Arthroscopic Debridement for Mucoid Degeneration of Anterior Cruciate Ligament - A Single Institution Experience from Nepal.

Background Mucoid degeneration of anterior cruciate ligament is characterized by infiltration of mucoid-like material scattered throughout the anterior cruciate ligament substance. It is an uncommon condition, but previously, underdiagnosed or often misdiagnosed as an anterior cruciate ligament tear. Objective To present our early experiences with mucoid degeneration of anterior cruciate ligament in last five years in terms of clinical presentation and the outcomes of arthroscopic management. Method This was a retrospective descriptive cross-sectional study on patient who received arthroscopic debridement for mucoid degeneration of anterior cruciate ligament in Dhulikhel Hospital over five years period (2017 May to 2022 April). Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale that has been translated and validated to be used in local (Nepali) language and context was used for evaluation of outcome evaluation. Result Twenty-one patients of mean age 44.21 years, predominantly females (18), were managed in five years period. The mean Western Ontario and McMaster Universities Osteoarthritis Index score was 16.33±10.47 with a range of 0 to 36 (11.57 to 21.09 at 95% confidence interval). The mean Western Ontario and McMaster Universities Osteoarthritis Index score converted on a scale of 0 to 100 was 17. Thirteen patients had isolated Mucoid degeneration of anterior cruciate ligament whereas nine others had associated either meniscal tear or chondral lesions. Conclusion Mucoid degeneration of anterior cruciate ligament could be a cause of knee pain in middle-aged patients and arthroscopic debridement can improve the patient's symptoms and provide a good functional outcome.

A Study of Trauma Patients in the Emergency Department of a Tertiary Care Hospital in Nepal during Lockdown in COVID-19 Pandemic.

Background The nationwide lockdown was imposed upon by the Government of Nepal with regards to the COVID-19 pandemic. Even during times of limited mobility and travel, trauma cases were presenting to the hospital. Objective To asses trauma patterns among patients presented to the Emergency department in Dhulikhel hospital during the lockdown period. The assessment of the burden of trauma during the pandemic could aid in planning allocation of resources and improving trauma care. Method A retrospective cross-sectional study design was used to assess all patients with a history of trauma during the period of lockdown announced by the Government of Nepal for COVID-19 from March 24 to June 14, 2020. Result Among 2097 patients that visited the emergency department, 23% were trauma cases. In comparison to the corresponding time-period in 2019, trauma cases reduced by more than half (54.5%). The majority of patients utilized ambulances as a means of transportation; a few patients utilized Dhulikhel emergency medical services. The most common mechanism of injury was fall injury, followed by motor vehicle accident and physical assault. Traumatic brain injury occurred in 30% of patients. Of all patients, 71% were discharged after initial treatment, 26% were admitted to different wards and 3% were referred to other health centres. Conclusion Fall injury is a crucial public health concern followed by motor vehicle accident among trauma patients even during the pandemic condition. Thus, emergency rooms should aid in planning for preparedness, mitigation of trauma during situations like these, in planning the allocation of resources and improving trauma care.

First-Generation SARS-CoV-2 Vaccines: A Comparative Analysis between Vaccinated and Unvaccinated Hospitalized Patients Infected with SARS-CoV-2.

Background Severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) variants, which have emerged due to several mutations in spike protein, have a potential to escape immune protection provided by the first-generation vaccines, thereby resulting in breakthrough infections. Objective To identify the socio-demographic factors, clinical features, and outcomes in both vaccinated and unvaccinated hospitalized patients infected with SARS-CoV-2. Method Socio-demographic details, clinical features, and the outcomes among fully vaccinated (double for Covishield/AstraZeneca and BBIBP-CorV and single for Janssen), partially vaccinated, and unvaccinated hospitalized patients with coronavirus disease of 2019 (COVID-19) were collected and analyzed using SPSS version 17. Result Among the hospitalized COVID-19 patients (n=299), 175 (58.5%) patients received a single-dose, 82 (27.4%) double-dose, and 124 (41.5%) did not receive any dose of the COVID-19 vaccines. The risk of SARS-CoV-2 infection when compared between vaccinated and unvaccinated patients was found to be associated among professional degree holders (23.4% versus 9.7%) (p<0.05), professional workers (43.4% vs. 25.0%) (p<0.05), hospitalization to general ward (76.6% vs. 72.6%) (p<0.05), and presence of multiple symptoms (> or equel 3) (86.8% vs. 75.0%) (p>0.05) and comorbidities (> or equal 2) (15.5% vs. 13.7%) (p>0.05). Despite such approximate incidences, the risk of in-hospital mortality among the vaccinated patients was reduced (0.6% vs. 3.2%) (p>0.05), when compared to the unvaccinated patients. The risk of in-hospital mortality was associated with the older age and the presence of multiple comorbidities including bronchial asthma, diabetes, and hypertension. Conclusion Full or partial vaccination against the SARS-CoV-2 variants of concerns might be effective in preventing in-hospital mortality among COVID-19 patients.

