bluuebunny/crossref_metadata_2025 huggingface dataset:
Reaching the Unreached- A Model for Sustainable Community Development Through Information and Communication Technology
Authors: Jha A K , Gurung D
Published: September 2018

Telemedicine, which is defi ned as ‘the practice of healthcare using interactive audio, visual and data communications and includes healthcare delivery, diagnosis, consultation and treatment as well as education and transfer of medical data’, has been gaining popularity in the health services sector. Dermatology as a specialty is particularly suitable for telemedicine and more so in geographic regions with scarcity of qualifi ed manpower, where it has greatly facilitated the outreach of specialist care delivery. However, the cost of telemedicine technology is a signifi cant hurdle which makes the sustainability of such services challenging. Maximum utilization of such technology by active participation of well motivated benefi ciary communities and bringing innovative strategies for its use will be crucial in sustaining such services in rural communities.
Nepal Health Insurance Bill: Possible Challenges and Way Forwards
Authors: Kandel Nirmal
Published: September 2018

Nepal has one of the highest proportions of out of pocket expenditures on health and one quarter of the people is living below poverty line. In recent time, there is some increase of the health budget but country still relies on development partners. The endorsement of the national health insurance bill has enabled government to establish the national health insurance scheme through development of adequate policies, strategies and mechanisms for implementation at national and federal level. The scheme has many challenges to address on governance and leadership, financing, information, health services, workforce, and essential medicines and technologies. Therefore, it is imperative to establish a robust mechanism like a “tree”, which has strong roots of building blocks of health systems, which produces fruits that ensure improved responsiveness, efficiency and equity and financial protection. It is necessary to learn and apply from the experiences of other countries while implementing the national health insurance scheme.
Calcaneal Myxoid Chondrosarcoma: A Rare Case
Authors: Joshi A , Shahi R , Singh S , Chand P , KC B R
Published: September 2018

Skeletal myxoid chondrosarcoma is an extraordinarily rare neoplasm with a distinct histological morphology. Although it grows slowly, the clinical course was found to be worse than usual chondrosarcoma. We report a case of a Skeletal myxoid chondrosarcoma in the calcaneus of a 21-year-old female who presented to us with a feature of gradually increasing benign swelling left foot for last two years. Initial investigations were indicating towards a benign lesion for which excision of the lesion was performed. But intra operative findings were suggestive of an aggressive lesion, and to our utter surprise histopathologically it turned out to be Myxoid Chondrosarcoma. Because of its high malignant nature below knee amputation was performed as second definitive surgery. Since her clinical course and radiological pictures were suggestive of benign lesion we got carried away with a diagnosis of chondrmyxoid fibroma and excision of the lesion was attempted without attempting histopathological diagnosis by less invasive methods.

Keywords: caldaneal; chondrosarcoma; myxoid.
Molecular Confirmation of G1138A Mutation in FGFR gene in Achondroplasia
Authors: Khanal Shyam Bahadur , Shrestha Mitesh , Chaudhary Hemanta Kumari , Shrestha Smita , Pokharel Rohit Kumar
Published: September 2018

Introduction: Achondroplasia (ACH) is the most common form of skeletal dysplasia of genetic origin in humans which is characterized by disproportionate rhizomelic dwarfism. Heterozygous mutation in the transmembrane domain of the FGFR3 gene (4p16.3) occurs as a de novo mutation in most of the cases.

 Methods: DNA was isolated from seven samples, out of which, five had clinical features of Achondroplasia while one was dwarf but did not show symptoms of the disorder and one as negative control. PCR was performed for the region incorporating the hotspot region viz. 1138th nucleotide. PCR amplicon of size 164 bp was obtained from all the samples, and was sequenced.

Results: Sequence analysis showed the presence of mutation (G to A transition) in all of the five samples. The five samples that showed the clinical features of Achondroplasia had mutation in the region being analyzed while the single patient who had no clinical manifestations of the disorder despite being dwarf had no such mutation. Among the five patients studied, one patient had a family history of Achondroplasia as observed through pedigree analysis while the remaining four cases were sporadic in nature.

 Conclusions: This study further supports that the G1138A mutation is the one of the most common point mutation among Achondroplasia cases. Genetic diagnosis can be useful to identify the disease prenatally and differentiate other life threatening dwarfism for the safety of both mother and fetus.

 Keywords: achondroplasia; dwarfism; fibroblast growth factor receptor 3 (FGFR3); point Mutation.
Unusual Presentation of Duodenal Dieulafoy’s Lesion in a Toddler
Authors: Rao S , Shenoy R , Kamath N , Rao S
Published: September 2018

Dieulafoy’s lesion is a rare cause of massive upper gastrointestinal haemorrhage in any age. It predominantly occurs in the proximal stomach. We report on a child who presented with massive rectal haemorrhage and a clear nasogastric aspirate due toduodenal Dieulafoy’s lesion.

Keywords: clear nasogastric aspirate; hematemesis; massive rectal haemorrhage; vascular malformation
Knowledge of Alzheimer’s Disease Among Medical Students of a Medical College
Authors: Sharma Rachana , Sharma Subhash Chandra , Pardhan Sudarshan N , Chalise Pratikshya , Paudel Luna
Published: September 2018

Introduction:Dementia is a public health concern as the prevalence is increasing worldwide with significant increase being in low-middle income countries. However these countries appear to be less prepared in handling this rise in terms of diagnosis and management.

