Sydenham's Chorea with Silent Cardiac Lesions, Mimicking.

Sydenham's chorea is an uncommon neurological manifestation of rheumatic fever and has many and varied differential diagnosis. It may mimic encephalitis when presents as an isolated feature even when silent cardiac lesions are present. Early diagnosis, treatment and penicillin prophylaxis prevents recurrence and progression of cardiac lesions. Prompt symptomatic relief and alleviation of distress is obtained with therapeutic intervention. A case of rheumatic chorea with silent cardiac valve lesions which mimicked herpes simplex encephalitis with choreoathetosis, in a 13 year old girl is presented along with review of literature.

Therapeutic drug monitoring of antiepileptic drugs.

Commonly used conventional antiepileptic drugs for pharmacotherapy in epilepsy are phenytoin, carbamazepine and valproic acid. These drugs have complex pharmacokinetic properties leading to fluctuation in their plasma level at given same therapeutic dose. The present study was done to monitor their plasma levels. A prospective observational study was conducted at National Public Health Laboratory. After taking detail history, blood samples were taken from epileptic patients of all age groups and both gender who were on usual therapeutic dose of one or two combined antiepileptic drugs. Plasma level of these drugs were analyzed by using Fluorescence Polarization Immuno Assay (FPIA) technique. Out of total 417 testing, 81 were tested for phenytoin , 241 for carbamazepine and 95 for valproic acid. Their levels were further analyzed to find therapeutic, subtherapeutic and toxic levels. Out of total 81 blood samples tested for phenytoin, 38.8% had plasma drug at therapeutic level, 38.8% at subtherapeutic level and 28.4% had toxic level. Carbamazepine was tested in 241 samples and 79.3% cases had at therapeutic drug level, 15.8% had subtherapeutic drug level and 4.9% had toxic level. Out of 95 samples tested for valproic acid, 62% had therapeutic level and 20% had subtherapeutic and 18% had toxic level of drug. Therapeutic drug monitoring of phenytoin showed wide fluctuation in its plasma level. Its toxic and subtherapeutic levels were quite high. It is suggested that the dose of phenytoin should be adjusted after regular plasma level monitoring only. Monitoring of carbamazepine and valproic acid were also helpful when their toxicity and efficacy are doubtful.

A study of abdominal pain in children.

Pain abdomen is a common pediatric complaint that brings patient to the hospital in Nepal. Knowledge about its etiology and frequency helps in its evaluation and management. The present study was undertaken to find out the causes and their frequency of pain abdomen in Nepali children. Children with pain abdomen presenting at the emergency room and pediatric outpatient department of Kathmandu Medical College, Kathmandu from January, 2006 to December 2007 were clinically evaluated and investigated to find out the causes and frequency of their pain abdomen. The outcomes were tabulated and analyzed for interpretation. Of 444 patients attended, 356 completed investigations and came for follow up. Cause of pain abdomen was apparent in 117 (32.9%) only. 91.5% were medical causes, comprising predominantly of diarrheal diseases (28.3%), infantile colic (9.4%), urinary tract infection (7.7%) and acid peptic disease (6.8%). 8.5% causes were related to surgical conditions, which needed operative management. Secondary or extra-abdominal causes were found in 20 cases (17.1%). Pneumonia (2), functional (5), vulvovaginitis (2) and infantile colic (11) were predominant causes. Our study showed that the causes of pain abdomen in children were predominantly medical. Gastroenteritis was the most frequent cause. Secondary causes, including functional and emotional causes were infrequent. Small percentage needing surgical management formed a diagnostic challenge.

A study of the first 350 cases referred for EEG in Kathmandu Medical College Teaching Hospital.

UNLABELLED: Electroencephalography or EEG is a neurological test that uses an electronic monitoring device to measure and record electrical activity in the brain. Epilepsy is defined as a recurrent tendency to unprovoked seizure. About 0.5% to 2% of the population has epilepsy. MATERIAL AND METHODS: This is a retrospective study of the first 350 odd cases referred for EEG at Kathmandu Medical College Teaching Hospital, Kathmandu during period November 2002- September 2002 (Mangsir 2058- Bhadra 2059). RESULTS: Most patients fall in the age group of 11-20 years and more than 50% referred cases fall in the prime of life, i.e., 11-30) years. 16% of patients with the history of seizure did not use any AED and 32% who though had no history of seizures were actually using AED. It is seen that out of 149 reported normal, 57 (38%) had history of seizure; but out of 208 reported abnormal in EEG only 92 (42%) had history of seizure. DISCUSSION: EEG is not a very sensitive or a specific tool; however, in our study it was seen to be more sensitive than specific. It is till very useful in classifying seizure types, in locating epileptic focus prior to surgery or in some confusing situation when movement disorder may simulate seizure disorder or vice versa. CONCLUSION: Although EEG is not a very sensitive or specific investigation, it is more sensitive than specific.

