Patients were allotted by computer-generated random series into two groups; Group N received nerve block (transtracheal and bilateral recurrent laryngeal nerve block) and Group A received atomized lignocaine. Result The time taken for awake fiberoptic intubation was significantly lower in nerve blocks group as compared with the atomizer group [Group N: 90.2±11.7secs and Group A: 210.4±10.6 secs (p=0.041)]. Atomizer group had an increased coughing and gagging episodes than nerve block group [Group N: one patient, Group A: 11 patients (p=0.006)]. Ease of intubation and patient comfort were significantly better in nerve block group. Demographic and hemodynamic parameters were comparable in the two groups. Conclusion The nerve blocks (bilateral superior laryngeal and transtracheal recurrent laryngeal) provides adequate airway anesthesia, lesser patient discomfort, and faster intubation to aid in awake fiberoptic intubation in patients with anticipated difficult airway as compared to topical anesthesia using atomizer.

Minimal Invasive Gynaecological Surgeries in Dhulikhel Hospital: One and Half Decade Long Experience

Background One of the greatest achievements in the surgical fields is the paradigm shift from open surgery to minimal invasive surgery. Dhulikhel Hospital is one of the very few institutions in Nepal where minimal invasive gynaecological surgeries are being regularly performed since early years of its establishment. There are very few publications related to experiences of minimal invasive gynaecological surgeries published in Nepal. Objective To review the varieties of minimal invasive gynaecological surgeries and find out the different milestones those were crossed in this field. Method This is retrospective study of minimal invasive gynaecological surgeries performed from January 1, 2004 to June 30, 2018. Result A total of 1849 cases were performed by mid 2018. Almost half of the cases were of Brahmin/Chhetri caste (49.9%). Mean age of the patients who underwent gynaecological minimal invasive surgeries in DH was 36.70±10.60 years (with range 12-81 years). More than half of the patients were from Kavre (58.2%). Abnormal uterine bleeding, ovarian lesions and chronic pelvic pain were the most common indications for these procedures. Among these procedures, hysteroscopy (769 cases), diagnostic laparoscopy with or without chromotubation (385 cases), operative laparoscopy (419 cases) and LAVH/TLH (242 cases) were performed. In this study, 34 minimal invasive surgeries cases (1.8%) were converted to laparotomy for certain reasons. Of them eight cases were of laparoscopic hysterectomies. Only very few major and minor complications were experienced during this period. Conclusion Varieties of minimal invasive surgeries for various gynaecological problems were performed with minimal complications. We scaled up these minimal invasive surgeries over the period.

C-reactive Protein in Periodontitis and its Comparison with Body Mass Index and Smoking Behaviour

INTRODUCTION

Chronic periodontitis is an infectious disease resulting in inflammation within the supporting tissues of the teeth, progressive attachment loss, and bone loss. In addition to declining oral health, there is always low grade infection present in periodontitis. Studies show increased levels of systemic biomarkers in periodontal disease such as CRP, which is considered a key-marker of CVD. Research has also shown positive association between BMI and smoking with periodontitis and CRP. The objective of the study was to assess the levels of CRP in patients with and without periodontitis and their relation with BMI and smoking behaviour.

METHODS

Patients visiting the Dental department of Bir Hospital were invited to participate in the study. Total 31 subjects in each group: Case (periodontitis) and Control (without periodontitis) were selected using convenience sampling technique. All subjects underwent periodontal examination by a single examiner. Serum CRP samples were taken before periodontal treatment. Data analysis was done by SPSS 17 software program.

RESULTS

Increase in mean CRP levels in periodontitis (5.8595mg/L) with high statistical significance (P=0.000) in comparison to subjects without periodontitis (1.1214mg/L) was observed. BMI showed positive association with periodontitis (P=0.046) but not with CRP (0.213). Smoking behaviour showed no significant relation with either CRP (P=0.344) or periodontitis (P=0.541).

