Clinical Epidemiology of Acute Burn Injuries at Nepal Cleft and Burn Centre, Kathmandu, Nepal.

BACKGROUND: Burn injury is a global health problem mainly occurring in developing countries. The Nepal Cleft and Burn Centre at Kirtipur Hospital, Kathmandu, has been providing the acute burn care since 2013 with 7 intensive care unit beds, 30 general beds, and 2 dedicated operating rooms. A similar descriptive study was performed in this center in 2014. These studies will be helpful for developing prevention strategies and monitoring the progress in the standard of care of acute burn patients. METHOD: This is a descriptive retrospective study of the clinical data of acute burn patients admitted from January 1, 2015 to December 31, 2016. RESULTS: There were a total of 567 patients who came from 63 of 75 total districts of Nepal. Two hundred ninety-six (52.2%) patients were females and 271 (47.8%) were males. Two thirds of the patients were young adults. Most of the injuries occurred inside the house (72.1%). Flame burn was the most common mode of injury (66%) followed by scald (21.6%). Only 64 (11.3%) patients arrived on the same day of the injury. The longest time elapsed was 60 days with a median of 4.3 days. Range of total body surface area (TBSA) involved was 1% to 95%. The mean and median TBSAs were 25% and 15%, respectively. Range of hospital stay was 1 to 105 days with a median of 13.3 days.A total of 448 surgical procedures were performed in 384 patients (67.7%). A total of 110 (19.4%) patients died at the hospital. Only 13 patients (3%) survived deep burn injury involving 40% or more TBSA with either cadaveric skin allograft or with skin allograft from the live relatives. CONCLUSIONS: The outcome of burn injuries in Nepal is very poor. Children and females are at high risk. There is a lack of knowledge about burn prevention, proper first aid, and skin donation among the Nepalese population. Delay in presentation and extensive burns are poor prognostic factors. Awareness programs about the proper first aid and the need of a skin bank has to be done to improve the burn scenario in Nepal. Availability of allograft can increase the chances of survivability of patients with extensive burns in Nepal.

Review of the First 108 Free Flaps at Public Health Concern Trust-NEPAL Hospitals: Challenges and Opportunities in Developing Countries.

BACKGROUND: Free tissue transfer is one of the most important and essential techniques in reconstructive surgery. The underlying complexity, steep learning curve, high cost, and fear of failure make it very difficult to establish as a regular service in developing countries such as Nepal. METHODS: A retrospective cohort study design was used to analyze the challenges with and opportunities for reconstructive surgery in Nepal. Medical records were reviewed for patient demographics, indications, types of free flaps, hospital stay, complications, and involvement of a microsurgery teaching workshop. RESULTS: A total of 16 microsurgical workshops were carried out by 3 international organizations over the study period (2007-2017). Altogether 108 free flaps in 103 subjects were reviewed during the study period at different hospitals of the Public Health Concern Trust-NEPAL (phect-NEPAL) and National Trauma Center. Of 103 patients, 60 were males and 43 were females with an average age of 34.5 years (range, 8-73 years). The most common indications for microsurgical reconstruction were tumor, trauma, and burns. Radial artery forearm flap, anterolateral thigh flap, and free fibular flap were the most common types of flaps. Ten different types of flaps were performed. Four cases needed more than 1 flap; one of them needed 3 flaps. Flap success rate approached 90%. Four patients died in the hospital postoperatively. CONCLUSION: Reconstructive microsurgery is challenging in Nepal and more generally in developing settings. However, persistent technical support such as training and workshops can make it feasible.

Arts of electrical impedance tomographic sensing.

