Pre-menstrual Syndrome and Pre-menstrual Dysphoric Disorder in Female Medical Students of Nepal.

Background Pre-menstrual Syndrome and Pre-menstrual Dysphoric Disorder can have negative impact on medical students and remains mostly underdiagnosed. Different treatment modalities like medications (doctor-prescribed or self-medicated), and alternative therapies are used by students to cope with pre-menstrual symptoms. Objective To estimate the prevalence and severity of Premenstrual Syndrome and Premenstrual Dysphoric Disorder among medical students in Nepal along with its impact in their quality of life, their health seeking behavior and treatment modalities used to cope with these disorders. Method A cross-sectional study was conducted among female medical students studying MBBS in various medical colleges in Nepal using a self-administered questionnaire from September 2020 to March 2021. Result The prevalence of Premenstrual Syndrome and Premenstrual Dysphoric Disorder among female medical students in Nepal was 64% and 36.3% respectively as per this study. Among the areas impacted by premenstrual symptoms, concentration in class was the most affected (68.1%), followed by distress (64.6%). Only 7.3% of the responding participants sought medical consultation for their symptoms. Among those who suffered from at least one symptom for any length of time, 34.8% of participants reported of using at least one medication (either prescribed or selfmedication). Similarly, alternative remedies were used by 44.4% of the participants. Conclusion Premenstrual syndrome and premenstrual dysphoric disorder were found to be common in female medical students of Nepal. However, very few students sought medical consultation despite a significant impact in their academic and other activities. Self-medication and traditional therapies were common modalities used for treatment of premenstrual symptoms.

Ventricular Tachyarrhythmia after Aortic Cross Clamp Release in Cardiac Surgeries.

BACKGROUND: Ventricular tachyarrhythmia (VT/VF) after aortic artery cross clamp release in cardiac surgery is common and the occurrence has been described but the incidence and risk factors are not well defined. This study was designed with the aim to evaluate the prevalence of VT/VF after aortic cross clamp release and to identify risk factors of patients developing such arrhythmias. METHODS: A retrospective observational study 1052 patients over a period of 12 months from March 2011 to February 2012 undergoing various cardiac surgeries with aortic cross clamp were monitored for new-onset ventricular tachyarrhythmia intraoperatively. RESULTS: The prevalence of ventricular tachyarrhythmia was 24.4%. We found age above 30 years, increasing body mass index (BMI), valvular surgeries and male gender as risk factors for VT/VF after cross clamp release in cardiac surgeries. CONCLUSIONS: Ventricular tachyarrhythmia is common following all cardiac surgeries, especially valvular heart diseases. There is a strong relationship between ventricular arrhythmias and age above 30 years, coronary artery bypass surgery (CABG), high (BMI) and male gender. It is essential for intense monitoring of these patients.

Prevalence and factors associated with childhood overweight/obesity of private school children in Nepal.

INTRODUCTION: Childhood overweight/obesity is a global health problem because of adverse health and nutrition consequences worldwide. Currently, there is a paucity of information on childhood overweight/obesity in Nepal. Therefore, the objective of this study was to assess the prevalence of, and the factors associated with, childhood overweight/obesity among primary school children. METHODS: A cross-sectional study was conducted in June-December, 2013. We collected data using the structured self-administered questionnaire with parents of children aged 6-13 years in grades 1-6 studying at private schools of the Lalitpur district of Nepal. Height and weight measurements of 986 children were taken, and the corresponding body mass index (BMI)-for-age was calculated. The prevalence of childhood overweight/obesity was reported in proportion. Factors associated with childhood overweight/obesity were examined using the Chi-square tests followed by multiple logistic regression analyses. RESULTS: Of 986 children, 144 (14.6%) were overweight and 111 (11.3%) were obese. Overall, 255 (25.9%) children were found to be overweight/obese. Children from families, having ≤2 siblings (adjusted odds ratio (aOR)=1.958, 95% confidence interval (CI): 1.163-3.296), upper class family (aOR=3.672; 95% CI: 1.154-11.690), and advantaged ethnic group (aOR=1.561; 95% CI: 1.00-2.437) and children who were of larger birth weight (>4.0kg) had a greater likelihood of being (aOR=2.557, 95% CI: 1.222-5.349) overweight/obese. CONCLUSIONS: A quarter of children were found to be overweight/obese in private primary schools. Preventive interventions should focus on the advantaged ethnic groups, families with fewer siblings, and upper class families. A greater emphasis ought to be placed on formulation and implementation of policies aimed at addressing the newly emerging problems of childhood overweight/obesity in Nepal. New school health programs are to be launched and strengthened including avoidance of high energy junk food, and promoting outdoor activities.