CONCLUSIONS

We found highly significant association between periodontitis and CRP levels but not always with BMI and smoking. CRP, which is an established marker for CVD was significantly increased in periodontal infections. Hence, a close interaction among Physician, Periodontist and Patient to prevent adverse health situations is recommended.

Clinico-bacterial correlation of bacterial index in Hansen’s disease

Background: Leprosy has a broad spectrum of clinical manifestations. Clinical information along with Bacterial evidence is necessary to achieve accurate diagnosis. The present study was carried out to nd out clinical and bacterial correlation in various presentations according to Ridley Jopling classi cation of Hansen’s Disease. Materials and Methods: It was a hospital based cross-sectional comparative study of 72 leprosy patients over a period of 1 year and it’s clinico-Bacterial correlation was done with the help of Slit Skin Smear and clinical classi cation. Results: This study included 72 leprosy patients at various stages according to Ridley Jopling classi cation. Maximum cases belonged to Borderline Tuberculoid leprosy 28(38.88%) followed by Tuberculoid leprosy 15(20.83%). Slit Skin Smear showed 12(42.85%) of Borderline Tuberculoid and 3(20%) of Tuberculoid cases had disparity and didn’t match corresponding clinical subtype. Conclusion: Clinical features along with Bacterial index is useful in making accurate diagnosis so that appropriate treatment could be started and hence deformity and disability could be prevented. 

Cognitive Dysfunctions in Patients with Alcohol Dependence Syndrome in a Tertiary Hospital in Kathmandu

INTRODUCTION

Alcohol dependence is a chronic disorder, accompanied by neuropsychological deficits. Patients with alcohol dependence were evaluated to identify the cognitive dysfunctions.

METHODS

The study followed descriptive design and recruited participants (N=62) from inpatient services of the Department of Psychiatry and Mental Health by convenient sampling. Participants were evaluated with the Severity of Alcohol Dependence Questionnaire, Frontal Assessment Battery and PGI Memory Scale for the severity of alcohol dependence, executive impairments and memory dysfunctions respectively once they had completed alcohol detoxification.

RESULTS

Total duration of alcohol consumption was 13.93 ± 8.74 years, period of dependence was 2.97 ± 2.23 years and 56.5% had moderate level of dependence. 33.9% of the participants had executive impairments particularly in conceptualization, programming and mental flexibility. 38% of variance in executive dysfunction was explained by illness variables, where period of alcohol dependence and education were significant predictors. 54.8% had significant memory dysfunction particularly in visual retention, remote memory, verbal retention of dissimilar pairs and delayed recall. Memory dysfunction differed significantly among the age groups (F=10.22, p<0.01) and age was a significant predictor (β=.542, p<0.001). 19% variance in memory dysfunction was explained by illness variables, where duration of alcohol consumption was a significant predictor (β = .485, p<0.01).

CONCLUSION

Findings indicate that cognitive dysfunctions are prevalent among patients with alcohol dependence. Hence, routine neuropsychological assessment is of particular importance for early detection and remediation of underlying deficits, which completes the treatment of alcohol dependence.

Problems Faced by Antiretroviral (ARV) Drug Users in Kathmandu

BACKGROUND

Antiretroviral Therapy (ART) offers an opportunity to improve the prognosis and quality of life of People Living with HIV/AIDS (PLHIV). However, inability to achieve adherence even after drug introduction in Nepal is a matter of concern. Some efforts are to be applied in order to lend a hand to identify and minimize these problems. This study aims to assess the problems faced by antiretroviral drug users attending ART centers of Kathmandu.

METHODS

A descriptive study was carried out in Sukraraj Tropical and Infectious Disease Control Hospital, Teku and Bir Hospital in 2071. Non-probability convenience sampling technique was used to recruit 82 respondents. Semi-structured questionnaire was used for conducting the interview.

