Journal of Chitwan Medical College <p>The official journal of Chitwan Medical College. Full text articles available.</p> en-US <p><strong>Copyright Notice&nbsp;</strong><a href="">&nbsp;</a></p> <p>© Authors retain the copyright.</p> <p><strong>&nbsp;</strong>Authors grant the journal right of first publication with the work simultanously licensed under&nbsp;a&nbsp;<a href="">Creative Commons Attribution 4.0 International License</a>(CC-BY 4.0). This license permits use, distribution and reproduction in any medium, provided the original work is properly cited.</p> (Prof. Dr. Harish Chandra Neupane) (Sioux Cumming) Wed, 24 May 2017 12:00:14 +0000 OJS 60 Comparative study between 3-ports and 4-ports laparoscopic cholecystectomy for the cases of gall stone disease <p><strong>Background:</strong> Laparoscopic cholecystectomy is currently accepted approach for the management of patients with cholelithiasis. The standard method for removal of gall bladder in laparoscopic cholecystectomy is by using four ports. Although other techniques such as by using 3 ports or only single port are being practiced, their safety and efficacy has not been established. This study was done to assess the efficacy and safety of the use of only three ports for laparoscopic cholecystectomy.</p><p><strong>Methods:</strong> Between August 2013 and February 2014, 78 patients with the diagnosis of cholelithiasis were operated. Patients were randomized into 3-ports group and 4-ports group using random number. Operative time taken for the procedure and operative findings were noted. Postoperative pain and complications were noted in both groups. The two groups were compared using student-T test and chi square test.</p><p><strong>Results:</strong> There was no significant difference in the operating time taken for the 3-ports laparoscopic cholecystectomy and 4-ports laparoscopic cholecystectomy. However operating time was significantly higher when the cases that had dense adhesions present were compared with those who did not have. Conversion from 3-ports technique to 4-ports technique was determined mainly by the degree of adhesions and to some degree by the BMI of the patient. Postoperative wound infection rate was similar among the two groups. There was no incidence of biliary injury in both the groups.</p><p><strong>Conclusion:</strong> 3-ports laparoscopic cholecystectomy is safe and efficient approach for the selected patients who seek for lesser invasive method of laparoscopic cholecystectomy.</p> Kishor Kumar Tamrakar, Pragyan Khwaunju, Keshar Bahadur Sah ##submission.copyrightStatement## Wed, 24 May 2017 12:00:11 +0000 Meningoencephalitis in intensive care unit: Do Japanese Encephalitis cases go unsuspected? <p><strong>Background:</strong> Meningoencephalitis (ME) is a medical emergency. Acute infective encephalitis is usually viral. Nepal has the second highest prevalence of JE in South East Asia. About one third of the JE cases results in death. The records of the JE in the laboratory of B.P. Koirala Institute of Health Sciences (BPKIHS) showed 760 samples to have the evidence of JE infection out of 3352 tested during the period of 2001-2011 AD. The present study aimed to conduct an audit on meningoencephalitis cases admitted in the ICU of our hospital in an attempt to find its burden.</p><p><strong>Methods:</strong> Medical records of all the adult patients with the provisional diagnosis of Meningoencephalitis at BPKIHS over the period of 2009-2011 AD were examined. Laboratory findings of all the patients diagnosed with ME who were admitted to the eight bedded general intensive care unit (ICU) were also reviewed. The diagnosis was made based on the findings of medical history, clinical examination and cerebrospinal fluid analysis for biochemistry and cytology, results of anti JE IgM test performed on CSF and/or serum.</p><p><strong>Results:</strong> Altogether 127 samples of CSF were obtained from adult patients admitted in different inpatient department of BPKIHS with the clinical diagnosis of meningo encephalitis between 2009-2011 AD. Out of them, 25 (19.68%) were tested positive of JE. A total of 684 patients were admitted over the same period with different diagnoses in 8 bedded ICU of hospital. Fifteen (2.19%) were transferred to the ICU with the ME. In the ICU, 9(60%) were treated as viral encephalitis. Among them CSF of only 4 patients’ were sent for testing for JE and found positive in 2 cases. Seven (46.6%) patients expired while 4(26.6%) were taken home by the relatives against medical advice in critically ill conditions and remaining 4 (26.6%) improved and transferred to ward. Among the expired patients 5 (71.4%) had viral encephalitis.