Journal of Nepalgunj Medical College

Bacterial Meningitis Score as Clinical Prediction Rule in Children with Acute Meningitis

Roma Km, Gaurav Jung Shah, Shyam Nandan Sah — Sat, 31 Dec 2022 00:00:00 +0000

Introduction: The early presentation of bacterial meningitis and aseptic meningitis are similar however treatment and outcome are different. The Bacterial Meningitis Score helps to differentiate bacterial meningitis from aseptic meningitis.

Aims: To evaluate bacterial meningitis score as clinical prediction rule in children with acute meningitis.

Methods: This was a hospital based prospective study done at pediatric department of Nepalgunj Medical College, Nepalgunj, a tertiary care reference hospital in Nepal, conducted from September 2020- August 2021. All the patients who were suspected of meningitis during the study period between the ages of 29 days to 15 years were included in this study.

Results: A total of 138 patients were included in our study with 86 patients as aseptic meningitis and 52 patients as bacterial meningitis. Taking cut-off point of bacterial meningitis scoreto be 1.5 it’s sensitivity and specificity was found to be 100%. Area under ROC curve was found to be 1 showing 100% predictivity of bacterial meningitis score . The outcome of aseptic meningitis group was significantly better than bacterial group.

Conclusion: Bacterial meningitis had grave prognosis associated with high mortality. Bacterial meningitis score is helpful to differentiate aseptic meningitis from bacterial meningitis to plan appropriate management timely.

Comparative Study of Temporalis Fascia Graft versus Cartilage Shield Tympanoplasty in Chronic Otitis Media - Mucosal Type

Kumar Shrestha, Dhundi Raj Paduel, Shama Bhandari, Subhash Chandra Mahaseth — Sat, 31 Dec 2022 00:00:00 +0000

Introduction: Tympanoplasty is the procedure of choice for surgical correction of tympanic membrane perforation triggered by either chronic otitis media or trauma. Various types of autologous grafts have been used to close tympanic membrane perforations among which temporalis fascia and tragal cartilage are preferred, due to their anatomic proximity, ease of harvesting and suppleness.

Aims: To compare clinical and audiological outcomes of type 1 tympanoplasty where temporalis fascia and tragal cartilage were used as the graft material.

Methods: A prospective study was conducted on 50 patients of ages ranging from 10 to 50 years with Chronic Otitis Media - Mucosal. All the patients underwent type 1 tympanoplasty and were categorized into Group-A (Temporalis fascia graft) and Group-B (Cartilage graft), each group comprising of 25 patients. Graft uptake rate, hearing gain and air bone gap closure were compared between the groups in 4 and 8 weeks after surgery.

Results: Out of total 50 patients, 20 were male and 30 were female. The average age of the patients was 28.20 years. The total hearing gain in the whole series was 14.94 dB while the total air bone gap closure was 14.78 dB respectively. The difference between pre and post-operative hearing was statistically significant for both air bone gap and air conduction, (P<0.05) in the whole series. There was 15.56 dB improvement in mean hearing threshold and 15.64 dB mean air bone gap closure in the fascia group, compared to 14.32 dB improvement in mean hearing and 13.92 dB mean air bone gap closure in the cartilage group. Graft uptake rate in the temporalis fascia group was 84% and the cartilage group was 92 % with significant difference in the graft uptake rate between the groups.

Conclusion: The graft uptake rate and hearing results of tragal cartilage are comparable to those of temporalis fascia. Cartilage tympanoplasty has a higher graft uptake rate with low failure rate and also shows a high degree of reliability in high risk cases. Both cartilage and fascia tympanoplasty provided similar improvements in the hearing outcome post-operatively. Thus, cartilage tympanoplasty is recommended as an alternative option.

Self-Assessment of Undergraduate Medical Students Regarding the Clinical Knowledge in Forensic Medicine

Sugam Shrestha, Sharmila Gurung, Binus Bhandari — Sat, 31 Dec 2022 00:00:00 +0000

Introduction: Clinical forensic medical services play crucial role in emergency department followed by all other specialty.

Aims: The preliminary survey was undertaken to assess the knowledge about the clinical forensic medicine among the medical students during their clinical posting in forensic medicine, Nepalgunj Medical College.