RESULTS

The overall problems faced by antiretroviral drug users include side-effects of drugs (65.9%), long waiting time (24.4%), unsatisfactory service (4.9%), geographical (68.3%) and financial barrier (25.6%), etc. Few were turned off from social/religious (70.7%) and recreational activities (51.2%). Absence of disclosure (14.6%), lack of spousal support (10.9%), humiliation (34.1%), etc. were also present. Stigmatization materializes as having to lose job (8.5%), feeling of ashamed (30.5%), feeling of isolation (34.1%), etc. Adherence towards medicine was found to be 86.5%.

CONCLUSIONS

ART is a long term process and to achieve it rationally, a user has to cope with lots of problems, associated not only with physical health but also with outcomes of psychosocial issue. Further worsening of the situation is due to financial constraints. Policy making, planning and service delivery seek improvement in various steps. Awareness is another demand to end psychosocial discrimination.

Rational for Conducting PTSD Research and Challenges of Recruiting and Training Volunteers to Screen and Treat PTSD among the Nepal 2015 Earthquake Survivors

Post-traumatic Stress Disorder (PTSD) is common psychiatric morbidity among earthquake survivors, and if untreated people suffer from it for years. Government of Nepal and NGOs provided various short-term mental health services to the victims of the 2015 earthquake in Nepal, but there was no plan or provision for long-term mental health problems. The prevalence of PTSD following natural disasters depends on various local factors requiring understanding and further investigation before identifying affordable evidence based interventions. This paper discusses the need for PTSD research among the survivors of the 2015 earthquake in Nepal, and describes the challenges and difficulties of recruiting and training PTSD volunteers.

Isolation and molecular characterization of Salmonella spp. from chevon and chicken meat collected from different districts of Chhattisgarh, India

AIM

The aim was to assess the prevalence of Salmonella in raw chevon and chicken meat sold in the retail meat shops situated in and around Durg, Rajnandgaon, Dhamtari, Raipur, and Bilaspur districts of Chhattisgarh. Studies were also conducted to find out the antibiotic resistance in Salmonella isolates.

MATERIALS AND METHODS

A total of 400 samples comprising of 200 chevon meat and 200 chicken meat samples were processed for isolation of Salmonella and all isolates were further confirmed on the basis of cultural and biochemical characters and by targeting invA gene of Salmonella. All Salmonella isolates were also examined for their antimicrobial drug susceptibility/resistance pattern against commonly used antibiotics.

RESULTS

Out of 400 samples, the prevalence of Salmonella in chevon and chicken meat was found 9% and 7% respectively, with an overall prevalence of 8%. Polymerase chain reaction targeting invA gene of Salmonella showed positive result with 31 isolates. All 32 Salmonella isolates were found to be highly sensitive to ciprofloxacin while 96.87%, 96.87% and 93.75% were sensitive to gentamicin, imipenem, and ceftazidime, respectively. 93.75% and 59.37% isolates were resistant to erythromycin and oxytetracycline, respectively. Out of 32, 14 isolates had multiple antibiotic resistance index equal to or more than 0.2.

CONCLUSION

Salmonella in chevon and chicken meat samples is prevailing in the areas of sampling due to poor hygienic conditions and also demonstrated the varied spectrum of antimicrobial resistance, including several multiple drug resistance phenotypes. Therefore, the present study emphasizes the need for continued surveillance of zoonotic foodborne pathogens including antimicrobial-resistant variants throughout the food production chain.