</p><p><strong>Conclusion:</strong> JE is a real problem but many cases are likely to have been gone undetected. Adoption of a more intensive approach with much liberal serology testing policy seems to be appropriate for better detecting JE cases in the setting.</p> Ashish Ghimire, Balkrishna Bhattarai, Basudha Khanal, Suchana Marhatta, Gopendra Prasad Deo ##submission.copyrightStatement## Wed, 24 May 2017 12:00:11 +0000 Prevalence of vitamin D deficiency/insufficiency among children and adolescents <p><strong>Background:</strong> Vitamin D is an essential prohormone for the normal skeletal and extraskeletal health. Vitamin D deficiency/insufficiency is an unrecognized epidemic among children and adults worldwide. There are growing data from studies of young children and adolescents in other countries, but a limited information are available regarding the prevalence of this nutritional deficiency/insufficiency among the Nepalese children and adolescents. Thus this study was aimed to find out the prevalence of vitamin D deficiency/insufficiency among children and adolescents, who has attended in Chitwan Medical College (CMC).</p><p><strong>Methods:</strong> This was a retrospective hospital based study in children between 2 months and 19 years of age, conducted in CMC from April 2015 to December 2016.</p><p><strong>Results:</strong> Among 108 total studied, overall 74.1% (80) patients had 25(OH) D levels lower than 30 ng/ml with 27.8% having severe deficiency (&lt; 10 ng/ml), 28.7% deficiency (10-19 ng/ml) and 17.6% insufficiency (20-29 ng/ml) category . The prevalence was found higher in females (95.2%), though the difference in prevalence between sexes was not statistically significant (P –value 0.243).</p><p><strong>Conclusion:</strong> Our study concluded that a high prevalence of low Vitamin D status (deficiency/insufficiency) found among the paediatric population (all paediatric age groups) indicates a need for further national level study to find out the actual prevalence of this nutritional deficiency, as well as the need for vitamin D supplementation to all children and adolescents.</p> Shanti Regmi, Ananda Prasad Regmi, Santosh Adhikari, Disuja Shakya ##submission.copyrightStatement## Wed, 24 May 2017 12:00:11 +0000 Ear diseases in school going children of Sunsari and Morang districts of Nepal <p>This study was carried out to find the prevalence of ear diseases in school-going children of the Sunsari and Morang district of Eastern Nepal. This is a prospective, cross sectional, clinical study in 3729 school going children of up to 15 years of the Sunsari and Morang district of eastern Nepal done in year 2014 and 2015 AD. Informed consent was obtained. 1346 (36.09%) children had different ear ailments. Ear wax 616 (45.76%) and otitis media with effusion 226 (16.79%) were the commonest diseases found. Chronic otitis media mucosal type was found in 104 (7.73%) children. Chronic otitis media squamous 6 (0.45%), Otomycosis 155 (11.51%), otitis externa 16 (1.19%), acute Otitis media 119 (8.84%), Eustachian tube dysfunction 92 (6.84%), Perichondritis 4(0.29%), Foreign body in the ear 2 (0.15%), Preauricular sinus 2 (0.15%) and sensorineural hearing loss 4 (0.29%) were the other diseases found. Ear diseases are important health problems among school-going children of the Sunsari and Morang district of eastern Nepal. Health education,nutrition, improvement of socioeconomic status and health care facilities should be helpful in reducing the prevalence of ear diseases.</p> Sanjeev Kumar Thakur, Rabin Acharya, Sanjay Kumar Singh, Nisha Ghimire ##submission.copyrightStatement## Wed, 24 May 2017 12:00:12 +0000 Correlation between glycemic parameters and lipid profile in type 2 diabetic patients attending tertiary care centre in central region of Nepal <p><strong>Background:</strong> Diabetes Mellitus (DM) is a chronic metabolic disease characterized by hyperglycemia with type 2 DM accounting for more than 90% of adult diabetes cases worldwide. Hyperglycemia in type 2 DM is strongly linked with dyslipidemia which in turn increases risk for development of cardiovascular diseases. This study aimed to determine the correlation between glycemic parameters (fasting blood sugar-FBS, postprandial blood sugar-PPBS and glycated hemoglobin-HbA1c) and serum lipid profile in type 2 diabetic patients.