Evaluation of patient dose during a digital breast tomosynthesis.

INTRODUCTION: When the patient dose in mammography is assessed, it is important to evaluate both average glandular dose (AGD) and entrance surface dose (ESD). A dose survey on both AGD and ESD in mammography has never been studied in Sri Lanka. Therefore, the present study aimed to evaluate the patient dose received during a full-field digital breast tomosynthesis (DBT) examination by determining both AGD and ESD. METHODS: The study was performed on 140 patients who underwent DBT examination. The AGD, ESD, compression breast thickness (CBT), half-value layer (HVL), target/filter combination, kVp, and mAs values were obtained from the machine, and AGD for each projection was calculated using the equation proposed by the Dance 2011. RESULTS: The measured mean AGDs and ESDs of both the breasts were statistically significantly lower than the reference values given by European protocol (p < 0.05). There were no statistically significant differences in both AGDs and ESDs between the right and left breast, between right craniocauidal (RCC) and left craniocaudal (LCC), and between right mediolateral oblique (RMLO) and left mediolateral oblique (LMLO) examinations (p > 0.05). The measured median AGDs and ESDs received for MLO projections of both breasts were statistically significantly higher than that of CC projections (p < 0.05). CONCLUSION: The patients receive a low radiation dose during their DBT examination with both lowered AGD and ESD than the recommended values. IMPLICATIONS FOR PRACTICE: The results can be used as a baseline to optimize the radiation dose in mammography in Sri Lanka.

Comparison of Hearing Result and Graft Uptake Rate between Temporalis Fascia and Tragal Cartilage in Endoscopic Myringoplasty.

Background There are different methods to repair the perforation of the tympanic membrane. Recently cartilage has been used for the repair and results are comparable to temporalis fascia. For surgical procedure endoscope had added good assistance in middle ear surgery. Though the one hand technique the image quality and results are on par with the use of a microscope. Objective To compare the graft uptake rate and hearing results between temporalis fascia and tragal cartilage in endoscopic myringoplasty. Method This is a prospective, longitudinal study conducted among 50 patients who underwent endoscopic myringoplasty using temporalis fascia and tragal cartilage with 25 patients in each group. The hearing was assessed by comparing pre with post-operative ABG (Air bone gap) and ABG closure in speech frequencies (500Hz, 1 KHz, 2 KHz, 4 KHz). The status of graft and hearing results was evaluated on 6 months of follow up in both the groups. Result Out of total 25 patients enrolled for study in both (temporalis fascia and cartilage) groups, 23 (92%) patients in each group had graft uptaken. The audiological gain in the temporalis fascia group was 11.37±0.32 dB whereas in the tragal cartilage group it was 14.56±1.22dB. The audiological gain between the two groups did not show any statistically significant (p = 0.765). However, the pre and post-operative hearing difference was statistically significant in both temporalis fascia and tragal cartilage group. Conclusion Tragal cartilage has similar graft uptake rate and hearing gain when compared with temporalis fascia in endoscopic myringoplasty. Hence, tragal cartilage can be used for myringoplasty whenever required without any fear of deterioration in hearing.

Indoor Air Pollution (IAP) Traceable to Household Fuel Consumption and its Impact on Health.

Energy is an essential and obligatory prerequisite of life. Indoor air pollution is one of the biggest environmental problems in the world being specifically concentrated in resource limited settings. Inspite of the availability of cleaner fuel technologies, people in resource limited setting still depend on traditional fuel to meet their basic needs resulting even in premature deaths. In Nepal people in rural areas are the pre-dominant users of biomass fuel, there is limited research focusing on rural areas particularly; women as they spend most of their time in kitchen. Reports were extensively searched for literature using preset keywords in English language peer-reviewed journals databases PubMed and Google Scholar published between the years 2005 to 2020. Citation details were examined, titles and abstracts screened for eligibility and if relevant, full text was also reviewed in greater detail. Findings were then presented primarily under two bold themes: Household fuel consumption: existing theories and evidence; and health impact of indoor air pollution. Several health effects were reported of indoor air pollution including respiratory illnesses, cardiovascular diseases, cancer, endocrine system disruption and pregnancy complications. These exposures almost double the health risks predominantly among children and women of rural communities as they are directly involved in household activities causing air pollution. Based on our review of evidence, women and children of rural households were the major victims. Further, determinants of household fuel consumption and health effects should be considered while formulating policies in regard to promoting accessibility of clean fuels and reducing household air pollutants.