A unique presentation: rectus sternalis

Rectus Sternalis is a rare flat slip of muscle present parasternally in the thoracic wall. During the regular dissection of pectoral region, three slips of Sternalis muscle were observed bilaterally in an adult male cadaver. On the right side there was a single slip (RS 1) while on the left side two slips (RS2 and RS3) were present. All three slips were present anterior to the Pectoralis Major muscle of respective side and each muscle had fleshy origin and tendinous insertions. RS1 had two heads arising from the aponeurosis of External Oblique and Rectus Abdominis. RS2 had a single origin from aponeurosis of Rectus Abdominis and RS3 took its origin from the aponeurosis of Pectoralis Major muscle. Indistinct tendinous intersections were noted in both RS1 and RS3 slips proximal to fusion of both Sternalis muscle (RS1 and RS3) with each other. Out of three slips, right Rectus Sternalis was largest with breadth 3.8cm near its origin while the second slip of Rectus Sternalis on the left was longest with length of 12.5cm. RS2 was smallest and shortest among the three slips. The RS1 even presented a flattened tendon running upwards which fused with the membranous origin of right Sternocleidomastoid muscle. The Rectus Sternalis when present arises from hypomeres as longitudinal group of muscles which usually disappears in the thoracic region. The knowledge about Sternalis muscle and its variations is important for anatomists and clinicians (radiologists and surgeons) to avoid any confusion and misdiagnosis as well as anthropologists.

Clinico-Pathological Study of Lung Carcinoma

Background: Lung cancer is currently the most frequently diagnosed cancer in the world and the number one cause of cancer mortality worldwide.Materials and Methods: A descriptive study was conducted in 55 diagnosed lung carcinoma cases being treated in a Kathmandu based hospital over a period of 18 months from 22nd Oct. 2012 to 21st April 2014.Results: Out of total 55 lung carcinoma cases, 33 patients were male and 22 were female with Male: Female ratio of 1.5:1. The most frequent age group was 71-80 years. Lung cancer was more common among smokers (52.73 % of cases). Out of 47.27% non smokers, 76.92% were female. Squamous cell carcinoma was found to be the most common cancer type, comprising 63.64% of cases followed by adenocarcinoma (29.09% of cases) and small cell carcinoma (7.27% of cases). Among various diagnostic methods, CT guided Fine needle aspiration cytology (FNAC) and Pleural fluid cytology was found to be the best methods.Conclusion: Smoking showed a positive correlation among carcinoma of lung patients. Squamous cell carcinoma and adenocarcinoma were the most common tumors encountered among the smokers and non-smokers respectively. CT guided Fine needle aspiration cytology (FNAC) and Pleural fluid cytology yields the most diagnostic materials.DOI:  http://dx.doi.org/3126/jpn.v4i8.11496   Journal of Pathology of Nepal; Vol4, No.8 (2014) 623-625Background: Lung cancer is currently the most frequently diagnosed cancer in the world and the number one cause of cancer mortality worldwide.Materials and Methods: A descriptive study was conducted in 55 diagnosed lung carcinoma cases being treated in a Kathmandu based hospital over a period of 18 months from 22nd Oct. 2012 to 21st April 2014.Results: Out of total 55 lung carcinoma cases, 33 patients were male and 22 were female with Male: Female ratio of 1.5:1. The most frequent age group was 71-80 years. Lung cancer was more common among smokers (52.73 % of cases). Out of 47.27% non smokers, 76.92% were female. Squamous cell carcinoma was found to be the most common cancer type, comprising 63.64% of cases followed by adenocarcinoma (29.09% of cases) and small cell carcinoma (7.27% of cases). Among various diagnostic methods, CT guided Fine needle aspiration cytology (FNAC) and Pleural fluid cytology was found to be the best methods.Conclusion: Smoking showed a positive correlation among carcinoma of lung patients. Squamous cell carcinoma and adenocarcinoma were the most common tumors encountered among the smokers and non-smokers respectively. CT guided Fine needle aspiration cytology (FNAC) and Pleural fluid cytology yields the most diagnostic materials.DOI: 3126/jpn.v4i8.11496   Journal of Pathology of Nepal; Vol4, No8(2014)

