Diabetic Foot Ulcer and its Associated Risk Factors in Diabetic Patients with Peripheral Arterial Disease Presenting in the University Hospital of Nepal.

Background Diabetic foot ulcers (DFUs) are a common complication in diabetic patients especially in those with peripheral arterial disease (PAD). However, it can be prevented if its risk factors can be identified and adjusted. Objective To investigate the frequency of diabetic foot ulcers and their associated risk factors in diabetic patients with peripheral artery disease. Method Diabetic patients under medication with known peripheral arterial disease diagnosed with Doppler ultrasonography were recruited from the outpatient department of the cardiothoracic and vascular unit, at Dhulikhel Hospital. The patients were interviewed about their demographic details, presenting clinical symptoms, and the risk factors such as smoking, hypertension, cardiovascular diseases, duration of diabetes, and hyperlipidemia. Also, the patients were assessed for any ulcers in their feet. Descriptive statistics and chi-square tests were used to analyze the data. Result The analysis demonstrated diabetic foot ulcers in 24.1% of the total 54 diabetic patients with peripheral arterial disease. The risk factors such as smoking (24.1%), increasing age (68.5%), hypertension (31.5%), and duration of diabetes (72.2%) were found in the majority of the patients. Out of these risk factors, smoking (Odds ratio: 6.81) and increasing age (Odds ratio: 0.28) were significantly associated with diabetic foot ulcers. (p < 0.05) Conclusion Diabetic foot ulcers affected about a quarter of diabetic patients with peripheral arterial disease and were found to be associated with increasing age and smoking.

Comparison of the Mean Cross-sectional Area of the Median Nerve between Pregnant and Non-Pregnant Women Using Ultrasonography in a Tertiary Level Hospital, Nepal.

Background The median nerve is subjected to compression in the carpal tunnel giving rise to a constellation of symptoms known as carpal tunnel syndrome. It is the most frequent form of peripheral entrapment neuropathies and is most prevalent in the middle age females. The most common cause of this syndrome is idiopathic. One of the known secondary causes is pregnancy. Objective To compare the mean cross sectional area of median nerve using ultrasound in pregnant and non-pregnant females at carpal tunnel inlet and its variations with different trimesters. Method The study was conducted during a period of one year (October 2014 to September 2015). A total of 204 participants were evaluated among which 102 were nonpregnant and 102 were pregnant. Among the 102 pregnant participants, 34 females each were in the first, second, and third trimesters. A convenience sampling technique was used for the selection of the participants. The mean cross-sectional area of the median nerve was calculated in both of these groups in both hands by using the direct method. The mean cross-sectional area of non-pregnant female was used as the reference value to which that of pregnant female were compared. Data obtained were compiled and analyzed using Statistical Package for Social Sciences Version 16. Result The overall mean cross-sectional area of the median nerve in non-pregnant females was 6.76 ± 1.05 mm2 and in pregnant females was 6.84 ± 1.09 mm. No statistically significant difference was noted in the mean cross-sectional area of the median nerve in either hand in both pregnant and non-pregnant females. No statistically significant difference was noted in the overall mean cross-sectional area between the non-pregnant and pregnant females. There was no significant difference in the mean cross-sectional area within the different trimesters in both hands on intergroup comparisons. Conclusion Ultrasound examination of the median nerve and measurement of its crosssectional area is a useful diagnostic tool in the evaluation of carpal tunnel syndrome. Ultrasound has the advantage of easy availability, low cost, quick scan time, able to scan a long segment of nerve and examine the structures in both static and dynamic states. Besides, it also helps in the identification of various anatomic variants and pathologies within or adjacent to carpal tunnel.

Arthroscopic Debridement for Mucoid Degeneration of Anterior Cruciate Ligament - A Single Institution Experience from Nepal.