A comparison of midazolam co-induction with propofol priming in propofol induced anesthesia.

BACKGROUND: Combination therapy with two or more different drugs, with the intension of reaching the same therapeutic goal, was heavily criticized for a long time. However, it is accepted today, especially when advantage over monotherapy can be proved. Our study was undertaken to compare whether propofol priming and midazolam predosing would affect total induction dose requirement of Propofol. METHODS: A prospective randomized, double blind control study was conducted where 120 patients (16-65 years) were divided into 3 groups. Group P received 0.4 mg/kg of Propofol, Group M received 0.05 mg/kg of Midazolam and Group N received 3 ml of Normal Saline 5 minutes after intravenous pethidine 0.75 mg / kg given for analgesia. We compared the total dose of propofol requirement for induction of anaesthesia in all the 3 groups, taking loss of verbal contact as the end point. Additionally, changes in haemodynamic status like blood pressure and heart rate at various intervals were studied and compared among the groups. RESULTS: The groups were similar in terms of age, sex, weight and American Society of Anesesthesiologists Physical Status.The dose of Propofol required to induce anesthesia in Midazolam group was 1.58 mg/kg,1.86 mg/kg in Propofol group and 1.96 mg/kg in the control group. There were less hemodynamic changes in Midazolam group compared to the other two. CONCLUSIONS: Pre-dosing with Midazolam is more effective than Propofol priming in reducing the dose of Propofol induced anaesthesia associated with minimum hemodynamic alterations.

Intended location of future career practice among graduating medical students: perspective from social cognitive career theory in Nepal.

BACKGROUND: Medical workforce shortages and mal-distributions world-wide make understanding how, where and what our future doctors wish to practice is increasingly important. Understanding of factors such as available infrastructure, provision of incentives and many others influences the decisions of doctors to leave or to stay. Therefore the strategies effective for retention, is imperative in conducting the study based on a sound theoretical framework in predicting future medical workforce needs. The study used the theoretical framework of Social Cognitive Career Theory to identify the predictors on future practice location. METHODS: The study was cross-sectional descriptive in design targeting the Nepalese medical students in the final year and doing internships in Nepal. Anonymous self administered questionnaire was distributed among 480 students but 393 students were involved due to non response and incompleteness. Findings of the study were presented in frequency tables for univariate descriptive analysis and bivariate findings were presented by cross tabulation. RESULTS: About two thirds 259 (65.9%) of the participants had chosen within country location for future practice. Among those who had chosen within country choice, about an equal percentage of the respondents had chosen rural 131 (50.8%) and urban 128 (49.2%) location. Among those who had chosen within country for future practice location, less than one fifth of the participants had chosen private sector for future practice. CONCLUSIONS: Majority of the medical graduates wish to practice within country location. Most of which chose public sector for future practice. None of the SCCT construct had any significant association within country location.

Household passive smoking and acute respiratory infection among under-five children attending Kanti Children's Hospital.

BACKGROUND: Worldwide, children are more heavily exposed to passive smoking than any other age group where majority of these occur in child's house.Children's passive smoking and risk of developing respiratory diseases has been well established in several studies. However, such studies are limited in Nepal. Therefore, the objective of this study was to determine association between household passive smoking and acute respiratory infection among under- five children attending Kanti Children's Hospital. METHODS: A descriptive, cross-sectional study using quantitative method was carried out in Kanti Children's Hospital. Data was collected by face-to-face interview from 198 parents.Bivariate and multivariate analyses were performed to see association between household passive smoking and acute respiratory infection. RESULTS: Among 198 children, 79(39.9%)were passive smokers. Among the total passive smokers, 31(39.2%) were exposed to paternal smoking, 18(22.8%) to parental smoking, 18(22.8%) to other member's smoking and 12(15.2%) to maternal smoking. Among 36 daily passive smokers, 18(50.0%) were exposed to high amount and 18(50.0%) to low amount of passive smoking. Household passive smoking had a slight risk of developing acute respiratory infection where adjusted odds ratio was 1.35;however it was not statistically significant. CONCLUSIONS: Children exposed to passive smoking had a slight risk of developing acute respiratory infection than non-passive smokers however, it was not statistically significant.

