Risk factors and outcome analysis of patients with intraoperative rupture (IOR) of ruptured cerebral aneurysm during microsurgical clipping.

PURPOSE: To analyse baseline characteristics of patients with intraoperative rupture (IOR) or non-IOR who underwent microsurgical clipping for ruptured intracranial aneurysms. Additionally, to asses functional outcome in terms of Glasgow Outcome Scale (GOS) at 6 and 12 months. METHODS: A retrospective analysis of 471 patients who underwent microsurgical clipping for ruptured intracranial aneurysms from 2007 to 2018 in Nepal Mediciti Hospital, Nepal. Patients who underwent surgery for unruptured aneurysm were excluded from the study. The association of the base line characteristic in IOR and non-IOR were analysed. Variables analysed were the Hunt and Hess Scale (HHS) dichotomized as (1-3) and (4-5), Modified Fisher Scale dichotomized as (0-2) and (3-4), type of rupture, use of brain retractor, timing of IOR during surgery, aneurysmal factors (size of the neck, location, lobulation) and time of surgery. Outcome, GOS dichotomized into favourable (4-5) and unfavourable (1-3), assessed at 6 months and 12 months. RESULTS: Out of 471 patients treated for ruptured intracranial aneurysm, IOR occurred in 57 (12.10%) with mean age 49.47 (SD ±12.9), occurred more in smoker than non-smoker (45.6% vs. 18.6%; p=.000) and regular alcohol consumers (36.8% vs. 17.9%; p=.004). Favourable outcome with GOS (4-5) at 6 months was observed among patients with lower HHS (1-3), p=.025 and lower MFS (0-2), p=.04. However, outcome at 12 months was better associated with MFS (p=.013) and aneurysm size (p=.038), with more favourable outcome associated with aneurysm less than 10 mm. CONCLUSIONS: Alcohol consumption and smoking are associated risk factors that may contribute to IOR. HHS and MFS are strong predictors of outcome for IOR patients at 6 months. However, at 12 months, MFS is more predictive of outcome. Aneurysms greater than 10 mm had a strong association with outcome at 12 months than 6 months.

A Study of Occupational Characteristics and their Association with Cardiovascular Disease among Industrial Workers in Eastern Nepal.

Background An understanding of occupational characteristics of a worker is essential to establish policies, legislation in order to protect the health of the worker. The concept of Occupational Safety and Health is in initial stage in our country. Work-related cardiovascular disease (CVD) is caused by occupational factors that increase the oxygen requirements of the heart or decrease the capacity of the heart to use oxygen. It can be very difficult to link a specific work-related exposure to the development of cardiovascular disease in an individual person. This is because of issues of latency, multiple possible risk factors, lack of specific work-related features and various factors that influence diagnosis. Objective To study occupational characteristics and their association with cardiovascular disease among relatively young male industrial workers between 20-59 years of age in Sunsari-Morang industrial corridor of Eastern Nepal. Method A cross sectional study was conducted among men between 20 -59 years of age in two randomly selected industries in the Sunsari-Morang corridor of Eastern Nepal from July 2012 to July 2013. The data was collected using a pre-tested semi-structured questionnaire. Systematic random sampling was done to select the required number of samples. Chi-square and Fisher Exact tests were used. Crude and adjusted analyses were done. Result Majority (85%) were day shift workers. About 40% of the workers worked for 70-80 hrs/week. Most of them have stress sometimes at work. Noise was experienced by 40.9% of the workers. Earplug was used by only 5% of the workers. Hypertriglyceridaemia was seen in 49.3% of the workers. Long working hours, not using earplug and financial stress were seen to be associated with cardiovascular disease on bi-variate analysis. However, only earplug was significant in multivariate analysis. Conclusion Risk of cardiovascular disease was seen more among those who worked for more hours; those who did not use earplug and those who had financial stress. The results need further exploration to establish a causal association between occupational characteristics of the workers and cardiovascular disease in industrial set-up of eastern Nepal.

