Profile of Skin Biopsies and Patterns of Granulomatous Skin Diseases in a Tertiary Care Center of Western Nepal

Background: Granulomatous skin diseases are one of the leading causes of morbidity in tropical countries like Nepal. These granulomatous skin lesions often pose diagnostic challenge to clinicians as well as to dermatopathologists. Histopathologic examination of a biopsy specimen represents one of the most informative and cost-effective procedure and may help to avoid other, costlier and invasive diagnostic workup. Materials and Methods: This cross-sectional observational study from October 2018 to October 2019, at department of dermatology, enrolled 142 cases of skin biopsies. Correlation between clinical impression and histopathological findings was evaluated. Results: Out of 13940 dermatology visits/ consultations, 142 (1.01%) skin biopsies were performed. Head, neck and face were the commonest sites of biopsies (29.6%). The most common biopsy technique was incisional type in 70 (50.4%). Histopathology showed granulomatous features in 49 (34.8%) cases, out of which tuberculoid type was the commonest, in 29 (58.0%). Positive clinicopathological correlation was seen in 117/142 (82.4%) for all biopsies and 41/49 (85%) for granulomaous skin lesions. Conclusion: Tuberculoid type was the most common cutaneous granuloma. High clinicopathological correlation in our study supports histopathology as an important tool for diagnosis of granulomatous as well overall skin disorders.

Obstetrics Outcomes: A Comparison between Birthing Center and Conventional Labor Ward

Introduction: Birthing Centers (BC) are increasingly accepted worldwide as an alternate low cost place of birth. The concept is especially relevant for developing countries with limited resources and constraints regarding availability of specialists and hospital beds. The various studies have concluded that when proper risk analyses are conducted and referral rules followed, there is no evidence of increased maternal or perinatal risk at BC compared to standard hospital deliveries. Materials and Methods: This was a prospective, observational and comparative hospital based study done at Paropakar Maternity and Women’s Hospital (PMWH),Kathmandu. The study was conducted on pregnant women without any known risk factors for complications who were admitted in BC and labor ward (LW) for delivery. Details on mode of delivery, genital tract status, Postpartum hemorrhage (PPH) and neonatal outcomes were collected. Descriptive data analysis was done using SPSS. Results: Out of 5132 deliveries, 25.3% had no known risk factor and hence were eligible for study; no statistically significant difference was observed between BC & LW in relation to mode of delivery, perineal trauma, PPH and neonatal outcomes; however, practice of episiotomy was significantly less frequent in BC. Conclusion: When proper risk analyses are conducted and referral rules followed, there is no evidence of adverse obstetrics outcome at BC as compared to standard hospital deliveries. Triaging of low risk pregnancy to a BC is a viable strategy, especially in a resource poor country. This lessens the burden in standard maternity unit so that specialists will be able to provide a quality care to high risk pregnancies.

Evaluation of Malnutrition in Children Admitted in Nutritional Rehabilitation Home of Pokhara Academy of Health Sciences- A Retrospective Cross-sectional Hospital Based Study

Introduction: The burden of malnutrition is of significant concern in Nepal. The objectives of this study are to classify the nutritional status in children admitted in nutritional rehabilitation home of Pokhara Academy of Health Sciences and to relate the demographic characteristics and the effectiveness of the nutritional intervention measures on status of malnutrition which can help in the policy formulation to tackle the burden of malnutrition. Materials and Methods: This is a hospital based retrospective study in which total of 238 children with malnutrition admitted in nutritional rehabilitation home of Pokhara Academy of Health Sciences during July 2014 to July 2018 were followed. The socio-demographic factors and nutritional status were analyzed at admission and at discharge using the available record. Data was analyzed using SPSS 16. Results: Out of 238 malnourished children, 167(70.2%) were cases of moderate acute malnutrition and 76(29.8%) were cases of severe acute malnutrition. The mean weight at admission was 7.18±1.73 kg, mean weight at discharge was 7.82±1.82 kg and mean weight increased after nutritional intervention was 0.62 kg±0.40. The average weight gain in severe acute malnutrition was 4.7gm/kg/day. A statistically significant difference was obtained between mean weight (p=0.00, t= - 24.62) of children at admission and discharge. There was significant statistical difference between mean weight gain (p<0.05, t= -3.1) in severe acute malnutrition (0.76±0.49 kg) and in moderate acute malnutrition (0.59±0.34 kg). Conclusion: Nutritional rehabilitation homes are effective in improving the nutritional status of undernourished children, more effective in severe acute malnutrition. However it is important to reassess the management protocol to meet the intake targets so that the rate of weight gain is improved.