Background Mucoid degeneration of anterior cruciate ligament is characterized by infiltration of mucoid-like material scattered throughout the anterior cruciate ligament substance. It is an uncommon condition, but previously, underdiagnosed or often misdiagnosed as an anterior cruciate ligament tear. Objective To present our early experiences with mucoid degeneration of anterior cruciate ligament in last five years in terms of clinical presentation and the outcomes of arthroscopic management. Method This was a retrospective descriptive cross-sectional study on patient who received arthroscopic debridement for mucoid degeneration of anterior cruciate ligament in Dhulikhel Hospital over five years period (2017 May to 2022 April). Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale that has been translated and validated to be used in local (Nepali) language and context was used for evaluation of outcome evaluation. Result Twenty-one patients of mean age 44.21 years, predominantly females (18), were managed in five years period. The mean Western Ontario and McMaster Universities Osteoarthritis Index score was 16.33±10.47 with a range of 0 to 36 (11.57 to 21.09 at 95% confidence interval). The mean Western Ontario and McMaster Universities Osteoarthritis Index score converted on a scale of 0 to 100 was 17. Thirteen patients had isolated Mucoid degeneration of anterior cruciate ligament whereas nine others had associated either meniscal tear or chondral lesions. Conclusion Mucoid degeneration of anterior cruciate ligament could be a cause of knee pain in middle-aged patients and arthroscopic debridement can improve the patient's symptoms and provide a good functional outcome.

Outcomes of Laparoscopic Cholecystectomy in a Tertiary Hospital in Nepal.

Background Laparoscopic Cholecystectomy (LC) is the gold-standard surgery for symptomatic cholelithiasis with low mortality and morbidity. Objective The main objective of this study is to study the outcomes of laparoscopic cholecystectomy in Dhulikhel Hospital over the period of seven years. Method The records of all the patients who underwent laparoscopic cholecystectomy in Dhulikhel Hospital from January 1, 2015, to December 31, 2021 were reviewed. Patient demographics, indication of surgery, hospital stay, and number of conversions to open cholecystectomy were collected. The percentage, mean and median were calculated for socio-demographic information and Chi-square test was performed to measure the association between socio-demographic characteristics, duration of hospital stay, and operative procedure. Result Out of 2106 patients who underwent laparoscopic cholecystectomy from January 1, 2015, to December 31, 2021, 584 (27.73%) were male, and 1522 (72.27%) were female. The female-to-male ratio was 2.6:1. The median age of the patients was 40 years (IQR=52-30). Most common indications for surgery were symptomatic cholelithiasis in 1740 (82.62%) patients along with chronic cholecystitis in 268 (12.73%) patients, and Post ERCP Cholecystectomy in 92 (4.37%) patients. Median hospital stay was three days. Out of 2106 cases, 24 cases were converted to open cholecystectomy. Conclusion Laparoscopic cholecystectomy is the gold standard treatment for benign diseases of the gallbladder and can be performed safely as day care surgery to reduce the cost, length of hospital stay, and long waiting list in low and middle-income countries.

Sellar Tuberculosis Mimicking Pituitary Adenoma.

Tuberculosis of central nervous system accounts for only 1% of tuberculosis cases worldwide, of which pituitary is an extremely unusual site. We report a case of pituitary tuberculosis in a 29-year-old female presenting with complains of headache and diminished vision on right eye. It was misdiagnosed as pituitary adenoma on radiology. Biopsy showed epithelioid granulomas, langhans giant cells and caseous necrosis. Ziehl nelseen stain showed presence of acid fast bacilli confirming the tubercular etiology. Therefore, histology remains the mainstay for diagnosis of these lesions. Early diagnosis and prompt use of antitubercular drugs results in good outcome.

Awareness Regarding Diabetes Mellitus among General Population of Banepa Municipality.