Effectiveness of Visual Inspection with Acetic Acid and Cervical Cytology in Early Detection of Precursors of Cervical Cancer in Nepal.

Background Cervical cancer ranks as the first, most frequent cancer amongst Nepalese women. This can be prevented through primary prevention and early detection using screening techniques. Though cervical cytology is a standard screening tool in most of the developed countries, it fails to be the screening method of choice in low and middle income countries (LMICs) with limited resources due to financial and technical constraints. Objective This study aims at early detection of pre-cancerous lesion in cervix with cervical cytology and visual inspection with acetic acid. Method This is a hospital based, descriptive cross-sectional study. It included 104 women attending Obstetrics and Gynecology out-patient department (OPD) in Dhulikhel Hospital. Visual inspection of cervix with acetic acid (VIA) and liquid based cytology (LBC) was performed followed by cervical biopsy for positive VIA, or having abnormal cytology, or having unhealthy appearance of cervix even after treatment. Result The incidence of positive VIA and cytology screening was 38.5% and 7.7% respectively. The negative predictive value of VIA and cytology were similar whereas VIA was found to be more sensitive than cytology. Conclusion Cytology screening is used as an investigation of choice for screening of cervical cancer. In Nepal, VIA can be a good alternative for early detection of cervical cancer as it is found to be more sensitive than cytology.

The Trend and Outcomes of Laparoscopic Appendectomy for Complicated Appendicitis in Nepal: A retrospective study from 2014 to 2018 in a University Hospital.

Background Globally, appendicitis is the most frequent emergency surgical procedure. Laparoscopic Appendectomy (LA) is recommended as a standard surgical procedure to remove appendix. In Nepal, studies showed improved outcomes of Laparoscopic Appendectomy than Open Appendectomy (OA) in treating acute appendicitis. However, effectiveness of in Complicated Appendicitis (CA) has not yet studied in Nepal. Objective This study aims to assess the temporal trend of Laparoscopic Appendectomy in management of Complicated appendicitis and to compare outcomes with Open Appendectomy. Method The study is a retrospective descriptive study. The outcome measures in the study are age, sex, ethnicity, length of postoperative stay (LOS), and conversion rate. Secondary data of 174 patients with complicated appendicitis were extracted and reviewed from the operation theater records and the discharge summary from the period of 2014 to 2018. Result The mean age of the patients is 33.2 (SD ±19.4). Predominantly increased incidence is observed among male patients (66%). Mean Length of stay was 4.07(SD±2.1) days. Laparoscopic Appendectomy had shorter hospital stays than open and converted cases. The conversion rate was 10.92% for the observation period, and it was in a decreasing trend with the latest of 4.54%. The temporal trend for the percentage of patients who underwent Laparoscopic Appendectomy was increasing in the observation period. Conclusion The utilization of laparoscopic appendectomy in complicated appendicitis is growing in Nepal, and has decreasing conversion rate.

Awake Fiberoptic Intubation in Cervical Spine Injury: A Comparison between Atomized Local Anesthesia versus Airway Nerve Blocks.

Background In cooperative patients with cervical spine injury, awake fiberoptic intubation is an excellent option for elective and semi urgent situations. It allows documentation of neurologic examination before and after intubation and surgical positioning. We have compared anesthesia of airway by nerve block and the local anesthesia atomizer undergoing awake fiberoptic intubation in cervical spine injury patients, in terms of the intubation time and discomfort. Objective To compare the intubation time and discomfort in patient with cervical spine injury with anticipated difficult airway potential to aggravate pre-existing injury undergoing awake fiberoptic intubation, based on cough and gag scores, between anesthesia of airway by (transtracheal and bilateral superior laryngeal) nerve block with local anesthetic agent and the local anesthesia atomizer. Method After institutional ethical approval and having informed written consent, 30 patients scheduled for elective surgery who require awake fiberoptic intubation, were included in the study. Patients were allotted by computer-generated random series into two groups; Group N received nerve block (transtracheal and bilateral recurrent laryngeal nerve block) and Group A received atomized lignocaine. Result The time taken for awake fiberoptic intubation was significantly lower in nerve blocks group as compared with the atomizer group [Group N: 90.2±11.7secs and Group A: 210.4±10.6 secs (p=0.041)]. Atomizer group had an increased coughing and gagging episodes than nerve block group [Group N: one patient, Group A: 11 patients (p=0.006)]. Ease of intubation and patient comfort were significantly better in nerve block group. Demographic and hemodynamic parameters were comparable in the two groups. Conclusion The nerve blocks (bilateral superior laryngeal and transtracheal recurrent laryngeal) provides adequate airway anesthesia, lesser patient discomfort, and faster intubation to aid in awake fiberoptic intubation in patients with anticipated difficult airway as compared to topical anesthesia using atomizer.

