Antimicrobial Resistance Pattern of Pseudomonas aeruginosa Isolates from Tertiary Care Hospitals in Kathmandu.

Background Antimicrobial resistance, caused by Pseudomonas aeruginosa (P. aeruginosa), poses a global health threat, limiting treatment options and increasing morbidity and mortality rates due to its intrinsic and multidrug resistance. Objective To determine the antimicrobial resistance patterns of P. aeruginosa isolates from patients visiting or admitted to tertiary care hospitals in Kathmandu. Method A cross-sectional study was conducted at Bir Hospital and Tribhuvan University Teaching Hospital (TUTH) from December 2021 to December 2022. Isolates were identified and tested for antibiotic susceptibility following standard microbiological guidelines. Result The antimicrobial resistance of 200 P. aeruginosa isolates increased from low to high levels, as per the recommended anti-pseudomonal antibiotics by the Clinical and Laboratory Standards Institute (CLSI), from 0% to 94%. piperacillin/tazobactam exhibited significantly lower resistance at 18(9%) and while considerably higher resistance was observed with ceftazidime at 188(94%) compared to different antibiotics, followed by amikacin 34(17%), imipenem 58(29%), ciprofloxacin 42(21%), aztreonam 51(25.5%), and fosfomycin 44(22%). No resistance was observed to colistin and polymyxin B. P. aeruginosa resistant to carbapenem was accounted for 33.5% of the total, and multidrug resistance categories included multidrug resistance (MDR) at 39.0%, extensively drug resistance (XDR) at 13.5%, and P. aeruginosa difficult-to-treat (DTR PA) at 4.6%. Conclusion Most of the isolates were resistant to anti-pseudomonal antibiotics; however, colistin, polymyxin B, amikacin, doripenem, piperacillin/tazobactam, and fosfomycin were effective against MDR P. aeruginosa. Regular surveillance measures are essential to manage antimicrobial resistance.

Evaluation of Anterolateral Plating of Distal Third Tibial Fractures.

Background Distal one-third tibial fractures with or without articular involvement can be difficult to manage. Variety of treatment methods have been suggested for these injuries, including conservative treatment, external fixation with or without limited internal fixation, intramedullary nailing, plate fixation (medial or anterolateral) and more recently minimally invasive plate osteosynthesis (MIPO). All of these techniques have advantages and disadvantages. None of these techniques can be considered the "gold standard" for these injuries. Objective The objective of this prospective study was to evaluate the results of anterolateral plating of these fractures. Method Forty-five fractures of distal third of tibia were treated with open reduction and internal fixation with anterolateral tibial plate from December 2011 to December 2016. All the patients were followed up at least for nine months for the study. Radiological union was finally assessed in nine months. Result All the fractures united within nine months of plating without angulation in sagittal or coronal plane. One patient (2%) had limb length shortening of more than one cm. Full range of motion of ankle and knee joint was achieved compared to the normal side by nine months follow up. 17 (38%) patients developed marginal skin necrosis. Three (7%) patients developed superficial wound infection. These complications were seen more in patients in whom posterior below knee slab was used for pre-operative splintage (as compared to calcaneal traction). Conclusion Hence distal one-third tibial fractures with or without articular involvement can be treated with anterolateral tibial plate.

Sonographic Assessment of the Normal Dimensions of Liver, Spleen, and Kidney in Healthy Children at Tertiary Care Hospital.

Background Ultrasonography is one of the most common imaging modality to measure dimensions of visceral organs in children. However, the normal limit of size of visceral organs according to age and body habitus has not been specified in the standard textbooks. This might result in under detection of organomegaly in pediatrics population. Objective The objective of this study was to determine the normal range of dimensions for the liver, spleen, and kidney in healthy children. Method This is prospective cross-sectional, hospital-based study done at Tertiary-care teaching hospital. Participants included 272 pediatric subjects (152 male and 120 female) with normal physical or sonographic findings who were examined because of problems unrelated to the measured organs. The subjects were one month to 15 year (180 months) old. All measured organs were sonographically normal. Relationships of the dimensions of these organs with sex, age, body weight and height were investigated. Limits of normal dimensions of these organs were defined. Result Normal length of liver, kidneys and spleen were obtained sonographically for 272 children (152 male [55.9%] and 120 female [44.1%]) in the age group from 1 months to 15 (180 months) years. The mean age was 45.78 months (SD, 44.73). The measured dimensions of all these organs showed highest correlation with height and age so the descriptive analysis of the organ dimensions (mean, minimum, and maximum values, SD and 5th and 95th percentiles) were expressed in 10 age groups along with height range of the included children. The mean length of right kidney was shorter than the left kidney length, and the difference was statistically significant (p = 0.001). Conclusion This study provides practical and comprehensive guide to the normal visceral organ dimension in pediatric population. The normal range limit of the liver, spleen, and kidney determined in this study could be used as a reference in daily practice in local radiology clinics.