Examining stratified cesarean section rates using Robson classification system at Tribhuvan University Teaching Hospital.

BACKGROUND: Caesarean section rates have been increasing worldwide over the past few decades, with most countries and regions exceeding the World Health Organization recommended rate of 15% of all deliveries. METHODS: This study was carried out with the objective of reviewing the rates of cesarean sections over five years (2005-2010) and to assess the stratified rates of cesarean sections for audit of intrapartum management in University Teaching Hospital, Institute of Medicine. Data was stratified into 10 mutually exclusive groups, by using the method presented by Michael Robson. RESULTS: A total of 5907 women had under gone caeserean section over a period of five years. The results showed a growing trend of cesarean section rate from 16.6% to 25.4%. The results of this analysis using the Robson classification has shown that group 1(Nulliparous, single cephalic ≥ 37 weeks gestation in spontaneous labour) has the largest number of cesarean deliveries followed by group 3(Multiparous, single cephalic ≥37 weeks gestation in spontaneous labor, no previous CS), although Robson classification showed that group 5 was the biggest contributor. CONCLUSIONS: The growing and uniform distribution (throughout the year) of cesarean section has been observed for five years. This analysis provides evidence-based data so we can analyze where to aim our preventive measures and focus efforts in reducing the rate of CS. We would like to suggest that all hospitals and health authorities apply this standardized classification system as to monitor their CS rates and find ways to reduce it, and improve quality care.

Q-Switched Neodymium-Doped Yttrium Aluminum Garnet laser therapy for pigmented skin lesions: efficacy and safety.

BACKGROUND: Nepalese population with Fitzpatrick skin types III-V has high prevalence of pigmentary disorders and it is a growing cosmetic concern. Q-Switched Neodymium- Doped Yttrium Aluminum Garnet (QS Nd-YAG) laser is an efficacious tool in the treatment of pigment disorders. OBJECTIVE: To highlight the efficacy and safety profile of various pigment disorders. METHODS: A prospective study done in Dhulikhel Hospital, Kathmandu University Hospital from January 2009 to January 2011. Patients undergoing laser for pigmented skin lesions were followed for response and safety profile. We included total 270 patients in the study with various disorders especially nevus, tattoos and melasma. Settings were repeated at 3-4 weeks interval and response was evaluated on clinical basis. Efficacy was then evaluated according to various parameters. RESULTS: For nevus, total 840 treatment sessions had been performed with an average of 6.88 sessions (range 3-11). Nd: YAG laser was very efficacious in removal of blue and black colored tattoos with an average of 7.9 and 9.5 sessions respectively. However, red mixed with blue and or green tattoos were relatively resistant to treatment and required average 10.33 treatment sessions. Melasma and freckles both responded to the therapy but recurrence rate was high. CONCLUSION: Our results indicate that QS Nd: YAG laser is an effective modality for pigment disorders among Nepalese population. Nevus and melasma respond well but recurrence rate of melasma is high. Blue tattoos respond well while mixed colored tattoos are quite resistant to Nd: YAG laser alone. Transient pain and temporary hyperpigmentation are common side effects.

Comparative study of effectiveness of oral acyclovir with oral erythromycin in the treatment of Pityriasis rosea.

BACKGROUND: Pityriasis rosea is an acute, self-limiting disease, probably infective in origin, affecting mainly children and young adults, characterized by distinctive skin eruptions and minimal constitutional symptoms. Both oral Erythromycin and oral Acyclovir have been used in its management. OBJECTIVES: To compare the effectiveness of oral Erythromycin and oral Acyclovir in the treatment of Pityriasis rosea. METHOD: Forty two patients with clinical diagnosis of Pityriasis rosea were enrolled. They were randomized into two groups. One group was given high-dose oral Acyclovir and another group oral Erythromycin in standard dose. The participants were evaluated one, two, four, six and eight weeks and six months after commencement of the study. RESULTS: Forty two patients including 26 males and 16 females completed the study. After 8th week, all patients showed complete response in both the groups. The response to oral Acyclovir compared with that to oral Erythromycin was better and was statistically significant in 1st, 2nd, 4th and 6th weeks. CONCLUSION: Although it is a self-limiting disease which resolves within three weeks to three months, this study reveals that both oral Acyclovir and oral Erythromycin are helpful in decreasing the severity and duration of Pityriasis rosea. Moreover, the study also indicates that oral Acyclovir is more effective than oral Erythromycin in reducing the severity and duration of Pityriasis rosea.

