Radiographic Evaluation of Crestal Bone Loss in Pre-loading and Post-loading States of Endosteal Implants in Maxilla and Mandible- A prospective study.

Background Peri-implant tissue integrity depends upon healthy peri-implant mucosa and bone. The crestal bone is one of the governing factors for successful implant therapy both functionally and esthetically. There are limited radiographic studies in Nepalese population for determination of crestal bone loss around peri-implant area comparing the bone loss at pre- and post-loading state. Objective To evaluate the bone loss in mesial and distal, maxilla and mandible before and after the implant supported prosthesis delivery. Method A 6-months prospective study was planned and conducted in 26 endosteal implants (13 maxillary and 13 mandibular) which were placed in 20 patients fulfilling the inclusion criteria. The crestal bone loss was measured and compared using digital radiography images using the designated software. The differences among the crestal bone loss in mesial and distal, maxilla and mandible in pre- (3 months of implant placement) and post-loading states (3 months of prosthesis delivery) were evaluated using the appropriate statistical tests. Result The crestal bone loss was more pronounced in the pre-loading stage (1.12 mm) compared to post-loading (0.48 mm). Initially, the bone remodelling was higher in the distal aspect whereas there was no significant difference between mesial and distal aspect in post-loading phase. Comparing maxilla with mandible, there were no significant differences in bone loss in both phases. Conclusion Within the limitations of this study, the crestal bone loss was found upto the physiological limit of bone remodelling provided the implants placed in strict, aseptic condition with proper case selection and planning.

Semi-customized Scleral Shell Prosthesis for a Pthisical Eye.

One of the most common causes of eye loss is ocular trauma that overtime results in shrunken, non-functional eye known as a pthisical eye. The prosthetic options for such case include either prefabricated prosthesis or custom-made prothesis. Various materials and techniques are used for the fabrication of the prosthesis. Semi-customized prosthesis uses stock iris while the scleral shell is customized. This prosthesis has the advantages of both stock and custom-made prosthesis providing functionally and esthetically satisfactory result. This case report demonstrates the case of a 32 years old male who reported to the Department of Prosthodontics and Crown-Bridge, College of Dental Surgery, BP Koirala Institute of Health Sciences, Dharan, Nepal for eye prosthesis to mask his pthisical eye. For this case, a semicustomized scleral shell prosthesis was planned and fabricated.

Idiopathic Bilateral Optic Neuritis.

Idiopathic bilateral optic neuritis in adult has been reported very rarely. The objective of this report is to present a case of idiopathic bilateral optic neuritis in adult and treatment responses. A nineteen year old female presented with bilateral optic neuritis. It was characterized by decreased visual acuity, painful ocular motility and sluggish pupillary reaction with Relative Afferent Pupillary Defect (RAPD) in left eye, hyperemic and generalized optic disc swelling and central scotoma in Humphrey visual field of both eyes. MRI showed diffuse thickening and irregularly outlined optic nerves of both eyes. Idiopathic bilateral optic neuritis in adults is a rare presentation. Prompt treatment with optic neuritis treatment trial (ONTT) improved the visual outcome.

Masson's Hemangioma of the Cheek: A Case Report.

We report a rare case of intravascular papillary endothelial hyperplasia (IPEH) of the cheek. This neoplasm, known as Masson's tumor, is an unusual vascular lesion of proliferating endothelial cells. It is usually confined to the lumen of preexisting vessels or vascular malformations. The principal significance of IPEH is its resemblance to a variety of benign and malignant diseases and possible misdiagnosis as such. Achieving a correct diagnosis is essential to avoid subjecting a patient to either unnecessarily aggressive or inadequate therapy. For this reason, awareness of this lesion is very important.

Herpes zoster ophthalmicus with retrobulbar neuritis.