Functional outcome of operatively treated displaced intra-articular calcaneal fractures using two parallel contoured reconstruction plates.

INTRODUCTION: The treatment of displaced intra-articular calcaneal fracture is controversial. Conventionally, they were treated non-operatively. However, some surgeons are now operatively treating these fractures because of continuing dissatisfaction with the outcome of conservative treatment of these fractures and improvements that have occurred in surgical techniques and complication rates. OBJECTIVE: The aim of this study was to determine the functional outcome of operatively treated displaced intra-articular calcaneal fractures using two parallel contoured reconstruction plates. MATERIALS AND METHODS: 12 patients with 14 displaced intra-articular calcaneal fractures involving the subtalar joint were included in the study conducted between July 2005 and December 2008. The fracture site was exposed using extended lateral approach. Internal fixation was done by two nearly parallel 3.5mm reconstruction plates and screws contoured to form a gentle curve in all cases with the fi rst plate fixed just below the articular surface. At the end of follow up, the patients' foot function was assessed by Calcaneal Fracture Scoring System of Kerr et al. Patients were also inquired about their satisfaction with their treatment outcome. RESULTS: The patients were followed up for duration of 12 to 24 months (mean 15.64 months). The outcome score as measured by Calcaneal Fracture Scoring System ranged from 48 to 94 (mean 83.64). 11 of 12 patients (91.6 %) were satisfied with the treatment. CONCLUSION: Displaced intra-articular fractures treated by open reduction and internal fixation, using two nearly parallel, contoured reconstruction plates through an extensile lateral approach and following the principles of treatment of intraarticular fractures, have good functional results with high patient satisfaction rate.

Osteosynthesis of intercondylar humerus fracture using Bryan and Morrey approach.

BACKGROUND: The olecranon approach has been the gold standard for surgical approaches to fracture fixation of distal articular surface of humerus. Although it provides a good exposure, it also has disadvantages of delayed union, nonunion and implant related complications at the osteotomy site. OBJECTIVE: The aim of this study was to determine the functional outcome of displaced intra-articular distal humerus fracture fixation using an alternative approach: the Bryan and Morrey approach. MATERIALS AND METHODS: Twenty patients with twenty AO type C1 and C2 intercondylar fractures of the distal humerus had bicolumnar fixation of the distal humerus with two contoured reconstruction plates and screws on the dorsal surface or various combinations of a single reconstruction plate, screws and K-wires using a Bryan and Morrey approach. Twelve of the patients were male and eight were female. The average age of the patients was 44.8 years. Eleven patients had sustained the injury as result of fall and nine of the patients had sustained it in road traffic accidents. Right elbow was involved in fifteen patients and left in five. All patients were followed up for 12 months post operatively. RESULTS: All twenty fractures had united at 4 months follow-up. The mean fixed flexion deformity was 9.0º (range 0º-15º) and the mean arc of motion was 115.0 º (range 85 º- 130º). All patients had grade 4 triceps strength and stable elbows at the end of 12 months follow up. One patient had deep seated wound infection resulting in necrosis of the triceps tendon requiring a second operative procedure. CONCLUSIONS: Bryan and Morrey approach is a simpler, easier and better approach as compared to the other posterior approaches to the elbow joint, and therefore, can be used as the approach of choice for fixation of fractures of the distal articular surface of humerus.

External and internal fixation for comminuted intra-articular fractures of distal radius.