Minimal Invasive Gynaecological Surgeries in Dhulikhel Hospital: One and Half Decade Long Experience.

Background One of the greatest achievements in the surgical fields is the paradigm shift from open surgery to minimal invasive surgery. Dhulikhel Hospital is one of the very few institutions in Nepal where minimal invasive gynaecological surgeries are being regularly performed since early years of its establishment. There are very few publications related to experiences of minimal invasive gynaecological surgeries published in Nepal. Objective To review the varieties of minimal invasive gynaecological surgeries and find out the different milestones those were crossed in this field. Method This is retrospective study of minimal invasive gynaecological surgeries performed from January 1, 2004 to June 30, 2018. Result A total of 1849 cases were performed by mid 2018. Almost half of the cases were of Brahmin/Chhetri caste (49.9%). Mean age of the patients who underwent gynaecological minimal invasive surgeries in DH was 36.70±10.60 years (with range 12-81 years). More than half of the patients were from Kavre (58.2%). Abnormal uterine bleeding, ovarian lesions and chronic pelvic pain were the most common indications for these procedures. Among these procedures, hysteroscopy (769 cases), diagnostic laparoscopy with or without chromotubation (385 cases), operative laparoscopy (419 cases) and LAVH/TLH (242 cases) were performed. In this study, 34 minimal invasive surgeries cases (1.8%) were converted to laparotomy for certain reasons. Of them eight cases were of laparoscopic hysterectomies. Only very few major and minor complications were experienced during this period. Conclusion Varieties of minimal invasive surgeries for various gynaecological problems were performed with minimal complications. We scaled up these minimal invasive surgeries over the period.

C-reactive Protein in Periodontitis and its Comparison with Body Mass Index and Smoking Behaviour.

INTRODUCTION: Chronic periodontitis is an infectious disease resulting in inflammation within the supporting tissues of the teeth, progressive attachment loss, and bone loss. In addition to declining oral health, there is always low grade infection present in periodontitis. Studies show increased levels of systemic biomarkers in periodontal disease such as CRP, which is considered a key-marker of CVD. Research has also shown positive association between BMI and smoking with periodontitis and CRP. The objective of the study was to assess the levels of CRP in patients with and without periodontitis and their relation with BMI and smoking behaviour. METHODS: Patients visiting the Dental department of Bir Hospital were invited to participate in the study. Total 31 subjects in each group: Case (periodontitis) and Control (without periodontitis) were selected using convenience sampling technique. All subjects underwent periodontal examination by a single examiner. Serum CRP samples were taken before periodontal treatment. Data analysis was done by SPSS 17 software program. RESULTS: Increase in mean CRP levels in periodontitis (5.8595mg/L) with high statistical significance (P=0.000) in comparison to subjects without periodontitis (1.1214mg/L) was observed. BMI showed positive association with periodontitis (P=0.046) but not with CRP (0.213). Smoking behaviour showed no significant relation with either CRP (P=0.344) or periodontitis (P=0.541). CONCLUSIONS: We found highly significant association between periodontitis and CRP levels but not always with BMI and smoking. CRP, which is an established marker for CVD was significantly increased in periodontal infections. Hence, a close interaction among Physician, Periodontist and Patient to prevent adverse health situations is recommended.

Rational for Conducting PTSD Research and Challenges of Recruiting and Training Volunteers to Screen and Treat PTSD among the Nepal 2015 Earthquake Survivors.

Post-traumatic Stress Disorder (PTSD) is common psychiatric morbidity among earthquake survivors, and if untreated people suffer from it for years. Government of Nepal and NGOs provided various short-term mental health services to the victims of the 2015 earthquake in Nepal, but there was no plan or provision for long-term mental health problems. The prevalence of PTSD following natural disasters depends on various local factors requiring understanding and further investigation before identifying affordable evidence based interventions. This paper discusses the need for PTSD research among the survivors of the 2015 earthquake in Nepal, and describes the challenges and difficulties of recruiting and training PTSD volunteers.

Tricuspid valve repair: DeVega's tricuspid annuloplasty in moderate secondary tricuspid regurgitation.