Epidemiological Study of Tobacco Smoking Behaviour amongst Residents of the Hill Region of Nepal.

Background Tobacco use is still a serious public health problem in the world and represents a major cause of morbidity and mortality in most parts of the world. Objective To measure the prevalence of tobacco use and to identify the factors associated with tobacco use among the residents of Dhankuta Municipality. Method The cross-sectional study was conducted among the residents of the Dhankuta Municipality where 205 households were taken as subjects. Pretested semistructured questionnaire was used for data collection and face to face interview was conducted. Univariate and multivariate logistic regression was used to see the association between various factors and tobacco use and identify the predictor variables. Result Overall prevalence of tobacco consumption in Dhankuta Municipality was found to be 57.1%. Prevalence of tobacco consumption among the male was significantly higher (67%) than female (47.1%) (p<0.05). Most of the respondents (56.4%) started consuming tobacco due to peer pressure and for recreation (24.8%). The multivariate logistic regression showed that the people with illiterate have higher chances of consuming tobacco than above School Leaving Certificate (OR 38.395, 95% CI=3.209- 459.417). The respondents below poverty line (<1.25 US$) was consuming tobacco more than above poverty line (> 1.25 US $) (OR 6.814, 95% CI= 1.255-36.986). Conclusion The aims of this study was to measure the prevalence of tobacco use and to identify the factors associated with tobacco use among the residents of the Dhankuta Municipality. We conclude that the prevalence rate of tobacco consumption in the Dhankuta Municipality was found to be moderately high. Factors like male in gender, Brahmin/Chhetri in ethnicity, lack of education, poor occupation like farmer and housewife, poor economic status were associated with tobacco use.

Characteristic of low vision patients attending an eye hospital in eastern region of Nepal.

INTRODUCTION: Low vision is an important public health problem. OBJECTIVE: To study the profile of low vision patients in a hospital of Nepal. MATERIALS AND METHODS: Information related to the patients' profile, visual status, ocular disease and, low vision devices prescribed were obtained retrospectively from the records of 1,860 visually- impaired patients, regardless of the cause, presenting to the low vision department of the Biratnagar Eye Hospital, Biratnagar, Nepal, over a period of four years. These patients, after a comprehensive ocular examination, underwent low vision examination by an ophthalmologist and a low vision specialist. RESULTS: Of 1,860 patients, males comprised 1298 (70 %), while 562 (30 %) patients were female. Six hundred and one (32.3%) patients were of less than 20 years while 398(21.4%) were more than 60 years of age. Agriculture (500, 27 %), household work (341, 18 %) and students (308, 17 %) were the common occupations. Retinal diseases were the commonest cause of low vision. They were: macular disorders 408 (22 %), retinitis pigmentosa 226 (12.1 %) and other retinal causes 361 (19.4 %) (diabetic retinopathy, choroidal coloboma, post laser for retinal vasculitis and central retinal/branch retinal vein occlusion, healed macular chorioretinal scar secondary to retinochroiditis and choroiditis). Refractive error 215 (11.5 %), amblyopia 49 (2.6 %), optic atrophy 144 (7.8 %) and microphthalmos 105 (5.6 %) were the other causes. Uncorrected distance visual acuity was between 6/24 and 6/60 in 509 (27.4 %) and between 5/60 and PL in 1,327 (71.3 %) patients. Similarly, near visual acuity with vision better than 2.50 M (N 20) and worse than 2.50 M (N20) was present in 643(34.5%) and 1,217(65.5%) patients. About 67% and 54.5% of the patients had some improvement in their distance and near visual acuity with glasses and low vision aids. Distance spectacles 909 (49 %), near spectacles 106 (5.7 %), hand held magnifiers 78 (4 %) and telescopes 18 (1 %) were the optical devices prescribed. CONCLUSION: The prevalence of low vision is common among the people of the younger and older age groups. Retinal diseases are common among the causes for low vision. Adequate prescription and availability of low vision devices can improve the visual acuity.