BACKGROUND: Distal radius fractures are a common injury and without proper treatment leads to high functional impairment and frequent complications. OBJECTIVE: The aim of this study was to see the functional outcome in patients with comminuted distal radius fractures treated with combined external fixation and open reduction and volar plating. MATERIALS AND METHODS: All comminuted distal radius fractures classified as type C in AO/OTA classification were enrolled for the study from 2005 till 2008. The clinical scoring chart modified by Cooney was used to evaluate the functional outcome. RESULTS: There were twenty-two patients with the average age of 42.18 years (range 19-60) with 15 male and 7 females. The follow-up period was from 14 to 46 months. Accordingly, there were 11 (50%) excellent, 7 (31%) good, 2 (9%) fair and 2 (9%) poor results. There were very few complications in our series. In three patients additional K-wire supplementation was necessary along with external and open internal fixation. CONCLUSIONS: Comminuted intra-articular fractures of distal radius should be treated by open reduction and combined internal and external fixation to achieve a high rate of patient satisfaction and satisfactory functional outcome.

Sub-trochanteric fractures of the femur: results of ORIF at KMCTH.

Sub-trochanteric fractures of the femur are not commonly encountered as compared to trochanteric or neck of femur fractures. Relatively younger persons are injured more and a considerable violence is required for this fracture to occur. These fractures, treated conservatively by methods like traction, splints or casts, are often associated with complications like non-union, mal-union, shortening of the limb etc. Thus, we undertook this study of 10 consecutive cases of sub-trochanteric fractures of the femur treated by open reduction and internal fixation and bone grafting in Kathmandu Medical College Teaching Hospital, Sinamangal, from the year Nov. 2000 to April 2006. There were 4 females and 6 male patients. Their age on average was 46.8 years (range 15 to 86 years). Most of the patients were in Type II or III in Seinsheimer classification; Type II A, B, and C, one, two and one respectively, and in Type III A and B three patients each. Seven patients were treated with dynamic hip screw. Three patients with type III were managed with centro-medullary interlocking nail with one cerclage suture. They were followed for a period of minimum 6 months to 6 years (average 3.5 years). Union was achieved in all, on an average 4 months postoperatively. Results were excellent and complications like nonunion, malunion or breakage of the implants, were not encountered in any patient.

Percutaneous extensor tenotomy for chronic tennis elbow using an 18G needle.

INTRODUCTION: Tennis elbow is a common orthopaedic problem presenting in office orthopaedics, but its exact patho-aetiology has not been identified to date. It is treated operatively when conservative measures including multiple local steroid injections are not helpful to the patients. MATERIAL AND METHOD: This was a retrospective study to assess the outcome of tennis elbow patients on whom percutaneous release of the common extensor origin was performed using an 18 gauge hypodermic needle. 17 patients with 21 elbows were included in the study. Data was collected by going through the patients' medical records, and follow -up by questionnaire mailed to the patient's home, to assess the outcome and patient satisfaction with the procedure. RESULTS: 14 of the 21 (66.7%) elbows became completely pain free. The time taken to achieve a completely pain free elbow ranged from 1 day to 3 months (average 60.3 days). Those that did not achieve a pain free elbow had a residual pain of 1.5 to 8.5 on the VAS (average 2.64). 9 elbows (42.9%) had an excellent outcome, 7(33.3%) had good, 4(19%) had satisfactory and 1(4.8%) had poor outcomes. CONCLUSION: Tennis elbow probably results from degenerative tear of common extensor origin and a percutaneous tenotomy using an 18 gauge hypodermic needle is a simple, safe, patient friendly, effective and easily reproducible method of treating it in those who require surgery and can be done as an office procedure.

Supracondylar extension type III fracture of the humerus in children: percutaneous cross-pinning.