Oral tranexamic acid for the treatment of melasma.

BACKGROUND: Melasma poses a great challenge as its treatment is unsatisfactory and recurrence is high. Treatment of melasma using tranexamic acid (oral, topical or intralesional) is a novel concept. OBJECTIVE: To compare the efficacy of oral tranexamic acid with routine topical therapies for the treatment of melasma. METHODS: It is a prospective, interventional, randomized controlled trial conducted among 260 melasma patients. Patients were divided into two groups consisting of 130 patients each. First group (Group A) was given routine treatment measures and oral Tranexamic Acid while second group (Group B) was treated only with routine topical measures. Capsule Tranexamic Acid was prescribed at a dose of 250 mg twice a day for three months and cases were followed for three months. Response was evaluated on the basis of Melasma Assessment Severity Index (MASI). Mean scores between the two groups were then compared. RESULTS: Statistically significant decrease in the mean Melasma Assessment Severity Index from baseline to 8 and 12 weeks was observed among group A patients (11.08±2.91 vs 8.95±2.08 at week 8 and vs. 7.84±2.44 at week 12; p<0.05 for both). While among group B patients the decrease in mean score was significant at 8 weeks and insignificant at 12 weeks follow up (11.60±3.40 vs 9.9±2.61 at 8 weeks and vs. 9.26±3 at 12 weeks; p<0.05 for former but p>0.05 for later). CONCLUSION: Addition of oral tranexamic acid provides rapid and sustained improvement in the treatment of melasma.

Prevalence of sexually transmitted infections in a tertiary care centre.

BACKGROUND: The burden of sexually transmitted infections is huge and is disproportionately affecting developing nations. In Nepal, recent available data on sexually transmitted infections are mostly targeted to high risk population. A prevalence study was thus done to explore the pattern of sexually transmitted infection syndromes among general population of Nepal. OBJECTIVES: To highlight the prevalence and changing pattern of sexually transmitted infections among general population. METHODS: A retrospective study. The study was conducted among 145 patients attending Department of Dermatology and Venerology, Dhulikhel Hospital Kathmandu University Hospital, for voluntary counseling and testing from April 2010 to April 2011. Syndromic case management approach was used for the classification and treatment of the patients. RESULTS: 106 patients were suffering from Sexually Transmitted Infections and 2 patients were positive for Human Immunodeficiency Virus. The most common diagnosis was genital viral infections (41.7%). Prevalence was highest among drivers/conductors (26.9%) and migrating workers (23.1%). Age group 20 to 24 years was the maximum sufferers (37%). Unsafe sexual activity (66.7%) was the most potential exposure and majority of the patients were not consistent in using condom. CONCLUSIONS: Genital viral infections constitute the major bulk of sexually transmitted infections. Majority of the patients suffering from sexually transmitted infections were in the age group 20 to 24 years and were mostly drivers, conductors or migrating workers by occupation. In the background of few available baseline data, the results are expected to assist successful target interventions in the near future.

Anaesthetic management of patients with Xeroderma pigmentosum. A series of three cases.

Xeroderma pigmentosum is a rare autosomal recessive disorder with clinical and cellular hypersensitivity to ultraviolet radiation and defective DNA repair. Skin cancer, mainly on the face, head or neck is very common. Inhalational anaesthetic agents and muscle relaxants are best avoided due to the possibility of inducing DNA damage and prolonged effects of muscle relaxants. These patients may have a difficult airway. These patients may have immature brain development which may render them sensitive to synergistic effect of benzodiazepines and opioids as seen in the first case. Total intravenous anaesthesia is preferred. Nonsteroidal anti inflammatory agents and opioids for multimodal analgesia may be beneficial.

Comparative study of 5 % potassium hydroxide solution versus 0.05% tretinoin cream for Molluscum Contagiosum in children.

BACKGROUND: Molluscum contagiosum is one of the commonest cutaneous viral infections in children. All treatment modalities are associated with substantial pain, tissue destruction, and frequent recurrence. OBJECTIVES: To compare the efficacy and side effects of KOH 5% solution with tretinoin 0.05% cream for the treatment of molluscum contagiosum in children. METHODS: Fifty patients were randomly divided into 2 groups; 25 each for 5% KOH solution and 0.05% tretinoin cream. The given medication was applied at bed time over molluscum lesions. The assessment of response and side effects were performed weekly for 4 weeks. RESULTS: At the end of 4 weeks, the mean lesion count decreased from 9.48 +/- 3.00 SD to 1.67 +/- 0.58 SD and from 8.35 +/- 2.82 SD to 2.00 +/- 1.00 SD in patients treated with 5% KOH solution and 0.05% tretinoin cream respectively. CONCLUSION: The result of both KOH and tretinoin showed good response, well tolerated by children but between the two, KOH showed fast recovery and most lesions were resolved before 4 week. The side effects could be minimized if applied as stated above. On the other hand, tretinoin showed delayed response and even some of lesion extended beyond 4 week but the side effect were less, and hence can be used in recurrent cases.