Optical studies of Sm³⁺ ions doped zinc alumino bismuth borate glasses

Zinc Alumino Bismuth Borate (ZnAlBiB) glasses doped with different concentrations of samarium (Sm(3+)) ions were prepared by using melt quenching technique and characterized for their lasing potentialities in visible region by using the techniques such as optical absorption, emission and emission decay measurements. Radiative properties for various fluorescent levels of Sm(3+) ions were estimated from absorption spectral information using Judd-Ofelt (JO) analysis. The emission spectra and con-focal photoluminescence images obtained by 410 nm laser excitation demonstrates very distinct and intense orange-red emission for all the doped glasses. The suitable concentration of Sm(3+) ions in these glasses to act as an efficient lasing material has been discussed by measuring the emission cross-section and branching ratios for the emission transitions. The quantum efficiencies were also been estimated from emission decay measurements recorded for the (4)G5/2 level of Sm(3+) ions. From the measured emission cross-sections, branching ratios, strong photoluminescence features and CIE chromaticity coordinates, it was found that 1 mol% of Sm(3+) ions doped ZnAlBiB glasses are most suitable for the development of visible orange-red lasers.

Tricuspid Valve Repair: Devega’s Tricuspid Annuloplasty in Moderate Secondary Tricuspid Regurgitation

Background Moderate secondary tricuspid incompetence has variable natural history if left unattended during mitral valve surgery. Recent data suggest progression of the secondary tricuspid incompetence over time. Secondary moderate tricuspid regurgitation in rheumatic mitral valve disease may regress after mitral valve surgery without direct intervention. Objectives: The present retrospective comparative hospital based tudy was done to assess early result of DeVega tricuspid valve annuloplasty amongst those with moderate tricuspid regurgitation due to rheumatic mitral valve disease. Methods: Group I (mitral valve replacement with tricuspid repair) and Group II (mitral valve replacement only) were compared regarding functional class, heart rate, rhythm, cardiac dimensions, function and valve pathology. The two groups were followed up at three months post-operatively and evaluated for their functional class and echocardiography variables. The data was analyzed with SPSS 16.0 Results: There were 43 patients who underwent mitral valve replacement with moderate tricuspid regurgitation. Twenty three underwent mitral valve replacement with tricuspid repair group (Group 1). Most of the patients were women (28/43). The mean age was 31.4 + 14.8 and 25.13 + 9.4 years. Group I had 21(91.3%) and Group II had 17 (85%) in NYHA class III & IV. The pre-operative echocardiographic cardiac left ventricular and left atrial dimensions, left ventricular function and valve lesions were statistically similar for both groups, except PASP was higher amongst tricuspid repair (Group 1: 38.60 + 12.75mHg, Group 2: 61.52 + 19.76mmHg; p= <0.05). At three month’s review after surgery, four patients were in NYHA II amongst those without tricuspid repair (Group II), whilst the rest were in NYHA I. Left ventricular dimensions, Left Ventricular function and valve prosthetic valve function were similar between groups. Eleven (47.8%) patients in Group I and only five (25%) of Group II had trace or less TR at the follow-up (p < 0.05). There were 7 (16.2%) patients who had persistent moderate TR. Higher PASP and larger LV dimensions at three months were predictive of persistent moderate TR. Conclusion Mitral valve replacement does decrease the severity of tricuspid regurgitation amongst those with secondary moderate tricuspid regurgitation by at least one grade, but DeVega’s annuloplasty confers a better repair result. http://dx.doi.org/10.3126/kumj.v9i1.6266 Kathmandu Univ Med J 2011;9(1):64-8

Isolation and characterization of aerobic culturable arsenic-resistant bacteria from surfacewater and groundwater of Rautahat District, Nepal

Arsenic (As) contamination of groundwater is a serious Environmental Health Management issue of drinking water sources especially in Terai region of Nepal. Many studies have reported that due to natural abundance of arsenic in the environment, various bacteria have developed different resistance mechanisms for arsenic compound. In this study, the culturable arsenic-resistant bacteria indigenous to surfacewater as well as groundwater from Rautahat District of Nepal were randomly isolated by standard plate count method on the basis of viable growth on plate count agar amended with arsenate ranging from 0, 0.5, 10, 40, 80 to 160 milligram per liter (mg/l). With respect to the morphological and biochemical tests, nine morphologically distinct potent arsenate tolerant bacteria showed relatedness with Micrococcus varians, Micrococcus roseus, Micrococcus luteus, Pseudomonas maltophilia, Pseudomonas sp., Vibrio parahaemolyticus, Bacillus cereus, Bacillus smithii 1 and Bacillus smithii 2. The isolates were capable of tolerating more than 1000 mg/l of arsenate and 749 mg/l of arsenite. Likewise, bioaccumulation capability was highest with M. roseus (85.61%) and the least with B. smithii (47.88%) indicating the potential of the organisms in arsenic resistance and most probably in bioremediation.