BACKGROUND: Retrobulbar neuritis in Herpes Zoster Ophthalmicus (HZO) has been reported very rarely. OBJECTIVE: To report a very rare case of HZO with retrobulbar neuritis with detailed clinical features and treatment responses. CASE: A fifty-eight- year old male presented with Herpes zoster-retrobulbarneuritis in the left eye. It was characterized by decreased visual acuity, mid dilated pupil with sluggish reaction, normal optic disc and central scotoma in Humphrey visual field. Visual acuity improved with systemic Acyclovir and steroids. CONCLUSION: This is a rare case of HZO associated with retrobulbar neuritis. Prompt treatment with systemic antiviral and steroid improve the visual outcome.

The impact of hearing loss in older adults: a tertiary care hospital based study.

Hearing loss is the most common sensory deficit in the elderly, and is becoming a severe social and health problem. Presbycusis is the result of aging which can lead to communication problems compromising the quality of life (QoL).Since the elderly population is increasing worldwide, presbycusis is showing a similar trend. This study intended to identify the impact of hearing loss in the social life of the elderly. A total of 70 elderly patients attending Nepal Medical College Teaching Hospital who were found to have sensorineural hearing loss (SNHL) on pure tone audiometry (PTA) were recruited for this study.None of the patients had used hearing aids in the past. To assess their handicap due to hearing impairment a Hearing Handicap Inventory for the Elderly (HHIE) questionnaire was used and patients were graded as: no handicap, mild to moderate handicap and significant handicap. Pure-tone averages (PTA) were calculated for the thresholds at 0.5, 1 and 2 kHz in each ear. Patients with their PTA values between 26 to 40 dBHL were interpreted as having mild SNHL, those between 41 to 55dBHL as moderate SNHL and those above 55 dBHL as severe SNHL. Out of 70 patients, 65 had some degree of handicap ranging from mild to severe. The severity of handicap was significantly associated with the degree of hearing loss in both ears.

USG assisted and USG guided percutaneous renal biopsy at Nepal Medical College Teaching Hospital: a three and half years study.

A prospective study was carried out from 2009 to 2013 in the Department of Radiology and Imaging of Nepal Medical College and Teaching Hospital, Attarkhel, Jorpati, Kathmandu, Nepal, in which a total of 75 patients underwent percutaneous renal biopsy with a 16 or 18 gauge needles. This was done blindly by marking a site on the skin, or, whenever there was difficulty with the blind procedure, by direct real time USG guidance. In all cases, the marking in the skin was done by the radiologist and the biopsy was performed by the Nephrologist, with the aid of the radiologist in cases of real-time USG guided renal biopsy. This study was carried out to assess the safety and efficacy of the USG aided, and USG guided renal biopsy, to see for the types and severity of complications arising from renal biopsies to determine the optimal period of observation required after the procedure. All renal biopsies were performed after the patients were admitted to the hospital at least 1 day prior to the procedure. Coagulation profile was done in all patients prior to the procedure. All patients were kept under strict complete bed rest for 24 hours post procedure. The ages of the patients ranged between 14 years to 71 years, with 42 female and 33 male patients. A mean of 21.8 glomeruli was obtained in each specimen, with absent glomerular yield seen in only 3 patients. Minimal change disease was seen in 19 patients, being the most common histopathological diagnosis followed by a spectrum of others. The overall complication rate was 4% and all of these were self-limiting needing no other intervention, or management except for observation and bed rest. Late complications were not seen. Percutaneous renal biopsy with the help of USG is a safe and efficacious procedure with less chance of minor complications.

Clinical and contact allergological observations on hand eczema: a descriptive study.

Hand eczema (HE) is a common and distressing condition that is perplexing to the patient and the physician alike. To study the frequency and clinical features of hand eczema and to correlate the frequency of atopy and contact sensitization with different clinical features a total of 61 clinically diagnosed patient of Hand eczema were included within a period of one year. Patch test was done in 47 patients and graded accordingly. The frequency of hand eczema was 0.57%. Morphologically pompholyx was the most common type while aetiologically endogenous hand eczema was the commonest. Contact allergy was observed in 55.3% of the cases of which nickel sulphate (18.5%) was found to be the commonest sensitiser followed by Gentamicin and Fragrance mix though contact allergens with positive patch test in different morphological types of hand eczema have no apparent relevance but it still could contribute to the persistence or exacerbation of hand eczema.

