Review of Paediatrics Inpatient at a Zonal Hospital.

Introduction: Childhood illnesses cause significant number of admissions in different level hospitals. This retrospective study was undertaken to analyze the morbidity pattern in the Paediatric ward at a Zonal Hospital with aim that the results obtained will help in planning, prioritizing and implementing preventive, promotive and curative health care activities of the children in resource poor community. Materials and Methods: This study was carried out retrospectively for one year from July/Aug 2010 – June/July 2011. Age, sex, diagnosis, month of admission, duration of admission and the frequency of diseases were evaluated. Results: A total number of 977 patients were admitted during the study period. There were 579(59%) male and 398(41%) female children. Less than five years age group accounted for 569(58%) excluding the neonates. In the study period, respiratory tract infections were the commonest cause of admission 309(31.6%), gastrointestinal including diarrhoeal diseases were 278(28.5%), enteric fever comprised of 69(7%), and other diseases comprised of about 390(39.5%). Of the total admissions, CNS diseases comprised of 128(13%) of which 29(3%) were meningitis and meningoencephalitis. Sixty seven (52%) of the total CNS cases were due to febrile convulsion. Renal and cardiovascular diseases were 8.5% and 1.5% respectively. Conclusion: Children under five years of age being the most common age group amongst all, with respiratory and gastrointestinal diseases still being the most predominant cause of paediatric morbidity; community level interventions including IMCI should be strengthened for reducing hospital admissions, along with allocation of hospital beds and supplies as per morbidity pattern.

Study of Clinico-Epidemiological Profile and Outcome of Poisonous Snake Bites in Children.

Introduction: Snake bite poisoning in children is an emergency condition with significant mortality. It is more prevalent in Terai and Inner Terai regions of Nepal especially during monsoon season. There is no study on snake bite poisoning in this part of the country after the introduction of national snake bite management guideline in 2003. This retrospective study was conducted to evaluate the clinicoepidemiological profile, amount of anti-snake venom used and outcome of snake bites. Materials and Methods: Two hundred and forty six cases of snake bite poisoning admitted in emergency department of the hospital up to the age of 14 years, over a period of 6 years from 2004/2005 to 2009/2010 were evaluated retrospectively. Results: The study showed male predominance (57.3%) in snake bites with higher incidence of children above ten years of age (58%). The most of the poisonings (71.9%) was seen during June, July and August months which correspond to the monsoon season in Nepal. Majority of the victims had been bitten by unidentified snakes (52 %), mostly on the fingers & hands (64.6 %). Ptosis was observed in all cases of snake bite poisoning. Slightly less than 1/3rd of the children had respiratory distress needing respiratory support. Average ASV used was 18.2 vials. Case fatality rate (CFR) was quite high (28.2%) with more fatality on those with respiratory distress. Conclusion: As mortality due to snakebite poisoning and consumption of antisnake venom is not reduced by the use of the national protocol 2003, further study to evaluate alternate protocol is recommended.

Accuracy of 7-8-9 Rule for Endotracheal Tube Placement in Nepalese Neonates.

Introduction: Neonatal intubation is done for cardiopulmonary resuscitation, hypoxemia, and hypercapnia, for surfactant therapy or for airway protection. When correctly placed, endotracheal tube (ETT) tip should be at mid tracheal position which is half way between the clavicles and the carina to prevent complications of ventilation. Objective: To assess the accuracy of 7-8-9 Rule in neonates at Kanti Children’s hospital. Methodology: Prospective observational study was conducted in neonates who required oral intubations from July 2009 to December 2009 at NICU of Kanti Children’s Hospital. The initial ETT depth of insertion was determined using admission weight in the 7-8-9 Rule calculation. This depth was compared to the midtracheal depth to determine clinical accuracy of the 7-8-9 Rule. Results: Mean gestation age of the 69 infants was 36.01 weeks (26 to 42 weeks) and weight was 2411 g( 900 g to 3800 g ). 7 (10.1%) neonates weighed 1000 g or less, 19 (27.5%) weighed between 1001 to 2000 g, 31 ( 44.9%) weighed between 2001 to 3000 g, 12(17.4%) weighed between 3001 to 4000 g. The accuracy of 7-8-9 rule in clinical setting with auscultation and Chest x-ray resulted in ETT depth 0.11 cm above midtracheal position. (-1.5 to 1.5 cm). Using this rule ET tube was placed 0.11 cm above the mid tracheal position. Conclusions: The 7-8- 9 Rule appears to be an accurate clinical method for endotracheal tube placement in Nepalese neonates.