Chronic bilateral dislocation of temporomandibular joint

Dislocation of the condyle of the mandible is a common condition that may occur in an acute or chronic form. It is characterised by inability to close the mouth with or without pain. Dislocation has to be differentiated from subluxation which is a self reducible condition. Dislocation can occur in any direction with anterior dislocation being the commonest one. Various predisposing factors have been associated with dislocation like muscle fatigue and spasm, the defect in the bony surface like shallow articular eminence, and laxity of the capsular ligament. People with defect in collagen synthesis like Ehler Danlos syndrome, Marfan syndrome are said to be genetically predisposed to this condition. Various treatment modalities have been used ranging from conservative techniques to surgical methods. Acute dislocations can be reduced manually or with conservative approach and recurrent and chronic cases can be reduced by surgical intervention. Though the dislocation in our case was 4 months a simple manual reduction proved to be successful. We believe that manual reduction can be attempted as first line of treatment prior to surgical intervention.

Color Vision Defects in School Going Children

Introduction: Color Vision defect can be observed in various diseases of optic nerve and retina and also a significant number of people suffer from the inherited condition of red and green color defect.  Methods: A cross-sectional descritptive study was designed with purposive sampling of students from various schools of Kathmandu Valley. All children were subjected to color vision evaluation using Ishihara Isochromatic color plates along with other examination to rule out any other causes of color deficiency.  Results: A total of 2001 students were examined, 1050 male students and 951 females with mean age of 10.35 (±2.75) and 10.54 (±2.72) respectively. Among the total students examined, 2.1% had some form of color vision defects. Of the male population , 3.9% had color vision defects while none of the female was found with the deficiency.  Conclusions: The prelevance of color vision defect in Nepal is significant and comparable with the prelevance quoted in the studies from different countries. Keywords:color vision; congenital red green color effect; Nepal; prevalence.

Color vision defects in school going children

INTRODUCTION

Color vision defect can be observed in various diseases of optic nerve and retina and also a significant number of people suffer from the inherited condition of red and green color defect.

METHODS

A cross-sectional descriptive study was designed with purposive sampling of students from various schools of Kathmandu Valley. All children were subjected to color vision evaluation using Ishihara Isochromatic color plates along with other examination to rule out any other causes for color deficiency.

RESULTS

A total of 2001 students were examined, 1050 male students and 951 females with mean age of 10.35 (+/- 2.75) and 10.54 (+/- 2.72) respectively. Among the total students examined, 2.1% had some form of color vision defects. Of the male population, 3.9% had color vision defects while none of the female was found with the deficiency.

CONCLUSIONS

The prevalence of color vision defect in Nepal is significant and comparable with the prevalence quoted in studies from different countries.

A study of ocular morbidity of patients attending a satellite clinic in Bhaktapur, Nepal

A community based retrospective study was conducted in the satellite clinic of Nepal Medical College Teaching Hospital at Jhaukhel VDC of Bhaktapur, from March 2007 to February 2008. A total of 395 patients were examined, where males comprised of 135 patients (32.9%) and females 265 patients (67.1%). The common ocular diseases observed in this study were refractive errors 22.5%, age related cataract 17.5%, extra ocular diseases like conjunctivitis 14.9%, conjunctival degenerations 10.8%.