This paper reviews governing theorems in electrical impedance sensing for analysing the relationships of boundary voltages obtained from different sensing strategies. It reports that both the boundary voltage values and the associated sensitivity matrix of an alternative sensing strategy can be derived from a set of full independent measurements and sensitivity matrix obtained from other sensing strategy. A new sensing method for regional imaging with limited measurements is reported. It also proves that the sensitivity coefficient back-projection algorithm does not always work for all sensing strategies, unless the diagonal elements of the transformed matrix, A(T)A, have significant values and can be approximate to a diagonal matrix. Imaging capabilities of few sensing strategies were verified with static set-ups, which suggest the adjacent electrode pair sensing strategy displays better performance compared with the diametrically opposite protocol, with both the back-projection and multi-step image reconstruction methods. An application of electrical impedance tomography for sensing gas in water two-phase flows is demonstrated. This article is part of the themed issue 'Supersensing through industrial process tomography'.

Non-destructive label-free continuous monitoring of in vitro chondrogenesis via electrical conductivity and its anisotropy.

Non-destructive label-free continuous monitoring of in vitro tissue culture is an unmet demand in tissue engineering. Noting that different compositions of cartilage lead to different electrical tissue properties, we propose a new method to measure the electrical conductivity and its anisotropy during in vitro chondrogenesis. We used a conductivity tensor probe with 17 electrodes and a bio-impedance spectroscopy (BIS) device to measure the conductivity values and the anisotropy ratios at the bottom and top surfaces of the tissue samples during the culture period of 6 weeks. Clearly distinguishing glycosaminoglycans (GAGs), collagen, and also various mixtures of them, the measured conductivity value and the estimated tissue anisotropy provide diagnostic information of the depth-dependent tissue structure and compositions. Continuously monitoring the individual tissue during the entire chondrogenesis process without any adverse effect, the proposed method may significantly increase the productivity of cartilage tissue engineering.

Long-standing retroperitoneal schwannoma in a 36-year-old female: A case report.

INTRODUCTION: Schwannomas are encapsulated nerve sheath tumors derived from Schwann cells, primarily found in the head, neck, and extremities. Retroperitoneal schwannomas are rare and typically asymptomatic. CASE PRESENTATION: A 36-year-old female presented with a long-standing, asymptomatic right lower abdominal mass. Imaging revealed a retroperitoneal cystic mass displacing adjacent structures. The tumor was surgically excised, and histopathology confirmed the diagnosis of schwannoma. The patient had an uneventful postoperative recovery and remains symptom-free with no signs of recurrence. DISCUSSION: Schwannomas are benign nerve tumors primarily affecting women aged 30 to 50. This case involved an asymptomatic retroperitoneal schwannoma displacing the inferior vena cava without neurological symptoms. Imaging methods like ultrasound and CT are useful but often lack definitive results, and preoperative biopsy is not recommended due to risks of vascular injury. While conservative management may be suitable for asymptomatic cases, complete surgical excision is crucial to prevent recurrence. Although some suggest partial excision, most literature supports curative resection with negative margins, as incomplete removal can lead to a 10-20 % recurrence rate. The patient underwent successful complete resection. CONCLUSION: Retroperitoneal schwannomas are rare tumors that are difficult to diagnose preoperatively. Radiologic findings are usually nondiagnostic. The treatment of choice is complete surgical excision.

Hand Injury among Patients Visiting Emergency Department in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: The hand is a complex organ responsible for activities of daily living, making it susceptible to injuries and accidents. Hand injuries can result in significant functional impairment and it occurs in a younger productive age group. Therefore, it is important to understand the prevalence and patterns of hand injuries. The aim of the study was to find out the prevalence of hand injuries among patients visiting the emergency department of a tertiary care centre. Methods: A descriptive cross-sectional study was in the Emergency Department of a dedicated trauma centre from 1 June 2022 to 31 August 2022. Ethical approval was obtained from the Institutional Review Board (Reference number: 148412078179). Demographic profile, pattern, and mechanism of hand Injuries of all 96 consecutive patients were assessed after taking informed consent. Convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated. Results: Among 4679 patients visiting the emergency department of the trauma centre, hand injuries were seen in 96 (2.05 %) (1.64-2.46, 95% Confidence Interval). Conclusions: The prevalence of hand injuries was found to be lower than in other similar studies done in similar settings. Keywords: finger injuries; hand injuries; occupational injuries.