BACKGROUND: Moderate secondary tricuspid incompetence has variable natural history if left unattended during mitral valve surgery. Recent data suggest progression of the secondary tricuspid incompetence over time.Secondary moderate tricuspid regurgitation in rheumatic mitral valve disease may regress after mitral valve surgery without direct intervention. OBJECTIVES: The present study was done to assess early result of DeVega tricuspid valve annuloplasty amongst those with moderate tricuspid regurgitation due to rheumatic mitral valve disease. METHODS: Group I(mitral value replacement with tricuspid repair) and group II (mitral value replacement only).The two groups were followed up at three months post-operatively and evaluated for their functional class and echocardiography variables. RESULTS: There were 43 patients who underwent mitral valve replacement with moderate tricuspid regurgitation. 23 underwent mitral valve replacement with tricuspid repair group (Group 1). Most of the patients were women (28/43). The mean age was 31.4 + 14.8 and 25.13 + 9.4 years. Group I had 21(91.3%) and Group II had 17 (85%) in NYHA class III and IV. The pre-operative echocardiographic cardiac left ventricular and left atrial dimensions, Left ventricular function and valve lesions were statistically similar for both groups, except PASP was higher amongst tricuspid repair (Group 1: 38.60 + 12.75 mHg, Group 2: 61.52 + 19.76 mmHg; p equals or less than 0.05). At three month review after surgery, four patients were in NYHA II amongst those without tricuspid repair (Group II), whilst the rest were in NYHA I. Left ventricular dimensions, Left Ventricular function and valve prosthetic valve function were similar between groups. Eleven (47.8%) patients in Group I and only five (25%) of Group II had trace or less TR at the follow-up. This was found to be statistically significant on chi square test (p less than 0.05). There were 7 (16.2%) patients who had persistent moderate TR. Higher PASP and larger LV dimensions at three months were predictive of persistent moderate TR. CONCLUSION: Mitral valve replacement does decrease the severity of tricuspid regurgitation amongst those with secondary moderate tricuspid regurgitation by at least one grade, but DeVega's annuloplasty confers a better repair result.

Prophylactic low dose ketamine and ondansetron for prevention of shivering during spinal anaesthesia.

BACKGROUND: Perioperative shivering is a common problem during anaesthesia. Apart from physical warming many drugs have also been used for prevention of shivering. Ketamine has been used for preventing shivering during anaesthesia in doses of 0.5 to 0.75mg kg(-1), but even these doses causes too much sedation and hallucination. Ondansetron (8 mg) has been recently evaluated for its perioperative antishivering effect in patients under anaethesia. Present study was conducted to evaluate the efficacy and safety of low dose Ketamine (0.25mg kg(-1)) and Ondansetron (4 mg) for prevention of shivering during spinal anaesthesia. PATIENTS #ENTITYSTARTX00026; METHODS: Total 120 patients undergoing lower abdominal surgery under spinal anaesthesia were included. 3ml of hyperbaric bupivacaine 0.5% was used for spinal anaesthesia. After intrathecal injection, the patients were randomly divided in 3 groups of 40 each who received Ketamine 0.25mg kg(-1)or Ondansetron 4mg IV or Saline. Vitals, temperature and shivering scores were recorded every 5 minutes. Side effects i.e. hypotension, nausea and vomiting, sedation and hallucinations were also recorded. RESULTS: Fall in temperature was more significant in saline and ondansetron group (gp) than in ketamine group at all time interval. Out of 40 patients, shivering was maximum & seen in 17 patients (42.50%) in saline gp, 4 patients (10%) in ondansetron gp and in only 1patient (2.5%) in ketamine gp. Odd ratio of ketamine, ondansetron and saline are 1, 4.33 and 28.33 respectively which means that shivering in saline gp was 28.83 times higher than ketamine gp and 6.65 times higher than in ondansetron .Shivering rate was 4.33 times higher in ondansetron gp than in ketamine gp. Hypotension was lowest in ketamine gp (10%) in comparison to ondansetron gp (22.5%) and saline gp. (20%). Mild sedation was seen in almost all (95%) patients in ketamine gp, CONCLUSION: Prophylactic low dose ketamine (0.25mg kg(-1)) and Ondansetron (4mg) significantly decreased shivering in patients undergoing spinal anaesthesia without significant side effects.

Change in refractive status of the patients undergoing phacoemulsification surgery.

