Journal of Patan Academy of Health Sciences

Mixed warty and sarcomatoid squamous cell carcinoma of vulva: a rare occurrence

Sailuja Maharjan — 2022-12-30

Vulvar cancer is a rare tumor accounting for <5% of female genital tract tumors. The most common type of vulvar malignancy is squamous cell carcinoma. There are many histological variants of squamous cell carcinoma, keratinizing type being the most common one. Sarcomatoid variant is an extremely rare variant in vulva and comprises both epithelial and mesenchymal features. Due to the rarity of this tumor in the vulva and limited cases reported in the literature, no proper management guidelines have been established yet. In the current case report, we describe a case of mixed warty and sarcomatoid squamous cell carcinoma of vulva.

Groin hit death due to femoral vein rupture in a drug abuser

Kaschev Shrestha — 2022-12-31

Recreational drug use has become an imminent social and health problem throughout the world. Intravenous injection for drug misuse has been described in both the upper and lower limbs and is a major cause of millions of deaths each year; deaths are primarily due to fatal overdose and the trauma and infection caused by repeated injections. This paper presents an accidental death due to massive blood loss, which resulted from rupture to the right femoral vessel based on autopsy findings. In case of accidental injuries, a thorough medico-legal process, including death scene investigation, autopsy examination and toxicological analyses, are always necessary to determine the manner of death.

Analysis of cesarean section using Robson’s criteria in tertiary care center

Padma Gurung — 2022-12-30

Introduction: This study aims to analyze all the women delivering in our institute according to the Robson’s classification. Robson’s ten group classification system (TGCS) endorsed by WHO, is a global standard tool for assessing, monitoring and comparing cesarean section rates at all levels.

Method: This cross sectional study was conducted in the department of obstetrics and gynecology, Patan hospital, Patan academy of health sciences (PAHS), Lalitpur, Nepal over 12 months’ period. All women who delivered during this period were classified according to the Robson’s classification (TGCS) into a specific group. Relative size and overall cesarean section rate of each group were calculated.

Result: A total of 4,985 cases were analyzed. The cesarean section rate was 57.7%. Group 1+2 represented nearly half (49%) of the obstetric population served during the study period. Group 2A was found to be the highest contributor (27.4%) followed by Group 5 (22.8%) and Group 1 (13.0%). In terms of indication for cesarean section -Fetal distress and previous cesarean section were found to be the most common indications. Similarly, nulliparous women were three to four times more likely to be delivered by cesarean section when labor was induced.

Conclusion: From this study, we can conclude that for an effective reduction in the overall high cesarean section rate in our Institution, we need to focus on a more stringent protocol for inducing labor especially among nulliparous women and to practice evidence based guidelines. Redefining failed induction needs to be considered critically as well.

Factors predicting early re-bleeding and in-hospital mortality after acute variceal hemorrhage in patients with cirrhosis

Roshan Shrestha — 2022-12-30

Introduction: Risk factors for early re-bleeding and in-hospital mortality following acute variceal hemorrhage (AVH) are incompletely understood. The aim of this study was to find out the risk factors for early re-bleeding within 5 days and in-hospital mortality after AVH in patients with cirrhosis.

Method: This was an analytical cross-sectional study conducted in Department of Medicine, Patan Hospital, Patan Academy of Health Sciences (PAHS), Nepal from July 2021 to June 2022. The ethical clearance was obtained from the Institutional Review Committee-PAHS. Informed consent was taken from the patients. Patients aged >18 y with diagnosed case of liver cirrhosis and endoscopy confirmed variceal bleeding were enrolled. All cases of early re-bleeding within 5 days and in-hospital outcome were recorded.

Result: In this study total 72 patients were enrolled. The mean age of our patients was 51.68 y. Sixty seven (93%) of the patients improved, 3(4.16%) had early re-bleeding and 5(6.9%) died during the same hospital admission. Univariate analysis showed that early re-bleeding was significantly associated with the high PT/INR (p<0.001) and high Child-Turcotte Pugh (CTP) score (p=0.032), whereas in-hospital mortality of patients was significantly associated with low Protein (p=0.044), high CTP score (p=0.041), high Model for End stage Liver Disease (MELD) score (p=0.002) and presence of gastric varices (p=0.008).

Conclusion: High PT/INR and high CTP score are the risk factors of early re-bleeding after AVH in cirrhotic patients. Low Protein, high CTP and MELD scores, and presence of gastric varices are the factors associated with in-hospital mortality in these patients.

