bluuebunny/crossref_metadata_2025 huggingface dataset:
A genetic perspective of Metformin induced Vitamin B12 deficiency in Type 2 Diabetes mellitus patients
Authors: Cassinadane Ananda Vayaravel , Ramaswamy Ramesh , Govindarajan Radhika , Srinivasan Abu Raghavan
Published: January 2018

Metformin, a commonly prescribed hypoglycemic agent is a first line medication for the management of Type 2 diabetes mellitus. Numerous studies have depicted that metformin therapy has been associated with vitamin B12 and folate deficiency. Vitamin B12 deficiency is frequently missed or misdiagnosed by the clinicians because it is not routinely tested by most of the physicians, further the low end of the laboratory reference range is too low and misinterpreted as diabetic peripheral neuropathy. Vitamin B12 deficiency is a silent epidemic with serious consequences. Long term use of metformin has been associated with increased homocysteine levels and malabsorption of vitamin B12 leading to its deficiency and  neurological manifestations. Polymorphisms of certain genes associated with the metabolism of vitamin B12 and folate might help in predicting the deficiency status of vitamin B12.Asian Journal of Medical Sciences Vol.9(1) 2018 11-14
Eight decades of asymptomatic Morgagni Hernia
Authors: Manappallil Robin George , Sabir Mele Chelakkoth , Rahman Shameemu
Published: January 2018

NO ABSTRACTAsian Journal of Medical Sciences Vol.9(1) 2018 73-74
Palliative Care in Resource-poor Settings: Inequalities, Challenges, and Opportunities
Authors: Dangal Ganesh , Paudel Bishnu Dutta , Jha Anjani Kumar
Published: January 2018

N/A
Public Health Interventions for Control of Malaria in the Population Living in the Terai Region of Nepal
Authors: Awasthi Kiran Raj , Adefemi Kazeem , Awasthi Mamata Sherpa , Chalise Binaya
Published: January 2018

Infectious diseases are a major problem for developing countries. Controlling and eradicating these diseases have remained a challenge because of the multitudes of social and environmental factors involved. However, a multi-sectoral and collective effort in dealing with these diseases has been shown to result in positive outcomes. This paper looks at the current situation of Malaria in Nepal and a population that is at high risk. It explains the impact that social and environmental determinants have on this target population. This review then critically examines the various possible public health interventions that could potentially help in the control of malaria in this high risk population, drawing from evidences and experiences reported from other countries with suggestions for adapting these interventions to the Nepali environment.
Safety and Efficacy of Intravenous Ferric Carboxy Maltose in Iron Deficiency Anaemia During Postpartum Period
Authors: Mishra Vineet , Roy Priyankur , Gandhi Khushali , Choudhary Sumesh , Aggarwal Rohina , Hokabaj Shaheen
Published: January 2018

Background: Iron deficiency is the commonest treatable cause of postpartum anaemia. Parenteral iron therapy results in faster and higher replenishment of iron stores and correction of haemoglobin levels with better compliance. Ferric Carboxy Maltose is an effective and a safe option which can be administered intravenously in single total correction dose without any serious adverse effects.The study was done to evaluate the efficacy and safety of Ferric Carboxy Maltose in the treatment of iron deficiency anaemia in post-natal patients.Methods: It was an open, single arm study including 615 women with diagnosis of Iron deficiency anaemia and haemoglobin (Hb) levels between 4gm% and 11gm% from January 2013 to December 2016. Intravenous Ferric Carboxy Maltose(500-1500mg) was administered and the improvement in haemoglobin levels and iron stores were assessed after three weeks of total dose infusion.Results: Out of the 615 women, 595 women were included in the analysis. Most of the women were in the age group of 27-30 years. Most of the women had mild anaemia as per World Health Organisation guidelines. Mean hemoglobin levels significantly increased over a period of three weeks after Ferric Carboxy Maltose administration. Other parameters like total iron binding capacity, Ferritin and Iron also had a significant improvement after Ferric Carboxy Maltose administration. No serious adverse events were observed after Ferric Carboxy Maltose.Conclusions: Intravenous Ferric Carboxy Maltose was an effective and a safe treatment option for iron deficiency anaemia and has an advantage of single administration of high doses without serious adverse effects.
Knowledge, Attitude, and Practice on Menstrual Hygiene Management among School Adolescents
Authors: Yadav Ram Naresh , Joshi Shrijana , Poudel Rajesh , Pandeya Pawan
Published: January 2018

Background: Menstrual hygiene management remains a taboo in many communities in Nepal. Cultural beliefs about menstruation such as food taboos and untouchability have negative impact on dignity, health and education of adolescent girls. The objective of the study was to assess the current knowledge, attitude and practice of school adolescents on menstrual hygiene management in Doti District in Far-Western Nepal.Methods: This cross-sectional study was carried out from October to December 2016 at seven village development committees in Doti district, Nepal. This study was done among 276 students from grade seven and eight of 11 schools. Self-administered structured questionnaire was used to obtain information from school students. Descriptive analysis was done to analyse the knowledge, attitude and practice of school adolescents on menstrual hygiene management.Results: 67.4% respondents had fair knowledge and 26.4% respondents had good knowledge on menstrual hygiene management. However, out of 141 female adolescent respondents, only 56 (40%) were engaged in good menstrual hygiene practices. Around half of the respondents had positive attitude towards menstrual hygiene management related issues.Conclusions: Although knowledge on menstrual hygiene management among school adolescents is fair, still attitude and practice need to improve. Findings indicate the need of behavior change communication campaigns along with frequent reinforcement of school health education programs.
Magnetic Resonance Imaging Findings in Spondylodiscitis
Authors: Panta Om Biju , Pathak Yagya Raj , Karki Dan Bahadur
Published: January 2018