Methods: This cross-sectional study was conducted in Kathmandu medical College, from June 2017 to July 2017. Purposive sampling was done and the medical students who were in their first and final year of study were included in the study after obtaining an informed consent.

Results: Total 185 students were included in the study, 80 (43.24%) from first year and 105 (56.75%) from final year of medical study. The mean score of knowledge among the students was 17.44± 2.46; 15.32± 1.22 among first year and 19.06± 1.87 among the final year students. Majority of the students said they have heard about dementia however, only 3 (3.75%) of first year and 43 (41.9%) from final year students have either attended a class or CME on dementia

Conclusion:The knowledge about dementia was found to be average among medical students but better among final year medical students in comparison to first year. The knowledge was found to be better statistically among those who had either attended a class or CME on dementia or had exposure through different medias.

Keywords:alzheimer`s disease; dementia; knowledge; medical students.
Estimation of Stature from Percutaneous Hand Length Among the Students of A Medical College
Authors: Pandey Anup , Atreya Alok
Published: September 2018

Introduction: Anthropometry is commonly used technique for the measurement of bone and soft parts in Anatomy and other fields of science. It has practical implications mainly in the field of anatomy and forensic medicine. The present study is aimed to determine the average hand length with stature among the students of a medical college.

Methods: A cross sectional study was done among 185 students including 98 females and 87 males of Devdaha Medical College and Research Institute. Hand length and stature were measured and collected data was entered and analyzed in SPSS 21. The differences in measurements of hand bone length and stature among males and females were calculated. The regression equation for the estimation of stature from hand length was calculated.

Results: The mean hand length among the total population was 17.80±1.04 cm and stature was 160.50±6.73 cm. The mean hand length and stature were higher among males as compared to females. The range of hand length and stature among the total population is 16.00-21.20 and 146.00-176.50 respectively. The regression equation for the estimation of stature from hand length revealed statistically significant value among the males and females.

Conclusions: Our study reveals higher value of hand length and stature for males as compared to females. Also there is significant correlation between the hand length and the stature. The present values are obtained from the small population of an institute. Further studies have to be carried out to develop the regression formula for the Nepalese population with larger sample size.
Distal Renal Tubular Acidosis in Adolescence with Severe Growth Retardation and Nephrocalcinosis
Authors: Sigdel M R , Kafle M P , Raut K B
Published: September 2018

Chronic acidosis is an important, often overlooked cause of growth retardation. Here we present the case of a girl with distal renal tubular acidosis who had visited multiple hospitals before the diagnosis was made. She presented to us in adolescence with non anion gap metabolic acidosis, hypokalemia, severe growth retardation and nephrocalcinosis. In 18 months follow up with alkali therapy, she had good weight gain and growth velocity.

Keywords: growth retardation; hypokalemia; nephrocalcinosis; renal tubular acidosis.
Superficial BrachialArtery with its High Division
Authors: Sharma R , Singla R K , Sharma R , Sharma T
Published: September 2018

The upper extremity arterial system shows a large number of variations attributed to the complex and multiple sites of their embryonic development. It is important to be aware of arterial variations in this region because upper extremity is a frequent site of injury. Moreover, brachial artery is of significance in cardiac catheterization for angioplasty, pedicle flaps, or arterial grafting. Accurate knowledge and relationships of major arterial conduits and their variational patterns is important in reparative surgery in the arm, forearm and hand. One such variation is superficial brachial artery with prevalence rate of 0.2- 25%. In this report, the brachial artery emanated normally but coursed superficial to the median nerve and about five cm above the intercondylar line, bifurcated into its terminal branches i.e. radial and ulnar artery.

Keywords: brachial artery;high division; variations.
Strengthening District Health Care System through Partnership with Academic Institutions: The Social Accountability of Medical Colleges in Nepal
Authors: Magar A , Subba K
Published: September 2018

Approximately 25-30% of the Nepalese population live below poverty line. Majority of them reside in a geographically inaccessible place while most of the health centers are focused in the urbanized cities of Nepal. Hence, they are deprived of quality health care at that level and need urgent attention by the concerned authorities. The government has not increased its human resource for health in the last two decades, while population has doubled up but the number of doctors serving in public sectors has remained the same as it was in 1990s.

We have got 19 medical colleges at the moment. If one district is allocated to each medical colleges, it could help improve district health system at local level in Nepal. This can be accomplished by posting postgraduate resiendts in the peripheral district hospital as a part of their training and later encouraging them to serve for certain years. This could be a perfect example of government envisioned public private partnership in the country. This is a concept that has already been started in many parts of the world that can be moulded further to improve health service at peripheral part of the country. It is also the social accountability of the medical colleges for the development of the nation.

Keywords: district health care system; medical education; social accountability.
Surgical Site Infections due to Non-Tuberculous Mycobacteria
Authors: Yadav Rohit Prasad , Baskota Bashudev , Ranjitkar Rabin Ratna , Dahal Sandesh
Published: September 2018

Introduction: Non-tuberculous Mycobacteria are increasingly recognized, nowadays as an important pathogen in delayed surgical site infection in post operative cases. We here in describe cases of surgical site infection caused by Non-tuberculous Mycobacteria, seen in two centers in Jhapa. The aim of the study was to increase awareness of this atypical mycobacterial infection, prompt diagnosis, and treatment that may ultimately provide better care to patients.