Factors for abortion seeking among women attending health facilities.

BACKGROUND: Unsafe abortion contributes to high maternal mortality in the country which is 281 per 100,000 live births. In line with the expansion of safe abortion services to all 75 districts, it was time for us to look into the depths of the determinants that lead women to seek abortion. METHODS: A cross-sectional descriptive study was conducted in three centers providing safe abortion services in Kathmandu valley, viz. Paropakar Maternity and Women's Hospital, Marie Stopes International (MSI), Nepal, at SatDobato and Tribhuvan University Teaching Hospital (TUTH) from 16th July to 31st August 2009. A total of 450 respondents were interviewed, out of them 270 (60%) were from public centers and 180 (40%) from INGO run centers. RESULTS: It was observed that 32% of the respondents were in the group of 25-29 years;more than a third (34.9%) of the respondents was pregnant for the third time;58% were using some kind of contraceptive prior to this pregnancy and 90.4% showed a desire to use some kind of contraceptive after the abortion. The main reasons cited for termination were completed desired family size and mistiming and 101 (22.4%) had a history of previous induced abortion. CONCLUSIONS: There was a significant association between the uses of contraceptive methods prior to the index pregnancy in women who had sought previous induced abortion and it was also seen that women having previous termination had completed their desired family size of two and the age of the last child was above five.

Live birth following treatment of post molar choriocarcinoma.

A G3P(1+1) who underwent dilatation and curettage (D and C) for persistent vaginal bleeding after a month of molar evacuation, underwent successful treatment of choriocarcinoma with methotrexate and was able to have normal baby weighing 2800 gms with good Apgar score and normal placenta. This shows that a normal menstruation and uncomplicated term delivery can be expected after complete chemotherapy for gestational trophoblastic neoplasia (GTN).

A simple new technique of performing myomectomy for a predominantly subserosal myoma quickly within few minutes.

Removing a degenerated myoma located around the uterine cornu by an innovative technique shelling the myoma a little away from the base by choice of a low placed incision, advantageous in terms of no requirement of blood transfusion because of the reduction in the surgical time is described in a 24 years old lady demanding a fertility conserving surgery.

Natriuretic peptides and their therapeutic potential.

Natriuretic peptides are a group of naturally occurring substances that act in the body to oppose the activity of the renin-angiotensin system. There are three major natriuretic peptides: atrial natriuretic peptide (ANP), which is synthesized in the atria; brain natriuretic peptide (BNP), which is synthesized in the ventricles; and C-type natriuretic peptide (CNP), which is synthesized in the brain. Both ANP and BNP are released in response to atrial and ventricular stretch, respectively, and will cause vasorelaxation, inhibition of aldosterone secretion in the adrenal cortex, and inhibition of renin secretion in the kidney. Both ANP and BNP will cause natriuresis and a reduction in intravascular volume, effects amplified by antagonism of antidiuretic hormone (ADH). The physiologic effects of CNP are different from those of ANP and BNP. CNP has a hypotensive effect, but no significant diuretic or natriuretic actions. Three natriuretic peptide receptors (NPRs) have been described that have different binding capacities for ANP, BNP, and CNP. Removal of the natriuretic peptides from the circulation is affected mainly by binding to clearance receptors and enzymatic degradation in the circulation. Increased blood levels of natriuretic peptides have been found in certain disease states, suggesting a role in the pathophysiology of those diseases, including congestive heart failure (CHF), systemic hypertension, and acute myocardial infarction. The natriuretic peptides also serve as disease markers and indicators of prognosis in various cardiovascular conditions. The natriuretic peptides have been used in the treatment of disease, with the most experience with intravenous BNP in the treatment of CHF. Another pharmacologic approach being used is the inhibition of natriuretic peptide metabolism by neutral endopeptidase (NEP) inhibitor drugs. The NEP inhibitors are currently being investigated as treatments for CHF and systemic hypertension.