Background: Magnetic Resonance Imaging is the imaging modality of choice for imaging spinal infection due to its high sensitivity and specificity. This study aims to study the magnetic resonance imaging changes in patients with spondylodiscitis.Methods: The study was a retrospective study carried in a multimodality imaging centre in Kathmandu. Magnetic resonance imaging records and clinical record of 3 years duration were reviewed and patients with clinical and radiological diagnosis of spondylodiscitis were included in the study. Three radiologists interpreted Magnetic Resonance Imaging with mutual consensus in disputed issues. Data analysis was done with Statistical Package for Social Sciences21.0.Results: A total of 52 patients were included in the study. The mean age of the patients was 43.9 ± 17.6 years. Spondylodiscitis involved lumbar spine in 26(50%) case, cervical and thoracic spine in 13(25%) cases each. Multiple IV discs were involved in 24(46.2%) cases, which was most common in cervical spine and least common in thoracic spine. Only one vertebral end plate was involved in 16(30.8%) cases. Epidural collection was seen in 23(44.2%) cases and paravertebral collection was noted in 63(33.5%) cases. Statistical significant difference in region of spine involved (p=0.02) and epidural collection (p=0.04) was noted between genders.Conclusions: Lumbar spine was the most common level involved with spondylodiscitis, perivertebral enhancing soft tissue was present in all cases, and involvement of disc and the endplates were the most common pattern.
Organ Dysfunctions among Deaths in Critically Ill Patients
Authors: Maharjan Leison , Shah Aarzoo , Bajracharya Uday , Shrestha Gambhir
Published: January 2018

Background: Multiple organ failure is recognized as the final pathway preceding majority of deaths in intensive care unit. This study aims to find out the prevalence of organ dysfunctions/ failures in patients at the time of their demise irrespective of the underlying diseases in a tertiary care hospital. Methods: This study was done in medical intensive care unit of Blue Cross Hospital. Medical records of all deceased patients in two years period were thoroughly reviewed retrospectively. Status of six organ systems was categorized into five sub-groups: No organ dysfunction, Mild organ dysfunction, Acute organ failure, Acute-on-chronic organ failure, and Chronic organ failure. The proportion of organ dysfunction involved was analyzed along with other variables.Results: Among 204 deaths, majority 165 (80.9%) had Multiple Organ Dysfunction Syndrome. Circulatory system was most affected system with “acute organ failure” 134 (65.5%) followed by acute respiratory failure 128 (62.7%), and acute neurologic failure 114 (55.8%). Neurologic system was most affected with “mild organ dysfunction” 47 (23%) followed by Respiratory system and Renal system. Of the patients who had chronic organ failures at the time of admission, 72 (81.8%) developed “acute-on-chronic failures”.Conclusions: Multiple Organ Dysfunction Syndrome was present in the majority of deaths in critically ill patients. Most common acutely failed organ was the circulatory system.
Factors Associated with the Utilization of Institutional Delivery Service among Mothers
Authors: Pathak Pratima , Shrestha Shovana , Devkota Rashmi , Thapa Basanta
Published: January 2018

Background: Assessment of utilization of institutional delivery services is crucial to reduce risk of maternal mortality and morbidity in countries like Nepal. This study was conducted to find out the proportion of utilization of institutional delivery service and associated factors among mothers.Methods: Data was collected from the total of 129 mothers of Kathar VDC, Chitwan district who delivered baby within last one year proceeding the period of data collection using census method. Descriptive statistics and binary logistic regression analysis were applied.Results: Out of 129 mothers, 78.3% had their delivery in the health facilities. Binary logistic analysis showed number of factors associated with utilization of institutional delivery service such as ethnicity, respondents educational level, number of pregnancy, number of ANC visit and birth preparedness status. But in the multivariable logistic regression analysis, no. of ANC visit (AOR = 10.03, 95 % CI = 1.02-98.29) was only independent factors affecting institutional delivery service utilization.Conclusions: A number of factors have been shown to affect the utilization of institutional delivery. Therefore, concerned authority should plan and implement awareness programme aiming at increasing antenatal clinic visits and utilization of institutional delivery service.
Workplace Violence and its Associated Factors among Nurses
Authors: Pandey Manisha , Bhandari Tulsi Ram , Dangal Ganesh
Published: January 2018