Knowledge, Attitude, and Practices Related to COVID-19 among Healthcare Personnel in a Tertiary Care Hospital in Nepal: A Cross-sectional Survey.

Background COVID-19 is significantly affecting the healthcare system globally. As a result, healthcare workers need to be updated on the best practices for the proper management of the disease. Objective The purpose of this study was to assess the knowledge, attitude, and practices (KAP) related to COVID-19 among healthcare personnel. Method This was a cross-sectional study conducted among medical personnel at Dhulikhel Hospital Kathmandu University Hospital using a semi-structured questionnaire on KAP related to COVID-19 from May 8th to June 8th, 2020. We analyzed survey data by using descriptive statistics. Spearman rank correlation, chi-square test and binary logistic analysis were used to examine the association between sociodemographic characteristics with KAP related to COVID-19. Result Among 220 participants, the majority were nurses (60%) followed by doctors (27.7%), paramedics (10%) and technicians (2.3%). The results showed that 68.6% of healthcare personnel had a good knowledge with appropriate practices (98.5%) and negative attitude (59.3%). In the multivariate binary logistic analysis, the healthcare workers with the clinical experience level of one to five years (OR:.42, 95% CI:.19- .96) and more than 5 years (OR: .16, 95% CI: .04-.63) were significantly associated with negative attitude. The confidence score for managing COVID-19 (OR:1.16, 95% CI:1.02-1.34) was significantly associated with an optimistic attitude. Conclusion Healthcare workers are knowledgeable about COVID-19 and proactively practising to minimize the spread of infection but lack optimistic attitudes. Hence, the constantly updated educational programmes related to COVID-19 for targeted groups will contribute to improving healthcare workers' attitude and practices.

Study on Acute Renal Colic and Comparison of Diclofenac and Ketorolac in Pain Management in University Hospital, Kavre, Nepal.

Background Acute renal colic is the most frequent clinical presentations of renal stone and a common cause of patient visits to emergency departments worldwide. The prevalence of the renal stone disease has increased steadily over the past decades. Objective To describe the prevalence, epidemiological features and clinical management of renal colic patients at emergency department in Kathmandu University Hospital, Kavre, Nepal. Method Two hundred and thirty-six patients with acute renal colic presented in emergency department during a six-months period were included in the study. Using a standard predesigned proforma, demographic characteristics, presenting symptoms, practice of pain management and outcome were investigated. Renal colic attacks in patients were defined according to International Classification of Diseases, Tenth Revision, and Clinical Modification-10. Result Prevalence of renal colic was 2.61%. Mean age of the patients was 33.9±13.7 years. More than half of participants were male (54%). Majority of the patients (47.9%) were from Kavrepalanchowk district. The most common presenting symptom of the patients was flank pain on affected side (79.2%). In almost 43% of patients, diclofenac sodium was administered as a first line analgesic. There was no significant difference between diclofenac and ketolorac with respect to the need of second line analgesic (Chi-square value: 0.19, p value = 0.664). Conclusion Prevalence of renal colic was 2.61% at Dhulikhel hospital. More male pateints were affected and the most common presenting symptom was flank pain on the affected. Diclofenac and ketorolac are equally effective for the pain management of renal colic patients.

Reasons for Summoning Ambulance Services in the Hilly Region of Nepal.