Effect of haemodynamic and metabolic predictors on echocardiographic left ventricular mass in non-diabetic hypertensive patients.

BACKGROUND: Left ventricular hypertrophy is a forerunner of coronary heart disease, congestive cardiac failure, stroke and may also lead to sudden death. Estimation of left ventricular mass by echocardiography offers prognostic information better than the evaluation of traditional cardiovascular risk factors. OBJECTIVE: The aim of this study was to determine the relative contributions of haemodynamic and metabolic factors affecting left ventricular mass in non-diabetic patients with essential hypertension. MATERIAL AND METHODS: 100 non-diabetic hypertensive patients were taken. The association between age, gender, smoking, alcohol, height, weight, heart rate, clinic blood pressure, fasting blood glucose, lipid profile, haemoglobin, body mass index and stroke volume with LV mass was studied. Left ventricular mass was measured by using standard M-mode echocardiography measurement obtained by way of standard recommended by the American Society of Echocardiography. RESULTS: Left ventricular mass was analyzed as a continuous variable. In males body mass index (r = .35, p < .004) and stroke volume(r = -.26, p<.039) were significantly correlated with LV mass. In females body weight was significantly related to left ventricular mass(r = .36, p < .02). The independent association between significant factors and left ventricular mass was assessed by stepwise multivariate logistic regression. Body mass index and systolic blood pressure came as independent determinants of left ventricular mass in all patients. A maximum of 13% of left ventricular mass variability could be explained by these two factors. CONCLUSION: In untreated patients with hypertension patient's body mass index and systolic blood pressure are independent predictors of left ventricular mass after adjustment for other haemodynamic and metabolic factors. They explain a maximum of 13% of left ventricular mass variability. More knowledge is needed about factors that may alter cardiac morphology in the evolution of hypertensive patients.

Chronic cough in thymoma.

Cough is one of the most common symptom for which patients seek medical attention from primary care physicians and pulmonologists. Although tuberculosis and other lung infections are common throughout the developing world, they are not among the most common causes of chronic cough. We report a case of a 23 years old male who presenting to the outpatient clinic with chronic cough not responding to regular and symptomatic treatment that was diagnosed to have thymoma. After all the common causes for chronic cough have been ruled out, unusual causes should also be considered in the differential diagnosis.

Left ventricular hypertrophy in hypertension: correlation between electrocardiography and echocardiography.

BACKGROUND: Hypertension is an important modifi able cardiovascular risk factor. Left ventricular hypertrophy - the marker of hypertension, has emerged as an independent risk factor that can be detected by electrocardiography (ECG)and echocardiography (ECHO). OBJECTIVE: Correlation of electrocardiography and echocardiographically detected left ventricular hypertrophy in hypertensive patients. MATERIALS AND METHODS: Hundred patients with hypertension were studied for left ventricular hypertrophy by the help of electrocardiography and echocardiography. Left ventricular hypertrophy on ECG was assessed by the help of Sokolow-Lyon Voltage Criteria (SLV) and Romhilt - Estes Point Score (R/E). RESULTS: Among 100 patients, 60 were males and 40 were females. Mean age for male was 54.82 + or - 12.10 years and 52.95 + or - 11.63 years for female. The mean systolic blood pressure for male was 150.47 + or - 20 mmHg and for female 148.60 + or - 16.95 mmHg; where as Diastolic blood pressure for male was 93.67 + or - 11.13 mmHg and for female it was 96.05 + or - 12.47 mmHg. Echocardiography detected left ventricular hypertrophy in 64% patients. Electrocardiography detected Left Ventricular Hypertrophy by R/E and SLV criteria 13% and 34% respectively. CONCLUSION: In developing and under developed country ECG is a useful tool for detection of LVH where the facilities of echocardiography and trained echocardiographer are still not in a common man's reach.

Hospital-based community cataract surgery: comparison of visual outcomes between conventional extra-capsular cataract extraction and small incision cataract surgery.