Background: Workplace violence among nurses is prevalent worldwide. If nurses become aware of the workplace violence and its risk factors then only they can protect themselves. This study assessed the prevalence of workplace violence and its associated factors among nurses in Pokhara, Nepal. Methods: A hospital-based descriptive cross-sectional study was conducted in Pokhara. The required sample size of the study was 200 nurses. We adopted self-administered questionnaire developed by International Labor Office, International Council of Nurses, World Health Organization (WHO), and Public Services International. Out of 21 hospitals of Pokhara, we selected five hospitals using simple random sampling method. The number of nurses in each hospital was fixed proportionately considering the total number of employed nurses. Individual nurses were selected on the first meet first basis to gain the required number. Results: Two-thirds (64.5%) nurses experienced some type of violence in the last six months at their workplace. The proportion of verbal violence was higher (61.5%) compared to the physical (15.5%) and sexual violence (9%). Most perpetrators of the violence were the relatives of patients and hospital employees. Age of nurses and working stations had statistically significant association with workplace violence (p-value < 0.05). Conclusions: Workplace violence among nurses is a noteworthy problem in Pokhara whereas nearly two-thirds of nurses faced some type of violence in last six months. It is an urge to widen awareness level of nurses on the violence thus, they can take precaution themselves and ask hospital administration and other stakeholders to address the workplace violence.
Prevalence and Awareness of Hypertension among Adults and its Related Risk Factors
Authors: Maharjan Basant
Published: January 2018

Background: Hypertension is a modifiable risk factor for cardiovascular diseases. Various studies conducted in the world showed high prevalence of hypertension, which is in increasing trend in Nepal also. The aim of this study was to assess hypertension status and risk behaviours among adult population in Kirtipur Municipality. Methods: A cross sectional descriptive study was conducted among 580 adults of age 20 - 59 from December 2015 to April 2016. Data was collected by observation method to determine hypertension prevalence and Body Mass Index. Questionnaire was used to assess exposure to the risk factors. Results: Among all hypertension prevalence was 37.0% (215 out of 580). The prevalence was 41.6% (110 out of 264) among male and 32.2% (105 out of 316) among female (P <0.03 at 95% CI). Among 215 hypertensives, 37.2% were not aware about themselves having hypertension. Within last 12 months, 453 (78.1%) participants had checked their blood pressure. Proportion of hypertension was increasing with higher BMI and advancing age. Among all, 136 (23.7%) were current smokers, and 58.1% among them had hypertension.Conclusions: This study indicated that hypertension prevalence was high among adults in Kirtipur municipality. Prevalence of smoking was also high, and among them hypertension prevalence was very high. About one-third participants with hypertension were not aware that they had hypertension. Habit of doing regular physical exercise was very low.
Oral Cancer Knowledge and Awareness in Patients Visiting Kantipur Dental College
Authors: Bajracharya Dipshikha , Gupta Sujaya , Sapkota Manish , Bhatta Shishir
Published: January 2018

Background: Lack of knowledge and awareness about oral cancer, its risk factors and negligence of the early warning signs play crucial role in raising the incidence of the disease. The present study was carried out to evaluate the awareness of oral cancer among patients visiting Kantipur Dental College, Kathmandu, Nepal.Methods: The cross-sectional study was done in 471 patients from 15-85 years. Self administered questionnaire was prepared which comprised of knowledge of oral cancer, source of information, its early signs and symptoms along with the awareness of its risk factors.Results: Most of the participants (41.80%) had not heard of oral cancer. 31.60% recognized tobacco smoking and tobacco chewing as the chief risk factor with 15.50% and 10.80% of participants who identified white patch and red patch as early sign of oral cancer respectively. Pearson’s chi square test was used which showed statistically significant association of total mean knowledge score and awareness score with age, education level and occupation (p<0.05).Conclusions: This study done in dental patients showed lack of knowledge and awareness in general public about oral cancer. There seem to be a need for more planned awareness programs through newspapers, radio, television and health campaigns regarding the association of habits in the development of oral cancer and benefits of detecting oral cancer at early stage for better prognosis.
Motivational Profiles of Medical Students of Nepalese Army Institute of Health Sciences
Authors: Shrestha Lochana , Pant Shambhu Nath
Published: January 2018

Background: Students enter the medical study with different types of motives. Given the importance of academic motivation for good academic achievement of the students, the present study was designed to reveal the possible relationship between academic motivation and achievement in medical students.Methods: In this cross-sectional study medical students (N=364) of Nepalese Army institute of Health Sciences were participated and classified to different subgroups using intrinsic and controlled motivation scores. Cluster membership was used as an independent variable to assess differences in study strategies and academic performance. Results: Four clusters were obtained: High Intrinsic High Controlled, Low Intrinsic High Controlled, High Intrinsic Low Controlled, and Low Intrinsic Low Controlled. High Intrinsic High Controlled and High Intrinsic Low Controlled profile students constituted 36.1%, 22.6% of the population, respectively. No significant differences were observed as regards to deep strategy and surface strategy between high interest status motivated and high interest-motivated students. However, both of the clusters had significantly deeper, surface strategy and better academic performance than status-motivated and low-motivation clusters (p < 0.001). Conclusions: The interest status motivated and interest-motivated medical students were associated with good deep and surface study strategy and good academic performance. Low-motivation and status-motivated students were associated with the least academic performance with less interest learning behaviors. This reflected that motivation is important required component for good learning outcomes for medical student.
Assessing Caregiver Burden in Caregivers of Patients with Schizophrenia and Bipolar Affective Disorder in Kathmandu Medical College
Authors: Sharma Rachana , Sharma Subhash Chandra , Pradhan Sudarshan N
Published: January 2018