Methods: The questionnaire was used in this study to evaluate the student’s knowledge.

Results: As many as 108 medical students were included in the survey (70 male and 38 female). The maximum participants were 23 years old 38(35.2%) and youngest participant was 21 years old 6(5.6%). Maximum students were able to perform clinical forensic skills except traffic accident cases 27(25%) followed by gunshot wounds cases 46(42.6%). The students stated that they could master forensic pathology skills in asphyxia cases 80(74.07%) followed by dead victims in blunt and sharp violence cases 76(70.4%) and least in sudden death cases 31(28.7%), criminal abortion 43(39.8%), infanticide 45(41.7%) and sexual offences 49(45.3%). The students were able to issue medical certificate 99(91.7%) followed by issue a death certificate 98(90.7%) and provide information to the police 96(88.9%) but least could give expert statement 30(27.8%).

Conclusion: In this survey, found the validity of student self-assessment in determining the ability of clinical knowledge, it is influenced by several factors of objectivity and subjectivity of assessment in terms of students.

Comparative Study of Opioid Free versus Opioid Anaesthesia in Patients Undergoing Laparoscopic Cholecystectomy

Shailendra Shakya, Preeti Vaidya, Bibek Paudel — Sat, 31 Dec 2022 00:00:00 +0000

Introduction: Opioids have been used as a part of balanced anaesthesia and have known side effects. Opioid Free Analgesia is an emerging technique, based on avoiding intraoperative opioids.

Aims: To compare the effectiveness of opioid-free versus opioid based anaesthesia.

Methods: This comparative study involved 100 patients undergoing elective laparoscopic cholecystectomy under general anaesthesia with American Society of Anaesthesiologists I or II physical status. Out of 100 patients, 50 received Fentanyl (Group A) while another 50 (Group B) received Ketamine and Lignocaine. Parameters measured and compared were the gender, age, weight, ASA physical status, hemodynamic stability, postoperative pain intensity (VAS) and opioid requirements, as well as side effects.

Results: Both groups were comparable with regards to age, gender, weight, American Society of Anaesthesiologists I or II physical status, mean duration of surgery. There was no significant difference between groups hemodynamics at all assessed times (p>0.05) intraoperatively. Visual Analogue Scale pain score in the first 24 hours postoperatively showed that patients in Group A, at all analyzed time points had higher Visual Analogue Scale scores than Group B, but statistically significant difference was confirmed during the first hour (p = 0.001). Seven(14%) in Group A and 5(10%) patients in Group B got intravenous tramadol only once while 5(10%) patients in Group A required twice, which was statistically significant (p=0.05). Intraoperatively, 2 patients (4%) in group A had bradycardia while none in group B, which was statistically insignificant (p=0.153). Postoperatively, nausea was more in group A than Group B i.e. 8% vs 4% (p=0.4).

Conclusion: Opioid Free anaesthesia has a better benefit over Opioid anaesthesia with regard to postoperative pain score, opioid consumption and its side effects.

Radiopathological Correlation in Diagnosis of Adnexal Lesions: A Hospital Based Comparative Study

Sat, 31 Dec 2022 00:00:00 +0000

Introduction: Transabdominal and transvaginal ultrasound can be used in distinguishing lesions of adnexa. Transvaginal ultrasound has higher diagnostic accuracy than transabdominal ultrasound when compared with gold standard histopathology. It also provides better resolution as compared to transabdominal ultrasound.

Aims: To find the diagnostic accuracy and efficacy of transvaginal and transabdominal sonographic techniques in adnexal pathologies by comparing against the gold standard of biopsy.

Methods: Hospital based cross sectional comparative study done in 108 cases who underwent transabdominal and transvaginal sonography and histopathological study post operatively. Diagnostic findings of transabdominal and transvaginal sonogram were compared with the diagnosis of histopathology.

Results: Of total 108 cases, most cases were benign. Sensitivity, specificity, accuracy, positive predictive value and negative predictive value for transabdominal were 63.15 %, 95.5%, 89.8%, 75% and 92.3% respectively. Sensitivity, specificity, accuracy, positive predictive value and negative predictive values of transvaginal were 73.6%, 95.5%, 91.6%, 77.7% and 94.4% respectively.

Conclusion: Transvaginal sonography has higher diagnostic accuracy as compared to transabdominal ultrasonography.