INTRODUCTION: the small-incision cataract surgery is gaining popularity among the ophthalmic surgeons. OBJECTIVE: to compare the visual outcome of conventional extra-capsular cataract extraction (ECCE) and small-incision cataract surgery (SICS) in a hospital based community cataract program. MATERIALS AND METHODS: aprospective interventional study without randomization was carried out including the patients undergoing cataract surgery by either conventional ECCE or manual SICS. They were followed up for 6 weeks postoperatively. The visual outcomes were compared between the two groups. STATISTICS: the statistical program Epi-Info version 2000 was used to analyze the data. Mean values with standard deviations, 95% CI and p value were calculated. The p value of<0.05 was considered significant. RESULTS: of 85 patients, 44 (M: F=10:34) underwent ECCE and 41 (M: F=15:26) SICS (RR= 0.71, 95% CI=0.42-1.2, p value=0.16). Unaided visual acuity on the 1st postoperative day in the ECCE group was e"6/ 18 in 22.7%,<6/18-6/60 in 63.6 %,< 6/60 in 13.7%, whereas in the SICS group, the same was e"6/18 in 70.7%,<6/18-6/60 in 22 %,< 6/60 in 7.3% (95% CI= 0.23 -0.48, p=0.001). Best corrected visual acuity on the 6th week follow-up in the ECCE group was e"6/18 in 79.5%,<6/18-6/60 in 18.2 %,< 6/60 in 2.3% and in the SICS group the same was 6/18 in 90.5% and <6/18-6/60 in 4.9% (95% CI=0.44 -0.73; p=0.00 12). CONCLUSION: both ECCE and SICS are good procedures for hospital based community cataract surgery but within the 6 weeks postoperative period SICS gives better visual outcome. Remarkably higher number of female patients can be provided service in a hospital based community cataract programme as compared to males.

Association of cardiovascular events with glycosylated haemoglobin in diabetic patients.

BACKGROUND: In persons with diabetes, chronic hyperglycemia (assessed by glycosylated hemoglobin level) is related to the development of microvascular disease; however, the relation of glycosylated hemoglobin (HbA1c) to macrovascular disease is less clear. OBJECTIVE: To study the association of cardiovascular events (CVE) with glycosylated haemoglobin in diabetic patients. DESIGN: Case control study. SETTING: B. P. Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal. MATERIALS AND METHOD: Fifty diabetic patients with recent cardiovascular events: myocardial infarction (MI) or stroke was included in the study. There were 25 patients of myocardial infarction and 25 patients of stroke. Fifty diabetic patients without cardiovascular events were taken as control. RESULTS: After adjustment for age, smoking, body mass index, systolic blood pressure and total cholesterol at baseline, level of HbA1c was statistically significant (p = 0.017) among patients with CVE. For MI, level of HbA1c was statistically significant (p = 0.018) while for stroke, level of HbA1c was not significant (p = 0.694). Mean blood glucose also predicted CVE and MI but not stroke in this study (p values = 0.006, 0.006 and 0.670 respectively). Fasting and postprandial plasma glucose was statistically significant in CVE (p values = 0.024 and 0.019 respectively). Urine protein was statistically significant for CVE, MI and stroke (p values = 0.000, 0.032, 0.032 and OR 4.571 (95% CI: 1.963-10.646), 2.667 (95% CI: 1.043-6.815), 2.667 (95% CI: 1.043-6.815) respectively. LIMITATIONS: Sample size was limited due to time constraint and limited resources. Cases with peripheral artery disease were not included in the study. CONCLUSION: Glycosylated haemoglobin is associated with cardiovascular events and myocardial infarction but not stroke.

Exploring the iceberg of hypertension: a community based study in an eastern Nepal town.