Background Nepal lacks a unified and countrywide emergency medical services system as other developing countries. However, the emergence of ambulance service initiatives in the past decade shows a promising future for pre-hospital care. Nepal Ambulance Service (Est. 2011) and Dhulikhel Emergency Medical Services (Est. 2013) are the existing emergency medical services initiatives in Nepal. Objective To describe the reason for summoning ambulance services and demographics of the patients who were transported by Dhulikhel Emergency Medical Services at Dhulikhel hospital, hilly region of Nepal. Method One thousand three hundred and ninety three patient records at Dhulikhel hospital transported by Dhulikhel Emergency Medical Services during the five-year period (2013 - 2018) were included in the study. Chief complaints and demographic data were collected and categorized into overarching systemic categories. Result Among 1393 patients, majority were female (60.4%) and the most common age group was 20-29 years. The most common reason for calling ambulances was gastrointestinal problem (22.6%). Similarly, respiratory (17%), obstetric and gynecological (15.2%), trauma (12.7%) and neurological (9.6%) problems were other common reasons. The number of respiratory problem was increased during the winter season. The overall percentage of patients arriving at hospital with trauma problems was increased steadily, but it was not statistically significant. Conclusion Gastrointestinal problem was the most common reason, followed by respiratory and obstetric and gynecological problems for summoning ambulances services in the hilly regions of Nepal. The incidence of respiratory problem significantly increased during the winter season.

The role of fish intake on asthma in children: A meta-analysis of observational studies.

BACKGROUND: The evidence is mixed on the use of long chain Omega-3 fatty acids in the prevention and management of childhood asthma. METHODS: We conducted a systematic search and meta-analysis investigating the role of fish intake, the main dietary source of long chain omega-3 fatty acids, on asthma in children. RESULTS: A total of 1119 publications were identified. Twenty-three studies on fish intake in association with childhood asthma were included in the final review. In 15 of 23 studies, early introduction of fish (6-9 months) and regular consumption (at least once a week) improved asthma symptoms and reduced risk in children 0-14 years as compared to no fish consumption; 6 of 23 showed no effect and 2 of 23 studies suggest adverse effects. Meta-analysis revealed an overall "beneficial effect" for "all fish" intake on "current asthma" [OR: 0.75; 95%CI: 0.60-0.95] and "current wheeze" [OR: 0.62; 95%CI: 0.48-0.80] in children up to 4.5 years old. An overall protective effect of "fatty fish" intake as compared to "no fish" intake in children 8-14 years old was also observed [OR: 0.35; 95%CI: 0.18-0.67]. CONCLUSION: This meta-analysis suggests that introduction of fish early in life (6-9 months) and regular consumption of all fish (at least once a week) reduces asthma and wheeze in children up to 4.5 years old, while fatty fish intake may be beneficial in older children. Future well-designed clinical trials are recommended to confirm the promising findings documented in this literature analysis.

Patient's Mode of Transportation Presented in the Emergency Department of a Tertiary Care Centre, Kavre, Nepal.

Background In many developing countries, emergency medical services, especially pre-hospital emergency care, has long been neglected. It is the major obstacle for provision of timely care. Patients are regularly brought to emergency department by the relatives in taxis, bus or other readily available mode of transportation that lacks emergency medical services. Development the Nepal Ambulance Service established its first proper ambulance service in Nepal in 2011 and Dhulikhel Emergency Medical Services in 2013 at Dhulikhel Hospital, Kathmandu University Hospital. Proper prehospital emergence medical service can improve survival rates. Objective To determine the mode of transportation used by patients to arrive at the emergency department and effectiveness of medical services specific to Dhulikhel Hospital, Kavre, Nepal. Method In this study, 160 patients who arrived to emergency department during one-month period were included. The emergency physicians and paramedics collected data on a predesigned questionnaire regarding demographic details, mode of transport used by the patients to arrive emergency department, reason for not using ambulance, knowledge on emergency medical services at Dhulikhel Hospital and their acceptability for those services. Result Mean age of the patients was 46±18 years and (52%) were men. Out of them, only 31% arrived to the emergency department by ambulance while the rest other patients used other forms of transport such as private vehicles (21%), bus (16%), taxi (13%), motorbike (11%) and van (7%). Among 50 patients who used ambulance, 24% of the patients who used Dhulikhel Hospital ambulance received medical care and trained medical staff services; all patients were satisfied with the services. 155 out of 160 patients mentioned the need of a trained medical personal in ambulance. The mean duration for waiting time for ambulance was 33.78 minutes. The main reasons to not using ambulance were they did not know the ambulance number, ability to find other vehicles easily and having own private vehicle. Conclusion A prominent proportion of patients did not arrive by ambulance to the emergency department and the main reason was that they didn't know the number of ambulance service. Developing three-digit phone number for ambulance service at the local level will make people easier to remember and contact. Similarly, education and training must be developed to improve emergency medical services. These strategies along with team management of patients could significantly improve patient care in Nepal.