Rouviere’s Sulcus: An Important Anatomical Landmark in Laparoscopic Cholecystectomy

Suraj Raj Bhattarai, Poonam Acharya, Prabin Kumar Yadav, Paras Rajbhandari — Sat, 31 Dec 2022 00:00:00 +0000

Introduction: Though laparoscopic cholecystectomy is a gold standard treatment for symptomatic cholelithiasis, safe dissection of Calot's triangle is important to avoid major complications like injury to bile duct, vessels and nearby organs.

Aims: This study was designed to determine the frequency, description of Rouviere’s sulcus and its role in safe laparoscopic cholecystectomy.

Methods:This prospective cross-sectional study was conducted at the Department of Surgery, Karuna Hospital, Nepal from January 2022 to September 2022. Patients who underwent laparoscopic cholecystectomy, presence of Rouviere’s sulcus were identified and classified, kept in Group A and absent in Group B. If the common bile duct outline visualized, its relation with Rouviere’s sulcus was noted and used as reference point for gall bladder dissection. The perioperative complications, conversion to open procedure, operative time and hospital stay were recorded.

Results: Among 100 patients, the Rouviere’s sulcus was present in 79% and absent in 21%. Type I is the most common (65.82%). It was found above the level of common bile duct line in 84.81%. Cystic artery injury was present in 1.26% (Group A) and 14.28% (Group B). Bile/stone spillage 1.26% (Group A) and 9.52% (Group B), port hematoma 2.52% (Group A) and 9.52% (Group B), operative time 43.17±8.57 minutes (Group A) and 61.29±12.07 minutes (Group B), conversion to open procedure was none in Group A and 9.52% (Group B) and hospital stay 1.23±0.59 days in group A and 3.16±1.16 days in Group B.

Conclusion: Rouviere’s sulcus is an important extrabiliary anatomical landmark, seen in majority of patients for safe laparoscopic cholecystectomy.

Functional Outcome of Isolated Middle to Distal Third Ulnar Shaft Fracture in Adults with Square Nail Fixation

Dipendra KC, Dinesh Kumar Shrestha, Prateek Karki, Sabin Shrestha, Sushil Yogi — Sat, 31 Dec 2022 00:00:00 +0000

Introduction: Isolated ulnar shaft are uncommon injuries with most of the fractures occurring following direct trauma. Open reduction and internal fixation with plating is the gold standard treatment but is associated with complications. Treatment with square nail provides rotational stability, is cheaper, safer with minimum complications of plating.

Aims: To evaluate the functional outcome of isolated fracture of middle third to distal third ulna treated with square nail.

Methods: This prospective observational study was conducted in the Department of Orthopedics at Nepalgunj Medical College Teaching Hospital Kohalpur from September 2018 to August 2022. Patients aged above 18 and below 60 years who had displaced isolated fracture of middle third or distal third of ulna were evaluated for demographic details, union, functional outcome and associated complications. All of the fractures of ulna were treated by square nail and outcomes were evaluated using disability of arm, shoulder and hand (DASH) score and Grace and Eversmann scoring system.

Results: In this study of 39 patients with the mean age of 30.84±8.12 years, 56.4% of the patients were in age group 18-30 years, 27 (69.2%) were males and 12 (30.8%) were females. The right limb was fractured in majority, distal third was more commonly involved, physical assault was the most common mode of injury, transverse was the most common fracture pattern. The average time to union was 11.61±2.74 weeks. Most (74.4%) of the patients had good result in DASH score and most (94.9%) had good to excellent result in Grace and Eversmannscoring at final follow-up. The most common complication noted was olecranon bursitis (17.94%) followed by skin irritation (12.82%).

Conclusion: Square nail fixation of isolated middle third to distal third ulna is safe procedure with few complications, produces excellent to good results.

Alvarado Score: A Promising Tool in Diagnosis of Acute Appendicitis

Bimarsh Adhikari — Sat, 31 Dec 2022 00:00:00 +0000

Introduction: Appendicitis is the inflammation of vermiform appendix, one of the most frequent diagnoses for emergency department visits, resulting in hospitalization. Accurate and prompt diagnosis of acute appendicitis may reduce the incidence of morbidity and mortality resulting from perforation and other gravid complications.