Methods: Forty four patients underwent different kinds of operations in two different private hospitals in Jhapa district of Nepal. All patients were presented with painful, draining subcutaneous nodules at the infection sites. Repeated aspiration of abscess, incision and drainage of the wound were done and specimen was sent for microbiological and histopathological examination. All patients were treated with repeated wound debridement and tab. Clarithromycin and inj. Tobramycin for 45days.

Results: Mycobacterium Chelone were isolated from the purulent drainage obtained from wounds by routine microbiological techniques. Of the forty four cases, thirty of them had acid fast bacilli stain positive, two had acid fast bacilli culture positive. All the patients except two cases were treated with injection Tobramycin and Clarithromycin for six weeks.

Conclusions: There should be high level of clinical suspicion for patients presenting with delayed post- operative wound infections for the diagnosis of non-tubercular mycobacreria as causative agents. These infections not only cause physical but also emotional distress that affects both the patients and the surgeon. Emphasis should be given on good sterilization technique to avoid such infections.
Lifetime Experience of Violence in Early Adulthood Female
Authors: Silwal Kalpana , Dhakal Prativa , Raut Krishna Bahadur , Chaudhary Rajendra Kumar
Published: September 2018

Introduction: Despite political commitment and a supportive legal and policy framework, violence against women remains a significant problem in Nepal. Nepal Demographic and Health Survey reported more than one in five women experience violence in lifetime. Three fourth of women who had experienced physical or sexual violence had not sought any help. 

Methods: Descriptive cross-sectional study was carried out in an Institute in Lalitpur. Accessibility sampling was used to find out the experience of violence from their childhood to this date. The data were collected by self-administered questionnaire was distributed to the female students. Data were analyzed using SPSS. Frequency, mean, percentage and standard deviation were calculated.

Results: More than three fourth 71 (79.8%) of the female students were victim of violence and among them most 67 (75.3%) were at age of 11 to 19 years. Majority 63 (70.8%) were victimized from strangers followed by friends 11 (12.4%). Teasing 55 (61.8%) and unwanted touching 35 (39.3%) were the most common type of violence. Most 51 (57.3%) were the victim while traveling by public vehicle and walking on road 47 (52.8%). More than half (57.7%) were suffered <5 times. One third 34 (38.2%) told strict punishment to the offenders followed by awareness program 32 (36%) for the prevention of violence.

Conclusions: Majority of the female students were victim of violence and offenders were young adult. Awareness program, strict rules and punishment to offenders should be implemented to prevent the violence among girls.
Angiographic Estimation of Culprit Vessel Disease Severity in Acute ST- Segment Elevation Myocardial Infarction after Thrombolysis
Authors: Ahmed W , Noon M J , Haq A , Mustafa B
Published: September 2018

Introduction: To study the angiographic disease severity of the infarct vessel after thrombolysis in patients with acute ST-elevation myocardial infarction and their 90 days outcome. 

Methods: We conducted a retrospective analysis of a prospectively maintained cardiology database at Shifa International Hospital from February 2011 to August 2011. A total of 57 patients who underwent thrombolysis for acute ST elevated Myocardial Infarction and subsequent coronary angiographies within 24 hours of hospitalization were studied. Angiographic disease severity in the infarct vessel was quantified as mild (<50%), moderate (50-70%), severe (70-99%) and total occlusion (100%). Secondary outcomes of recurrent ischemia/reinfarction, target lesion revascularization and death were also assessed at three months follow up. 

Results: Thrombolysis was successful in 48 patients. All nine cases of failed thrombolysis underwent rescue PCI. Mean time of catheterization from thrombolysis was 16 ±4 hours. Total 56 (98.2%) patients had severe (>70%) and 1 patient had moderate (50-70%) angiographic disease of the infarct vessel. Left anterior descending artery was the infarct vessel in 32 (56%) cases and right coronary artery in 20 (35%). Total 15 (26%) patients had double vessel and 11 (19%) had triple vessel coronary artery disease. Percutaneous coronary intervention was performed in all patients using bare metal stents or drug eluting stents. At three month follow-up, only one patient had recurrent myocardial infarction due to stent thrombosis. 

Conclusions: The overwhelming majority of patients presenting with ST elevation myocardial infarction have angiographic evidence of severe underlying disease in the infarct vessel despite clinically successful hrombolysis.

Keywords: acute coronary syndrome; coronary angiography; myocardial infarction; thrombolysis.
Benefits of an Electronic Medical Records System in Rural Nepal
Authors: Watkinson-Powell A , Lee A
Published: September 2018

Introduction: Electronic medical records systems may improve the efficiency and quality of health services in developing countries. However the supporting evidence is limited as there are a number of barriers to their implementation, including lack of infrastructure, resources and skills. The objective of this study was to evaluate the introduction and assess the potential benefits of an Electronic Medical Records System in Rural at an NGO-supported health post in rural Nepal.

Methods: Original research in the form of a case report was carried out using participant observation of health clinics, semi-structured interviews with health workers and recording of time spent on clinic activities at the pilot and a control site.

Results: This evaluation found that the Electronic Medical Records System was well used and easy to learn. Health workers thought it improved continuity of care and found decision-support tools useful. Monthly report creation was faster but the system was difficult to integrate with government services, which limited the reduction in paperwork. Other problems identified included minor software issues, a lack of back-up, continuity of power supply and inadequate technical support. There was no significant impact on consultation length or time spent interacting with patients.