Assessment of Practice of Endodontic Treatment Protocols among General Dental Practitioners in Pokhara, Nepal

Introduction: Endodontics is specialty field, but the majority of endodontic treatment in Pokhara is provided by the general dental practitioners. The aim of this study was to assess the practice of endodontic treatment protocols among general dental practitioners in Pokhara, Nepal. Materials and Methods: A cross sectional questionnaire based study was conducted among all the general dental practitioners working in various government, private hospital and clinic of Pokhara. Information about the materials and techniques used in endodontic treatment was collected and descriptive statistical analysis was done. Results: Out of 89 respondents, only 82 completely filled the questionnaires which were included in the study. Most general dental practitioners (96.34%) regularly treat single rooted endodontic cases. Only 10.97% occasionally use rubber dam during endodontic treatment. Most general dental practitioners (96.34%) used radiographic technique for working length determination. Ninety two percent used stainless steel hand files and step back was the choice of technique by 90.24%. Sodium hypochlorite irrigation and calcium hydroxide intra canal medicaments were used by 93.9% and 98.78% of general dental practitioners respectively. 75.6% used zinc oxide eugenol as root canal sealer and 95.12% obturated root canals with lateral compaction technique. The common complication encountered was mid treatment pain. They seem to overuse antibiotics in cases requiring endodontic therapy. Only 52.43% used autoclave for sterilization of endodontic files. About 92.68% felt the need of further endodontic training and 74.39% preferred post graduate program. Conclusion: This study indicates that many general dental practitioners of Pokhara are not following well acknowledged endodontic quality guidelines; hence there is a need for further endodontic training.

Incidence of Inguinal Herniotomy in Children. A Prospective Study at a Regional Hospital

Background: Inguinal hernia is one of the most common surgical conditions in children. Herniotomy is the surgery performed for a pediatric hernia and hydrocele. This study was done to know the demography and outcome of pediatric herniotomy at our center. Materials and methods: A prospective study on patients who underwent herniotomy from 10th May 2016 to 9th May 2017 was conducted at the Department of Surgery, Western Regional Hospital. Results: During this study 112 patients underwent herniotomy out of which 98 were boys while 14 were girls. 59(52.67%) patients had unilateral hernia, 40(35.71%) had unilateral hydrocele and 13(11.6%) had bilateral condition among which 8 had hernia and 5 had hydrocele. 69(61.6%) patients presented with a right-sided, 30(26.7%) with left-sided, and 13(11.6%) with bilateral conditions. 13 patients (11.6%) presented at the emergency with irreducible hernia. Two among the patient who underwent emergency herniotomy developed postoperative wound infection and one among the elective surgery had recurrence. Conclusion: Pediatric inguinal hernias and hydroceles are often difficult to diagnose clinically. Herniotomy is often performed by junior consultants who have no specific training in pediatric surgery. Timely planning of surgery is required to minimize preoperative complications.

Etiological Spectrum of Hoarseness of Voice in Western Regional Hospital, Pokhara, Nepal

Background: Hoarseness of voice is a common symptom presentation in the Department of ENT. The etiology ranges from benign to malignant causes. Video nasopharyngolaryngoscopy is an effective method of evaluation of the laryngeal pathologies. The aim of the study was to study the different etiological factors of hoarseness of voice presenting in the Department of ENT at Western Regional Hospital, Pokhara. Materials and Methods: A retrospective observational longitudinal study was done in the Department of ENT, Western Regional Hospital after approval from IRC, Pokhara Academy of Health Science. A total of 275 patients presenting to the ENT Department with hoarseness of more than two weeks duration were examined with video nasopharyngolaryngoscopy (NPL) from April 2018 to March 2019. The data were electronically entered and analyzed with SPSS Version 21. Results: Total number of cases were 275 among which 187 (68%) were females whereas 88 (32%) were males. Vocal cord nodules were observed in 107 patients (38.9%), features of laryngopharyngeal reflux were observed in 54 patients (19.6%) muscle tension dysphonia was seen in 49 (17.8 % ), vocal cord polyp in 6 patients (2.2%), left vocal cord palsy in 7 patients ( 2.5%), right sided vocal cord palsy in 2 patients (0.7%). The hemorrhagic polyp, leucoplakia and ventricular dysphonia were observed in 3 patients each. Conclusion: Since causes of hoarseness of voice range from simple benign diseases to malignant diseases, it is mandatory to evaluate every cases of hoarseness of voice replace with of more than 2 weeks duration with history, videolaryngoscopic examination and investigations.

Study of Poisoning Cases Admitted in ICU of Western Regional Hospital

Introduction: Acute poisoning, irrespective of the etiology, is a medical emergency which requires prompt diagnosis and treatment. Such cases require ICU set up for better management. Central level hospitals in Nepal have ICU facilities to manage such cases. Materials and Methods: Current study is a retrospective type hospital based study conducted in Western Regional Hospital, Pokhara. Data collected from ICU department of Hospital in a period of one year from 2073 Ashad 16 to 2074 Ashad 16. It was analyzed and presented. Results: In this study it is observed that total 90 cases admitted in ICU department of WRH in a period of one year. Female patients outnumbered the male patients. Age group of 10-20 years is predominance in present study. Most of the patients were from Kaski district as the hospital belongs to Kaski district and one of the renowned tertiary care centers in the Gandaki province. Maximum number of patients consumed the OP compound. Outcome was better as out of 90 cases 80 were discharged and only 10 were died during the course of treatment. Conclusion: Early identification of the cause and type of poisoning, close monitoring and standard management, preferably in the ICU for at least a first few days, reduces the complication and improves the survival. The commonly available insecticides and rodenticides are the most common cause of acute poisoning.