Improving Knowledge, Skill and Confidence of Novice Medical Doctors in Trauma Management with Principles of ABCDE.

Background Trauma is one of the major public health concerns clamming about five million death annually worldwide. Experience and confidence of a doctor in the management of trauma patients have big impact on the overall outcome. Objective This study aims to evaluate the outcome of a trauma course in improving the knowledge, skill and confidence of novice doctors in managing trauma victims. Method A pre/post test analytical study was carried out among novice medical doctors from Kathmandu University School of Medical Science (KUSMS) who participated in a standard two and a half day trauma course, that utilizes the principles of ABCDE, as a part of their regular training. Pre-course knowledge and skill were compared with immediate post-course scores on the same guidelines. Objective structured and subjective written feedbacks from the participants were analyzed qualitatively to identify the perceptions of candidates. Result Sixty-eight males and twenty-nine females completed the course. The average pre-test scores in knowledge and skill were 8.3(33.2%) and 19.6(78.5%) respectively. Similarly the post-test scores were 16.04(64.2%) and 22.45 (89.5%) respectively, showing statistically significant improvements (P 0.000). The mean percentage improvement in knowledge was 48.8% and that in skill was 160.9%. The feedback analysis showed majority of the participants were satisfied with the course and they perceived improved "self-confident" in handling trauma cases. Conclusion All the novice doctors should participate in a standard trauma course hence their knowledge, skill and confidence in handling a trauma can be improved.

Effect of Sildenafil Citrate on Pulmonary Arterial Systolic Pressure and Sub-maximal Exercise Capacity in Chronic Obstructive Pulmonary Disease.

Background Pulmonary hypertension (PH) often complicates Chronic Obstructive Pulmonary Disease (COPD). Sildenafil reduces pulmonary arterial pressure associated with multitude of diseases. Objective To evaluate the use of Sildenafil in Pulmonary Hypertension associated with COPD. Method This randomized control study enrolled 72 patients: 61 completed the study. Thirtypatients with COPD received Sildenafil 25 mg thrice daily and 31 patients with COPD received optimal medical therapy for four weeks. Symptom assessment and dyspnoea grading was done with modified Borg scale and Modified Medical Research Council (MMRC) grade. The functional assessment was done with WHO functional classification. The estimation of pulmonary arterial systolic pressure and six minute walking distance was done before and after four weeks of the administration of therapy in both groups. Adverse reaction profiling was done for Sildenafil. The primary outcomes were the changes in pulmonary arterial systolic pressure and six minute walk test. The secondary outcomes were change in modified Borg scale for dyspnoea, MMRC grading and WHO functional class. Result The mean decrease in pulmonary arterial systolic pressure in Sildenafil group was significant as compared to controls (9.87+7.84 mmHg Vs 5.93+7.44 mmHg, P=0.048). The mean increase in six minute walk distance was significantly more in cases as compared to controls (48.13+25.79 m Vs 32.59+32.96 m,P=0.047). The changes in modified Borg scale was not significant (1.20+1.92 to 1.55+1.23; P=0.401). There was significant changes in MMRC grade (p=0.037). There was no significant change in WHO functional class after four weeks (p=0.071). Conclusion Sildenafil marginally decreased pulmonary arterial systolic pressure and increased six minute walk distance in COPD patients. It improved MMRC grading without affecting modified Borg's Scale and WHO functional class.

Six Minute Walk Distance and Reference Equations in Normal Healthy Subjects of Nepal.

BACKGROUND: The self-paced six minute walk test is a simple assessment for sub-maximal functional capacity. It correlates well with sophisticated tests and gives good prediction for morbidity, mortality, quality of life and pulmonary functions. OBJECTIVE: To evaluate six minute walk distance in healthy adults to identify reference values and formulate reference equations. METHOD: We conducted six minute walk test on 250 random volunteers at and above 18 years of age as per standard protocol. Age, gender, height and weight were measured. Pretest and post-test vital parameters were recorded including pulse oximetry. The six minute walking distance was identified in all subjects. Multiple regression analysis was done to formulate regression equations to predict six minute walking distance. This also correlated age, gender, height, weight, body mass index with six minute walking distance. RESULT: The mean six minute walking distance was 489±86 meters with males walking 509±82 meters and females 445±78 meters. Age, gender, weight and body mass index had significant contribution for prediction of six minute walking distance. Gender was the single most important predictor. Height had the least significance. Depending on coefficients of these variables we formulated three regression equations and tested them for accurate prediction. The two best equations were identified as: Predicted SMWD = 395-1.5xAge+2.47xWT-35.89xGender and Predicted SMWD = 440-1.82xAge-53.07xGender+5.12xBMI. CONCLUSION: Gender, age and height are the most important predictors of six minute walking distance. Reference values and equations for both genders, different age groups with varying weights were derived for local population.