Anatomic variation of celiac axis and hepatic artery as evidenced in multidetector computed tomography in patients at tertiary care center in Nepal

Dinesh Maharjan — 2022-12-30

Introduction: There are many potential anatomic configurations of celiac axis and hepatic artery. Michel’s classified hepatic arterial variations in 10 categories. Knowledge about these variations in patient is invaluable before surgery. Multidetector computed tomography (MDCT) can accurately depict the vascular anatomy of celiac axis and hepatic artery non-invasively. The aim of this study was to find out the prevalence of different types of anatomical variation of celiac axis and hepatic artery in patients undergoing multiphase CT.

Method: Cross-sectional, prospective study was done in Department of Radiology, Patan Hospital, Patan Academy of Health Sciences. MDCT of abdomen of 178 patients with arterial phase images done between December 2021 and March 2022 were evaluated for arterial anatomy of celiac axis and hepatic artery. Arterial anatomy was categorized according to Michel’s classification. Prevalence of each variant anatomy and gender wise prevalence were calculated.

Results: CT scans of 178 patients were evaluated out of which 94 were male and 84 were female. Among these individuals 133 (74.7%) had normal anatomy (Type I) and 45 (25.3%) had some sort of variant anatomy. Type III was commonest type of variant anatomy seen in 18 (10.1%) individuals. We found 6(3.4%) individuals with the anatomy other than classified by Michel.

Conclusion: There are multiple variation in of celiac axis and hepatic artery anatomy in our population. Knowledge of such anatomical variation will be of great importance for surgeon and interventional radiologist for planning of surgical or vascular procedures and to prevent vascular complication.

Delivery site preferences and associated factors among married women of Panauti Municipality, Kavrepalanchok district, Nepal

Pratiksha Pathak — 2022-12-30

Introduction: Maternal mortality is a top global developmental agenda. The main cause of being underutilization of available delivery services especially in a developing country like Nepal. Various socio-demographic, socio-cultural and health service-related factors affect the utilization of these services. Thus, the study aims to identify the delivery site preferences and its associated factors among the married women of Panauti municipality of Kavrepalanchok district.

Method: A cross-sectional study was conducted among the married women between the ages of 15-49 y residing in Panauti municipality. The face-to-face interviews were conducted using semi-structured questionnaires. The statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 21.

Result: A total of 106 women of 15-49 y were included in the study. The proportion of institutional delivery among the participants was 68%. 90.6% of total participants would prefer health facility for their future deliveries; 7.5% were not sure about their preferences and very few (1.9%) preferred to deliver at home. The factors like knowledge regarding safe-motherhood program and age at marriage were found to be significantly associated with their delivery site preference (p<0.05).

Conclusion: In a country like Nepal, home delivery is still in practice and pregnancy and childbirth are regarded as normal life events. Thus, efforts should be made to change that perception, increasing utilization of available services and improving maternal and child health. This in turn will help to achieve the Sustainable Development Goal target in reducing the Maternal Mortality Rate.

Efficacy of morning-only dose compared with split-dose polyethylene glycol electrolyte solution in bowel cleansing for afternoon colonoscopy

Roshan Shrestha — 2022-12-30

Introduction: The efficacy of colonoscopy in detecting abnormalities within the colon is highly dependent on the adequacy of the bowel preparation. The objective of this study was to compare the efficacy and tolerability of morning only dose vs split-dose administration of polyethylene glycol (PEG) solution for colon cleansing in patients undergoing afternoon colonoscopy.

Method: This was a comparative study conducted in Department of Medicine, Patan Academy of Health Sciences (PAHS), Patan Hospital, Nepal from November 2021 to June 2022. The ethical clearance was obtained from the Institutional Review Committee. Informed consent was taken from the patients. Patients aged >18 y undergoing elective colonoscopy were randomly assigned to one of the two bowel preparation regimens- morning only or split-dose of PEG. The adequacy of bowel preparation was assessed by the endoscopist using Boston Bowel Preparation scale. Preparation to colonoscopy (PC) interval, adverse events and risk factors for poor bowel preparations were noted.

Result: In this study, 110 patients were included in the final analysis- 55 received morning only regimen and 55 received split-dose. Mean Boston bowel preparation scales of Morning only and Split-dose regimen were 7.60 and 7.09 respectively (p= 0.019). Split-dose group had significant sleep disturbances compared to Morning only regimen (p< 0.001), whereas nausea occurred significantly more often in Morning only regimen (p=0.012). Preparation to colonoscopy interval between 4-6 hours resulted in better bowel cleansing compared to PC interval of greater than 6 hours.