Effectivity of Nd Yag PI in treatment of acute primary angle closure glaucoma.

A Prospective hospital based study to note the efficacy of Nd Yag Peripheral Iridotomy (PI) in the treatment of acute primary angle closure glaucoma was carried out in Nepal Eye Hospital from Jan 2007 to Jan 2008. All the Patients (n=50) with acute primary angle closure glaucoma admitted to our hospital were selected for the study. Patients with secondary angle closure glaucoma were excluded. It is more common in age of 56-65 years (20%), in females (70%), and in tibetoburman ethnic group (56%). Mean duration of presentation to hospital was 5 days (22%) (Range 4-7 days). Grade 1 Angle closure was present in 74%. All 50 patients (100%) with AACG had undergone Yag PI. Out of 50 patients, 11 patients (22%) were surgically operated i.e. trabeculectomy. Among 11, 1 patient (9%) who had undergone trabeculectomy had presented with acute on chronic angle closure glaucoma. Majority of cases (66%) presented with visual acuity (VA) 1/60-PL at the time of presentation and the Intraocular pressure (IOP) in affected eye was 31-40 mmHg (42%). After performing Yag PI the mean visual acuity in the affected eye at the time of discharge was 6/60 (20%) and the IOP was 12 mmHg (40%). Prolonged duration of attack, elderly age, acute on chronic angle closure glaucoma, very high IOP at presentation, patients needing repeat Yag PI were found to have failure Yag PI. In this study 78% eyes had controlled IOP following Yag PI.

Bladder outflow problems in females.

This is a prospective study that included 188 females who had bladder outflow problems, either due to urethral stricture disease or failure to empty the bladder. The data was taken from a computer database and included patient data since 11 years, who were on follow-up for their conditions. The women ranged from 23 to 97 years old, with a median value of 59 years. The aim of the study was to assess the bladder outflow problems in females and their treatment, which included either cystoscopy alone or in combination with urethral dilatation followed by long-term clean intermittent self catheterisation or dilatation (CISC/ISD). Out of the 188 patients, there were 135 patients who had problems with emptying the bladder due to various conditions. These females did well withCISC, which is an accepted treatment modality in this group of patients. They also used catheters of a smaller size as compared to patients using ISD for stricture disease. Thirty-eight patients among the total number had urethral stricture disease, whereas 15 patients presented with both conditions. Among the patients having treatment for stricture disease, the majority needed urethral dilatation repeated during follow-up. However, none of them needed any reconstructive surgery during that period of time. Most of the patients were comfortable doing ISD, in spite of using larger catheters comparatively. The catheters most used were the Lofric catheters. It was also seen that the majority of patients were satisfied doing CISC/ISD.

Impact of patch testing on quality of life in patients with hand eczema: a follow-up study.

BACKGROUND: Patch testing has previously been shown to influence the quality of life, although a very few studies have shown if this is dependent on the result of the patch tests. OBJECTIVE: To assess the impact of patch testing on the quality of life (QOL) in patients with hand eczema (HE). METHODS: A total of 50 patients diagnosed of hand eczema at the time of patch testing, aged 16 years and above participated in this study. Detailed demographic information and diagnosis of hand eczema were collected on the day of the patch test. After six weeks, the patients were asked about the hand eczema, knowledge of their allergies and change in their life style to avoid the relevant allergens demonstrated on the patch test. Dermatology Life Quality Index (DLQI) was used to measure the QOL on both occasions. RESULTS: The patch test positivity was found in 68% of patients to one or more allergens. The sum score of DLQI at baseline was 12.16 ± 5.58 with median 12.0. HE had most impact on symptoms and feelings. Patients with both positive patch test (mean baseline= 11.94± 5.88; mean at six weeks=2.81± 2.01; P <0.001) and negative patch test (mean baseline=12.63± 5.03; mean at 6 weeks=5.4± 3.56; P=0.001) showed significant improvement in DLQI scores, however it was more improved in patients with positive patch test than in patients with negative patch test. CONCLUSIONS: Hand eczema had an appreciable impact on the QOL. Patch testing had been beneficial to most patients in improving patient quality of life considerably.