OBJECTIVES: Hypertension is an important public health challenge in the developing and the developed world alike. However, community-based studies on cardiovascular diseases including hypertension in a developing country like Nepal have been limited. The primary aim of this study is to measure the prevalence of hypertension in the Dharan town of Eastern Nepal and to explore the 'iceberg phenomenon' of hypertension in the study population. METHODS: A population-based cross-sectional analytical study was undertaken in the Dharan municipality in 2004-5 with one thousand males aged 35 years and above as participants. The subjects were recruited by simple random sampling of the households in each ward. RESULTS: The overall prevalence of hypertension in the study population was 22.7% which was comparable to the studies from Northern and Western India. The comparison between the population with normal and high blood pressure at time of study shows significant differences in terms of age, religion, current job status, occupation, socio-economic status, physical activity and tobacco use. CONCLUSION: The study shows that while a vast majority of the hypertensive population was not aware of their high blood pressure status, at the same time, a large fraction of the population with increased blood pressure did not have their blood pressure under control. A surveillance system to detect population with high blood pressure, follow up the detected cases of hypertension, as well as motivate and/or counsel the 'hard-to-treat' cases for regular follow-up should be valuable.

Sinonasal inverted papilloma in eastern part of Nepal.

OBJECTIVE: To evaluate the clinicopathological profile of sinonasal inverted papilloma in a tertiary referral center in eastern part of Nepal. METHODS: A prospective study consisting of total 28 histologically proven cases of sinonasal inverted papilloma was conducted in the ENT department of the center. The study period was from April 2002 to November 2005. RESULT: Out of 28 cases studied, 21 were males and 7 were females with male to female ratio of 3:1. The highest incidence was seen in the 5th and 6th decades of life. The duration of symptoms varied from 5 months to 20 years with mean duration of 3.9 years. The lateral nasal wall and nasal cavity involvement was seen in all 28 cases. Maxillary sinus was involved in 27(96.4%) subjects followed by ethmoid (20), sphenoid (10) and the frontal sinus (7). The principle presenting symptom was nasal obstruction seen in 96.4% of the patients. Twenty two cases were treated by lateral rhinotomy with medial maxillectomy while, orbital exenteration was done in two cases. Associated carcinoma was noticed in 10.15% of all the subjects studied. CONCLUSION: Sinonasal papilloma mostly presented in fifth to six decades of life mainly affecting the male patients. Majority of the patients were treated by lateral Rhinotomy with medial maxillectomy surgery. Early presentation would have given chances for endoscopic surgery.

Pott's spine and paraplegia.

Spinal tuberculosis is usually secondary to lung or abdominal involvement and may also be the first manifestation of tuberculosis. Spinal tuberculosis (often called Pott's disease) is by definition, an advanced disease, requiring meticulous assessment and aggressive systemic therapy. Physicians should keep the diagnosis in mind, especially in a patient from a group with a high rate of tuberculosis infection. This review aims on updating the knowledge on spinal tuberculosis and its management. Skeletal involvement has been reported to occur in approximately 10% of all patents with extrapulmonary tuberculosis, and half of these patients develop infection within the spinal column. Symptoms of spinal tuberculosis are back pain, weakness, weight loss, fever, fatigue, and malaise. It is much more prone to develop neurological manifestation, paraplegia of varying degree. The palpation of spinous process in routine clinical examination is the most rewarding clinical method and is an invaluable measure for early recognition. Diagnosis of spinal tuberculosis is made on the basis of typical clinical presentation along with systemic constitutional manifestation and the evidence of past exposure to tuberculosis or concomitant visceral tuberculosis. Magnetic resonance imaging can define the extent of abscess formation and spinal cord compression. The diagnosis is confirmed through percutaneous or open biopsy of the spinal lesion. Surgery is necessary as an adjunct to antibiotic therapy if the vertebral infection produces an abscess, vertebral collapse, or neurologic compression. Some patents need aggressive supportive care owing to tuberculous meningitis or encephalopathy. Moreover, the importance of immediate commencement of appropriate treatment and its continuation for adequate duration along with the proper counseling of the patient and family members should not be underestimated for successful and desired outcome.

Epidemiological study of kala-azar by direct agglutination test in two rural communities of eastern Nepal.