Conclusion: Morning-only bowel preparation is more effective than Split-dose for achieving adequate colon cleansing for afternoon colonoscopy.

Prevalence of suicide risk and its associated factors in patients presenting in antenatal clinic

Reena Shrestha — 2022-12-30

Introduction: Suicide during the antenatal period is one of the major indirect causes of maternal death. This study aims to determine the prevalence of suicidal risk and its related factors among the patients attending the antenatal clinic of a tertiary care center.

Method: This is a cross-sectional study conducted in the antenatal clinic Patan Hospital, Lalitpur, Nepal among 124 pregnant patients using purposive sampling and face-to-face interviews applying a semi-structured proforma and P4 suicide screener. Ethical approval was obtained. The percentage of patients with suicide risk was calculated and stratified into minimal, lower, and higher risk of suicide. The association between suicide risk and different sociodemographic and clinical variables was done using the Chi-square test. A p-values ≤0.05 was considered statistically significant.

Result: The prevalence of suicide risk was 32 out of 124 patients (25.8%). When risk stratification was done a maximum of 22(17.7%) had a higher risk for suicide. The risk was associated the employment status (p=0.039), history of previous suicide attempts (p=0.04), and diagnosed mental disorder (p=0.027).

Conclusion: Our study shows the suicide risk among antenatal females was 25.8% reaffirming the need for proper screening and referral.

Should research and publication be included in the undergraduate medical curriculum?

Nabees Man Singh Pradhan — 2022-12-30

Scientific papers are the key to advancements that humans have leaped through in different fields of science. Members of the scientific community use research to explore, discover and accumulate knowledge/skills to contribute to society which makes humans stand out among all the existing species on the planet. The publication has been used as a tool to document the findings/discoveries, and also to build up the foundation of the knowledge which has kept growing over time for humans to have the ability to develop complex and advanced stuff, which in other words is termed ‘development.’

Psychological distress among patients receiving haemodialysis in a teaching hospital

Jyoti Maharjan — 2022-12-30

Introduction: A psychological distress is highly prevalent conditions among haemodialysis patients, but is often under diagnosed and untreated. It could have negative impacts on their treatment and prognosis of the disease. The purpose of this study was to assess the prevalence of psychological distress in the patients receiving haemodialysis in a teaching hospital.

Methods: This quantitative cross-sectional study comprised of 59 patients of Chronic Kidney Disease (CKD) receiving haemodialysis at Patan Hospital. The respondents were selected using purposive sampling technique. After taking informed consent, data was collected using interview technique based on structured questionnaires. Depression Anxiety Stress Scale-21 was used to assess the levels of depression, anxiety and stress. Data was analyzed using descriptive statistics in terms of mean, frequency and percentage.

Results: The prevalence of depression, anxiety and stress were 71.18%, 62.71% and 20.33% respectively. Majority (30.51%) of the respondents had moderate depression, 20.34% had mild, 10.17% had severe and extremely severe depression. Similarly, 32.20% had moderate anxiety, 15.25% had mild, 6.78% had severe and 8.47% had extremely severe anxiety. Likewise, 11.86% had mild stress, 6.78% had moderate stress, and 1.69% had severe stress. The mean and standard deviation of DASS scores were 34.51 ± 19.31. The prevalence of psychological distress among respondents was 42.37%.

Conclusions: The results of the study showed that more than two fifth of the respondents had psychological distress. The highest prevalence was depression which was present in more than two third of the respondents.

Prevalence of long COVID-19 syndrome among health care workers of Patan Academy of Health Sciences

Bimal Pandey — 2022-12-30

Introduction: Any symptoms acquired after COVID-19 infection that persists beyond 12 weeks period and not explained by any other disease either already present or acquired after COVID-19 infection is termed as long COVID 19 by World Health Organisation. We tried to find out the prevalence of long COVID 19 in healthcare workers.

Method: Questionnaire was made in google form based on COVID-19 Yorkshire Rehabilitation Screening Tool (COVID YRS Tool). Ethical approval was taken from IRC-PAHS. Data collected from all health care workers of PAHS from 2022/05/20 to 2022/07/20. Difference in Precovid and Postcovid status in different domains were compared by statistical tests.