Background Diabetes is a silent disease and many people with diabetes may become aware of it only after life-threatening complications. The presence of knowledge of diabetes could contribute in early diagnosis and minimize the occurrence of complications. Hence, healthcare and public policy makers are putting extensive efforts to aware them on diabetes. Objective To assess the level of diabetes knowledge and its risk among the general public of Banepa municipality. Method A Cross sectional study was conducted to assess the awareness about diabetes among the general public of Banepa municipality. During the period of November 2019 to January 2020, 273 respondents of Banepa municipality were included with informed consent. Data was collected using a pre-tested structured questionnaire through one-to-one interviews. Indian Diabetes risk score (IDRS) was used to identify the risk of diabetes among them that consists of four elements i.e. age, abdominal obesity, physical activity, and family history. Data entry and analysis was done using SPSS version 20. Result It was found that 61.9% had a higher level of knowledge of diabetes. IDRS score shows more than half percent (53.5%) of respondents were in high risk, 39.2% were in medium risk and 7.3% were in low risk. Conclusion This study implies that there was good knowledge about diabetes among people. However, the majority of them are at risk for developing diabetes in future which may be due to lack of practical implication of knowledge. It reflects the necessity to educate and reinforce the public regarding prevention of diabetes which further postpones its complications.

Vaginal Atresia with Cervical Agenesis, a Rare Congenital Malformation.

Congenital vaginal atresia and cervical agenesis is a rare congenital abnormality of the female genital tract. Here we report a case of 15-year old girl with primary amenorrhea with hematometra, presented with lower abdominal mass. She was symptomatic since 5 months and visited local hospital after 4 months of onset of her symptoms when it became severe, where diagnostic laparotomy was performed for suspected Adnexal mass. Intraoperatively adnexal mass was adhered with and extended up to the uterus with 16 weeks size of uterus. Abdomen was closed without any further intervention and was referred to higher center for needful. When she presented to Kathmandu Model Hospital, she was asymptomatic on her 5th post-operative day of laparotomy. We planned for surgical intervention after examination and investigation. Drainage with vaginoplasty with amnion graft with placement of mould was done.

COVID-19 Pandemic: An Experience of OBGYN Residents at Kathmandu Model Hospital.

COVID-19, a novel corona virus has affected the life of each and every individual worldwide. Nepal being the neighborhood country of china, though, we had a late case detection. But, since the month of July this virus has spread in an alarming manner in Nepal. Nepal being one of the developing countries, we lack in equipments, manpower resources and also in treatment centers. Looking into the devastating scenario of Covid 19 in China, Italy, New York, Brazil and our neighboring countries like India, Pakistan and Bangladesh is scary. We wondered how we were going to handle this pandemic if similar circumstances happened in our country too. At the same time being OBGYN residents, we all know pregnancy is very crucial and our patients have faced much difficulties to receive the maternal health services. In this manuscript, we have shared our experience regarding preparedness for COVID-19, management of positive cases and its effect in OBGYN trainee.

Misleading Diagnosis of Dysgerminoma in a Young Asymptomatic Patient.

Dysgerminomas account for approximately one third of all malignant ovarian germ cell tumors (tumors arising from ovarian germinal elements) and are the most common ovarian malignancy detected during pregnancy. They are the only germ cell malignancy with a significant rate of bilateral ovarian involvement that is 15-20 percent. They have a variable gross appearance, but in general are solid, pink to tan to cream colored lobulated masses. They have the best prognosis of all malignant ovarian germ cell tumor variants. Two thirds are stage I at diagnosis, and prognosis is excellent even for those with advanced disease due to exquisite tumor chemosensitivity. The 5 year disease specific survival rate approximates 99 percent. This is a case report of a huge ovarian dysgerminoma in a young unmarried lady that was quite asymptomatic. She underwent laparotomy with right ovarian cystectomy.

Pregnancy Complicated by Acute Pancreatitis with Ascariasis.

Ascariasis lumbricoides infections are common in tropical and sub-tropical countries. As it is one of the common causes for common bile duct obstruction. But in pregnancy is a rare entity. It may present with complications like acute pancreatitis. Here we present a case of 24 year female gravida 2 para 1 at 34 weeks of pregnancy presented with chief complain of pain over epigastric region radiating to back and associated with two episodes of vomiting, non bilious, not mixed with blood. Ultrasonography showed long tubular hyperechoic structure in gallbladder lumen most likely ascariasis and then she was diagnosed as a case of acute pancreatitis with alive ascariasis.

Cheiro-Oral Syndrome.