Aims:To evaluate the effectiveness of Alvarado scoring system in preoperative diagnosis of acute appendicitis.

Methods: The study of 100 patients attending to Nepalgunj Medical College and Hospital during the year August 2021 to July 2022, with symptoms of acute appendicitis were included. The Alvarado score for each patient was evaluated. All the subjects included were scheduled for open appendicectomy and the specimens were subjected for histopathological evaluation. Patients with score less than 7 were categorized as Group A, whereas greater than 7 were categorized as Group B.

Results: Among 100 patients, there were 58 males and 42 females. Symptoms like pain in right iliac fossa (97%), nausea and vomiting (85%) and anorexia (41%) were common. Positive signs were tenderness in right iliac fossa (92%) and fever (53.5%) with leukocytosis (73%) and neutrophilia in 62 cases (88%). Of 100 patients 27 belonged to Group A, whereas 73 belonged to Group B. 17 patients out of 27 in Group A were diagnosed with acute appendicitis on histology, whereas, 10 showed negative results. 69 out of 73 subjects in Group B were diagnosed with acute appendicitis on histology, whereas 4 showed negative results on histology. The rate of negative appendectomy was significantly higher in group A than group B. The overall sensitivity, specificity, positive predictive value, negative predictive value were 80.20%, 71.42%, 84.52% and 37.03% respectively.

Conclusion: The Alvarado score when more than 7 enables risk determination in patients presenting with abdominal pain, linking the probability of appendicitis.

Knowledge and Prevalence of Emergency Contraceptive Pills among the General Population Visiting a Tertiary Care Centre

Aayush Bist, Rajshree Jha, Meeta Singh, Kanchan Devkota, Divya Das, Neha Das — Sat, 31 Dec 2022 00:00:00 +0000

Introduction: Emergency contraception is a contraceptive method used to prevent unwanted pregnancy in the first few days after unprotected sexual intercourse or contraceptive failure/accident. Many women are unaware of the existence of emergency contraception, misunderstand its use and safety, or do not use it when needed. Especially, residents of the rural regions of Nepal are deprived of family planning services and measures, which cover a major percent of our hospital patients.

Aims: To assess the knowledge regarding emergency contraceptive pills, family planning and their prevalence.

Methods: A descriptive cross-sectional study with a population size of 392 was performed at Nepalgunj medical college teaching hospital, Kohalpur, starting from January to April 2022. A pre-tested questionnaire containing structural, semi-structural, and open-ended questions in printed form was made as a data collection tool. All the people in this study were interviewed after receiving their consent.

Results: 363 out of 392(92.6%) people in our study have known about contraceptives. Only 74.93% responded to having used some sort of contraceptive measure. Oral contraceptive pills were found to be the most used measure in 265 (73%). 222(61.6%) of 363 have heard about emergency contraceptive pills but only 71(31.98%) of them have ever used them. Out of 222 respondents who were aware of emergency contraceptive pills, only 129(58.10%)correctly identified 72 hours as the time limit for the methods to be used. Nineteen respondents (8.56%) believed that emergency contraceptive pills could be used as regular pills. None of them were aware of the use of the intrauterine contraceptive device as an emergency contraception.

Conclusion: Despite having knowledge, only two-third population was found using any of the contraceptive measures. Among those having knowledge about emergency contraceptive pills, more than a half people preferred emergency contraceptive pills for any unplanned event. Emergency contraception awareness is essential to prevent unwanted pregnancy.

Correlation of Mastoid Pneumatization with Middle Ear Pathology in Unilateral Squamous Type of Chronic Otitis Media

Shama Bhandari, Dhundi Raj Paudel, Subhash Chandra Mahaseth — Sat, 31 Dec 2022 00:00:00 +0000

Introduction: Chronic otitis media is chronic inflammation of middle ear cleft followed by permanent abnormality of tympanic membrane. As mastoid a part of temporal bone is in close relation to middle ear; its pneumatization plays an important role in pathogenesis and prognosis of chronic otitis media.

Aims: To study the pneumatization pattern of mastoid in unilateral chronic otitis media and its relationship with contralateral mastoid, diseased side tympanic membrane and ossicular status.