Conclusions: The introduction of the Electronic Medical Records System was largely successful. With adequate technical support and training, Electronic Medical Records System could provide a relatively low-cost means of improving patient care and health worker efficiency in developing countries. However they must be designed to fit their intended environment.

Keywords: computerized; electronic health records; medical records; medical records systems..
Leprosy Disease in Nepal : Knowledge and Non-compliance of Patients
Authors: Chalise Suraj Chandra
Published: September 2018

Non-compliance among leprosy patients has always been a problem in Nepal. Many researches on drugcompliance has indicated that if a patient understands well about his /her disease and its treatment, he /sheis more likely to be motivated to take the whole prescribed course of treatment properly. It is widely believedthat the understanding and behavior of patients in relation to drug compliance are largely influenced bytheir socio-economic condition and level of knowledge.In order to determine the socio-economic characteristics of non-compliant leprosy patients and their level ofknowledge of leprosy disease and treatment, a non-intervention study was carried-out in Dhanusha - a highprevalent district in Nepal bordering India. A total of 57 non-compliant leprosy cases were selected usingsystematic sampling method on the basis of available clinical records and an interview-schedule was used fordata collection. The result shows that the majority of non-compliant cases were illiterate, laborers byoccupation and from poor economic class family background (73.7%).Data revealed that majority did not understand the cause of the disease and were not aware of the durationof treatment. It was interesting to note that an overwhelming majority (94.7%) were having strong beliefthat the disappearance of sign/symptoms was the only meaning of the “cure of leprosy disease”. In view ofthis, it is strongly recommended that the patient education and counseling, public/community awarenessprogram should be improved and further strengthened. A socio-economic rehabilitation program withvocational/trade training to leprosy patients or their family members should be arranged to up-lift theirsocio-economic status.Key Words: Leprosy, Patient Knowledge, Compliance.
Outcome of Newborns with Birth Asphyxia
Authors: Shah Gauri Shankar , Singh R , Das B K
Published: September 2018

Birth asphyxia is one of the common causes of mortality and morbidity in neonates and the incidence is 2–9per 1000 live borns. The present work is a retrospective hospital based observational study. Babies born atB.P. Koirala Institute of Health Sciences, Dharan, Nepal during the period from April 2002 to April 2003with gestational age 37 weeks with Apgar score 6 at 5 minutes were included in the study. The aim wasto study the clinical profile, the acid base parameters and the outcome of asphyxiated newborns. Babies withcongenital defects, evidence of infection and maternal drug addiction were excluded from the study. Allbabies were resuscitated according to the guidelines of American Heart Association. Data on 50 birth asphyxia cases were tabulated and analysed. There were 10 (20%) cases of severe birth asphyxia (Apgar score:1-3 ) and 40 (80%) cases of moderate birth asphyxia (Apgar score: 4-6). Staging of hypoxic ischaemic encephalopathy (HIE) was performed according to Sarnat’s staging. Thirty percent of these cases presentedwith various stages of HIE and the incidence was higher in low Apgar score group. The common presentations of HIE cases had depressed neonatal reflexes, seizures, lethargy, and pupillary abnormalities. Thecommon acid base disturbance was metabolic acidosis which was observed only in babies with HIE-3. Twoneonates (4%) died during the hospital stay due to multiorgan failure and severe metabolic acidosis.Key Words: Birth asphyxia, Hypoxic ischaemic encephalopathy, Apgar score
Prevalence of Pulmonary Tuberculosis in Kanchanpur District of Far Western Nepal
Authors: Joshi Yadav Prasad , Mishra P N , Joshi D D
Published: September 2018

Keeping in view of high prevalence of tuberculosis in far western development region in different reports, adoor to door survey of 125 household was carried out randomly in Mahendra Nagar municipality ward no13 of Kanchanpur district to pick up symptomatics suggestive of pulmonary tuberculosis and find the prevalence in the target population. A total of 200 sputum specimens from 70 symptomatics within the age rangeof 10-80 years were collected and subjected to smear microscopy by Ziehl - Neelsen's method. Out of 10positive cases (14.28%), infection in males and females was 80% and 20% respectively. The infection wasfound in the productive age group 20-69. The highest prevalence was obtained in 20-29 age group (25%)followed by 40-49 (11%), 30-39 (9%), 50-59 (8%) and 60-69 (8%). The diagnostic yield of single sputumspecimen examined was insufficient in field condition, especially where the sputum positivity was low. Of thethree sputum smears examined, the early morning specimen had the best result.Key Words: Pulmonary tuberculosis, prevalence, sputum smears.
Sympathetic Ophthalmia : A Blinding Complication of Ocular Injury
Authors: Subedi Sudesh
Published: September 2018

Sympathetic Ophthalmia is a rare and blinding ocular complication due to ocular injury. This condition in amale patient aged 25 years, is reported. The role of early recognition and management of this condition topreserve good vision is discussed.Key Words: Sympathetic ophthalmia, granulomatous panuveitis, ocular injury.
Aortic Aneurysm and Dissection : Evaluation with Spiral CT Angiography
Authors: Sharma Umesh Kumar , Gulati M S , Mukhopadhyay S
Published: September 2018