Cheiro-Oral Syndrome (COS) is a very rare neurological syndrome associated with varied etiology. We report a 53-year-old man presented with left sided perioral and ipsilateral hand/fingers burning sensation for a one-month duration. On examination, he had hypesthesia over left perioral and distal palmar aspect of all five fingers. MRI revealed subacute infarct in the posterior limb of right internal capsule adjacent to and minimally involving thalamus. He was diagnosed as CheiroOral Syndrome as a result of ischemic stroke and managed.

Intramedullary Nailing System in Unstable Both Bone Diaphyseal Fractures in Children.

Background Forearm fractures in pediatric population is usually managed conservatively. Unstable fractures need operative intervention like closed or open intramedullary nailing or open reduction and internal fixation with plates and screws. However, there is no consensus regarding the method of treatment according to age group. Objective To standardize the use of elastic nailing system as effective form of treatment in terms of function, cost and lower complications as compared to widely used titanium nails in developed countries.Method Sixty eight pediatric patients with both bone forearm diaphyseal fractures were managed with closed reduction and intramedullary fixation with rush nail or k-wire and followed at least for 6 months for evaluation of radiological and functional outcome. Result Patients were divided into two age groups, Group A for age of 5 to 9 years (26 patients) and Group B for age of 10-15 years (42 patients). The mean time for union for Group A patient was 7.31 weeks which was significantly lower than that of Group B patients of 9.33 weeks (p-value < 0.05). All the patients in Group A had excellent outcome and 36 (85.7%) patients had excellent outcome and 6 (14.3%) had good outcome in Group B. 5 out of 68 cases (7.35 %) had minor complications (2 in Group A and 3 in Group B). The mean time for implant removal was 17.9 weeks in Group A and 22.9 in Group B. Conclusion Intramedullary fixation for unstable diaphyseal both bone fractures of forearm is safe and cost effective method of treatment with good to excellent functional outcome with union time being significantly lower in younger age group.

Trigger factor assisted soluble expression of recombinant spike protein of porcine epidemic diarrhea virus in Escherichia coli.

BACKGROUND: Porcine epidemic diarrhea virus (PEDV) is a highly contagious enteric pathogen of swine. The spike glycoprotein (S) of PEDV is the major immunogenic determinant that plays a pivotal role in the induction of neutralizing antibodies against PEDV, which therefore is an ideal target for the development of subunit vaccine. In an attempt to develop a subunit vaccine for PEDV, we cloned two different fragments of S protein and expressed as glutathione S-transferase (GST)-tagged fusion proteins, namely rGST-COE and rGST-S1D, in E.coli. However, the expression of these recombinant protein antigens using a variety of expression vectors, strains, and induction conditions invariably resulted in inclusion bodies. To achieve the soluble expression of recombinant proteins, several chaperone co-expression systems were tested in this study. RESULTS: We firstly tested various chaperone co-expression systems and found that co-expression of trigger factor (TF) with recombinant proteins at 15 °C was most useful in soluble production of rGST-COE and rGST-S1D compared to GroEL-ES and DnaK-DnaJ-GrpE/GroEL-ES systems. The soluble rGST-COE and rGST-S1D were purified using glutathione Sepharose 4B with a yield of 7.5 mg/l and 5 mg/l, respectively. Purified proteins were detected by western blot using mouse anti-GST mAb and pig anti-PEDV immune sera. In an indirect ELISA, purified proteins showed immune reactivity with pig anti-PEDV immune sera. Finally, immunization of mice with 10 µg of purified proteins elicited highly potent serum IgG and serum neutralizing antibody titers. CONCLUSIONS: In this study, soluble production of recombinant spike protein of PEDV, rGST-COE and rGST-S1D, were achieved by using TF chaperone co-expression system. Our results suggest that soluble rGST-COE and rGST-S1D produced by co-expressing chaperones may have the potential to be used as subunit vaccine antigens.

Activity of aminoglycosides, including ACHN-490, against carbapenem-resistant Enterobacteriaceae isolates.

