Nepal Medical College Journal <p>Nepal Medical College Journal is the official journal of Nepal Medical College Pvt. Ltd (NMC), Attarkhel, Gokarneshwor Municipality-8, Kathmandu, Nepal. P.O. Box 13344, Phone: +977 01 4911008 &nbsp;| &nbsp;4912118 &nbsp;| Extension 607, Email: <a href=""></a>.</p> <p>It is also available on its own website <a href="" target="_blank" rel="noopener"></a></p> Nepal Medical College Pvt Ltd en-US Nepal Medical College Journal 2676-1319 Performance of Pediatric Index of Mortality-2 in a Pediatric Intensive Care Unit of a Tertiary Care Hospital of Nepal <p>Various scoring system have been developed and are becoming essential part of Pediatric and other critical care units. The Pediatric department wants to introduce Pediatric Index of Mortality-2 (PIM 2) as a predictive scoring system in Pediatric critical care unit of Nepal Medical College Teaching Hospital (NMCTH). This was a prospective cohort study done in Pediatric Intensive Care Unit (PICU) of NMCTH. Study was done from August 2017 to December 2018. All cases admitted in ICU were taken consecutively from term newborn to 14 yrs of age. PIM 2 scoring system was done in all patients. PIM 2 performed well in terms of discrimination with area under curve for PIM 2 scor e was 0.809 with 95% Confidence Interval of 0.0709 to 0.910 and Standard Error of 0.051. Good calibration was observed across deciles of risk as measured by Hosmer-Lemeshow goodness of fit test with P value of 0.163, chi-square value of 11.752 (8). Mortality observed in our PICU was 28.4% with standardized mortality ratio of 1. PIM 2 scoring system performed well in our PICU.</p> Sangita Puree Dhungana P.P. Panta S.K. Shrestha S. Shrestha ##submission.copyrightStatement## 2019-08-02 2019-08-02 21 2 89 94 10.3126/nmcj.v21i2.25105 Assessment of Various Parameters of Dental Anxiety Among Nursing Students in Rural and Urban Area of Bareilly City India –A Cross Sectional Survey <p>&nbsp;To assess the various parameters of dental anxiety among nursing students in rural and urban area of Bareilly city India. A cross-sectional survey was conducted among nursing students aged 18 to 25 years in Bareilly city of Uttar Pradesh State in India. Dental anxiety was measured using Modified Dental Anxiety Scale (MDAS). It consists of three six-item scales that also use the Likert format. The data obtained were analysed using Analysis of variance (ANOVA). The study group individuals in majority were slightly anxious (59.4% and 47.5%) when questioned about their feelings on visit to dentist and sitting in dentist’s waiting area, while they would feel extremely anxious (29.9%) if they were to receive local anesthesia respectively. The conclusion drawn from the present study was that all are "slightly anxious" as compare to others.</p> Karnika Yadav N. Lakshminaryan ##submission.copyrightStatement## 2019-08-02 2019-08-02 21 2 95 99 10.3126/nmcj.v21i2.25106 Visual Reaction Time in People with and without Diabetes - A Comparative Study <p>&nbsp;Peripheral neuropathy is a common complication of type 2 diabetes in patients with poor diabetic control where reaction time increases in comparison to normal individual. Early detection of neural dysfunction denoted by increased reaction time will be helpful for the patient, to control blood sugar in order to avoid diabetic complications. This study was conducted to find out the neural deficit in diabetes by comparing the visual reaction time using ruler drop method between non-diabetics and diabetics and assessing the relationship of reaction time with increase in glycated hemoglobin (HbA1C) titre. It was a case control study among 38 diabetics and 31 healthy volunteers. Among the volunteers of age groups 20-39 years and 40-59 years, all patients with poor diabetic control showed significantly high reaction time in comparison to their non-diabetic counterparts (180.66 ms vs 231.11ms; 197.27ms vs 224.44 ms respectively). In age groups of 60-79 years, reaction time was also more in patients with high HbA<sub>1C</sub> in comparison to their non-diabetic counterparts (224.00 ms vs 230.90 ms). In comparison to non-diabetics, diabetics with increased HbA<sub>1C</sub> (7- 9%, 9-11%, 11-13%, &gt;13%) all showed significantly higher reaction time (193.54 ms vs 219.00 ms; 193.54 ms vs 225.83 ms; 193.54 ms vs 236.66 ms and 193.54 ms vs more than 250 ms respectively). A positive Pearson Correlation (r = 0.4) was also noted between HbA<sub>1C</sub> (%) and reaction time (ms) amongst the patients with poor diabetic control. Damage of vasa nervosum and formation and accumulation of sorbitol and fructose in Schwann cells might disrupt structure and function of peripheral nerves leading to neuropathy and altered visual reaction time in diabetics.