The study was undertaken for aortic evaluation and to see its usefulness for assessing aortic aneurysm,aortic dissection and pseudoaneurysm by spiral CT angiography (CTA). A total of 28 patients with aorticaneurysm (n=19), aortic dissection (n=5) and aortic pseudoaneurysm (n=4) were included. CTA findingswere compared with ultrasonography in 14, digital subtraction angiography (DSA) in 14, MRI in 9; andsurgical findings in 12 patients. CTA was an excellent imaging modality for comprehensive evaluation ofaortic aneurysm, dissection and pseudoaneurysm combining the advantage of conventional contrast enhancedCT axial images and those of angiography in the form of 3D reformatted images.Key Words: Aortic aneurysm, dissection, pseudoaneurysm, CT angiography.
Tertiary Eye Care Centre Model for Development of Paediatric Cataract Surgery Services in Developing Countries
Authors: Shrestha U D
Published: September 2018

It is estimated that every minute a child becomes bilaterally blind in developing nations. Paediatric cataract blindness presents an enormous problem to developing countries in terms of the human social burden, economic loss, and morbidity. The management of the paediatric cataract is lens aspiration with intra ocular lens implantation with anterior vitrectomy. The surgery should be performed by paediatric ophthalmologist in tertiary eye care centres. Facilities of general anaesthesia should be available in these centres and the operating theatres should be well-equipped with vitrectomy machine, biometry and portable keratometer. Keywords: Blindness; paediatric cataract; tertiary eye care centre.
Epidemiology of Typhoid and Paratyphoid Fever in Kathmandu : Two Years Study and Trends of Antimicrobial Resistance
Authors: Malla S , Kansakar P , Serichantalergs Serichantalergs , Rahman M , Basnet S
Published: September 2018

Enteric fever is prevalent in developing countries including Nepal, where it still remains as a major healthproblem. Appropriate antibiotics are essential for the treatment of typhoid and paratyphoid fever. Aprospective study was carried out to characterize the epidemiological features of enteric fever in Kathmandu,Nepal and to analyse the recent trend of antimicrobial resistance pattern of the Salmonella isolated from thecases of enteric fever from different hospitals in Kathmandu during June, 2002 to June, 2004. A total of 1469Salmonella typhi and Salmonella paratyphi ‘A’ isolates collected during this period from five different hospitallaboratories situated in Kathmandu were studied. The antimicrobial susceptibilities of the isolates towardsAmpicillin (10mcg), Chloramphenicol (30mcg), Cotrimoxazole (25mcg), Ciprofloxacin (5mcg) and Ceftriaxone(5mcg) were determined by standard disc diffusion technique and Agar dilution technique were used todetermine the minimum inhibitory concentration (MIC) for Ampicillin, Ciprofloxacin, Chloramphenicoland Ceftriaxone. All the isolates tested were found to be sensitive to Ceftriaxone and Ciprofloxacin, the mostcommonly used antibiotic for treatment of enteric fever in Nepal. Of the total isolates studied, 15.5% from2002, 8% from 2003 and 3.45% from 2004 were found to be multidrug resistant (exhibiting resistance towardsAmpicillin, Chloramphenicol and Cotrimoxazole). Of the total multi drug resistant Salmonella isolates, 92%were Salmonella typhi. All the multidrug resistant isolates were also further tested for susceptibilities towardsTetracycline (30mcg), Nalidixic acid (30 mcg), Streptomycin (10units), Gentamycin (25mcg), Azithromycin(15mcg), Kanamycin (30mcg), Neomycin (30mcg). 50% of the multi drug resistant Salmonella typhi werealso resistant to Tetracycline. Plasmid analysis revealed that all of the Mutidrug resistant Salmonella typhiisolates with Tetracycline resistance harbored a large molecular weight (147 Kb) plasmid.Key Words: Enteric fever, Salmonella, Antibiotic, Plasmid, Multidrugresistant
Paroxysmal Nocturnal Hemoglobinuria
Authors: Paudyal Buddhi P , Zimmerman M , Karki A , Neupane H , Kayastha G
Published: September 2018

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hemolytic disorder of acquired origin and is clinically manifested by chronic hemolysis, thromboses in various sites, and bone marrow failure. The disease isso rare that the delay in the diagnosis is not uncommon and this bears a tremendous impact on patientmanagement. We present this case to draw attention to this uncommon cause of hemolytic anemia, whichshould be considered in any patient, of any age, who has signs of chronic hemolysis.Key Words: Paroxysmal Nocturnal Hemoglobinuria, Hemolytic anemia.
Doctor's Role in Early Detection of Diabetic Retinopathy and Prevention of Blindness from its Complications
Authors: Subedi Sudesh , Subedi K U , Badhu B P
Published: September 2018

Diabetic retinopathy (DR) is a microangiopathy, which is caused by chronic hyperglycemia, affecting theretinal arterioles, capillaries and venules, complications of which lead to incurable blindness.Approximately 10% of the diabetic population has type I diabetes mellitus (DM) which is diagnosed beforethe age of 30 years1 and rest is type II which is diagnosed after the age of 30 years. In UK 2% generalpopulation is affected by DM. In developed countries, diabetic retinopathy is an important and leadingcause of blindness in working age group where as in developing western countries this figure occupy 12% ofthe blindness.In developing countries like Nepal, cataract still remains a main cause of blindness and diabetes is notconsidered as a major problem. However due to a rapid urbanization and modernization of population,diabetes mellitus is becoming an endemic disease and bringing a new challenge in blindness reduction program.Key Words: Early detection of DR, Classification of DR, Complications, Prevention of blindness.
AMPUTATION REVISION IN AN ASIAN REHABILITATION CENTRE
Authors: Schwarz Richard J
Published: September 2018