OBJECTIVE: Supracondylar extension type III fractures in children are difficult to treat especially in maintaining reduction after closed manipulation, thereby increasing chances of complications. MATERIALS AND METHODS: Forty consecutive patients with supracondylar extension type III fracture of the humerus attending Kathmandu Medical College Teaching Hospital (KMCTH) between July 2004 to December 2005, treated by closed manipulative reduction and percutaneous cross-pinning under general anaesthesia, were the subject of this prospective study. RESULTS: There were 16 females and 24 males. The mean age of the patients was 6.5 years (2 to 12 years). Left side was injured in 27 patients and right side in 13. Patients were followed for a period of one year on average (6 to 18 months). Under general anaesthesia and C-arm image intensifier, closed manipulative reduction was performed. Two K-wires of size 1.6 to 2.0 mm were introduced from lateral and medial side in crossed fashion. Ulnar nerve was protected by pushing it posteriorly during medial pinning. Long arm plaster slab was applied post-operatively. Patients were discharged the next day of operation. Callus was visible in all patients on X-rays after 3 weeks. The long arm slab and K-wires were removed and active mobilization of the elbow joint was started. Fracture union was seen in all, 6 weeks post-operatively. At follow-up, range of motion of the elbow joint was 25 to 135 degrees after 6 weeks and 0 to 140 degrees after 3 months, which was similar to that of normal side. After 3 months of operation carrying angle was 8-10 degrees in all except in two cases (0 degrees). There were no neuro-vascular complications or cubitus varus deformity in any of the patients. CONCLUSION: Percutaneous crossed K-wire pinning after closed manipulation in supracondylar extension type III fracture of the humerus is a reliable and safe method of treatment and is recommended in all.

Pre-operative assessment of K-nail length in fracture shaft of femur.

INTRODUCTION: Internal fixation of diaphyseal fracture of shaft of femur in an adult by Kuntscher nail is the most common operative method of treatment in Nepal where operative facilities for the same exist. Since the complete range of K-nail sizes and length are not available in most operation theatres in Nepal, most orthopaedic surgeons assess the size and length of the K-nail pre-operatively by various methods and keep one size above and below the assessed length for the planned surgery. MATERIALS AND METHODS: The following measurements were taken in five hundred people involved in the study: Measurement No. 1: Tip of the greater trochanter to lateral knee joint line minus 2 cm. Measurement No. 2: Tip of the olecranon process to the tip of little finger, and Measurement No. 3: Tip of the greater trochanter to the upper pole of patella. An average of all three lengths were analysed to see if there were any differences in their mean lengths. RESULTS: Analysis showed that there were significant differences between the mean lengths measured by the three different methods. The average length of measurement no: 2 was 3 cm longer than the average length of measurement no: 1, which is the reference pre-operative length of K.nail. CONCLUSION: However, in practice since measurement no:2 is more convenient to perform and can also be used when the patient has sustained bilateral fractures of femur, an accurate pre-operative K-nail length assessment can be done by subtracting 3 cm from measurement no:2, i.e. the tip of the olecranon process to the tip of the little finger.

Piroxicam suppositories in the treatment of osteoarthritis of the knee joint.

The subjects were 231 patients aged 16 to 75 years with osteoarthritis of the knee joint. Each patient received 20 mg of piroxicam daily as a suppository administered before sleep; 75% of the patients were treated for 14 days or longer. Overall treatment outcome was excellent in 34% according to physicians' ratings and in 36% according to the patients' self-ratings, good in 39% and 41%, fair in 22% and 17%, and unimproved in 5% and 7%, respectively. Side effects were reported by 3% of the patients. It is concluded that treatment of osteoarthritis with piroxicam suppositories is safe and effective.

Effect of capacitively coupled electric fields on an experimental model of delayed union of fracture.

To evaluate the effect of capacitively coupled electric fields (CCEF) on delayed union of fractures, an experimental model of delayed union was produced in the radius of rabbits, and the process of healing was investigated by radiography, bone mineral density (BMD) measured with dual energy x-ray absorptiometry, and histological survey. It was confirmed radiographically and histologically that callus formation was enhanced in the group treated with CCEF. After stimulation, the average BMD increased more than 18% compared with the controls. Our experiment on a delayed union model suggests that CCEF is effective for the treatment of delayed union of fractures.

Oral heath status of 12-year-old children in Nepal in 1994.

A survey of twelve-year-old Nepalese children was undertaken in 1994 according to the WHO pathfinder methodology and examination criteria. The study sample was drawn from randomly selected schools within the capital city, and two randomly selected urban settings, together with children drawn from schools in four randomly selected villages within rural Nepal. Three hundred and sixty children were examined. Drinking water samples were obtained from all sources at each examination site and subsequently analysed for fluoride content. The overall caries experience in the country was found to be very low or low. Analysis of drinking water samples revealed that with the exception of one town in the south of the country, all sites had low fluoride levels.

Open reduction and internal fixation of supracondylar fractures of the humerus: revival of the anterior approach.