</p> Tapas Pramanik R. Dhakal R. Pandit ##submission.copyrightStatement## 2019-08-02 2019-08-02 21 2 100 103 10.3126/nmcj.v21i2.25107 Colorectal Cancer in Young Age Group: Where Do We Stand? <p>Colorectal cancers in young are in increasing trend. Young patients tend to ignore symptoms and present at advanced stage due to aggressive tumour biology, and also due to traditional dictum of routine screening after &gt;50 years these groups of patients are given less priority. The objective of our study was to estimate the burden of problem among young population and increase awareness among medical personnel and general population of early detection for disease. We conducted retrospective cross sectional study using whole sampling method among patients operated by single gastrointestinal surgery unit. Demographic details, malignancy information, surgical procedure and histopathological examination were studied. All cases admitted as colorectal cancer from 2013 to 2017 at gastrointestinal surgery unit of Shree Birendra Hospital were included. The collected data were entered in SPSS version 16 and analyzed. Likelihood of occurrence of adenocarcinoma was studied using logistic regression model. Among total 104 cases operated, only 99 cases were having complete data with median age: 55 years. Thirty seven percent of the individuals having colorectal malignancies were younger than 50 years. Rectum was the commonest site (52, 52.5%) for occurrence of colorectal malignancy. Males were 1.493 (0.402-5.545) times more likely to have colorectal adenocarcinoma than females. Young age (&lt;50 years) was associated with an increased likelihood of colorectal adenocarcinoma {OR=1.771(0.443-7.233)} than older people. Colorectal cancer in young age is in increasing trends. Increasing awareness among medical personnel and general population is must for early detection.</p> Sushil Bahadur Rawal U. Laudari A. Thapa M.K. Jha D.B. Shrestha M. Maharjan J. Rayamajhi S. Malla ##submission.copyrightStatement## 2019-08-02 2019-08-02 21 2 104 109 10.3126/nmcj.v21i2.25108 Drug Resistance and Biofilm Production among Pseudomonas aeruginosa Clinical Isolates in a Tertiary Care Hospital of Nepal <p>Clinical isolates of <em>Pseudomonas aeruginosa </em>often exhibit multidrug resistance due to their inherent ability to form biofilms. Drug resistance in <em>Ps. aeruginosa </em>is a major clinical problem, especially in the management of patients with nosocomial infections and those admitted to ICUs with indwelling medical devices. To evaluate the biofilm forming abilities of the clinical isolates of <em>Ps. aeruginosa </em>and to correlate biofilm formation with antibiotic resistance. A total of 90 consecutive isolates of <em>Ps. aeruginosa </em>obtained from various specimens collected from patients visiting the Manipal Teaching Hospital, Pokhara, Nepal between January 2018 - October 2018 were studied. Isolates were identified by standard microbiological methods. Antibiotic susceptibility testing was performed by Kirby-Bauer disc diffusion method. All the isolates were tested for their biofilm forming abilities by employing the tissue culture plate assay. Of the 90 <em>Ps. aeruginosa </em>isolates, maximum i.e 42 (46.6%) were from patients in the age group of &gt; 50 years. Majority (30; 33.3%) of the isolates were obtained from sputum samples. However, percentage isolation from other specimens like urine, endotracheal tube (ETT), pus, eye specimens and blood were 18.9%, 16.7%, 16.7%, 7.8% and 6.7% respectively. All the isolates were sensitive to polymixin B and colistin, 91.1% of the organisms were sensitive to imipenem, and more than 80% to aminoglycosides (80% to gentamicin, 83.3% to amikacin). A total of 29 (32.2%) organisms were biofilm producers. Maximum numbers of biofilm producing strains were obtained from ETT (8 of 15; 53.3%), pus (8 of 15; 53.3%) and blood (2 of 6; 33.3%) i.e from all invasive sites. None of the isolates from noninvasive specimens such as conjunctival swabs were biofilm positive. Significantly higher numbers of biofilm producers (23 of 29; 79.3%) were found to be multidrug resistant as compared to non-biofilm (6 of 61; 9.8%) producers (p=0.000). <em>Ps. aeruginosa </em>colonization leading to biofilm formation in deep seated tissues and on indwelling devices is a therapeutic challenge as majority of the isolates would be recalcitrant to commonly used antipseudomonal drugs. Effective monitoring of drug resistance patterns in all <em>Pseudomonas </em>clinical isolates should be a prerequisite for successful patient management.