A retrospective study was carried out of amputation revisions performed at Green Pastures Hospital andRehabilitation Centre between Jan 1990 and April 2004. The purpose was to determine the reasons forrevision and whether these were preventable, and as well assess the outcome of the revision itself. A totalof 26 revisions were performed; in 18 cases the primary amputation had been performed at anothercentre. The primary amputations were due principally to trauma, vascular disease and complications ofleprosy. A poorly formed stump was the most common indication for revision (9), followed by recurrentulceration (5) and infection (3). In 16 cases the need for revision was probably preventable. Only onepatient required an amputation at a higher level. Prior to revision only one patient was able to wear aprosthesis; all but one patient were able to ambulate with their prosthesis following revision in a mediantime of eight weeks. Amputation revision in a rehabilitation centre has a high success rate in ambulationwith a low complication rate. Greater attention to detail during the primary amputation will prevent theneed for revision in many cases.Key Words: Amputation, Revision, Rehabilitation, Complications.
A COMPARATIVE STUDY OF ONDANSETRON VERSUS METOCLOPRAMIDE IN THE PREVENTION OF POST-OPERATIVE VOMITING IN ROUTINE MAJOR GYNECOLOGICAL SURGERY UNDER GENERAL ANESTHESIA
Authors: Shrestha Babu Raja
Published: September 2018

This is a comparative study of ondansetron versus metoclopramide in the prevention of post-operativevomiting in routine major gynecological surgery under general anesthesia. The purpose of this study was toperform a comparative study of injection ondansetron 8 mg I.V. with injection metoclopramide 10 mg I.V.in preventing post-operative vomiting.This was a randomized, double blinded study conducted in sixtypatients of American Society of Anaesthesiologist (ASA) I and ASA II undergoing routine major gynecologicalsurgery (Transabdominal Hysterectomy, laprotomy and cystectomy, tubal surgery) under general anesthesia.Either of the drug was diluted to 5 ml of normal saline and given intravenously prior to induction ofanesthesia. The post-operative period of first 24 hours was divided into two phases, the early (0-6 hrs.) andlate (6-24 hrs.). The frequencies of vomiting and requirement of rescue antiemetics in both groups werestudied. The general characteristics of the patients in the two groups were similar. In both groups, induction,maintenance, duration of anesthesia as well as the type of surgery and opioids requirement were similar.The data recorded were statistically analyzed using Chi -square test and t - test. The frequency of vomitingwas less in ondansetron group compared to metoclopramide group. Rescue antiemetics was given only oncein ondansetron group patients, whereas the need of rescue antiemetics was eight times in the metoclopramidegroup. The difference was statistically significant (p=0.03). No unwanted effects were noticed in both groups.Ondansetron seems more effective in preventing Post-Operative Nausea & Vomiting (PONV) thanmetoclopramide but it has to be evaluated further by more clinical trials and tests in larger series.Key Words: Antiemetics, vomiting, general anesthesia, gynaecological surgery.
A COMPARATIVE EVALUATION OF PRESCRIBING PRACTICE OF ANTIBIOTIC PROPHYLAXIS IN HOSPITALS OF POKHARA VALLEY
Authors: Palikhe Nami , Pokhrel A
Published: September 2018

The main objective of the study was to assess the prescribing practice of antibiotic prophylaxis for differentsurgeries in hospitals of Pokhara valley. A descriptive, quantitative, retrospective study was used to evaluatethe patients who have undergone surgery between 15th April 2002 – 14th April 2003. A total of 950 patientswere taken from the medical record for the study. Data about patient (age, sex), surgery (type and indication),antibiotic/s prophylaxis (dose, duration) and length of hospital stay were collected. Caesarean Section (CS)was the common surgery in Western Regional Hospital (WRH) followed by cholecystectomy, 31.1% and24.4% respectively. In Manipal Teaching Hospital (MTH), dilatation and currettage (D and C, 21.6%) wasthe most common surgery followed by hysterectomy (21%). The mean length of stay in MTH for CS surgerywas 7.97 days whereas 7.01 days for WRH. Significant difference was found in length of stay of two hospitals(p<0.05). Antibiotic prophylaxis was given preoperatively in MTH (87%) and WRH (79.5%) respectively.Antibiotic prophylaxis was given intraoperatively in 1.2% cases of MTH. In MTH, the total antibioticduration in all surgeries is higher than WRH, significant difference was found only in cholecystectomy(p<0.05). In both hospitals Ampicillin+Cloxacillin was the most commonly used regimen, 12.4% in WRHand 34% in MTH. In WRH, Ciprofloxacin/Cefotaxim was also used by 12.4%. More than 79.1% of thepatients were exposed to, at least, two antibiotics as a prophylaxis in WRH where as more than 63.0% inMTH. Penicillin was found to be mostly used in both hospitals.Key Words: Antibiotic prophylaxis, Surgery.
SURGERY IN RURAL NEPAL
Authors: Prasad Pratap Narayan , Thakur R S , Aacharya R P
Published: September 2018