INTRODUCTION: Supracondylar fractures of the humerus occur commonly in the paediatric age group. Gartland type III fractures are treated by closed manipulation and percutaneous pinning with K-wires. Open reduction is indicated in open fractures, failed closed reductions and in a dysvascular limb. There are various approaches that can be utilized to perform an open reduction. The approach of choice must be safe, surgeon and patient friendly and should provide a good access to the fracture and the important surrounding structures. The anterior approach has been described as the most versatile approach. The aim of the study was to review the advantages and drawbacks of the anterior approach and to assess the functional outcome of fractures treated via this approach. MATERIALS AND METHODS: Twenty five (15 male and 10 female) patients out of a hundred and twenty eight children with Gartland type III extension variety of supracondylar fractures of the humerus from underwent open reduction and internal fixation with K-wires via an anterior approach January 2007 to January 2011. The results were assessed at six months using Flynn's radiological and clinical criteria. RESULTS: Twenty five patients (19.53%) out of hundred and twenty eight patients underwent open reduction and internal fixation. According to Flynn's clinical and radiological criteria, 20 (80%) were found to have excellent and 5 (20%) good results. CONCLUSION: The anterior approach is safe, easy and provides direct exposure of the surrounding neurovascular structures with good to excellent results.

Conservative treatment of nonarticular fractures of distal third tibia.

INTRODUCTION: Distal one third tibial fractures can be difficult to manage. Variety of treatment methods have been suggested for these injuries, including conservative treatment, external fixation, intramedullary nailing, and plate fixation. None of these techniques can be considered the "gold standard" for these injuries. The purpose of this prospective study is to evaluate the results of conservative treatment of these fractures. METHODS: Total 39 fractures of distal third of tibia were treated with closed reduction and long leg cast for six to eight weeks followed by PTB cast for six to eight weeks from January 2004 to October 2008. One year follow up was done with 32 patients, eight months follow up with three patients and four patients were lost to follow up. RESULTS: All the fractures united within six months of duration. Immediate post-reduction average angulation was 3.72 degree in sagital plane and 3.32 degree in coronal plane. Average final angulation was 5.04 degree in sagital plane and 4.32 degree in coronal plane. Average limb length shortening was 6.8 mm. Full range of motion of ankle and knee joint was achieved compared to the normal side by six months of follow up. Though there was displacement of fracture during conservative treatment final outcome was within acceptable limit. CONCLUSION: Hence distal one third tibial fractures can be treated conservatively with closed reduction and cast immobilization with numerous advantages over operative methods.

Antibiotic susceptibility of group A Streptococcus isolated from throat swab culture of school children in Pokhara, Nepal.

Group A Streptococcus (GAS) or Streptococcus pyogenes is estimated to be present in 5.0-15.0% of norma individual in the respiratory tract, vagina, skin and anus without any sign of disease. This study was carried out to find out the rate of asymptomatic throat carriage of S. pyogenes and antibiotic susceptibility of the isolates in school children of Pokhara, Western Nepal. A total of 487 randomly selected children younger than 16 years were included in the study. Throat swabs collected were subjected to 5.0% Sheep blood agar supplemented with crystal violet (CVBA).GAS was identified by a-haemolytic colonies, bacitracin sensitivity, cotrimoxazole resistivity, catalase negativity and PYR positivity. Antibiotic susceptibility test was performed on Muller Hinton agar (MHA) containing 5% sheep blood by modified Kirby-Bauer disc diffusion method. Out of total 487 throat swabs, GAS was isolated in 9.2% (n = 45). Among the isolates, 46.6% (n = 21) were from male children where as 53.4% (n = 24) from female children. There was no significant sex difference in colonization of GAS (p > 0.05). Out of 45 isolates, 100.0% isolates were sensitive to antibiotic penicillin-G and amoxycillin where as 15.6%, 6.6%, and 2.2% isolates were resistant to antibiotic erythromycin, tetracycline and azithromycin respectively.

Prevalence of methicillin resistant Staphylococcus aureus in school children of Pokhara.