We conducted a sero-epidemiological study of kala-azar in two endemic communities (Kasaini and Gidhaniya) situated in the Terai (plain) of eastern Nepal. Direct agglutination test (DAT) was used as a serological test for screening. Capillary blood samples were collected by filter paper method from 601 (96%) people of a total population of 628 in Kasaini and from 482 (94%) people of 515 in Gidhaniya. Positive DAT titres (1:2000) were found in 66 (6.09%) of 1083 sera tested. The male-female sero-prevalence ratio was 1.44:1 and the age group of 15 years and above was most affected. Among the bone marrow aspirates collected from 66 DAT seropositive cases, only 19 were positive for Leishmania donovani (LD bodies). Of the 47 DAT seropositive but LD bodies' negative cases, three were clinically active cases of kala-azar. Another nine developed clinical symptoms of kala-azar during 6 months follow-up and 23 were cases that had received prior treatment for kala-azar (within 1 year). The results of this study show the potential of the DAT on filter paper as a screening test for the surveillance of kala-azar at a community level.

Evaluation of new WHO diagnostic criteria for diabetes on the prevalence of abnormal glucose tolerance in a heterogeneous Nepali population--the implications of measuring glycated hemoglobin.

AIM OF THE STUDY: The present study was designed to (a) evaluate the implications of revised WHO diagnostic criteria on prevalence of abnormal glucose tolerance, (b) compare glycated hemoglobin level amongst healthy, impaired glucose tolerance (IGT), impaired fasting glucose (IFG) and diabetic subjects and (c) evaluate the assay of glycated hemoglobin in screening IGT, IFG from normal subjects. METHODOLOGY: Hospital based, cross-sectional study. Plasma glucose and glycated hemoglobin (gHb) were estimated by glucose oxidase and affinity chromatography method respectively. RESULTS: The crude prevalence of IFG, IGT and diabetes were 9%, 18% and 5.29% respectively with no significant difference between Mongol and non-Mongol population. Newly introduced IFG group falsely incorporate 12% diabetic subjects and fails to detect 83% IGT subjects as impaired glucose metabolism. The gHb level is raised in IGT and diabetic group but not in IFG group. CONCLUSION: The assay of gHb may be used to screen abnormal glucose tolerance but paired estimation of fasting glucose increases the reliability of diagnosis. The level of gHb in mild carbohydrate intolerance mostly depend on the level of rise in post prandial glucose (where the variation is wide, as in IGT) but not on the narrow variance in fasting plasma glucose level as found in IFG.

Clinico-haematological and management profile of aplastic anaemia--a first series of 18 cases from Nepal.

AIM OF STUDY: To study the prevalence, clinico-haematological and management profile of aplastic anaemia (AA) among severely anaemic patients treated at BP Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal. METHOD: A retrospective analysis of 18 cases of biopsy proven AA patients was done between September 1995 and August 1997. RESULTS: Over a period of 2 years, 140 patients with severe anaemia were admitted to our institution. Eighteen patients were diagnosed with AA. The ages of the AA patients ranged from 7 to 56 (median 15) years, with a male: female ratio of 1.23:1. Pallor, bleeding diathesis, weakness and fever were the most common presenting complaints. Blood counts showed pancytopenia in 16 cases. Bone biopsies of all the cases were hypoplastic. Sixteen cases were non-severe AA and the remaining 2 were severe. Of the 18 cases, 16 were idiopathic; 1 case each was associated with chloramphenicol toxicity and hepatitis B infection respectively. Most of the patients were treated with corticosteroids or androgens or a combination of both. Only six patients came for regular follow-up. CONCLUSION: The high (12.85%) prevalence of AA among patients admitted with severe anaemia in this hospital (which acts as a catchment area for the Eastern region) may not reflect the actual prevalence of the disease in the local community. However, a prospective study may delineate the causative factors peculiar to this region. The clinico-haematological profile is typical of the disease. However, the management profile is incomplete without a proper follow-up. This limitation may be overcome by providing free or subsidized treatment.