Antibiotic susceptibility of organisms causing urinary tract infection in patients presenting to a teaching hospital.

BACKGROUND: Urinary tract infections (UTI) are common. It causes severe morbidity and mortality, and it is important to know the causative organisms in the hospital and community for optimum management of UTI. METHODS: This is a prospective hospital based study to identify the organisms causing UTI and their antibiotic susceptibility. Consecutive patients presenting with symptoms of UTI had their clean catch midstream urine analysed. Antibiotic susceptibility was tested by Kirby-Bauer's disc diffusion method as described by National Committee for Clinical Laboratory Services (NCCLS) guidelines. RESULTS: Out of 1726 patients, 549 (31.8%) showed bacterial growth. Escherichia coli was most common (72.5%), followed by Klebsiella pneumoniae (11.3%), Staphylococcus aureus (3.1%), coagulase negative Staphylococcal species (2.7%) and others (10.1%). There was a female dominance of 3.2:1 compared to males, except in the 61 and above age range. Infections were most common in young adults (21-30 years). The most effective antibiotic was Nitrofurantoin followed by Norfloxacin, Ciprofloxacin and Ofloxacin. Some isolates were resistant to Norfloxacin, Ampicillin, Cotrimoxazole and Ciprofloxacin. CONCLUSIONS: The most common causative organism for UTI was Escherichia coli, and the best first line antibiotic was Nitrofurantoin. Organisms are developing resistance to antibiotics such as Norfloxacin, Ampicillin and Ciprofloxacin.

The study of prevalence of Helicobacter pylori in patients with acne rosacea.

BACKGROUND: Acne rosacea is an inflammatory disease affecting the central part of the face characterized by erythema, papules, papulo pustules and telangiectasias of unknown etiology. More recently numerous studies have described an association with Helicobacter pylori (Hp) and the extra gastric symptoms of cutaneous origin. OBJECTIVES: To establish the prevalence of Helicobacter pylori (Hp) infection in the stomach in patients with rosacea based on standard Hp serological test. METHODS: All patients with the clinical staging of 2, 3 and 4 rosacea attending the Dermatology Out Patient Department from May 2009-April 2010 were included in the study. Quantitative serological test using the SERION ELISA classic Helicobacter pylori IgG was done. RESULT: A total of 26 patients were enrolled in the study with the age ranging from 26-82 years. There were 14 males and 12 females and the male: female ratio was 1.6:1. Three (11.53%) patients presented with Grade IV rosacea, a severe clinical presentation and symptoms suggestive of acid peptic diseases were found in 14/26 (53.8%) patients. A positive serology to H. pylori was found in 17/26 (65.4%) of patients. A statistically significant correlation was found when association of H. pylori positivity in patients of rosacea compared with the seropositivity in controls. However correlation in the seropositivity was not found amongst the patients having gastritis and rosacea. CONCLUSION: There still proves to find a correlation of Hp infection with patients with rosacea but it can still be hypothesised as a cutaneous manifestation of an internal peptic ulcer disease.

Pain during rigid cystoscopy: a prospective randomized controlled study comparing the benefit of cooled and room temperature lignocaine gel.