Present study was carried out to find out the prevalence of methicillin resistant Staphylococcus aureus (MRSA) in school children of Pokhara city in western, Nepal. A total of 184 randomly selected children younger than 15 years were included in the study. Nasal swabs collected were subjected to standard bacteriological culture. S. aureus isolates were identified by mannitol fermentation, coagulase positivity and DNase positivity. Antimicrobial susceptibility test was performed on muller-hinton agar (MHA) by modified Kirby-Bauer disc diffusion method. Out of total 184 nasal swabs, S. aureus was isolated in 31.0% (n=57). Among the isolates, 35.1% (n=20) were from male children whereas 64.9% (n=37) were from female. There was no significant sex difference in colonization of S. aureus. Out of 57 isolates, 56.1% (n=32) were MRSA. MRSA isolates indicated relatively high rate of resistance to antibiotic cloxacillin (68.7%) followed by ofloxacin (40.6%), tetracycline (15.6%), erythromycin (9.4%), ciprofloxacin (6.2%) and vancomycin (3.1%).This study showed a high prevalence of MRSA carriage in school children indicating the spread of MRSA in the community.

Reduction of acute anterior shoulder dislocations: comparing intraarticular lignocaine with intravenous anesthesia.

Anterior shoulder dislocation is the most common dislocation in the body. Various methods of anesthesia are available for reduction. The objective of this study was to compare the application of intra-articular anesthesia with intravenous anesthesia for reduction of acute anterior shoulder dislocation. This study was conducted at Kathmandu Medical College Teaching Hospital (KMCTH) and Kathmandu Hospital and comprised of patients coming with anterior dislocation of shoulder from July 2001 to June 2005. Forty-five patients aged 17-55 years with no associated fractures of adjoining bones were included in the study. In twenty-three patients, reduction was done using intra-articular anesthesia and in 22 patients intravenous anesthesia was given. In five patients (three in intra-articular group and two in intravenous group) the reduction technique had to be changed to the Hippocratic method. In these three patients intravenous anesthesia had to be given after intra-articular anesthesia failed to relieve pain and spasm. In the intravenous group two patients had to be admitted overnight while in the intra-articular group none had to be admitted to the hospital. However, in the intra-articular group the average time taken from injection to reduction was significantly longer (<.001). The use of intra-articular lignocaine for reduction of shoulder dislocation is safe and effective especially when patients present early. In patients presenting late (more than 5 hours) intravenous anesthesia should be primarily considered as the method for shoulder reduction.

Results of autogenous trephine biopsy needle bone grafting in fractures of radius and ulna.

Cortico-Cancellous bone graft harvested from the anterior iliac crest by the conventional open method is associated with more morbidity and is more time consuming as compared to the percutaneous method using trephine biopsy needle. The aim of the study was to determine whether cancellous bone graft harvested from anterior iliac crest using trephine biopsy needle consistently achieved bone union in comminuted fractures and fractures of more than 3 weeks duration of radius and ulna and also to determine the morbidity at the donor site. Autogenous cancellous bone graft was harvested percutaneously from 28 iliac crests in 16 patients and applied at fracture sites of 30 forearm bones using a 4mm trephine biopsy needle after the fractures had been fixed with plate and screws. The patients were followed up regularly upto 6 to 9 months post - operatively in the OPD to determine the union status of the fractured bones and the morbidity at the donor site. 29 of the 30 fractures of the forearm bones united without any problems. The shaft of a trephine got bent during the harvesting procedure at the beginning of the study due to improper technique. Cancellous bone graft harvested from the anterior iliac crest results in predictable good union results in comminuted fractures of forearm bones and also fractures presenting after 3 weeks of injury. It is also an easier and quicker way of harvesting bone graft and is associated with lesser morbidity and earlier recovery as compared to conventional open method.

Reduction of acute anterior shoulder dislocations under local anaesthesia--a prospective study.

OBJECTIVE: To evaluate the application of local anaesthesia for reduction of acute anterior shoulder dislocation DESIGN: A prospective study of patients coming with anterior dislocation of shoulder to KMCTH from July 2002 to Sep 2003. SUBJECTS: Patients of aged 15-55 years with no associated fractures of adjoining bones. RESULTS: A total of fifteen patients with anterior inferior shoulder dislocation were studied and all were reduced safely under local anaesthesia. CONCLUSION: Use of intra-articular lignocaine for reduction of shoulder dislocation is safe and effective and is beneficial for countries like Nepal where health facilities are minimum in rural and suburban areas.