BACKGROUND: the emergence of carbapenemases in Enterobacteriaceae is driving a search for therapeutic alternatives. We tested ACHN-490, a sisomicin derivative that evades all plasmid-mediated aminoglycoside-modifying enzymes, against 82 carbapenem-resistant Enterobacteriaceae isolates. Comparators included internationally and locally available aminoglycosides. Methods The isolates variously had KPC (n = 12), SME-1 (n = 1), IMP (n = 13), VIM (n = 5), NDM (n = 17) or OXA-48 (n = 19) carbapenemases, or had combinations of impermeability with AmpC (n = 5) or extended-spectrum ß-lactamases (n = 10). They included 53 Klebsiella spp., 19 Enterobacter spp., 6 Escherichia coli and 4 others; most were multiresistant. Genes were identified by PCR and sequencing; MICs were measured by CLSI agar dilution. RESULTS: ACHN-490 was active at ≤ 2 mg/L against all 65 isolates with carbapenem resistance mechanisms other than NDM enzyme, mostly with MICs of 0.12-0.5 mg/L; isepamicin was active against 63/65 at ≤ 8 mg/L. In contrast, 35% were resistant to gentamicin at 4 mg/L, 61% to tobramycin at 4 mg/L and 20% to amikacin at 16 mg/L. However, 16 of the 17 isolates with NDM-1 enzyme were resistant to ACHN-490, with MICs ≥ 64 mg/L, and these were cross-resistant to all other human-use aminoglycosides tested. Their behaviour was associated with ArmA and RmtC 16S rRNA methylases. Apramycin (a veterinary aminoglycoside) retained its full activity, with MICs of 4-8 mg/L versus strains with armA or rmtC, though resistance was seen in one Klebsiella pneumoniae with AAC(3)-IV (MIC ≥ 256 mg/L). CONCLUSIONS: ACHN-490 has potent activity versus carbapenem-resistant isolates, except those also harbouring 16S rRNA methylases; isepamicin is also widely active, though less potent than ACHN-490. Evasion of 16S rRNA methylases by apramycin is noteworthy and may provide a starting point for future aminoglycoside development.

Impact of a clonal outbreak of extended-spectrum ß-lactamase-producing Klebsiella pneumoniae in the development and evolution of bloodstream infections by K. pneumoniae and Escherichia coli: an 11 year experience in Oxfordshire, UK.

OBJECTIVES: The objectives of this study were: (i) to describe an outbreak of multidrug-resistant Klebsiella pneumoniae in our population; (ii) to identify the potential source of this outbreak by examining antibiotic resistance trends in urocultures; (iii) to evaluate the contribution of this outbreak to resistance patterns over time in the two commonest Gram-negative blood culture isolates, namely K. pneumoniae and Escherichia coli; and (iv) to assess risk factors for multidrug resistance and the impact of this resistance on mortality and length of stay. METHODS: We searched Microbiology and Patient Administration Service databases retrospectively and describe resistance trends in E. coli and K. pneumoniae bloodstream infections (BSIs) in Oxfordshire, UK, over an 11 year period. RESULTS: An outbreak of a multidrug-resistant, CTX-M-15 extended-spectrum ß-lactamase (ESBL)-producing K. pneumoniae clone was identified and shown by multilocus sequence typing to belong to a novel sequence type designated ST490. This was associated with a sporadic change in resistance rates in K. pneumoniae BSIs with rates of multidrug resistance (defined as resistance to three or more antibiotic classes) reaching 40%. A case-control study showed prior antibiotic exposure as a risk factor for infection with this organism. During the same time period, rates of ESBL-producing Klebsiella spp. isolated from urocultures increased from 0.5% to almost 6%. By contrast, the rate of multidrug resistance in E. coli rose more steadily from 0% in 2000 to 10% in 2010. CONCLUSIONS: Changes in resistance rates may be associated with outbreaks of resistant clones in K. pneumoniae. Changing resistance patterns may affect important health economic issues such as length of stay.

An open-source handheld extruder loaded with pore-forming bioink for in situ wound dressing.