Lignocaine gel is an established topical anesthetic agent for cystoscopy in awake patients. We performed a prospective randomized study to evaluate whether cooling the lignocaine gel to 4 degrees C decreases the pain perception during cystoscopy in male patients. Sixty consecutive male patients undergoing rigid cystoscopy were randomized into two groups. Group I received 15 ml of 2% lignocaine hydrochloride gel at 4 degrees C and group II received the same agent at room temperature (20 degrees C). Cystoscopy was performed and pain perceived during the procedure was assessed by independent evaluator using Wong-Baker FACES pain scale rating chart. The mean pain score in group I was lower (4.32 +/- 1.70) than that in group II (5.28 +/- 1.99), but this difference was statistically not significant (p=0.191). However significantly greater percentage (84% Vs 52%) of patients with cooled lignocaine wished to have same anesthetic in future for similar procedure (p=0.032). In conclusion, cooling the lignocaine gel to 4 degrees C does not decrease the pain perception during rigid cystoscopy in male patients.

Clinicopathological association between BPH and prostatitis.

This was a prospective study done in Nepal Medical College Teaching Hospital, Kathmandu, Nepal to find out the relationship between BPH and BPH associated with prostatitis as regards their symptoms and histopathology. We looked at the symptoms of both disease processes and tried to establish whether we could differentiate between the two entities on a clinical basis. Our study included thirty six patients who were operated for symptoms suggestive of LUTS due to BPH. Prior to the operation they were asked about their symptoms and we correlated these for the two conditions. We analysed the results of the symptoms statistically according to the odd's ratio. We found that the most common symptom associated with BPH with prostatitis was dysuria, however, there was a lot of overlap of the symptoms. So unless there is a high degree of suspicion on the part of the health care worker it is difficult to make a diagnosis of prostatitis based on symptoms alone and it is difficult to distinguish between the two conditions. The histopathological specimens were analysed and it was found that 19 of the 36 patients had prostatitis associated with BPH. This was done by scrutinising the received histopathological specimens. Here it was found that the most common type of prostatitis associated with BPH was the stromal inflammatory pattern.

Ear diseases in children presenting at Nepal Medical College Teaching Hospital.

Ear diseases are a common presentation in the ENT out-patient department. These diseases can have sequelae if not treated early which may cause increased morbidity, hearing disability and even mortality. Identifying these conditions early and treating them can reduce these unwanted sequelae. A prospective study over a period of three years was undertaken in a tertiary care hospital in Kathmandu. All children presenting with ear diseases consecutively in the ENT out-patients were included and their data was recorded in a pro forma. The data was analysed for frequency and cross-tabulated. The study included 2218 children with ear diseases among which 868 (39.1%) were pre-school and 1350 (60.9%) were school going children. The male to female ratio was 1.5:1. The most common otological problem was wax impaction (40.2%), followed by acute otitis media (AOM) with 24.3%, chronic suppurative otitis media (CSOM) with 17.7% and acute otitis externa (AOE) with 7.5% of the total cases. The other conditions were otitis media with effusion (2.8%), foreign bodies in the ear (2.3%), otomycosis (1.7%), preauricular sinus (1.1%), sensorineural hearing loss (0.8%), trauma to the ear (0.7%), keloids (0.3%), microtia (0.2%) and perichondritis (0.2%).The three year olds had the highest number of otological diseases with 9.2% of the total among the ages studied. It is felt that proper education of health care providers regarding ear diseases and also awareness in the community can prevent and reduce the disability and complications of these conditions.

Errors on a handwritten cardex: is it time for a change?

A medical order is a medical and legal document and careful writing of this document is necessary. In Nepal the medical order in the admitted patients is written on a cardex which is utilised by the nurses to dispense medicines and to follow the doctor's orders. However, with the dawn of the electronic age this is being replaced by a computerized system, which is suggested to be better. The aim of this study was to identify if the existing cardex was adequate for the purpose of writing orders, or whether this needed modification. This was a prospective observational study were 240 cardexes from eight different Departments from the same Medical College Hospital were randomly looked into for errors. Thirteen different parameters were looked into including the legibility/readability of the handwriting. The results suggested the error rates to be high in certain parameters viz. utilization of the columns (77.9%), documentation of allergy history (77.5%), writing the prescribers name (89.6%) and writing date of discontinuation of medicines (62.5%). The handwriting was unreadable or difficult to read in 49.2% of the documents. However, the other parameters also had errors and no parameter was error free. The study suggested the need of the hour was to modify the existing cardex and also to educate the doctors to minimise errors. However, in the future we may have to move towards a computerized system in order to avoid errors related to bad handwriting.