Background: Schizophrenia and bipolar affective disorder are chronic psychiatric illness that requires long term care. This study tends to measure psychological burden and factors associated with it among caregivers of these two illnesses.Methods: This is a cross- sectional study that included participants by purposive sampling method. Self designed performa was used to collect the socio-demographic details of the caregivers. Modified caregiver strain index was used to assess the overall stress. Beck`s depression inventory and Beck`s anxiety inventory was used to assess depression and anxiety respectively.Results: Hundred caregivers, 50 each of schizophrenia and bipolar affective disorder were enrolled. Seventy-two percent of caregivers were found to have higher level of stress. Twenty-five percent had depression and 29% anxiety related problems. Stress was found to be significantly associated with being in debt, longer duration of illness, education level, marital status, subjective feeling of psychological stress and self- acknowledgement of need of professional help. Caregivers of both group experienced similar level of stress.Conclusions: Psychological burden is seen to be high in caregivers of patients of Schizophrenia and Bipolar Affective Disorder.
Prevalence of Tuberculosis in Patients with Liver Cirrhosis
Authors: Sharma Dilip , KC Sudhamshu , Jaisi Bikash
Published: January 2018

Background: Studies have shown that patients with liver cirrhosis are more susceptible to tuberculosis because of immune dysfunction; however there are only limited data. We carried out this study to know the prevalence and clinical characteristics of tuberculosis in patients with liver cirrhosis.Methods: In this retrospective study, medical files of 200 consecutive patients admitted with diagnosis of liver cirrhosis in the medical ward of liver unit, Bir Hospital from January 2011 to December 2014 were evaluated for the presence of TB and clinical characteristics of these patients were analyzed.Results: Eighteen patients were diagnosed to have tuberculosis with a prevalence of 9%. The median age of patients with tuberculosis and liver cirrhosis was 53 (35–71) years and M: F ratio was 2:1. 67%, P=0.01). Median CTP score of patients were 8.5 (5–12) (CTP A: B: C: 3:7:8). Extra pulmonary tuberculosis was more common (67%) than pulmonary (33%). In extra pulmonary tuberculosis, distribution was as pleural effusion (n=4), abdominal (n=4), intestinal (n=2), peritoneal (n=9), and pott’s spine (n=2). Conclusions: Tuberculosis is prevalent in patients with liver cirrhosis. Extra pulmonary tuberculosis was more compared to pulmonary tuberculosis. Tuberculosis was common in decompensated liver cirrhosis than compensated liver cirrhosis .
Tuberculosis in Staff and Students of Patan Hospital
Authors: Shrestha Poojan , Shakya Mila , Caws Maxine , Shrestha Surendra , Karki Bibek , Shrestha Shreejana , Karki Dan Bahadur , Maharjan Bhagwan , Shrestha Bhawana , Arjyal Amit , Karkey Abhilasha , Prajapati Krishna G. , Basnyat Buddha
Published: January 2018

Background: There is a high risk of occupational exposure to tuberculosis among healthcare workers in endemic countries. Regular screening for tuberculosis among healthcare workers is not carried out in Nepal. Infection control measures are also not routinely implemented. The aim of this study was to determine the prevalence of active tuberculosis among staff/students at Patan Hospital.Methods: Participants were given a self-administered questionnaire and invited to undergo chest radiography. Cases were scored and reviewed based on predetermined criteria, and presumptive tuberculosis cases were invited to undergo sputum smear and culture. Participants were categorized according to the extent of patient contact and asked about history of tuberculosis medication. Results: Among 560 participants, 76.8% had direct contact with patients. Fifty-eight (10.4%) gave history of cough >2 weeks. Based on symptom history and chest radiography, 20.0% (n=112) cases were reviewed, and 12.5% (n=14) of those reviewed had sputum tested for acid-fast bacilli. One participant had culture-positive tuberculosis. Fifty participants (8.9%) reported tuberculosis in the past, among which 42.0% (n=21) occurred after employment at Patan Hospital and 42.0% before joining Patan Hospital. Security staff, radiology technicians and ward cleaning staff had the highest proportion of cases with a history of tuberculosis.History of tuberculosis medication had no relation with age, sex, education, body mass index and smoking.The incidence rate of tuberculosis at Patan Hospital was 3.6 per 1000 person-years.Conclusions: Overall incidence of tuberculosis among healthcare workers is noteworthy. However, this study suggests when symptomatic tuberculosis occurs in healthcare worker at Patan Hospital, it is diagnosed and there is not a large pool of undiagnosed tuberculosis.
Knowledge, Attitude and Practice towards Kangaroo Mother Care
Authors: Shah Rakesh Kumar , Sainju Nayan Kamal , Joshi Sunil Kumar
Published: January 2018

Background: Kangaroo mother care is an effective and low cost technique which prevents neonate from hypothermia, a leading cause of preventable neonatal mortality. Knowledge and practice of Kangaroo mother care is of utmost importance in developing countries such as Nepal. Purpose of this study was to find out knowledge, attitude and practice of kangaroo mother care among health workers in tertiary health centres in Nepal.Methods: This cross sectional study was carried out in three teaching hospitals in Nepal during the period from January 2016 to April 2016. Doctors and nurses working in Paediatrics/Neonatal and Obstetrics/Gynaecology wards were surveyed using pretested questionnaire. Responses from the doctors and the nurses were compared.Results: Response rate of the survey was 65%. All of the doctors and 95.3% of the nurses who participated in the survey had knowledge about kangaroo mother care.37.7%of the doctors and 48.8% of the nurses thought that this method is only used for neonates with low birth weight (<2500grams) (p= 0.013).Three fourth of the doctors and half of the nurses agreed that KMC is practiced regularly in their ward (p = 0.016). 22.2% participants informed that main reasons for not practicing kangaroo care regularly could be lack of skill and knowledge. Conclusions: We found that general knowledge and attitude of majority of doctors and nurses towards kangaroo mother care was good, however, its practise was not uniform.
Evaluation of Endotracheal Tube Cuff Pressure in Laparoscopic Cholecystectomy and Postoperative Sore Throat
Authors: Lakhe Gajal , Sharma Surendra Mohan
Published: January 2018