Comparison of ultrasound guided transversus abdominis plane block versus local wound infiltration for post operative analgesia in patients undergoing gynaecological surgery under general anaesthesia.

BACKGROUND: Transversus abdominis plane block has been recently developed as a part of multimodal post operative analgesic techniques. We compared the analgesic efficacy of this technique with local bupivacaine infiltration in patients undergoing gynaecological surgeries with pfannenstiel incision and lower midline incision under general anaesthesia. OBJECTIVES: To evaluate the efficacy of ultrasound guided transversus abdominis plane block for postoperative analgesia. METHODS: Patients were randomly allocated to three groups: control group (n=15), transversus abdominis plane block group (n=15), who received bilateral transversus abdominis plane blockwith 0.25% bupivacaine, and local infiltration group (n=15), who received local wound infiltration with 0.25% bupivacaine at the end of surgery. All patients received intramuscular diclofenac 12 hourly and intravenous tramadol SOS in the postoperative period. Visual analogue scores for pain were assessed at 1,2,4,8,12 and 24 hours postoperatively and these were compared between the three groups. Average tramadol consumption in 24 hours were also compared among the three groups. Data were subjected to univariate ANOVA test and chi-square test. Level of significance was set at 0.05. RESULTS: Visual analogue scores were significantly less in transversus abdominis plane block group and effect lasted up to 12 hours at rest postoperatively and 8 hours during cough and movement. CONCLUSION: Bilateral Transversus abdominis plane block was effective in reducing postoperative pain scores for 8 to 12 hours postoperatively. This block was also successful in reducing postoperative opioid requirement.

A comparative study on epidemiology, spectrum and outcome analysis of physical trauma cases presenting to emergency department of Dhulikhel Hospital, Kathmandu University Hospital and its outreach centers in rural area.

BACKGROUND: Physical trauma is one of the major cause of mortality and morbidity among young and active age group and its increasing trend is of main concern. There are only few studies concerning the spectrum of physical trauma in Nepal. OBJECTIVE: This study aims to evaluate the epidemiological spectrum, the extent, severity of the physical trauma and the outcome evaluation of patients with physical trauma over a period of one year in the emergency department of the Kathmandu University Hospital and compare the same parameters with those patients presenting to the various outreach centers of the hospital in the community. METHODS: Patient treatment files from the emergency department and the reports from various outreach centers were retrieved for a period of one year (May 2011 to April 2012). Epidemiological information, mode, type and anatomic location of injuries were recorded. Outcome evaluation was assessed by number of patients discharged from emergency department of the hospital or the outreach centers after the treatment, patients admitted for inpatient management and referred to other centers for further specialty management. RESULT: In a period of one year, total 2205 (20%) of physical trauma cases presented to the emergency department and 1994 (6.12%) in the outreach centres. Most commonly involved age group in physical trauma both in Hospital set up and in Community set up were the young adults (15 to 49 years). Fall from height was the commonest mode of injury followed by road traffic accidents among the patients coming to the hospital while significant number of trauma patients coming to outreach centers were due to fall from height. In the hospital set up, 1525 (69.2%) of the cases were discharged while 537 (24.4%) needed inpatient management and 85 (3.8%) needed referral to other centers for the specialty management. In case of outreaches, half of the patients were discharged after the primary treatment and almost another half were referred to the hospital, mainly for need of further investigations. CONCLUSION: Fall related injuries and road traffic accidents are the most common mode of trauma in the hospital set up and fall related injuries are the single most important mode of trauma seen in the outreaches. Mostly young adults in their active period of life are involved in physical trauma so appropriate preventive measures through public health approach should be included in comprehensive trauma management for reducing mortality and morbidity rates related to physical trauma.

Preemptive use of small dose fentanyl suppresses fentanyl induced cough.