</p> Rajani Shrestha N. Nayak D.R. Bhatta D. Hamal S.H. Subramanya S. Gokhale ##submission.copyrightStatement## 2019-08-02 2019-08-02 21 2 110 116 10.3126/nmcj.v21i2.25109 Correlation between Symptom Severity and Objective Parameters in Elderly Men with Lower Urinary Tract Symptoms <p>&nbsp;Lower urinary tract symptoms (LUTS) are mostly due to benign prostate hyperplasia (BPH) in the elderly men. The severity of LUTS associated with BPH is measured with the international prostate symptom score (IPSS). Objective indicators of the disease severity in BPH are prostate volume, post void residual urine volume (PVRU), uroflowmetry values etc. However the correlation between the severity of subjective symptoms and objective parameters remains unclear. We designed this study to see if there actually is a correlation between the subjective symptoms and the objective parameters in evaluation of LUTS. Elderly male patients presenting with LUTS in the Urology OPD over a period of 10 months are enrolled in this study. These patients are asked to fill the IPSS with assistance if necessary from medical person. Prostate volume and PVRU are measured with trans-abdominal ultrasonography. Uroflowmetry evaluations are done to record maximum flow rate (Qmax) and average flow rate (Qave). Correlation of IPSS with age, prostate volume, PVRU and uroflowmetry parameters is evaluated using correlation regression analysis. Our results revealed significant positive correlation of IPSS with prostate volume and PVRU. Similarly there is significant negative correlation of IPSS with Qmax and Qave. Hence this study concluded that there is significant correlation between symptom severity and objective parameters in elderly patients with LUTS.</p> Krishna Kaji Bhomi B.R. Joshi ##submission.copyrightStatement## 2019-08-02 2019-08-02 21 2 117 121 10.3126/nmcj.v21i2.25110 Occlusal Traits of Primary Dentition among Children Visiting a Dental Hospital in Kathmandu, Nepal <p>&nbsp;Occlusion in deciduous dentition varies among children of different populations and races. Paucity of information in Nepalese literature provided the motive for this study. The objective of this study was to examine the occlusal traits of Primary Dentition among children aged 2-6 year old. A cross-sectional study comprising total of 307 children all having deciduous teeth were included in the study. The dentition was examined using a mouth mirror and explorer under illuminated light in Department of Pedodontics and the data was recorded. All the children were screened for molar and canine relationship, overjet, overbite, spaced and non-spaced dentition. Out of the total, Mesial step terminal plane (62%-left; 58%-right), Flush terminal (33%-left; 36% -right) and Distal step (5%-left; 6%-right) were seen. Most of the children had class I canine relation (83%-left; 84%-right), ideal overjet (68.4%), overbite (63.1%) and spaced dentition. Statistical significant difference was found among the gender with respect to overjet. Presence of spacing was more in maxilla than in mandible which was statistically significant. These findings suggested desirable occlusal characteristics and spacing in primary dentition. However, future longitudinal studies are required to examine whether the transition of these occlusal characteristics will lead to favorable outcome in permanent dentition.</p> Priyanka Shah J. Acharya S. Khanal ##submission.copyrightStatement## 2019-08-02 2019-08-02 21 2 122 127 10.3126/nmcj.v21i2.25111 Adverse Drug Reaction with Hyoscine and Valethamate for Cervical Dilation during Labour <p>&nbsp;Adverse drug reaction (ADR) is an injury caused by taking medication. ADR may occur following single dose or prolong administration of drug or combination of two or more drugs. While major advancements of discipline of pharmacovigilance have taken place in the West, not much has been achieved in Asian countries. Labour is characterised by forceful and painful uterine contraction that result in cervical dilation and foetus decent from the birth canal. Anti-spasmodic drugs like hyoscine butylbromide and valethamate bromide have been used to accelerate cervical dilation and thus reduce the labor duration. The objective was to observe ADR with hyoscine and valethamate for cervical dilation during labor. It was a hospital based cross sectional study. Investigation was carried out in the form of questionnaire. All the consecutive patients who were in active stage of labor were