Safety and efficacy of misoprostol for induction of labour

BACKGROUND

Induction of labour is widely carried over the world in cases where continuation of pregnancy is hazardous to mother or fetus. Varieties of techniques are available for induction of labour. Prostaglandin is one of the most effective means for achieving cervical ripening and induction of labour. This study was carried out to see safety and effectiveness of Misoprostol for induction of labour.

METHODS

This prospective study was carried out at Kathmandu University Hospital, Dhulikhel from Jan 2008 to Aug 2009. A total of 70 patients were included in this study. All patients received 50 μg of Misoprostol in the posterior fornix with maximum dose up to 3 doses at interval of 6 hours. Bishops scoring was reviewed each time before application of Misoprostol. When favourable cervix along with good uterine contraction is noted then augmentation with Oxytocinon was done holding Misoprostol. The measures used for the analysis of effectiveness and safety of Misoprostol were change in bishop score, total dose required, need for augmentation, side effects, duration of first, second and third stages of labour, duration from induction till delivery, mode of delivery and neonatal outcome. The primary outcome measures were induction to delivery interval and caesarean section rate.

RESULTS

Out of 70 patients, 21 (30%) required augmentation. Among 70 patients, 46 (65%) underwent normal delivery, 6 (8.6%) underwent instrumental delivery and 18 (25%) patients underwent cesarean section for various indications (p=0.00). Total 31 (44%) patients delivered within 10 hours of induction, 16 (22%) within 15 hours and 4 (4.7%) took more than 18 hours. Duration of second stage of labour was also found to be shortened with use of Misoprostol for induction of labour. Duration of second stage of labour was less than 30 minutes in 42 (60%) cases and more than 30 minutes in 9 (17%) cases.

CONCLUSIONS

Misoprostol is an effective cervical ripening agent with favorable outcome and comparable with other inducing agents.

Consultation liaison psychiatry at Nepal Medical College and Teaching Hospital

The authors reviewed the all referral cases from different inpatient and outpatient department, in Nepal Medical College and Teaching Hospital. It was a descriptive study. There were 484 referred cases during the study period. Around half the referral were from department of medicine (49.8%), surgery (11.2%), Eye/ENT (10.3%). The referral rate was 1.4%, with an average three cases per day. Among the referral cases depression was diagnosed in 26.9%, anxiety in 15.5% and substance related problem in 14.5%. The consultation liaison psychiatry service is satisfactorily used. Depression, substance use problem, anxiety, deliberate self harm is the main diagnoses in liaison psychiatry.

Delirium at Nepal Medical College Teaching Hospital: reason for referral and subtypes

The important neuropsychiatric disorder delirium is the most single important disorder in onsultation liaison psychiatry. There is a dearth of study in delirium. The purpose of this study was to find out the demographic profile, reason for referral, and subtypes of delirium. Thirty two consecutive cases of delirium diagnosed by psychiatrist in consultation liaison psychiatry were enrolled in the study. This is a descriptive study and diagnoses were made based upon 'The International Classification of Disease (ICD-10)'. The majority of cases were from age 70 and above, male sex being more common and most commononest reason for referral being disturbed behavior. The hyperactive subtype of delirium was the frequent finding. Medicine and ICU followed by surgery and post operative ward were the most referring departments.

Change in refractive status of the patients undergoing phacoemulsification surgery

This study was carried out with the objective of finding refractive status of patients undergoing phacoemulsification surgery for cataract extraction. Success of cataract surgery can be quantified with the improvement in visual acuity with least amount of refractive error. Prospective study of 44 patients was done pre operatively and with subsequent follow up in the first, third and eighth week post operatively. Pre and post operative evaluation was carried out in terms of visual acuity, refractive error and corneal curvature. Among patients undergoing surgery, 91.0% achieved visual acuity of 6/9 or better at eighth week follow up 73.3% of patients had astigmatism of 1.25 dioptric cylinder or less. Keratometry readings showed insignificant variability in the preoperative and postoperative period (p > 0.05). This confirms that phacoemulsification surgery does not change the corneal curvature significantly and thereby induces less amount of astigmatism.