Background: The use of nitrous oxide and carboperitoneum in laparoscopic cholecystectomy lead to increase in endotracheal tube cuff pressure. It may impair tracheal mucosal perfusion with subsequent tracheal damage. The purpose of this study was to evaluate cuff pressure and incidence of post-operative sore throat in patients undergoing laparoscopic cholecystectomy.Methods: In this prospective observational study, 128 patients aged 18-65 years of American Society of Anesthesiologist physical status I and II undergoing laparoscopic cholecystectomy were enrolled and allocated alternately into two groups, Study Group (Maintenance of anesthesia with sevoflurane 1-2%, oxygen/nitrous oxide mixture; 40/60), Control Group (Maintenance of anesthesia with sevoflurane 1-2%, oxygen/air mixture; 40/60) were analysed and comapared. Each group contained 64 patients. Aneroid manometer was used to monitor cuff pressure. Volume of air used to inflate the cuff, baseline cuff pressure, comparison of intraoperative cuff pressure and incidence of postoperative sore throat were measured.Results: The study results demonstrated higher cuff pressure in study group at all times after the creation of carboperitoneum (p=0.00) with increased incidence of sore throat(p=0.004).Conclusions: Increase in endotracheal tube cuff pressure was noted with the use of nitrous oxide in laparoscopic cholecystectomy with subsequent post-operative airway complication. Monitoring of cuff pressure is simple, noninvasive and efficient way of achieving therapeutic cuff pressure of 20-30 cm of H2O and thus recommends its use.
Differences in Return of Spontaneous Circulation in Early vs Late Endotracheal Intubation among Patients in Hospital Cardiac Arrest
Authors: Shrestha Battu Kumar , Sharma Apurb , Gyawali Parbesh Kumar
Published: January 2018

Background: Common airway management strategies during cardiopulmonary resuscitation are bag- mask-valve ventilation followed by endotracheal intubation. Timing of endotracheal intubation is controversial. This study was designed to compare the effect of early vs late endotracheal intubation in terms of return of spontaneous circulation.Methods: This is an observational retrospective study done at tertiary center for the period of two years. The study population was inpatient, adult and pediatric with witnessed cardiac arrest in whom airway management was initially done with bag-valve-mask ventilation followed by endotracheal intubation. Timing of intubations were grouped into early and late with cut off time of five minutes and the groups were compared in terms of return of spontaneous circulation.Results: There were total of 193 patients included in the study. Early intubation was done in 114 patients (59.06%) and late intubation was done in 79 patients (40.94%). Mean time for early intubation was 3.11 minutes. Mean time for late intubation was 7.89 minutes. Seventy three patients (37.8%) attained sustained ROSC. Thirty five patients (30.7%) achieved ROSC in early intubation group while 38 patients (48.1%) attained sustained ROSC in late intubation group(p = 0.016). Conclusions: Early intubation during cardiopulmonary resuscitation was associated with lower rate of return of spontaneous circulation.
Critical Appraisal of Published Literature in Specialty General Surgical Examinations in the United Kingdom
Authors: Shrestha Badri Man
Published: January 2018

The specialty general surgical examination in the United Kingdom, which needs to be qualified by the higher surgical trainees towards the end of their training prior to assuming consultant responsibility, includes “academic foundation viva” as a mandatory component. This section of examination is intended to assess candidate’s ability to critically appraise published literature with regards to its validity and clinical relevance, which is essential requirement for a surgeon to be able to deliver care to his patients based on robust evidence collected from properly conducted studies. The paper aims to outline the objectives of the assessment process, the details of appraisal methodology and techniques to acquire the skill.
Caesarean Scar Endometriosis
Authors: Sedhain Nesuma , Dangal Ganesh , Karki Aruna , Pradhan Hema K , Shrestha Ranjana , Bhattachan Kabin , Poudel Rekha , Bajracharya Nishma
Published: January 2018

Endometriosis is a common benign gynecologic disorder defined as the presence of endometrial glands and stroma outside of the normal location. The overall prevalence is 8–15% in women of reproductive age group. Scar endometriosis is a rare disease, and is difficult to diagnose. It is commonly seen following obstetrical and gynecological surgeries. The symptoms are non-specific, typically involving abdominal wall pain at the incision site at the time of menstruation and palpable tender mass in the incision site. The diagnosis is frequently made only after excision of the diseased tissue and its histological analysis. We present here a case of abdominal wall scar endometriosis in a woman who had undergone a caesarean section four years ago. Surgical excision led to the diagnosis of scar endometriosis. The pathogenesis, diagnosis and treatment of this rare condition are discussed.Keywords: Abdominal wall; caesarean section; painful scar; scar endometriosis.
Tungiasis: A Rare Parasitic Infestation in Genitals of a Native Male from Kathmandu
Authors: Shrivastav Shreya , Adhikari Ram Chandra
Published: January 2018