</p><p><strong>Methods:</strong> Altogether 160 type 2 diabetic patients (Male=80 and Female=80) aged between 30-70 years visiting Chitwan Medical College Teaching Hospital (CMCTH) for their routine medical check-up were included in this study. Data were collected using preformed set of questionnaires and biochemical data were obtained from the laboratory analysis of the patient’s blood samples. Statistical analysis was done with SPSS version 20.0.</p><p><strong>Results:</strong> Hyperglycemia was significant as evident by elevated FBS, PPBS and HbA1c. Also, the serum lipid profile was deranged with elevated TC, TG, LDL, VLDL and lowered HDL levels suggestive of dyslipidemia. There was a Direct and significant correlation of glycemic parameters (FBS, PPBS and HbA1c) with total cholesterol (TC), triglyceride (TG), low density lipoprotein cholesterol (LDL-C) and very low density lipoprotein cholesterol (VLDL-C) while the correlation with high density lipoprotein cholesterol (HDL-C) was just reverse.</p><p><strong>Conclusion:</strong> Chronic hyperglycemia in type 2 DM is associated with dyslipidemia which further exposes risk for the development of cardiovascular diseases. HbA1c, being the gold standard for the assessment of glycaemia is also the better predictor of dyslipidemia in type 2 diabetic patients.</p> Lokendra Bahadur Sapkota, Sangita Thapa ##submission.copyrightStatement## Wed, 24 May 2017 12:00:12 +0000 Serum HDL cholestrol and glycemic status assessment in post-menopausal women <p>Menopause is the consequence of the exhaustion of ovarian follicles which results in decreased production of estradiol and other hormones. Menopause is associated with a significant increase in cardiovascular diseases (CVD). Postmenopausal women have higher blood sugar values as compared to the control group because the estrogen hormone which makes the body cells more receptive or sensitive to insulin is either not secreted at all or is in limited supply. The estrogen hormone in females is protective for developing diabetes. Estrogen seems to contribute to glucose homeostasis in women. Significant negative correlation between fasting blood sugar and HDL with (r=-0.130, p= 0.369), suggesting that the fasting blood glucose levels were elevated whereas HDL levels were low normal in postmenopausal women thus associate with high risk of CVD in postmenopausal women.</p> Pashupati Ranabhat, Shekhar Yadav ##submission.copyrightStatement## Wed, 24 May 2017 12:00:12 +0000 Quality of life of hemodialysis patients in selected teaching hospitals of Chitwan <p>The quality of life (QOL) needs to be regularly assessed in hemodialysis patients. Hemodialysis patients suffer from average quality of life and survival. A descriptive research design was used, 96 respondents who had received haemodialysis treatment after completion of 1 month duration of hemodialysis in two different teaching hospital at Bharatpur, Chitwan. Data was collected by using standard tool Short Form-36 version2 through face to face structure interview schedule. The objective of study is to find out the quality of life (QOL) of haemodialysis patients. Various test such as one sample t-test, ANOVA test, independent t-test, Kruskal-Wallis test and Mann-Whittney U test, Pearson’s correlation was applied. The findings showed that higher proportion of respondents were from 40-59 years (41.0%) and male (62.2%). The mean±SD was 57.45±16.25, 55.72±22.41 and 60.04±11.50 in overall QOL, physical and mental component summary respectively which was slightly above the average. All dimention and sub scale was satistically significant. Younger respondents had statistically significant with overall QOL (p&lt;0.001) and physical component summary (p&lt;0.001). Non diabetics had better in overall QOL (p=0.040) and physical component summary (p=0.033). Level of educational had also positive impact in overall QOL(p=0.010), physical (p=0.006) and mental component summary (p&lt;0.001). Employment status (p=0.020) and sex (p=0.037) was also statistically significant with mental component summary. There was correlation between physical and mental component summary with overall QOL 0.970(p&lt;0.001) and 0.698(p&lt;0.001), and between the physical and mental component summary was 0.502(p&lt;0.001). Below average score were seen in the general health (32.86±25.74) and vitality (41.53±13.98) sub scale. In order to improve quality of life family, physician, nurses and policy makers can use this finding.