BACKGROUND: Fentanyl, a synthetic opioid, is a popular choice amongst anaesthesiologists in the operating room. Pre induction intravenous fentanyl bolus is associated with coughing in 28-65% of patients. Fentanyl induced cough is not always benign and can be remarkably troublesome at the most critical moment of anaesthesia when airway reflex is lost. OBJECTIVES: To study the effect of pre emptive use of minimal dose fentanyl through the peripheral venous cannulae on the incidence of cough by a larger bolus of intravenous fentanyl. METHODS: One hundred and fifty patients aged 18-75 years undergoing elective surgical procedures were randomized into three groups of 50 each. The first group received 0.5 ml saline 0.9% intravenously one minute prior to the administration of fentanyl 150 µg (3 ml); the second group received pre emptive fentanyl 25 µg (0.5 ml) prior to the administration of fentanyl 125 µg (2.5 ml); and the third group received preemptive fentanyl 25 µg (0.5 ml), followed by the administration of fentanyl 150 µg (3 ml). Based on the number of coughs observed, cough severity was graded as mild (1-2), moderate (3-5), or severe (>5). RESULTS: The incidence of fentanyl induced cough was significantly lower in both pre emptive group 4 (8%) for 125 µg fentanyl and 7 (14%) for 150 µg than in the saline group 15 (30%). CONCLUSION: Pre-emptive use of minimal dose fentanyl 25 µg administered one minute before a larger bolus dose of fentanyl (125 or 150 µg) can effectively suppress cough.

Comparison of sniffing position and simple head extension for visualization of glottis during direct laryngoscopy.

BACKGROUND: The ability of good glottis visualization during direct laryngoscopy is major determinant of easy tracheal intubation. Sniffing position for laryngoscopy is considered as gold standard and ideal position. Several studies have questioned the validation of sniffing potion. OBJECTIVES: This study aims to compare relative efficacy of sniffing position and simple head extension for visualization of glottis during direct laryngoscopy. METHODS: Four hundred patients undergoing elective surgery under general anesthesia requiring endotracheal intubation were randomized into two groups and study was concluded. Glottic visualization was assessed using modified Cormack and Lehane classification. After laryngoscopy, tracheal intubation was performed and intubation difficulty scale was noted. RESULTS: Both the groups were comparable regarding glottis visualization. Both the groups were comparable in demographic profiles. All the intubation difficulty scale variables were comparable in both the groups except N3. Total Intubation Difficulty Score was better in sniffing position than in simple head extension group. CONCLUSION: Glottic visualization and intubation difficulty score was better in sniffing position as compared to simple head extension.

Relationship between total serum immunoglobulin E levels, fractional exhaled breath nitric oxide levels and absolute blood eosinophil counts in atopic and non-atopic asthma: a controlled comparative study.

OBJECTIVE: Asthma is a prevalent non-communicable disease both in low- and high-income countries, including Nepal. Total serum immunoglobulin E levels and peripheral blood absolute eosinophil counts are known inflammatory markers of asthma. Fractional exhaled nitric oxide measurement in breath has also been proposed as a non-invasive biomarker to assess eosinophilic airway inflammation. This study explores the correlation between these three variables with the intent that one may replace the other in resource-limited setups. APPROACH: This prospective controlled trial evaluated 314 subjects with and without asthma, with the asthma group sub-divided into atopic and non-atopic categories. Total serum immunoglobulin E level, absolute eosinophil count in peripheral blood and fractional exhaled nitric oxide level were measured in all categories. RESULTS: The geometric mean of immunoglobulin E levels, absolute eosinophil count and fractional exhaled nitric oxide were 221.07 ± 774.55 IU/mL, 214 ± 360/uL and 37 ± 49 ppb in the asthma group and 59.13 ± 174.32 IU/mL, 164 ± 137/uL and 12 ± 21 ppb in the control group, respectively. Significantly higher levels were seen in the asthma group for total serum immunoglobulin E (p < 0.001), AEC (p = 0.002) and FENO (p < 0.001) levels. Total serum immunoglobulin E levels, absolute eosinophil count and fractional exhaled nitric oxide were 436.79 ± 822.40 IU/mL, 269 ± 395/uL and 76 ± 52 ppb in atopic asthma group. Similarly, total serum immunoglobulin E levels, absolute eosinophil count and fractional exhaled nitric oxide were 131.17 ± 692.96 IU/mL, 182 ± 328/uL and 23 ± 22.5 ppb in non-atopic asthma group. Significantly higher levels were seen in all three variables: tIgE (p < 0.001), AEC (p =  0.008) and FENO (p < 0.001). A moderate degree of positive correlation was identified between tIgE and FENO50 (Spearman's rho = 0.461) and tIgE and AEC (Spearman's rho = 0.315) with only small correlation between FENO50 and AEC (Spearman's rho = 0.299). SIGNIFICANCE: tIgE levels, FENO50 and AEC levels are higher in asthma, specifically in the atopic phenotype, as compared to normal. Total serum IgE levels have moderate correlation with FENO50 and AEC but FENO50 and AEC are weakly correlated.