Methods: Forty patients of 10-65 year of age diagnosed as unilateral chronic otitis media squamous type were selected. They were otoscopically evaluated for retraction and perforation of tympanic membrane and were subjected to high-resolution computed tomography of temporal bone. High resolution computed tomographies were analyzed for mastoid status of bilateral ear and ossicular involvement. During mastoidectomy ossicular status was noted and correlated with high resolution computed tomography.

Results: Forty cases were enrolled in the study. Age ranged from10-65 years. On radiological analysis of temporal bones, 21(52.5%) mastoids were sclerotic, 15(37.5 %) mastoid diploic and 4(10%) were pneumatized in the diseased sides. Contralateral side showed pneumatization in 23(57.5%), diploic in 11(27.5%) and sclerotic in 6(15%) Amongst 21 sclerotic mastoid, 11(52.3%) patient had retraction in pars tensa and 9(42.8 %) had retraction of pars flaccida. In total 15 diploic mastoids retraction of pars tensa was in 8(53.3%) and pars flaccid retraction in 8(53.3%) All three ossicles were involved in 8(38%), Malleus and incus were eroded in 3(14%), incus were eroded in 7(33.3%), malleus were eroded in 3(14%) and ossicles were intact in 3(14%)of 21 sclerosed mastoids on high resolution computed tomography. In remaining 19 non sclerotic mastoids all 3 ossicles were eroded in 4 (21%), malleus plus incus eroded in 8 (16%), incus were eroded in 5(26.3%) andossicular chain was intact in 2(10%).

Conclusion: Mastoid pneumatization pattern not only effect to the pressure of middle ear leading to chronic otitis media but also alter the pathogenesis and outcome of chronicotitismedia. Contralateral mastoid pneumatization is not altered in unilateral Chronic otitis media.

Pattern of Refractive Status in Patients with Vernal Keratoconjunctivitis at Birat Medical College Teaching Hospital

Neha Priyadarshani Chaudhary, Badri Prasad Badhu, Barun Dev, Prabhat Deo — Sat, 31 Dec 2022 00:00:00 +0000

Introduction: Refractive errors remain the most important cause of visual impairment in childhood worldwide which contributes to about 19% of total blindness in the world. This can be further complicated by other ocular conditions like vernal keratoconjunctivitis, which is a chronic, recurrent bilateral inflammation of conjunctiva and cornea.

Aims: To assess the pattern of refractive status in patients with Vernal keratoconjunctivitis.

Methods: This was a cross sectional hospital-based study conducted in patients attending the Outpatient department of ophthalmology at Birat Medical college Teaching Hospital with the clinical diagnosis of Vernal Keratoconjuctivitis from July 2020 to June 2021.The vision and baseline refractive status of all patients were assessed accordingly. All the data was recorded in a specifically designed proforma which was then entered in MS excel for statistical analysis.

Results: 80 patients were included in the study out of which 85% were male and 15 % were female. The most common presenting age group was 7 to 12 years. The most common type of Vernal Keratoconjunctivitis was found to be mixed type (58%), followed by limbal (22%) and papillary (20%). The most prevalent refractive error was found to be astigmatism (37.5%) followed by hypermetropia (16.25%) and myopia (11.25%). The remaining patients (35%)had a normal state of refraction.

Conclusion: Refractive error was commonly seen in patients with Vernal Keratoconjuctivitis in our study. Hence, awareness among the people about the disease is very important.

Study of the Relationship of Lipid Profile, BMI and Blood Pressure among Non-diabetic Hypertensive Patients - A Hospital Based Study

Sat, 31 Dec 2022 00:00:00 +0000

Introduction: Several research have demonstrated the connection between lipid levels, diabetes mellitus (DM), and hypertension, but none have focused specifically on the association between lipid levels and essential hypertension in Nepal's non-diabetic population.

Aims: To study the relationship between lipid profile, body mass index (BMI), and blood pressure (BP) in the nondiabetic hypertensive population.

Methods: A hospital-based cross-sectional study was conducted among 150 participants. Anthropometric measurements including height, weight and BP were taken. Blood was collected in serum vial for lipid profile [total cholesterol (TC), triglyceride (TG) and low and high density lipoprotein cholesterol (LDLC and HDLC)] after an overnight fasting.