</p> Srijana Ghimire, Milan Lopchan ##submission.copyrightStatement## Wed, 24 May 2017 12:00:12 +0000 Systemic association of uveitis in Nepalese population <p><strong>Background:</strong> Infectious diseases are very common in Nepal and almost all infections are capable of causing uveitis. Parasitic infestations affect large number of Nepalese population and any parasitic infestation can potentially lead to development of uveitis. Local and systemic viral infections, immunological disorder like autoimmune diseases and malignancies can lead  to uveitis. All these emphasize the necessity of proper systemic evaluation and investigation to identify the underlying systemic illness causing uveitis in order to see the pattern of systemic illness and determine the commonest associated systemic disease with uveitis.</p><p><strong>Methods:</strong> A prospective study was conducted at BP Koirala Lions Centre for Ophthalmic Studies from November 2008 to April 2010. All the patients underwent a standard diagnostic protocol when indicated by special tests and procedures performed in order of likelihood.</p><p><strong>Results:</strong> A total of 308 patients with uveitis was seen during the study period. For 146 (47.4%) patients, a specific diagnosis was established based on history, ocular examination and laboratory investigations. A definite association with systemic disease was determined for 82 (26.6%) patients. A well established clinical uveitis entity without a recognizable systemic disorder was present in 64 (20.8%) cases. A diagnosis could not be established in 162 (52.6%) cases. Toxoplasmosis was found to be most frequently associated with uveitis accounting for 5.8 % of the total cases followed by tuberculosis (3.6%), herpes infections (3%), ankylosing spondylitis (2.9%), leprosy (2.3%), sarcoidosis (1.6%) and parasitic infestations (1.3%).</p><p><strong>Conclusion:</strong> The importance of relevant systemic work up in uveitis cases in our set up has been reemphasized by the present study.</p> Jyoti Baba Shrestha, Dev Narayan Shah ##submission.copyrightStatement## Wed, 24 May 2017 12:00:13 +0000 Study of vitamin B12 status and the consequential clinico-hematological profile in healthy vegetarian population in Nepal <p><strong>Background:</strong> A strict vegetarian diet has been associated with an increased risk of vitamin B12 deficiency. Clinical manifestations of cobalamin deficiency are hematologic and neurological symptoms. The purpose of this study was to determine the prevalence of vitamin B12 deficiency in healthy vegetarian population and to study the clinical and hematological profile of vitamin B12 deficient subjects.</p><p><strong>Methods:</strong> A community based cross-sectional observational study was conducted through preplanned camps in Kathmandu Nepal. 166 vegetarian people were investigated for serum vitamin B12 level and their hematological profile was done. They were examined for neurological manifestation of vitamin B12 deficiency.</p><p><strong>Results:</strong> The mean serum vitamin B12 level of the vegetarian in this study was 271.34 ±241.74 pg/ml (mean ± SD)., 53.6 % had serum vitamin B12 deficiency. 56.5 % of male and 47.1 % of female had vitamin B12 deficiency. The risk of vitamin B12 deficiency is more in males than females with odds ratio 1.201 (CI=95%) which is not statistically significant with p-value 0.312. There was no significant difference in vitamin B12 level in different age group.The study population had mean hemoglobin of 13.12 ± 1.72 gm/dl. Anemia was present in 34.9 % of study population. 33.9 % of male and 37.3 % of female had anemia. There was no significant difference in anemia in male and female vegetarian (p-value 0.72). 40% of patient who had vitamin B12 deficiency had anemia.A significant low hemoglobin level and higher MCV were found as level of serum vitamin B12 decreased. Only one patient had macrocytic anemia.There were few symptoms but not specific to vitamin B12 deficiency.