included in the study. They were given Intravenous (IV) valethamate bromide 8mg and hyoscine butylbromide 20mg, 3 doses half an hour apart. After administration of the drug, the progress of labor was monitored and management was done as per protocol in obstetrics and gynaecology department. ADR reported were blurred vision in 47.7% of the patients, followed by dry mouth (36.9%) and tachycardia (19.2%). Other ADRs were nausea (6.2%), dizziness (3.8%), flushing (2.3%), vomiting (1.5%), fever (1.5%) and constipation (1.5%). No statistical significance was found when ADR was compared between the age group of 18-25 years and 26-35 years. Therefore, ADR reported were irrespective of the age of the patients and no life threatening or severe forms of ADR were seen with hyoscine and valethamate during cervical dilation.</p> Lujaw Ratna Tuladhar A. Shrestha R.K. Shrestha ##submission.copyrightStatement## 2019-08-02 2019-08-02 21 2 128 133 10.3126/nmcj.v21i2.25112 Effect of Neonatal Exposure of Monosodium Glutamate in Kidney of Albino Mice – A Histological Study <p>&nbsp;Monosodium Glutamate (MSG) is a commonly used food additive. Scientists have found that MSG has toxic effects in several tissues and organs like neurons, liver, testes, ovary, kidneys etc due to oxidative stress both after exposure in neonatal period as well as in adult animal models. Although various reports have suggested that MSG has damaging effect in kidneys only few histological studies are available. This study was done to observe any histological changes in kidneys of albino mice after neonatal exposure with MSG. Study showed significant changes in weight and volume of kidneys in gross morphology. Increased urinary space and dilatation of proximal convoluted tubules (PCT) and distal convoluted tubules (DCT) were constant finding in experimental animals. There were loss of luminal microvilli and reduced height of lining cells of both PCT and DCT.</p> Tapati Bhattacharya S.K. Ghosh ##submission.copyrightStatement## 2019-08-02 2019-08-02 21 2 134 141 10.3126/nmcj.v21i2.25113 Assessment of Septoplasty Outcome using Nasal Obstruction Symptom Evaluation Scale <p>&nbsp;Nasal obstruction, the most common presenting symptom in nasal and sinus disease, is defined as patient discomfort manifested as a sensation of insufficient airflow through the nose. Nasal septal deviation is the most common anatomical cause of nasal obstruction. Surgical correction of a deviated septum, nasal septoplasty, is the definitive treatment for septal deviation. Many studies have discussed about outcomes of septoplasty. However, there is limited published literature on nasal septoplasty and its outcome in Nepal. The aim of this study is to evaluate the outcome of septoplasty using Nasal Obstruction Symptom Evaluation (NOSE) scale, a validated outcome instrument assessing quality of life (QoL) related to nasal obstruction. A total of 52 patients aged 18 years and above, with nasal obstruction at least for 3 months, undergoing septoplasty alone were included in the study. Baseline NOSE score was calculated a week before surgery. The patients were followed up after 3 months to record postoperative NOSE score. On statistical analysis, the mean NOSE scores before and 3 months after septoplasty were 45.58±21.38 and 8.46±8.37 respectively. The mean difference was 37.11± 21.22 and p value on paired t test was less than 0.001(highly significant). The mean differences of each component of the NOSE scale questionnaire were also found to be highly significant statistically with p values less than 0.001. Gender and age did not seem to affect the outcomes. In conclusion, NOSE scale is a valid, reliable and responsive instrument that is brief and easy to complete and has potential use for outcome studies in adults with nasal obstruction. This instrument showed that septoplasty, if done in properly selected patients, results in significant improvement in nasal obstruction and disease specific quality of life with high patient satisfaction.