Results: 44.7% were female, and 55.3% were male with the age ranging between 28-80 years. Among 48.67% of the overweight participants, 56.8% were male. 25.33% were obese, among which 52.6% were male. 56% of participants had systolic blood pressure (SBP) ≥140 mmHg and 58% had diastolic blood pressure (DBP) ≥90 mmHg and showed no significance among the gender. Borderline TG level was observed in 76.2% of participants with SBP ≥140 mmHg and in 74.7% with DBP ≥90 mmHg. HDLC vs gender showed significance. SBP and DBP had a significant relationship with LDLC and TC. The association of BMI with BP and lipid profile was not significant.

Conclusion: Dyslipidemia is prevalent among non-diabetic hypertensive individuals. The majority of participants were overweight, however blood pressure and lipid profile did not correlate with BMI presumably because other anthropometric characteristics have better predictive values than BMI.

Knowledge, Attitude and Perceived barrier towards Medical Research among Undergraduates and Postgraduates Medical Students of Nepalgunj Medical College

Merina Shrestha, Rupak K.C., Prabesh Luintel, Anjali Joshi, Rajendra Mahat — Sat, 31 Dec 2022 00:00:00 +0000

Introduction: Medical science is one of the most advance and modern technology over the course of time period with extensive research and scientific knowledge of human body and health care to make incredible changes enabling the population remain healthy with mere absence of disease or infirmity. Research is considered as one of the useful measures to track the scientific advancement of a country. Promoting research skills in undergraduate and post graduate medical students help to develop scientific advancement in medical field of a country.

Aims: To assess knowledge, attitude, and perceived barriers among undergraduate and postgraduate medical students.

Methods: An institutional based cross sectional analytical study covering total 224 undergraduate and postgraduate medical students of Nepalgunj Medical College was from January 2022 to April 2022. A pre tested, pre designed, sets of questionnaire were provided to all recruited participants after obtaining informed written consent. Then informations generated by the study were analyzed for scientific result by using descriptive analysis and independent T- test.

Results: Male students were 135(60.3%) whereas female students were 89(39.7%) only. The mean knowledge score was 33.69 ± 3.8 and mean attitude score was 19.67 ± 2.34. The average 100(44.6%) had good knowledge and 118(52.7%) had positive attitude towards medical research. Most common perceived barrier was not having proper mentoring and research familiarity. Seventy Six(39.6%) undergraduate students had behavioral hesitation to participate in research while 21(65.6%) post graduate students showed social factor as one of the hesitancy to involve in research.

Conclusion: Most of the participants had good knowledge regarding research and expressed positive attitude toward involvement in research activity. Some of barriers were lack of funds, awareness and research skills. This study would improve scientific knowledge and research skills for academicians and clinicians too.

Fetomaternal Outcome of Instrumental Vaginal Delivery at Nepalgunj Medical College Teaching Hospital Kohalpur

Durga BC, Rajshree Jha, Ram Kumar Das — Sat, 31 Dec 2022 00:00:00 +0000

Introduction: Instrumental vaginal delivery is performed in second stage of labor to expedite delivery with aim to decrease cesarean section rate. Worldwide 10-20% of laboring women need obstetrics intervention for delivery.

Aims: To evaluate the indication and fetomaternal outcome of instrumental vaginal delivery.

Methods: This is a hospital based cross-sectional study conducted at the department of obstetrics and gynecology. The study was done from July 2021 to July 2022 for a period of one year. Data were collected, recorded in standard proforma and analyzed by using SPPS version 20.

Results: The out of 6123 deliveries, 149(2.4%) had instrumental vaginal delivery. Out of 149 participants, 41.6% were between 20-24 years, 10.7% were of age group 15-19 years and 4% ladies were of >35 years. Instrument delivery was more frequently applied in primigravida in comparison to multigravida (57.3% vs 42.3%) p=0.046. The most common indication for instrumentation was poor maternal effort (41%) followed by fetal distress (33.6%). About 14.1% had postpartum haemorrhage, 3.4% had vulval hematoma, and 38.3% babies had Neonatal Intensive Care unit admission.

Conclusion: Poor maternal effort and fetal distress were the common indications for instrumental delivery with some fetomaternal complications. Inspite of the complications, if used by an expertise, instrumental delivery can reduce the need of cesarean section.