Epilepsy in children: an epidemiological study at Kathmandu Medical College Teaching Hospital Kathmandu.

OBJECTIVES: To analyze the relative frequencies of various epileptic seizures and to study the age at onset of different seizure types in Nepalese children. DESIGN: Prospective study. SETTING: Hospital outpatient based in Kathmandu, Nepal, between November 2001 to October 2002. PARTICIPANTS: 50 children diagnosed as epilepsy excluding neonatal and febrile seizures. MAIN OUTCOME MEASURE: Diagnosis and classification of cases according to the International Classification of Epilepsy of the International League Against Epilepsy [ILAE] and number of patients in each category with various ages at first seizure. RESULT: Generalized seizures (78%) were 3.54 times commoner than partial seizures (22%). Most frequent seizure types were generalized tonic clonic (36%), tonic (16%), complex partial (14%), atonic (12%) and absence (10%). Generalized clonic, simple partial and partial with secondary generalization, each had less than 5% frequencies. In 40% cases the first seizure occurred when aged between 2-5 years. In partial seizures the peak age at onset was observed below 6 years while primary generalized seizure was more frequently seen in age group 2-10 years. CONCLUSION: More paediatric patients with primary generalized seizures (78%) were observed than with partial seizures (22%). In this age group, the most frequent seizure type was generalized tonic clonic (36%) with the peak frequency of age at onset of seizures in 2-5 years.

Salient and co-morbid features in benign prostatic hyperplasia: a histopathological study of the prostate.

OBJECTIVES: To study the salient histological features of prostatic tissues in relation to age and to analyse the co-morbid histopathological changes in benign prostatic hyperplasia. (BPH). DESIGN: Prospective study. SETTING: Histopathology unit of a busy clinical pathological laboratory in Kathmandu Metropolitan City. SUBJECTS: 106 prostatic biopsy specimens from patients diagnosed as BPH received for histopathological examination during 2001-2. MAIN OUTCOME MEASURES: Prominent histological features observed in prostatic biopsy specimens obtained from patients of various age groups and frequency of co-morbid histopathological changes in benign prostatic hyperplasia. RESULTS: Prominent histological features. All (106) specimens included in the series had BPH showing glandulostromal proliferation of which 4 cases (3.77%) (all aged below 70 years) showed predominantly stromal pattern. Corpora amylacea present in 25% (in 5th decade) increased in frequency to 100% (8th decade onwards) in the later years. Cystically dilated glands also showed age correlated increase (through 5th to 8th decade) from 50% to 100%. Other prominent features observed with an overall decreasing frequency in all age groups (taken together) were glands showing papillary infoldings (44.33%), lymphocytic collection/infiltration (31.13%), proteinaceous material (7.54%), calcification (6.60%), homogenous eosinophilic material (2.83%), and glands showing necrotic cells (1.88%). Of all these, corpora amylacea, proteinaceous material, cystically dilated glands and glands showing papillary infoldings were present in all cases beyond 7th decade. Co-morbid histopathological changes of BPH. Twenty six specimens (24.52%) showed co-morbid features in association with BPH which included inflammatory (16.98%) and neoplastic (7.54%). Acute prostatitis was observed in 2 cases (1.88%), chronic prostatitis in 16 cases (15.09%) and none showed features of both. Neoplastic changes( 8 cases) ranged from intraepithelial neoplasm (PIN) (2 cases), atypical glands (2 cases, both in 7th decade) to adenocarcinomatous changes (2 cases, one each in 6th and 7th decade) were also observed co-existent with BPH. Both PIN cases (1.88%) were grade PIN-2 and occurred one each in the 6th and 7th decade. CONCLUSION: Histological profiles of prostatic biopsy specimens were observed to correlate well with the senile changes of advancing age. A predominantly stromal proliferation was found in a relatively lower age group, while corpora amylacea and cystically dilated glands along with glandular proliferation heralded changes of senescence. Co-morbid histopathological features were associated with BPH in a quarter (24.52%) of cases. Prostatitis was twice as common as neoplastic changes. Adenocarcinomatous changes were observed (2 cases) incidentally. PIN was recorded in 1.88% of specimens examined. Peak frequency of prostatitis was noted in the 6th decade while 7 of 8 neoplastic changes occurred in those of 60-80 years.