Tungiasis is a common parasitic infection inmany parts of the world, including South and Central America and parts of Africa. It is rare in other places, such as in India and Pakistan and imported cases have been reported in Taiwan, Italy, the United States of America, etc. Our diagnosis was made based on histopathologiocal features of the parasite, which corresponds too ther reports and description of tungiasis.1-3 It was treated by surgical excision alone. The fact that the disease has never been reported in Nepal makes it difficult to diagnose clinically, but should be considered in the future. Histopathology can aid in diagnosingthis rare condition.Keywords: Nepal; tunga penetrans; tungiasis.
Partial Invasive Mole with Bilateral Torsion of Theca Lutein Cysts
Authors: Yadav Randhir Sagar , Shrestha Shumneva , Sharma Santosh , Singh Meeta , Bista Kesang Diki , Ojha Neebha
Published: January 2018

Gestational trophoblastic neoplasia is extremely rare entity accounting 1% of all gynecological malignancies. Invasive mole is a form of Gestational trophoblastic neoplasia which is locally invasive with propensity of metastasis. Association of partial mole with invasive mole and/or theca lutein cysts is a rare occurrence. Large cysts may present with complications. A case with these rare combinations presented at 15+3 weeks period of gestation as acute abdomen due to torsion of bilateral theca lutein cysts is reported. Right salpingo-ophorectomy with untwisting of left cyst was done. Six cycles of chemotherapy was given with regular βhCG monitoring. First trimester dating scan would have helped in early diagnosis, treatment and prevention of complications. Keywords: Invasive mole; theca lutein cysts; torsion.
Medical Errors in Autopsied Cases
Authors: Joob Beuy , Wiwanitkit Viroj
Published: January 2018

N/A
Defining the minimum clinically important difference for grade I degenerative lumbar spondylolisthesis: insights from the Quality Outcomes Database
Authors: Asher Anthony L. , Kerezoudis Panagiotis , Mummaneni Praveen V. , Bisson Erica F. , Glassman Steven D. , Foley Kevin T. , Slotkin Jonathan R. , Potts Eric A. , Shaffrey Mark E. , Shaffrey Christopher I. , Coric Domagoj , Knightly John J. , Park Paul , Fu Kai-Ming , Devin Clinton J. , Archer Kristin R. , Chotai Silky , Chan Andrew K. , Virk Michael S. , Bydon Mohamad
Published: January 2018

OBJECTIVE

Patient-reported outcomes (PROs) play a pivotal role in defining the value of surgical interventions for spinal disease. The concept of minimum clinically important difference (MCID) is considered the new standard for determining the effectiveness of a given treatment and describing patient satisfaction in response to that treatment. The purpose of this study was to determine the MCID associated with surgical treatment for degenerative lumbar spondylolisthesis.

METHODS

The authors queried the Quality Outcomes Database registry from July 2014 through December 2015 for patients who underwent posterior lumbar surgery for grade I degenerative spondylolisthesis. Recorded PROs included scores on the Oswestry Disability Index (ODI), EQ-5D, and numeric rating scale (NRS) for leg pain (NRS-LP) and back pain (NRS-BP). Anchor-based (using the North American Spine Society satisfaction scale) and distribution-based (half a standard deviation, small Cohen’s effect size, standard error of measurement, and minimum detectable change [MDC]) methods were used to calculate the MCID for each PRO.

RESULTS

A total of 441 patients (80 who underwent laminectomies alone and 361 who underwent fusion procedures) from 11 participating sites were included in the analysis. The changes in functional outcome scores between baseline and the 1-year postoperative evaluation were as follows: 23.5 ± 17.4 points for ODI, 0.24 ± 0.23 for EQ-5D, 4.1 ± 3.5 for NRS-LP, and 3.7 ± 3.2 for NRS-BP. The different calculation methods generated a range of MCID values for each PRO: 3.3–26.5 points for ODI, 0.04–0.3 points for EQ-5D, 0.6–4.5 points for NRS-LP, and 0.5–4.2 points for NRS-BP. The MDC approach appeared to be the most appropriate for calculating MCID because it provided a threshold greater than the measurement error and was closest to the average change difference between the satisfied and not-satisfied patients. On subgroup analysis, the MCID thresholds for laminectomy-alone patients were comparable to those for the patients who underwent arthrodesis as well as for the entire cohort.

CONCLUSIONS

The MCID for PROs was highly variable depending on the calculation technique. The MDC seems to be a statistically and clinically sound method for defining the appropriate MCID value for patients with grade I degenerative lumbar spondylolisthesis. Based on this method, the MCID values are 14.3 points for ODI, 0.2 points for EQ-5D, 1.7 points for NRS-LP, and 1.6 points for NRS-BP.
Image guidance in transdiscal fixation for high-grade spondylolisthesis in adults with correct spinal balance
Authors: Delgado-Fernández Juan , Pulido Paloma , García-Pallero María Ángeles , Blasco Guillermo , Frade-Porto Natalia , Sola Rafael G.
Published: January 2018

OBJECTIVE

Spondylolisthesis is a prevalent spine disease that recent studies estimate could be detected in 9% of the population. High-grade spondylolisthesis (HGS), however, is much less frequent, which makes it difficult to develop a general recommendation for its treatment. Posterior transdiscal fixation was proposed in 1994 for HGS, and the use of spine navigation could make this technique more accessible and reduce the morbidity associated with the procedure. The purpose of this study was to present a case series involving adult patients with HGS and correct spinal alignment who were treated with transdiscal pedicle screw placement guided with neuronavigation and compare the results to those achieved previously without image guidance.