Prevalence of antimicrobial chemotherapy in hospitalized patients in the department of internal medicine in a tertiary care center.

Use of antimicrobial agents (AMAs) is associated with significant reduction in morbidity and mortality. However, indiscriminate and injudicious use of AMAs leads to the ineffective treatment, increased adverse effects, exacerbation or prolongation of illness, emergence of bacterial resistance and an additional burden of an expensive medical cost to the patients. So controlled use of AMAs at right dose, right interval and right duration is of utmost importance. In this retrospective study, prevalence and prescription patterns, and cost of the prescribed AMAs in the hospitalized patients in the department of internal medicine in a tertiary care center were analyzed. A total of 428 hospitalized patients were included in the study. Out of 428 patients, 274 (64.0%, P < 0.01) patients received AMAs for therapeutic (66.4%) and prophylactic (24.1%) purposes. In 9.5% patients AMA prescription was inappropriate. Use of intravenous route was significantly higher (55.48, P < 0.01) than the oral route. COPD with acute exacerbation was most frequent condition for AMA prescription. Majority (90.42%) of AMA prescriptions were based on empirical basis. Mean number of AMA per patient was 2.12 (minimum 1 and maximum 8). Most frequently prescribed AMA was Ceftriaxone (30.2%) from cephalosporin group (33.9%, P < 0.05). Patients received AMAs for the duration of 1-31 days and total cost of single AMA dosage regimen was as high as $ 482.3. As most of the hospitalized patients were prescribed AMA empirically, strategic AMA prescription guidelines and AMA prescription monitoring systems are extremely necessary in the hospitals to prevent emergence of microbial resistance and to expedite the cost effectiveness of medical treatment.

Recent advancement in drug delivery system.

Ease of drug administration, safety, affordability and efficacy are the major concerns in pharmacotherapy leading to exploration of better drug delivery systems. Liposomes are lyotropic liquid crystals composed mainly of amphiphilic bilayers and these are more frequently used as drug carriers. Liposomes help reduce the toxicity and deliver the drug to the target tissue. So far, liposomes have been the most intensively studied lipid-based delivery system. In liposomes, a hydrophilic drug can be trapped in aqueous interior or channels between successive phospholipids bilayers whereas a hydrophobic drug can reside with the bilayer itself. The non-toxic and nonimmunogenic bilayers dissipate allowing the diffusion of the drug into the tissues. Attachment of polyethyl glycol to the surface of liposome (known as stealth liposome) aids in the better targeting of the drug to the tissues. Pegylated proteins and polymers of lactic and glycolic acids have been well studied as drug carriers and found to be resistant to phagocytosis and complement activation. Newer DNA based strategies including DNA vaccination and antisense oligonucleotides and immunomodulation show good results for new therapeutic systems. Though the DNA based therapeutic systems have high selectivity and specificity with few adverse effects, these systems are so far restricted to animal models and clinical trials.

Parkisonism with Shy-Drager syndrome--a case report.

A previously healthy 60 years old female patient presented with bradykinesia, postural instability and increased rigidity of both upper and lower limbs for 2 years and was diagnosed as Parkinsonism for last years. Later on she developed features of autonomic dysfunction including postural hypotension, hyperhydrosis and urinary incontinence so was diagnosed as Shy-Drager Syndrome. She was treated with fludrocortisone and nefidipine for the management of postural hypotension. Patient developed aspiration pneumonia during oral feeding, despite of ICU management for the same cause patient died of respiratory arrest.

When left ventricular failure complicates chronic obstructive pulmonary disease: hypoxia plays the major role.