The curriculum of the post graduate program in General Practice in Nepal is designed to developcomprehensive and effective health care as well as timely life-saving surgical services in the District Hospital.District hospitals in rural Nepal encounter many surgical emergencies. Most of the times, the patient cannot afford to go to higher centers. General Practitioners (GPs) are effectively providing surgical services atdistrict hospitals. The aim of this study is to focus the types of surgical cases that were managed by GP andestablish the role and utilization of General Practice (GP) specialist as a surgeon at district, zonal andregional hospitals in developing countries. This is retrospective study of all cases at district hospital, Surkhet,(25 beds) of western part of Nepal during the period of one year (March 2000 to February 2001), that weremanaged by GPs. The surgical services provided by GP specialist at the district hospital were analyzed. Atotal of 16,975 cases were attended in the hospital during above period. Out of this, a total of 2,327(13.7%)were hospitalized. The total numbers of surgical cases were 1,205(51.8%). Out of this, 514(42.7%) caseshad undergone surgery. The general surgery cases comprise 447(87.0%), Gynae / Obstetric and Orthopediccases 67(13.0%). All surgeries were performed in limited resources by GPs. GP specialist can effectivelymanage the surgical cases and perform surgery at the district hospital competently. In country like Nepal,where number of surgical specialist are less and not available in majority hospitals, GPs can substitute thesurgical specialist and provide emergency surgical services in urban areas (zonal and regional hospitals).Key Words: Surgery, Rural, General Practice, Nepal.
INFECTIVE ENDOCARDITIS DUE T O SALMONELLA TYPHI
Authors: Khanal Basudha , Sharma S K , Deb M
Published: September 2018

Rheumatic Heart Disease (RHD) remains an important predisposing lesion for infective endocarditis (IE)in developing countries. IE due to Salmonella typhi is rare but associated with potentially morbidcomplications.We report a case of Salmonella typhi in a patient with rheumatic heart disease. The diagnosisof IE was confirmed on the basis of Duke’s clinical criteria. She responded to ciprofloxacin and gentamicin.Key Words: Rheumatic Heart Disease, Infective endocarditis, Salmonella typhi.
JEJUNO-JEJUNAL INTUSSUSCEPTION DUE TO LIPOMA
Authors: Shrestha Sita Ram , Shah J N
Published: September 2018

Sixty eight year old lady from Kathmandu presented to Emergency Department, Patan Hospital with painand abdomen distention associated with vomiting and constipation. Abdomen examination revealed a massin infraumblical region. Emergency laparotomy for acute intestinal obstruction revealed jejuno-jejunalintussusception due to multiple lipoma of jejunum intestine. Resection anastomosis was done. Postoperativeperiod was uneventful.Key Words: Intussusception, Intestinal obstruction, Jejunum, Lipoma.
TRENDS OF ADOLESCENT CHILDBEARING IN NEPAL - LESSON AND POLICY IMPLICATION
Authors: Baral Kedar P
Published: September 2018

Adolescence is a transition period of second decade of life. What happen between age 10-19, whether goodor bad, determines how girls and boys live out their lives as adults. In addition to change in social relationship,in Nepal, marriage and child bearing are major events which have direct bearing to the health of adolescents.Fertility among adolescents in Nepal is high compare to develop countries and Nepal Family Health Survey2001 reported that only 59.6 percent married adolescent had no children. It was found that during 5 yearsperiod there is slight decrease in the prevalence of adolescent childbearing in Nepal. The best way toprevent adolescent pregnancy, as long-term measure, is by providing opportunities specially for educationand skills development through which their status increases. It is equally important to focus family planningservices and reproductive health education through health program to them.Key Words: Adolescent, adolescent childbearing, fertility, and contraceptive.
Pegylated interferon-alfa plus ribavirin therapies for chronic hepatitis C
Authors: Kanda T , Yokosuka O
Published: September 2018

Until HCV NS3/4A protease inhibitors become available at the end of 2011, the combination pegylated-interferon (PEG-IFN)-alfa and ribavirin (RBV) will remain the standard treatment for chronic hepatitis C patients. In some hepatitis C virus-infected patients, PEG-IFN plus RBV treatment against HCV should continue to be used because of side effects of new drugs such as anemia. Our Japanese experiences should provide new information for the treatment of chronic hepatitis C. 

Keywords: Direct-acting antiviral agents (DAA), HCV, pegylated interferon, ribavirin, standard of care (SOC ).
Values of Lymphocyte Subsets in Nepalese Healthy Adult Population
Authors: Shakya G , Dumre S P , Malla S , Sharma M , KC K P , Chhetri D B , Amatya R , Paudyal P
Published: September 2018

Introduction: CD4 T lymphocyte is the most commonly used cellular marker in tracking Human Immunodeficiency Virus (HIV) infection progression and monitoring effect of antiretroviral therapy (ART). Due to lack of local reference values of CD4 and other T lymphocytes in Nepal, most clinical decisions are based on the reference renges of western countries. 

Methods: This study was conducted at three major hospitals/laboratory of central, eastern and western Nepal during November 2008 through July 2009. Using the predefined criteria, 602 (200, 202 and 200 from central, eastern and western regions respectively) healthy adult volunteers of age range 18-60 years were recruited wiht equal representation from each age group and sex. Blood specimens were screened for HIV following standard algorithm using ELISA and two rapid test kits based on different principles. Samples with discordant test-results were excluded. HIV sero-negative specimens were further analyzed for CD4, CD8 and CD4:CD8 ratio, and absolute lymphocyte count (ALC) by FACS count (Becton Dickinson, USA) and automated cell counter (BC-3000 Plus, Shenzhen Mindray Biomedical Electronics, Germany) respectively.