This study was carried out with the objective of finding refractive status of patients undergoing phacoemulsification surgery for cataract extraction. Success of cataract surgery can be quantified with the improvement in visual acuity with least amount of refractive error. Prospective study of 44 patients was done pre operatively and with subsequent follow up in the first, third and eighth week post operatively. Pre and post operative evaluation was carried out in terms of visual acuity, refractive error and corneal curvature. Among patients undergoing surgery, 91.0% achieved visual acuity of 6/9 or better at eighth week follow up 73.3% of patients had astigmatism of 1.25 dioptric cylinder or less. Keratometry readings showed insignificant variability in the preoperative and postoperative period (p > 0.05). This confirms that phacoemulsification surgery does not change the corneal curvature significantly and thereby induces less amount of astigmatism.

Delirium at Nepal Medical College Teaching Hospital: reason for referral and subtypes.

The important neuropsychiatric disorder delirium is the most single important disorder in onsultation liaison psychiatry. There is a dearth of study in delirium. The purpose of this study was to find out the demographic profile, reason for referral, and subtypes of delirium. Thirty two consecutive cases of delirium diagnosed by psychiatrist in consultation liaison psychiatry were enrolled in the study. This is a descriptive study and diagnoses were made based upon 'The International Classification of Disease (ICD-10)'. The majority of cases were from age 70 and above, male sex being more common and most commononest reason for referral being disturbed behavior. The hyperactive subtype of delirium was the frequent finding. Medicine and ICU followed by surgery and post operative ward were the most referring departments.

Consultation liaison psychiatry at Nepal Medical College and Teaching Hospital.

The authors reviewed the all referral cases from different inpatient and outpatient department, in Nepal Medical College and Teaching Hospital. It was a descriptive study. There were 484 referred cases during the study period. Around half the referral were from department of medicine (49.8%), surgery (11.2%), Eye/ENT (10.3%). The referral rate was 1.4%, with an average three cases per day. Among the referral cases depression was diagnosed in 26.9%, anxiety in 15.5% and substance related problem in 14.5%. The consultation liaison psychiatry service is satisfactorily used. Depression, substance use problem, anxiety, deliberate self harm is the main diagnoses in liaison psychiatry.

Adult Brugia malayi mitochondrial and nuclear fractions impart Th1-associated sizeable protection against infective larval challenges in Mastomys coucha.

Protective immunity to the subperiodic human filariid, Brugia malayi, was explored in the rodent host, Mastomys coucha after vaccination with subcellular fractions derived from the adult stage of the parasite. The highest level of protection was conferred in animals vaccinated with the 'mitochondria rich' (MT) fraction, in which microfilaraemia and worm burden were markedly reduced by 67.2 and 65.9%, respectively, followed by the 'nucleus rich' (NR) fraction, showing reductions of 62 and 52.3%, respectively, over the non-immunized control group. Mastomys vaccinated with MT and NR, displayed a significant increase in the level of antigen-specific serum immunoglobulin G (IgG). The levels of IgG2a, IgG2b and IgM antibody isotypes were remarkably elevated in both the MT and NR immunized groups, while IgG1 and IgG3 levels were low. Apart from antibodies, both these fractions also led to marked antigen-specific lymphoproliferation in vitro, along with enhanced release of nitric oxide by peritoneal macrophages. There was an increased population of CD4+ and CD8a+T-cells in MT immunized animals, as measured by flow cytometry, accompanied by elevated levels of proinflammatory cytokines; interferon gamma (IFN-gamma), tumour necrosis factor alpha (TNF-alpha) and interleukin-1 beta (IL-1beta) in the culture supernatants of the activated splenocytes. The results suggest that both NR and MT contain proinflammatory molecules which evoke a protective Th1 type of immune response.

Mandibular reconstruction.

One of the most difficult problem in reconstructive surgery is the replacement of lost bone from trauma, tumour, infection or congenital anomaly. This is a case report of a 20 year old male who had suffered a blast injury of his lower jaw. From his first admission in the Plastic unit of Bir Hospital on Feb 19, 2003, he had undergone multiple operations until Nov 2003. This is a description of a follow up surgery done in Kathmandu Medical College (KMC), Sinamangal. Difficulties encountered and options available have also been discussed.

Rapid diagnosis of fowl pox with coagglutination assay.

The coagglutination test was standardised for detection of fowl pox antigen in infected scabs and chorioallontoic membrane of chicken embryos. The Staphylococcus aureus Cowan I strain, containing large amounts of Protein A in their cell wall, coated with fowl pox antibodies was found specific and sensitive for detection of fowl pox antigen. The test is easy to perform and rapid as the positive results can be read within 15 seconds.