INTRODUCTION: As the chronic obstructive pulmonary disease (COPD) progress, is usually accompanied by involvement of the both left ventricle (LV) and right ventricle (RV), and their systolic and diastolic function. Signs and symptoms of LV failure can be difficult to distinguish from those of COPD. OBJECTIVE: The study was carried out to determine the prevalence of LV systolic dysfunction in the COPD patients and to assess the possible risk factor behind such development. MATERIAL AND METHODS: It is a prospective study of 60 cases of COPD patients with or without cor-pulmonale attending Manipal Teaching Hospital. RESULTS: The prevalence of LV systolic dysfunction was found to be 26.7%, and the findings directly correlate with the severity of COPD i.e., the more the severity of the lung disease more the probability for the incidence of LV systolic dysfunction. These data are in support of the hypothesis that hypoxia and the excess accumulation of toxic metabolic products like lactic acid, significant right-to-left shunting through the bronchial circulation explains the diminished LV ejection fraction in severe COPD patients. CONCLUSION: Routine echocardiography investigation of the severe COPD patients is required for assessing the status of LV function and to rule out the possible association of LV systolic dysfunction.

Relationship between plasma leptin and plasma insulin levels in type-2 diabetic patients before and after treatment with glibenclamide and glimepiride.

Type 2 diabetes affects 100 million people throughout the world. Among the various factors implicated in the causation of this disease, the role of leptin, an obesity gene product, is increasingly being investigated. This especially assumes importance in the light of knowledge that obesity confers a minimum of 3-10 fold higher risk of diabetes. This study was planned to investigate the relationship between leptin and insulin levels in type 2 diabetic patients before and after treatment with glibenclamide or glimepiride. 60 type 2 diabetic patients were recruited for the study and were divided into 2 groups-one receiving glimepiride and the other group receiving glibenclamide for duration of 10 weeks. This study demonstrated a highly positive correlation of plasma leptin levels with BMI, plasma insulin and insulin resistance. No gender specific differences were observed in leptin concentrations. The study, however, failed to demonstrate any possible relationship between glycemic control as assessed by blood sugars/ glycosylated hemoglobin (HbAlc) and plasma leptin. The administration of glibenclamide or glimepiride significantly lowered blood glucose levels coupled with a decrease in (HbAlc). Both the drugs increased insulin concentrations. Glibenclamide increased leptin levels but they remained unaltered with glimepiride. Glibenclamide and glimepiride were found to be equally effective in their glucose lowering action. However, the patients receiving glibenclamide experienced higher episode of hypoglycaemic spells than those receiving glimepiride.

Prevalence of complications of simple tooth extractions and its comparison between a tertiary center and peripheral centers: a study conducted over 8,455 tooth extractions.

This study was conducted to investigate and compare the prevalence of complications of simple tooth extractions in a tertiary centre (BP Koirala Institute of Health Sciences, Dharan) and the peripheral centers (Mechi and Koshi zonal hospitals). This is a prospective descriptive study. Tooth extractions were carried out under local anesthesia in the tertiary and the peripheral centers during one year period (March 15"th 2004 to March H"111 2005). Intraoperative and postoperative complications were recorded and analyzed. Out of 8,455 tooth extractions in 6,639 [male-2,465 (37.12%) and females - 4,174 (62.88%)] patients aged between 5yrs- 65 yrs, 7,152 extractions were done in tertiary center and 1,393 extractions were done in peripheral centers.90 complications (1.06%) were observed. 53(58.89%) complications were intraoperative and 37(41.12%) complications were postoperative. 60(0.84%) complications were observed in the tertiary center and 30 (2.3%) complications were observed in the peripheral centers and the difference was highly significant (P<0.000001). The most frequent complication in the tertiary centre was fracture of tuberosity (0.15%) and in the peripheral centers it was 'roots left' (0.77%). Prevalence of 'roots left', injury to adjacent tooth and postoperative hemorrhage was significantly high (P<0.05) in peripheral centers. The higher prevalence rate of complications of tooth extractions in the peripheral centers should not be overlooked and well equipped and organized extraction procedure with qualified dental practitioner is strongly suggested to minimize the complications.

A rare case of pancreatic mediastinal pseudocyst.

Pancreatic pseudocysts are the most common cystic lesions of the pancreas, accounting for 75-80% of such masses. Pancreatic pseudocyst with mediastinal extension is a rare clinical entity and only a handful cases report on dysphagia associated with mediastinal pseudocyst formation.1 We present a case of pancreatic mediastinal pseudocyst that presented with palpitations and dysphagia. Demonstration of cystic lesion in relation to the pancreas on ultrasound and mediastinal extension of the cyst on CT suggested the diagnosis.