Results: The average value (mean± standard deviation) of CD4, CD8, CD4/CD8 ratio and ALC of Nepalese adult population were found to be 786 ± 248, 567±230, 1.52 ± 0.59 and 2712 ± 836 respectively. All four parameters but CD8 were significantly different with sex and females had relatively higher values. However, none of these parameters reported significant difference with age except the ALC.

Conclusions: Nepalese healthy adult populations have significantly different T lymphocyte subsets compared to other countries. The present reference ranges of CD4 and other T lymphocytes may be used for any clinical purposes including classifying and monitoring disease status in HIV infected individuals, immune status evaluation, monitoring ART and accordingly making amendment in national HIV treatment guidelines in Nepal.

Keywords:Absolute lymphocyte count, CD4, CD8, human immunodeficiency virus, T lymphocytes.
Organism Isolation in Corneal Ulcer- Utility of Different Techniques
Authors: Thapa M , Sharma A K , Shah D N , KC S , Shrestha S
Published: September 2018

Introduction: Various techniques are available for isolation of microorganism in cases of microbial keratitis including conventional methods of scraping, re-scraping inoculation in different media and corneal biopsy.

Methods: This was a cross sectional descriptive study conducted from February 2002 to July 2003. A total of 161 eyes of corneal ulcers were evaluated with scraping inoculation. Re-scraping and corneal biopsy were performed in those cases which did not grow any organism in the first scraping or which did not respond to initial treatment.

Results: Microorganisms were isolated in 116 patients (72.04%) after first scraping. S pneumoniae was seen in 50(42%), Fusarium in 21(18%) and Aspergillus in 16(14%) cases. Re-scraping was done in 22 culture negative and non improving cases of which 14 (63.63%) showed isolation of organisms. After re-scraping, Fusarium and Aspergillus were isolated in four patients each (18% each) followed by S. pneumoniae in 3 (14%), S. aureus in 2 (9%), and Penicillium in 1(5%) case.Corneal biopsy was done in 10 cases with isolation of microbial agents in 7 (70%) with Aspergillus and S. aureus in three each, and S. epidermidis in 1(10%).

Conclusions: Apart from conventional scraping, other isolation techniques should be considered in the treatment of non-responding and culture negative cases of corneal ulcers. Compared to bacteria, fungi are difficult to isolate in the first scraping and requires more frequent repeat scraping and corneal biopsy.

Keywords: Corneal biopsy, corneal scraping, corneal ulcer, microbial keratitis, organismal isolation.
ANTIMICROBIAL UTILIZATION PATTERN IN A TEACHING DISTRICT HOSPITAL OF NEPAL
Authors: Das B P , Sethi A , Rauniar G P
Published: September 2018

The objective of this study was to monitor the antimicrobial utilization in a teaching district hospital and tocompare it against the rational antimicrobial use guidelines.Total 106 data sheet of indoor patients admitted in year 2001 were randomly chosen and analyzed. Thenumber of antimicrobials prescribed in every prescription was taken into account to calculate the incidenceof use of more than one antimicrobial agent. The Patient sheet included patient information, drug information(name, indication, dose, frequency and duration of antimicrobial use), diagnosis or provisional diagnosisand investigations. Prescription auditing was done on the selected prescriptions.Male: female ratio was 40:65. In 90.57% diagnosis was established empirically and in only 4.7 % patientsconfirmatory diagnosis was made using relevant investigations. The antimicrobials were prescribed chieflyfor respiratory tract infections (RTI -26.41%), gastrointestinal infections (GIT -22.64%), genital tractinfection (13.20%), wound infections (8.48%), urinary tract infections (UTI-6.6%), bone & joint infections(4.71%) and miscellaneous (Typhoid, Malaria, meningitis etc-17.92%). The causative organism wasconfirmed using culture & sensitivity tests in only one patient (0.94%) out of 106 patients. In 77 (69.8%)patient prescriptions suspected pathogenic organisms were mentioned. These were streptococcus (29.58%),Chlamydia (11.27%), mycoplasma (18.30%), staphylococcus (23.94%), E. coli (32.39%) and S. typhi(15.49%). In 35 prescriptions (33.01) no causative organism was mentioned. It was further observed that atotal 452 drugs (i.e. 4.26 drugs per patient), out of this only 165 antimicrobials (1.55 antimicrobials perpatient) were prescribed in the 106 enrolled prescriptions. On further analysis of antimicrobials use, it wasobserved that most patients were prescribed a single antimicrobial agent (58.49%), two AMAs (24.52%),three AMAs (13.20%) and least was four AMAs (3.77%).The antimicrobials were given prophylacticallyin 14 (13.10%) and therapeutically in 85 (80.18%) prescriptions. The use of antimicrobials were not indicatedin 7(6.60%) prescriptions.. In 91 cases (85.85%) duration for which AMAs were considered was notmentioned. Ampicillin + cloxacillin (12.12%), ciprofloxacin (10.30%), metronidazole (10.30%), amoxycillin(10.30%) and cephalosporins (25.47%) were the most frequently prescribed AMAs. A fixed dose combinationof ampicillin & cloxacillin, ciprofloxacin and metronidazole were recurrently prescribed while gentamicin,cotrimoxazole and crystalline penicillin were relatively least prescribed antimicrobials agents.Inappropriate and irrationality in the Antimicrobial prescribing pattern was observed.Das B P*, Sethi A*, Rauniar G P*Key Words: Antimicrobial agent, Respiratory tract infection (RTI), urinary tract infection (UTI),gastrointestinal infection, prophylaxis, therapeutic.