Visual outcome of conventional extracapsular cataract extraction with posterior chamber intraocular lens implantation versus manual small-incision cataract surgery.

BACKGROUND: an effective method for cataract surgery should be identified to combat cataract blindness. AIM: to study the surgical outcome of conventional extracapsular cataract extraction versus manual small-incision cataract surgery. MATERIALS AND METHODS: a randomized clinical trial was carried out including one hundred eyes (88 patients) which were divided into two groups using systematic randomization: groups of conventional extracapsular cataract extractionwith posterior chamber intraocular lens (ECCE with PCIOL) implantation and manual small-incision cataract surgery (MSICS). The postoperative parameters/variables studied were the unaided and best-corrected visual acuity and astigmatism. STATISTICS: epi info 2000 version statistical software was used for data analysis and calculation of relative risk, 95% CI and p value. The p value of less than 0.05 was considered as significant. RESULTS: in the immediate postoperative period, unaided visual acuity of =or> 6/18 was achieved in 24 subjects in MSICS group versus 7 in ECCE with PCIOL group (RR=2.05, 95% CI= 1.44 - 2.94, p = 0.0002), whereas the same at 6 - 8 weeks postoperatively was found in 28 and 22 subjects in those groups respectively (RR=1l.27, 95% CI=0.86-1.89, p=0.23). The astigmatism of =or> 2 at6 - 8 weeks was found in 35 and 17 subjects from the conventional and MSICS groups respectively ( R=2.28, 95% CI= 1.39-3.73, p=0.0002). CONCLUSION: both MSICS and conventional ECCE with PCIOL are safe and effective techniques for treatment of cataract patients. A more rapid recovery of good vision can be achieved with MSICS than with conventional ECCE with PCIOL in the immediate postoperative period.

Intermittent self dilatation--still a viable option for treatment of urethral stricture disease.

The study was conducted to find out if intermittent self dilatation (ISD) is still a viable option for treatment of urethral strictures in patients who had undergone either urethral dilatation or urethrotomy prior to ISD. The study included 310 male patients with the age range from 17 to 93 years old from January 1996 to March 2007. The data was gathered from the computer data base kept by the urology unit in the hospital. A questionnaire was used to evaluate their tolerance towards the procedure and quality of life. Of the total number of patients 262 replied to the questionnaire. The mean follow up was 57.68 months with 67.7% continuing with the procedure. The procedure was well tolerated by 84.1% of patients and 79.6% had no technical difficulty. The most number of patients carrying out this procedure were in the 6th and 7th decade of life. There was a recurrence rate of urethral strictures of 16.9%. It is seen that even today ISD following an endoscopic procedure is a viable treatment option. The patients seem to tolerate this procedure well and it is an option in the elderly patient group who may not be fit or willing to undergo reconstructive surgery or urethroplasty.

Visual outcome and IOP control after cataract surgery in lens induced glaucomas.

Lens induced glaucoma is one of the important cause of secondary glaucoma in our population. Retrospective analysis of 40 cases of lens induced glaucoma presenting to Nepal Eye Hospital from January 2002 to December 2004 were analyzed to find the prevalence of sex, age, visual outcome, IOP control, and duration between appearance of symptoms and surgical invention. Females out numbered male (55:45 percent). Phacomorphic glaucoma was seen more than phacolytic type (65:35). Visual recovery was good in 45% cases (6/12-6/60) and moderately fair in 30% cases (VA <6/60). Preoperative IOP ranged from 24.0-59.0 mmHg. Postoperative IOP ranged from 14-22 mmHg. Duration between symptoms and surgery was 1 week to 4 months.