Result: The median age of our participants was 29 years. Prevalence of Long COVID 19 was 68.1%. 19 55.3% ha mild, 10.4% had moderate, 2.4% had severe symptoms. The most common symptom was fatigue (44%), anxiety (41%) and shortness of breath (36%). The COVID YRS Tool overall score was statically significant with p value <0.001. Pre COVID 19 and Post COVID 19, patients had statically significant in breathlessness, fatigue, nutrition, anxiety, usual activity, pain, anxiety and depression. Only 6% of our patients had severe COVID 19.

Conclusion: People are still experiencing various symptoms after COVID 19 infection. Long COVID 19 has now been a health care problem. Long COVID 19 patients have multisystem involvement and multi-speciality team is needed for their management and rehabilitation.

Antenatal visits and obstetric outcomes during nationwide COVID-19 lock down period in a tertiary hospital of Nepal

Padma Gurung — 2022-12-30

Introduction: Maternity services were disrupted during nationwide COVID-19 lock down period. This study aimed to evaluate the impact of nationwide COVID-19 lock down on antenatal visits and obstetric outcomes in a tertiary hospital of Nepal.

Method: A study was conducted at Patan hospital, Nepal with regard to antenatal visits and obstetric outcomes during COVID-19 lockdown period (24^th March to 14^th June 2020) and was compared to non COVID-19 period (24^th March to 14^th June 2019). A Chi-square test was used to determine the association between the outcome variables. The data was taken as statistically significant when the p-value was <0.05.

Result: A total of 4,157pregnant women visited antenatal clinic (ANC) during nationwide COVID-19 lock down period while 7,029 patients visited during same period a y back (non COVID-19 period) which is a 40.86 percentage decline. There was significant reduction in deliveries during COVID-19 lock down period (1604 during non COVID-19 and 1140 deliveries during COVID-19 lockdown period respectively) but mode of delivery was similar. Maternal complications like postpartum hemorrhage (PPH), intensive care stay (ICU), sepsis and cesarean hysterectomy were similar during both the period.

There was a significant reduction in preterm deliveries during COVID-19 lock down period (13 during non COVID-19and 8.7 percentage during COVID-19 period respectively). However, early neonatal sepsis (EONS) was significantly higher during COVID-19 lock down period.

Conclusion: While, there was a significant reduction in preterm births and increase in early neonatal sepsis during COVID-19 lockdown period, there was no difference in maternal outcome.

Socio economic challenges and coping strategies against COVID-19 among dentists of Nepal

Reshu Agrawal Sagtani — 2022-12-30

Introduction: COVID-19 has posed various challenges to health care professionals including dentists. We aimed to study financial impact, socio- economic challenges, coping strategies and areas where dentists of Nepal require support during the current pandemic.

Method: A descriptive study was conducted among registered dentists who were currently involved in clinical practice in Nepal. Data was collected via semi-structured online google form during the period of August – October 2020 through non-probability sampling. The online responses from google forms were transformed to datasheets which were analyzed using Microsoft Excel and summarized using descriptive statistics.

Result: More than a quarter (127, 29.8%) of the dentists were not able to practice dentistry during the pandemic. Among the salaried dentists, 113 (34.2%) of them did not receive any salary and 67 (15.7%) lost their jobs. More than 50% percent of decline in monthly income was experienced by 80 (18.7%). The most common challenge faced by the dentists was reduced income (95.2%) followed by access to PPE and sanitizers (72.9%). Social distancing was the most common (87.2%) coping strategy followed by strict use of PPE (86.9%), acquiring correct information regarding prevention of COVID-19 (76.8%). Provision of PPE was the area where 147 dentists needed the most support (36.4%) followed by cash allowance (31.7%) and rent waiver (28.4%).

Conclusion: The study showed that dentists in Nepal are facing serious financial challenges due to the current pandemic. The current study highlights a need to create a support system for dentists to sustain their clinical practice during the pandemic.

Basic concept of healthy aging

Hom Nath Chalise — 2022-12-30

Rapid population aging is a characteristic of 21^st century, regardless of a nation’s level of development. An ageing global population results burden in medical and social demographic problem worldwide. Addressing this problem is the highest priority for the care of the ageing population worldwide. Healthy ageing is an individual lived experience that is influenced by healthy behaviours over the course of a lifetime. This includes a person’s ability to: meet their basic needs; learn, grow and make decisions; be mobile; build and maintain relationships; and contribute to society. For the promotion of healthy aging, healthy life style is important. A healthy lifestyle for older adults includes: healthy eating, regular physical activity, staying at a healthy weight, improving mental health, social participation, regular health checkups and health screening, no smoking and taking steps to prevent falls.