Harvesting the anterolateral thigh flap with non-sizable perforators.

BACKGROUND: The anterolateral thigh flap (ALT) has proven over time to be one of the best reconstructive workhorses due to its versatility and reliability. Without preoperative imaging, vascular anomalies such as having no sizable perforator are sometimes encountered during dissection. We propose a technique, based on a modified version of the traditional myocutaneous ALT to allow harvest of the flap based on non-sizable perforators. This technique can also enable the splitting of a flap when only one sizable perforator is present. METHODS: A retrospective review of patients who received reconstruction with free ALT flap from 2013 to 2019 by the senior author HSS was performed and included all flaps in which non-sizable perforators were harvested. Data collected for analysis included patient demographics, flap size, defect location, inset type, and flap survival. SURGICAL TECHNIQUE: Despite detachment of the majority of skin paddle from the muscle, the flap is harvested with a sleeve of areolar tissue containing preferably more than one non-sizable perforator attached to a small muscular segment of the vastus lateralis containing the pedicle. RESULTS: A total of 349 ALT flaps were performed during the review period by senior author HSS, and 25 flaps were harvested with non-sizable perforator, 10 of which were to enable a split. There were no total losses and 6 partial losses; 2 were amenable to direct closure after debridement, 1 required skin graft, and 3 required a new flap for wound coverage. Incorporating more than one non-sizable perforator increases the reliability of the flap. This technique should be used with caution in patients with multiple underlying comorbidities and when a flow-through flap is required. We were able to achieve primary closure of all donor sites. CONCLUSIONS: It is possible to harvest the anterolateral thigh flap without sizable perforators by conversion to a modified version of the myocutaneous flap. In well-selected patients, using our technique, several non-sizable perforators can reliably perfuse an ALT without the need to use an alternative donor site. This maximizes the number of harvestable ALTs and increases the reconstructive potential by splitting previously "un-splitable" flaps.

Plastic Surgical Procedures for Lower Limb Reconstruction at a Tertiary Hospital in Nepal.

BACKGROUND: This study assessed the lower limb reconstruction outcome so that it will provide a baseline evidence to enable data-driven decision making to improve outcome in the future. METHODS: In this study, hospital records from 1st January to 31st December 2019 were collected retrospectively. Complete data of all patients' records treated for lower limb defects at Kirtipur Hospital were included and incomplete data were excluded. Univariate and Bivariate analyses were performed Results: In total 110 patients were included in this study with a male predominance of 66.4% (n=73). The mean age of the patients was 38.7 years (+/- 20). The majority of the patients were from outside Kathmandu valley 79.1% (n=87) and referred 55.5% (n=61). The commonest cause of lower limb defects was trauma 69.1% (n=76), the procedure performed was skin graft 48.5% (n=72), and complication was wound infections, 43% (n=13) of total complications. The hospital stay of more than two weeks was more common among the referred patients 63.9% (n=39) as compared to non-referred patients 30.6% (n=15) and trauma etiology 34.2% (n=26) had more complications than other etiology. The mean age of patients with complications (32.4 years) was lower than those without complications (41.1 years). More number of referred patients (n=43) required multiple surgeries than non-referred patients (n=21). CONCLUSIONS: Referred cases were more likely to have multiple surgeries and a longer hospital stay than non-referred cases. Infection was the commonest complication and the majority of complications were seen in trauma and younger age group.

Pilot Study to Assess Safety and Usability of the Kyron NPWT System.