The increasing demand in rapid wound dressing and healing has promoted the development of intraoperative strategies, such as intraoperative bioprinting, which allows deposition of bioinks directly at the injury sites to conform to their specific shapes and structures. Although successes have been achieved to varying degrees, either the instrumentation remains complex and high-cost or the bioink is insufficient for desired cellular activities. Here, we report the development of a cost-effective, open-source handheld bioprinter featuring an ergonomic design, which was entirely portable powered by a battery pack. We further integrated an aqueous two-phase emulsion bioink based on gelatin methacryloyl with the handheld system, enabling convenient shape-controlled in situ bioprinting. The unique pore-forming property of the emulsion bioink facilitated liquid and oxygen transport as well as cellular proliferation and spreading, with an additional ability of good elasticity to withstand repeated mechanical compressions. These advantages of our pore-forming bioink-loaded handheld bioprinter are believed to pave a new avenue for effective wound dressing potentially in a personalized manner down the future.

Intraperitoneal and periportal injection of bupivacaine for pain after laparoscopic cholecystectomy.

PURPOSE: To study the analgesic efficacy of intraperitoneal and periportal injection of bupivacaine following laparoscopic cholecystectomy. MATERIALS AND METHODS: 40 patients undergoing laparoscopic cholecystectomy were randomized into two groups of 20 each. Group A (study group) received 40 ml of intraperitoneal injection of 0.25% bupivacaine and 20 ml of same concentration in 4 ports, 5 ml each at the end of surgery. Group B (control) received no treatment. Post operative patient monitoring and pain assessment was done by another doctor blinded to the procedure using VAS score at 1, 2, 3, 6, 9 and 24 hours after surgery. Pethidine 50 mg intramuscular was given as rescue analgesic when demanded by patient within first 24 hours. RESULTS: When VAS score was analyzed in the two groups, the study group had less scores compared to control group though it was statistically not significant (p>0.05). The rescue analgesic requirement was significantly less in study group (p<0.00). CONCLUSION: Intraperitoneal and periportal injection of bupivacaine is effective in decreasing pain after laparoscopic cholecystectomy.

Surgery for recurrent lower lip carcinoma.

A 38 year old gentleman presented with recurrent squamous cell carcinoma of lower lip. He had earlier undergone previous surgeries and radiotherapy. At the time that he presented in KMCTH his lower lip area was much scarred and the tongue was shrunk and unavailable for vermilion reconstruction. This case report is an account of the various treatment carried out to reconstruct the lip. It was done with co-operation of the ENT department.

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.

Do we have to hyperventilate during laparoscopic surgery?

PURPOSE: The purpose of this study was to assess the effects of hyperventilation on patients undergoing laparoscopic surgeries on haemodynamics, partial pressure of carbon dioxide and acid base status. METHODS: 60 patients undergoing laparoscopic surgeries under General Anaesthesia were randomized into two groups, "control group" ventilated with tidal volume of 10 ml/kg and respiratory rate of 12/minute and "study group" same tidal volume with respiratory rate of 15/ minute. Hemodynamic variables (heart rate and mean arterial pressure) recorded and End tidal C02, PaC02, pH and Bicarbonate estimation done before, during and after C02 pneumoperitoneum and analyzed. RESULTS: There was no significant difference in hemodynamic variables but there was linear increase in ETC02 and PaC02 measurements in higher normal levels in control group (ETC02 33.3+/-3.20, 37.93+/-3.95 and 43.20+/-3.40; PaC02 30.08+/-2.35, 34.80+/-4.01 and 41.94+/-3.66 mmHg before, during, and after pneumoperitoneum respectively) compared to study group in which these parameters were in lower normal levels (ETC02 33.33+/-4.11, 28.00+/-4.10 and 36.73+/-2.49 mmHg and PaC02 31.80+/-2.73, 29.36+/-3.16 and 35.15+/-1.32 mmHg before, during, and after pneumoperitoneum respectively). There was highly significant difference in these parameters when intergroup comparison was done during and after pneumoperitoneum period. pH and bicarbonate levels were within normal limits but there was decreasing tendency towards acidosis side in control group. CONCLUSION: 10-15% increment in Minute Volume is beneficial during C02 pneumoperitoneum to prevent adverse effects of hypercarbia and acidosis.