</p><p><strong>Conclusion:</strong> The result of present study show that prevalence of vitamin B12 deficiency among healthy vegetarian was 53.6% with higher prevalence in male and elder age group.Prevalence of anemia was 34.9% in this study with elderly group and females being more affected.There was significant correlation between vitamin B12 and hemoglobin level and significant negative correlation with MCV. Although, not significant, leucocytes count, lymphocyte count and platelets were low in vitamin B12 deficient population.Few clinical features were present in vitamin B12 deficient subjects but neurological features specific to vitamin B12 deficiency were not seen.</p> Pramod Paudel, Jagdish Prasad Agrawal, Santosh Timilsena, Jyoti Subedi ##submission.copyrightStatement## Wed, 24 May 2017 12:00:13 +0000 Emerging cervical spine surgery in Chitwan Medical College: A case series <p>We report 10 consecutive patients who underwent anterior cervical disectomy and fusion (ACDF) or anterior cervical corpectomy and fusion (ACCF) from Nov 2015. Nine of these patients sustained fracture or dislocation of cervical spine and one patient had tuberculous spondylitis. Eight patients improved by at least one grade (Frankel spinal scoring system) post operatively while 2 patients who had respiratory distress pre-operatively expired on 3rd and 21st post operative day.</p> Akesh Prajapati, Jyoti Sitaula, Bishnu Dev Sharma, Sujit Shrestha, Pujan Pant ##submission.copyrightStatement## Wed, 24 May 2017 12:00:13 +0000 Hepatic resection for bile duct injury: A case report <p><strong>Background:</strong> Bile duct injury is a serious complication following both open and laparoscopic cholecystectomy. The extent of injury may be severe enough to consider biliary reconstruction procedures like Roux-en-Y hepaticojejunostomy or even hepatectomy in rare instances for the definitive management.</p><p><strong>Case:</strong> A 56 year old female, who underwent open cholecystectomy and detected bile duct injury intraoperatively. Small feeding tube was placed in the bile duct, exteriorized and patient was referred to our center for further management. Liver function tests at presentation revealed cholestatic patterns of liver derangement but the patient did not show any signs suggestive of sepsis. Endoscopic Retrograde Cholangiopancreatography revealed complete stricture of common hepatic duct. Magnetic Resonance Cholangiopancreatography revealed Bismuth type 4 bile duct stricture. The plan was to perform a bilateral hepaticojejunostomy, however, because of the very difficult anatomy and failure to identify the right duct, right hepatectomy with left duct hepaticojejunostomy was performed as a definitive management for her type IV bile duct injury. The patient had an uneventful post-operative course.</p><p><strong>Conclusion:</strong> Infrequently, liver resection remains an important therapeutic option in cases of complicated and major forms of bile duct injuries where the bilateral biliary reconstruction is not feasible.</p> Utsav Joshi, Ramesh Singh Bhandari ##submission.copyrightStatement## Wed, 24 May 2017 12:00:14 +0000 An approach to fish-hook injury in children in remote hospital: A case report and brief literature review <p><strong>Background:</strong> Fish-hook injury is a leisure activity based for many across the globe among adults. Sometimes, it has been occasionally happened in the playing group children when the fishing rod with hook kept carelessly and children try to play and caught hand or bodily injury. If the hook is snug then it becomes difficult to removal. We report two cases of such injury in the hand and discuss the technique for its removal with a short literature review.</p><p><strong>Cases:</strong> A 3 year and 15 years old male accidently suffered a fishhook into their great thumb. They came to the surgical OPD one day and same day respectively after the incident with pain. Unsuccessful attempts at removal were made. A retrograde pull method was applied to remove fish hooks successfully.</p><p><strong>Conclusion:</strong> Fish-hooks can be removed in children less traumatically following same technique for adult with a proper wound and pain care.</p> Suryaman Manyangbo, Harihar Devkota ##submission.copyrightStatement## Wed, 24 May 2017 12:00:14 +0000