Efficacy and tolerability of Ketotifen in Nepalese asthmatic children: a clinical study.

OBJECTIVE: To assess the efficacy of Ketotifen in asthmatic children and to record its adverse effects, if any. DESIGN: Prospective clinical trial. SETTING: Pediatric asthma follow up clinic of a teaching hospital. PARTICIPANTS: 23 asthmatic children between 3 and 15 years; 100% completed the trial on full protocol. INTERVENTIONS: Ketotifen 1mg (adjusted according to body weight, 50 mcg/kg/dose) orally twice daily for 9 months. PRIMARY OUTCOME: Decrease in frequency of asthmatic attacks and severity of exacerbations with improvements in peak expiratory flow rates (PEFR). Other measures included decrease in bronchodilator requirement, steroid doses and parental perception regarding patient quality of life. RESULTS: 34.78% children were symptom free by the end of 2nd 3 months and 65.21% had no further attack by the end of 3rd 3 months of Ketotifen prophylaxis. Those children with activity and sleep 'affected' (8.69%) and 'may be affected' (30.43%) together improved to 'may be affected' group (21.73%) by the end of 2nd 3 months and further reduced to 8.69% by the conclusion of 3rd 3 months. The duration of exacerbations was reduced in the remaining cases. Variability of PEFR decreased from 26.08% to 8.69% of children after the 3rd 3 months of Ketotifen prophylaxis. No significant adverse effect of therapy was observed during the study. CONCLUSION: Oral Ketotifen is effective and well tolerated for use in prophylactic treatment of bronchial asthma in children.

An evaluation of infants' growth in the Kingdom of Nepal.

BACKGROUND: The His Majesty's Government/Japan International Cooperation Agency Primary Health Care Project began in April 1993 in collaboration with the Saitama Prefectural Government, for the purpose of improving the health status of the people in model districts of the Kingdom of Nepal. Growth monitoring is one of the basic methods that defines the health and nutritional status of children. METHODS: Anthropometric indices were measured in 759 children in the Bhaktapur district. We used the World Health Organization prototype growth chart and national growth standard for Japanese children (1990) to analyze the growth data. RESULTS: We found that the average bodyweight growth curve of children up to 4 months of age followed the 50th percentile reference curve. For children of 5-12 months of age, there was a delay in bodyweight gain and the growth curve reached the 3rd percentile curve. For children more than 1 year old, the growth curve moved below the third percentile curve. Catch-up growth did not occur before the children reached 5 years of age. The main causes of catch-up growth being hampered were chronic undernutrition and inadequate nutritional balance. CONCLUSIONS: As this was the first opportunity to evaluate infant growth in this district, the first important consequence of the results was to analyze the causes of growth faltering and failure-to-thrive in Nepalese children. Even more important, was the need to give appropriate counseling on improving feeding and other health-related practices, and the most important consequence of all was to instruct Nepalese health workers that utilizing the growth charts is an integral part of health care.

Hypoglycaemia: a common problem among uncomplicated newborn infants in Nepal.

Among a cross-sectional sample (stratified by weight and age after birth) of 226 uncomplicated term newborns from the delivery and postnatal wards of a busy government maternity hospital in Kathmandu, the period prevalence of hypoglycaemia (corrected blood glucose of < 2.6 mmol/l) during the first 50 hours after birth was 38 per cent. (This compares with a reported prevalence rate of 12 per cent from studies of uncomplicated term newborns in the UK.) Hypothermia, young maternal age, low birth weight and early sampling after birth were independent risk factors for hypoglycaemia. Of 31 infants studied longitudinally during the same period, 27 (87 per cent) had at least one blood glucose measurement of < 2.6 mmol/l and 25 (81 per cent) a rectal temperature of < 35.5 degrees C. Fourteen infants (44 per cent) had three or more episodes of hypoglycaemia and seven infants (22 per cent) had three or more episodes of hypothermia. Hypoglycaemia is a common, preventable and neglected problem in many maternity hospitals in developing countries. Simple low-cost measures to reduce the incidence of hypoglycaemia may have a major impact on early infant mortality and neurodevelopmental sequelae of perinatal origin.