</p> Kundan Kumar Shrestha R.R. Joshi A.S. Rijal A. Dhungana S. Maharjan ##submission.copyrightStatement## 2019-08-02 2019-08-02 21 2 142 146 10.3126/nmcj.v21i2.25114 Efficacy and Safety of Spinal Anaesthesia in Paediatric Age Group between 3 to 14 Years for Infraumblicus Surgery <p>Spinal anaesthesia (SA) in paediatric patients was first introduced by August Bier in 1899. But this technique did not gain wide spread popularity in paediatric age group because of the introduction of various muscle relaxants and inhalational agents for general anaesthesia. SA in paediatric population has been gradually reintroduced as an alternate to general anaesthesia. The study was performed at the Nepal Medical College Teaching Hospital to evaluate the efficacy and safety of SA in paediatric age groups, compare the change in vital parameters such as heart rate, blood pressure and oxygen saturation during preoperative and intraoperative period, the complications of SA and time of demand for first rescue analgesia in postoperative ward. Sixty-seven patients aged between 3 years to 14 years of ASA I and ASA II were selected after screening for anaesthesia fitness. The duration of surgery ranged from 49.85 ± 11.55 to 56.30 ± 9.68 minutes and the blood loss was less than 10% of total blood volume, thus there was no need to transfuse during operation. The duration of analgesia ranged between 107.69 ± 7.25 to 115.00 ± 7.07 minutes in different age groups. Sixty patients (89.55%) achieved Bromage Scale Score (BSS) 3 with interpretation of complete block; seven patients (10.45 %) achieved Bromage Scale Score 2 (partial block) and were operated after supplemental intravenous sedation. None of the patients needed conversion to general anaesthesia. Successful CSF drain with placement of spinal needle in 1st attempt was achieved among 55 patients (82.1%) and in 2nd attempt among 12 patients (17.9%). No unsuccessful attempt was recorded. SA in children appears to be a relatively safe technique with few complications and may be considered as an alternative for general anaesthesia. It is cost effective in comparison to general anaesthesia as the drugs and equipment required are less and cheaper and the length of hospital stay is usually shorter.</p> Shailendra Nath Gautam S. Acharya G.R. Bajracharya S. Hyoju ##submission.copyrightStatement## 2019-08-02 2019-08-02 21 2 147 152 10.3126/nmcj.v21i2.25115 Amniotic Band Syndrome: A Silent Knife In-Utero <p>&nbsp;Amniotic band syndrome (ABS) is a rare, but serious congenital syndrome complex. It is associated with a wide range of fetal structural anomalies, notably craniofacial and limb anomalies. Early prenatal diagnosis is important to provide accurate information to the parents, predict the prognosis and in some cases perform in-utero lysis of the bands to restore the blood flow to the affected limb. A postnatal multidisciplinary approach involving vascular decompression, reconstructive surgery, prosthesis, and physiotherapy are some of the therapeutic options. It is necessary to consider ABS in prenatal screening with a high index of suspicion as early screening can allow a timely therapeutic strategy and reduce the severity of the associated defects.</p> N. Fatema Yogesh Acharya H.N.A. Yaqoubi ##submission.copyrightStatement## 2019-08-02 2019-08-02 21 2 153 159 10.3126/nmcj.v21i2.25116 Filariasis Diagnosed by Real Time Sonographic Imaging as Filarial Dance Sign: A Case Report <p>&nbsp;Lymphatic filariasis is a major public health problem. World Health Organization (WHO) has graded filariasis, as the second leading cause for permanent and long-term disability after leprosy. It is a chronic disabling parasitic disease prevalent in South Asia and Africa. A case of 26-year-old male resident of district Palpa presented with swelling of left inguinal region since 3-4 days and pain in inguinal region since a month. He had no history of trauma, fever or any other systemic symptoms. High frequency, high-resolution scrotal ultrasonography is a valuable technique for diagnosing scrotal filarial infection. This method revealed “Filarial Dance Sign” which is a distinctive and continuous pattern of movement of live microfilaria indicating active infection. It is a simple, rapid, sensitive and noninvasive technique. Noninvasive ultrasonography is preferable to the invasive FNAC.</p> Sumiran Shrestha R. Shrestha S. Gokhale ##submission.copyrightStatement## 2019-08-02 2019-08-02 21 2 160 163 10.3126/nmcj.v21i2.25117 Giant Solitary Trichoepithelioma: A Case Report <p>&nbsp;Giant solitary trichoepithelioma (GST) is a rare adnexal skin tumor with hair structure differentiation. It varies from trichoepithelioma in size (&gt;2cm) and location (common in thigh and perianal region). So far only 18 cases of GST have been reported worldwide. This is a case of GST in the thigh of a 42 year old man. This form of trichoepithelioma can be a cellular tumor which needs to be differentiated from trichoblastoma, keratotic basal cell carcinoma, nevoid basal cell carcinoma and microcystic adnexal carcinoma.</p> Geetika KC S.R. KC A. Lakhey M. Singh ##submission.copyrightStatement## 2019-08-02 2019-08-02 21 2 164 166 10.3126/nmcj.v21i2.25118