There is an evident need for Negative Pressure Wound Therapy (NPWT) systems specifically designed for use in resource-constrained settings to aid in the treatment of open wounds. METHODS: Prospective single-arm interventional pilot study of 14 patients with complex wounds was conducted at Kirtipur Hospital in Kathmandu, Nepal. A novel NPWT device, the Kyron Suction Unit, was used by 4 plastic surgeons. Primary outcomes were ease of use (10-point Likert scale) and device safety (adverse events recorded). Pain (Visual Analogue Scale score), quality of life (modified EuroQol Derived Single Index scores), and wound dimensions were recorded. RESULTS: User ratings on the 10-point Likert scale indicated high confidence and ease of use: median confidence setting up the device of 1.0 [interquartile range (IQR), 1.0; mean 2.3], median confidence maintaining the device of 1.0 (IQR, 1.0; mean, 1.5), and median ease of disassembly of 1.0 (IQR, 1.0; mean, 1.4). Significant improvement in Visual Analogue Scale scores (P = 0.03), modified EuroQol Derived Single Index scores (P < 0.001), and a reduction in wound volume [median, 47.25-9.75 cm3 (P = 0.01)]. Image analysis of wounds pretreatment and posttreatment demonstrated increase in granulation tissue surface area [median, 7.6-28.7 cm2 (P = 0.003)] and decrease in open wound surface area [median, 48.33-33.6 cm2 (P = 0.01)]. CONCLUSIONS: The Kyron Suction Unit was safe and easily managed by plastic surgeons. The device design promoted access to NPWT, a therapy proven to reduce healing time and decrease complications for patients with open wounds, in a resource-constrained setting.

Creation of Nepal's First Skin Bank: Challenges and Outcomes.

BACKGROUND: In Nepal, burn trauma causes more than 55,000 injuries each year. Burn-related mortality is high in Nepal, in part due to lack of allograft, leading to high infection rates. To address this challenge, our collaboration between Kirtipur Hospital, America Nepal Medical Foundation, Stanford University, and ReSurge International established Nepal's first skin bank. METHODS: We identified 3 major tasks to create a sustainable skin banking program: 1) identify and acquire the equipment and personnel needed to collect, process, store, and graft cadaveric skin for burn injuries; 2) develop safe donation protocols and documentation tools that remain feasible for low-resource settings; and 3) develop a long-term awareness program to educate the Nepali people on skin donation, a previously foreign concept. RESULTS: Kirtipur Hospital acquired the necessary equipment and materials for the skin bank through a combination of local and international fundraising efforts. Existing U.S. skin banking protocols were adapted for the Nepali setting and piloted on potential patients, donors, and physicians. For the first time in the hospital's history, patients with > 40% total body surface area burns were successfully treated with extensive allografts. CONCLUSIONS: It is feasible to create a skin bank in a country with no tradition of allograft skin use. Long-term sustainability now depends on spreading awareness and education in the Kathmandu Valley to overcome religious and cultural barriers that have hindered donor recruitment. Our low-cost and high-impact skin bank provides a model to expand this system to other hospitals both within Nepal and beyond.

Age of individuals undergoing cleft lip and cleft palate surgeries in Nepal.

INTRODUCTION: Timely repair of cleft lip and palate maximises the benefits of surgery. Developing countries have large number of adults with unrepaired clefts. The impact of a cleft program can be determined by observing the trends of lower age at surgery. Public Health Concern Trust, Nepal has been providing a comprehensive nationwide cleft service since 1999. This study was conducted to see any change in the age at surgery. METHODS: A retrospective cross sectional study was conducted to analyse the data of all the individuals' age at primary cleft surgery from July 1999 to June 2010. Mean and median age of individuals as well as the proportion of individuals operated on at the right age in different years were calculated and compared. RESULTS: The median age for cleft lip surgery decreased from 100 to 24 months. Similarly the median age for cleft palate surgery decreased from 70 to 28 months. Proportion of surgeries carried out in the recommended age also increased. A change in the policy of the program reaching out to more remote areas and removing the age barrier for surgery resulted in older adults receiving surgery and increased median age especially for cleft palate repairs. CONCLUSIONS: A nationwide cleft program for a decade had a small impact on age at surgery. There are still many individuals who are missing the ideal age for surgery. The program needs to reach more remote areas. This information will be useful for governmental as well as non-governmental organizations working in the area of clefts.