METHODS

The authors reviewed all cases in which adult patients with correct spinal alignment were treated for HGS with posterior transdiscal instrumentation placement guided with navigation between 2014 and 2016 at their institution. The authors compared preoperative and postoperative spinopelvic parameters on standing radiographs as well as Oswestry Disability Index (ODI) scores and visual analog scale (VAS) scores for low-back pain. Follow-up CT and MRI studies and postoperative radiographs were evaluated to identify any screw malplacement or instrumentation failure. Any other intraoperative or postoperative complications were also recorded.

RESULTS

Eight patients underwent posterior transdiscal navigated instrumentation placement during this period, with a mean duration of follow-up of 16 months (range 9–24 months). Six of the patients presented with Meyerding grade III spondylolisthesis and 2 with Meyerding grade IV. In 5 cases, L4–S1 instrumentation was placed, while in the other 3 cases, surgery consisted of transdiscal L5–S1 fixation. There was no significant difference between preoperative and postoperative spinopelvic parameters. However, there was a statistically significant improvement in the mean VAS score for low-back pain (6.5 ± 1.5 vs 4 ± 1.7) and the mean ODI score (49.2 ± 19.4 vs 37.7 ± 22) (p = 0.01 and p = 0.012, respectively). Six patients reduced their use of pain medication. There were no intraoperative or postoperative complications during the hospital stay, and as of the most recent follow-up, no complications related to pseudarthrosis or hardware failure had been observed.

CONCLUSIONS

Treatment with posterior transdiscal pedicle screws with in situ fusion achieved good clinical and radiological outcomes in patients with HGS and good sagittal spinal balance. The use of navigation and image guidance was associated with improved results in this technique, including a reduction in postoperative and intraoperative complications related to screw malplacement, pseudarthrosis, and instrumentation failure.
Assessment of radiographic and clinical outcomes of an articulating expandable interbody cage in minimally invasive transforaminal lumbar interbody fusion for spondylolisthesis
Authors: Massie Lara W. , Zakaria Hesham Mostafa , Schultz Lonni R. , Basheer Azam , Buraimoh Morenikeji Ayodele , Chang Victor
Published: January 2018

OBJECTIVE

The inability to significantly improve sagittal parameters has been a limitation of minimally invasive surgery for transforaminal lumbar interbody fusion (MIS TLIF). Traditional cages have a limited capacity to restore lordosis. This study evaluates the use of a crescent-shaped articulating expandable cage (Altera) for MIS TLIF.

METHODS

This is a retrospective review of 1- and 2-level MIS TLIF. Radiographic outcomes included differences in segmental and lumbar lordosis, disc height, evidence of fusion, and any endplate violations. Clinical outcomes included the numeric rating scale for leg and back pain and the Oswestry Disability Index (ODI) for low-back pain.

RESULTS

Thirty-nine patients underwent single-level MIS TLIF, and 5 underwent 2-level MIS TLIF. The mean age was 63.1 years, with 64% women. On average, spondylolisthesis was corrected by 4.3 mm (preoperative = 6.69 mm, postoperative = 2.39 mm, p < 0.001), the segmental angle was improved by 4.94° (preoperative = 5.63°, postoperative = 10.58°, p < 0.001), and segmental height increased by 3.1 mm (preoperative = 5.09 mm, postoperative = 8.19 mm, p < 0.001). At 90 days after surgery the authors observed the following: a smaller postoperative sagittal vertical axis was associated with larger changes in back pain at 90 days (r = −0.558, p = 0.013); a larger decrease in spondylolisthesis was associated with greater improvements in ODI and back pain scores (r = −0.425, p = 0.043, and r = −0.43, p = 0.031, respectively); and a larger decrease in pelvic tilt (PT) was associated with greater improvements in back pain (r = −0.548, p = 0.043). For the 1-year PROs, the relationship between the change in PT and changes in ODI and numeric rating scale back pain were significant (r = 0.612, p = 0.009, and r = −0.803, p = 0.001, respectively) with larger decreases in PT associated with larger improvements in ODI and back pain. Overall for this study there was a 96% fusion rate.

Fourteen patients were noted to have endplate violation on intraoperative fluoroscopy during placement of the cage. Only 3 of these had progression of their subsidence, with an overall subsidence rate of 6% (3 of 49) visible on postoperative CT.