Prevalence of peripheral arterial disease by ankle-brachial index and its correlation with carotid intimal thickness and coronary risk factors in Nepalese population over the age of forty years.

OBJECTIVES: Noninvasive measures of subclinical atherosclerosis such as the ankle brachial index (ABI) and common carotid artery intima-media thickness (CCA IMT) could improve risk prediction and provide more focused primary prevention strategies. This report describes the prevalence of subclinical atherosclerotic vascular disease in a Nepalese population over the age of forty years as measured by ABI and CCA IMT and their association with established cardiovascular risk factors. MATERIALS AND METHODS: Ultrasonic evaluation of ABI and CCA IMT was done in 195 individuals of age 40 years and above who had presented to an outpatient department. Patients with established diagnosis of coronary artery disease or symptomatic for peripheral arterial disease were excluded from the study. RESULTS: The prevalence of atherosclerotic disease as measured by ABI was 18.5% and there was a statistically significant correlation between ABI and CCA IMT and other established cardiovascular risk factors such as smoking, diabetes mellitus and hypertension. CONCLUSIONS: We recommend that ABI as measured by sphygmomanometer be incorporated into routine cardiovascular screening and when found to be abnormal further confirmed by Doppler assessment of ABI and CCA IMT as surrogate markers of atherosclerotic vascular disease.

Use of percutaneous thread loop to hold the vermiform appendix during laparoscopic appendectomy.

INTRODUCTION: Laparoscopic appendectomy, although not as widely performed as laparoscopic cholecystectomy, it has got definite advantage over the conventional open procedure. Controversy exists regarding the closure of stump. Our institute practices intracorporeal knot tying using 3 ports. Difficulties are observed in three port technique to hold the appendix during knot tying. We use a percutaneous thread loop. Advantage of the use of loop was evaluated. PATIENTS AND METHOD: Prospective study was carried out during 18 months. Total cases were randomly divided in non-loop and with loop group. Operative procedure was same. Cases were compared in terms of operating time, post-operative hospital stay and complications. RESULTS: Total patients were 66. Thirty two in non-loop group and 34 in with loop group. Mean age was 27.89 yrs. Most of the cases were females (62%). Mean operating time was less in loop group although statistically not significant. There was no difference in post operative hospital stay. Use of loop was not associated with added complications. CONCLUSION: Use of percutaneous loop to hold the appendix reduces the operating time and replaces the need of fourth port. It is safe and effective without any increased morbidity. Key words: Laparoscopic appendectomy, Intracorporeal knot, Percutaneous loop.

Effectiveness of 0.2% Glyceryl Trinitrate and 0.5% Nifedipine in the Treatment of Chronic Anal Fissure.

INTRODUCTION: Anal fissure is an ischemic ulcer caused by combination of spasm of internal anal sphincter and poor blood supply to the posterior midline of anal canal. This study aimed to assess the efficacy of Glyceryl Trinitrate and Nifedipine in the treatment of chronic anal fissure. METHODS: Ninety patients with symptomatic anal fissure in Kathmandu Medical College Teaching Hospital are allocated for study in two groups of 45 each from March 2013 to April 2014. The patients are assigned alternatively to GTN group and Nifedipine group. All patients were assessed every week till 8 weeks in regards to headache, compliance, healing and recurrence. The patients who had complete healing in 8 weeks were further followed up for 6 weeks to detect recurrence. RESULTS: Patients in the two groups were comparable in regard to demographic data (age and sex) as well as clinical factors. Headache was main complaint of patients using GTN in high percentage (16.6%) than complained by patients using topical Nifedipine (6.9%). This factor led to poor compliance with GTN compared with Nifedipine. Nifedipine showed better healing rate 82.5% compared with GTN 60%. Recurrence was comparable among the two groups. CONCLUSIONS: Nifedipine ointment showed better results than GTN ointment in chronic anal fissure regarding headache, compliance, healing and recurrence in 6 weeks of follow up period after complete healing of fissure in 8 weeks.