CONCLUSIONS

The use of this expandable, articulating, lordotic, or hyperlordotic interbody cage for MIS TLIF provides a significant restoration of segmental height and segmental lordosis, with associated improvements in sagittal balance parameters. Patients treated with this technique had acceptable levels of fusion and significant reductions in pain and disability.
Preoperative depression, lumbar fusion, and opioid use: an assessment of postoperative prescription, quality, and economic outcomes
Authors: O’Connell Chloe , Azad Tej Deepak , Mittal Vaishali , Vail Daniel , Johnson Eli , Desai Atman , Sun Eric , Ratliff John K. , Veeravagu Anand
Published: January 2018

OBJECTIVE

Preoperative depression has been linked to a variety of adverse outcomes following lumbar fusion, including increased pain, disability, and 30-day readmission rates. The goal of the present study was to determine whether preoperative depression is associated with increased narcotic use following lumbar fusion. Moreover, the authors examined the association between preoperative depression and a variety of secondary quality indicator and economic outcomes, including complications, 30-day readmissions, revision surgeries, likelihood of discharge home, and 1- and 2-year costs.

METHODS

A retrospective analysis was conducted using a national longitudinal administrative database (MarketScan) containing diagnostic and reimbursement data on patients with a variety of private insurance providers and Medicare for the period from 2007 to 2014. Multivariable logistic and negative binomial regressions were performed to assess the relationship between preoperative depression and the primary postoperative opioid use outcomes while controlling for demographic, comorbidity, and preoperative prescription drug–use variables. Logistic and log-linear regressions were also used to evaluate the association between depression and the secondary outcomes of complications, 30-day readmissions, revisions, likelihood of discharge home, and 1- and 2-year costs.

RESULTS

The authors identified 60,597 patients who had undergone lumbar fusion and met the study inclusion criteria, 4985 of whom also had a preoperative diagnosis of depression and 21,905 of whom had a diagnosis of spondylolisthesis at the time of surgery. A preoperative depression diagnosis was associated with increased cumulative opioid use (β = 0.25, p < 0.001), an increased risk of chronic use (OR 1.28, 95% CI 1.17–1.40), and a decreased probability of opioid cessation (OR 0.96, 95% CI 0.95–0.98) following lumbar fusion. In terms of secondary outcomes, preoperative depression was also associated with a slightly increased risk of complications (OR 1.14, 95% CI 1.03–1.25), revision fusions (OR 1.15, 95% CI 1.05–1.26), and 30-day readmissions (OR 1.19, 95% CI 1.04–1.36), although it was not significantly associated with the probability of discharge to home (OR 0.92, 95% CI 0.84–1.01). Preoperative depression also resulted in increased costs at 1 (β = 0.06, p < 0.001) and 2 (β = 0.09, p < 0.001) years postoperatively.

CONCLUSIONS

Although these findings must be interpreted in the context of the limitations inherent to retrospective studies utilizing administrative data, they provide additional evidence for the link between a preoperative diagnosis of depression and adverse outcomes, particularly increased opioid use, following lumbar fusion.
Short-term outcomes of lateral lumbar interbody fusion without decompression for the treatment of symptomatic degenerative spondylolisthesis at L4–5
Authors: Campbell Peter G. , Nunley Pierce D. , Cavanaugh David , Kerr Eubulus , Utter Philip Andrew , Frank Kelly , Stone Marcus
Published: January 2018

OBJECTIVE

Recently, authors have called into question the utility and complication index of the lateral lumbar interbody fusion procedure at the L4–5 level. Furthermore, the need for direct decompression has also been debated. Here, the authors report the clinical and radiographic outcomes of transpsoas lumbar interbody fusion, relying only on indirect decompression to treat patients with neurogenic claudication secondary to Grade 1 and 2 spondylolisthesis at the L4–5 level.

METHODS

The authors conducted a retrospective evaluation of 18 consecutive patients with Grade 1 or 2 spondylolisthesis from a prospectively maintained database. All patients underwent a transpsoas approach, followed by posterior percutaneous instrumentation without decompression. The Oswestry Disability Index (ODI) and SF-12 were administered during the clinical evaluations. Radiographic evaluation was also performed. The mean follow-up was 6.2 months.

RESULTS

Fifteen patients with Grade 1 and 3 patients with Grade 2 spondylolisthesis were identified and underwent fusion at a total of 20 levels. The mean operative time was 165 minutes for the combined anterior and posterior phases of the operation. The estimated blood loss was 113 ml. The most common cage width in the anteroposterior dimension was 22 mm (78%). Anterior thigh dysesthesia was identified on detailed sensory evaluation in 6 of 18 patients (33%); all patients experienced resolution within 6 months postoperatively. No patient had lasting sensory loss or motor deficit. The average ODI score improved 26 points by the 6-month follow-up. At the 6-month follow-up, the SF-12 mean Physical and Mental Component Summary scores improved by 11.9% and 9.6%, respectively. No patient required additional decompression postoperatively.

CONCLUSIONS

This study offers clinical results to establish lateral lumbar interbody fusion as an effective technique for the treatment of Grade 1 or 2 degenerative spondylolisthesis at L4–5. The use of this surgical approach provides a minimally invasive solution that offers excellent arthrodesis rates as well as favorable clinical and radiological outcomes, with low rates of postoperative complications. However, adhering to the techniques of transpsoas lateral surgery, such as minimal table break, an initial look-and-see approach to the psoas, clear identification of the plexus, minimal cranial caudal expansion of the retractor, mobilization of any traversing sensory nerves, and total psoas dilation times less than 20 minutes, ensures the lowest possible complication profile for both visceral and neural injuries even in the narrow safe zones when accessing the L4–5 disc space in patients with degenerative spondylolisthesis.