A Comparative Study: Is Misoprostol as Effective as Oxytocin in Active Management of Third Stage of Labor?

Background: The third stage of labor is that period from birth of the infant until the delivery of the placenta. Active management of the third stage of labor plays an important role in reducing maternal morbidity and mortality. Oxytocin is an effective drug in preventing postpartum hemorrhage (PPH) however; it requires a controlled environment and intramuscular administration. Misoprostol is an orally active uterotonic agent,stable at room temperature.The purpose of this study was to compare the efficacy of misoprostol with oxytocin in active management of third stage of labor. Materials and Methods: This was a hospital based study carried out in Paropakar Maternity and Women Hospital, Kathmandu, Nepal during six months period from February 2012 to July 2012. One hundred patients fulfilling inclusion criteria were recruited to receive either 10 unit of IM oxytocin or 600 mcg of oral misoprostol for the management of the third stage of labor. Results: The mean blood loss in misoprostol and oxytocin group was 209±76.7ml and 197±68.8 ml respectively with p value-0.41 which was insignificant. Similarly mean hemoglobin change was also not significant. The additional uterotonics needed in misoprostol was higher (9 cases) than that in oxytocin (5 cases) but it was also not significant. Shivering and fever were significantly high among misoprostol group than in oxytocin group. Conclusion: Efficacy of oxytocin and misoprostol is equal in active management of third stage of labor.

Antibiotic Prophylaxis in Laparoscopic Cholecystectomy: A Retrospective Study

Introduction: Laparoscopic cholecystectomy is considered as the gold standard treatment for gallstone disease. There has remained a controversy on use of peri operative prophylactic antibiotics during laparoscopic cholecystectomy in reducing perioperative prophylaxis surgical site infections. Various studies has been done to evaluate whether single dose/ three doses or multiple doses are needed to decrease the incidence of surgical site infections. The objective of this study was to identify the incidence of postoperative surgical site infections with three doses of perioperative antibiotics after laparoscopic cholecystectomy. Materials and Methods: This is a retrospective observational study conducted at a private hospital from November 2017 to March 2020. All the patients received three doses of ceftriaxone 1 gram within the first 24 hours of surgery. The incidence of surgical site infection was noted. Results: A total of 449 patients who fulfilled the inclusion criteria were studied. The age ranged from 16 to 88 years. Male to female ratio was 1:4. Seven cases (1.55%) developed postoperative surgical site infections. Conclusion: Three doses of perioperative antibiotics are recommended in laparoscopic cholecystectomy to prevent postoperative surgical site infections.

Anelgesic Efficacy of Intra-Thecal Tramadol as a Spinal Adjunct to 0.5% Heavy Bupivacaine in Lower Abdominal Surgery

Introduction: Hyperbaric Bupivacaine is the most widely used local anesthetic. A number of adjuvants have been used with local anesthetic agents in order to improve the quality and duration of analgesia and anesthesia. This study was carried out to assess the efficacy of intrathecal Tramadol as a spinal adjunct to prolong the duration of spinal anesthesia in lower abdominal surgeries. Materials and Methods: Sixty patients aged between 18 to 80 years, were randomly divided into two groups - Tramadol and Placebo group. Spinal anesthesia was given by using 25 Gauge Quinke spinal needle in sitting position with midline approach. Patients belonging to Tramadol group received 3 ml of 0.5% Bupivacaine along with 0.5 ml of Tramadol (25mg) and patients belonging to Placebo group received 3 ml of 0.5% Bupivacaine along with 0.5 ml of Normal Saline. In the postoperative ward, duration of analgesia was assessed by the time when first rescue analgesia was given. Visual Analogue Scale for pain was noted at the time of rescue analgesia. The total amount of opioid consumed over 24 hour postoperative period was noted. Hemodynamic like heart rate, systolic, diastolic and mean arterial blood pressures were also noted. Data were analyzed using independent t-test for continuous variables and chi-square test for categorical variables, p value <0.05 was considered significant. Results: The two groups were comparable with respect to age, weight, sex, ASA grading and duration of surgery. Mean duration of effective analgesia was 231.53 ± 22.00 min in Tramadol group and 125.40 ± 8.86 min in Placebo group (p = 0.001). The mean total amount of opioid consumption in 24 hours postoperative period was 145.00 ± 30.31 mg in Tramadol group and 171.67 ± 36.39 mg in Placebo group (p = 0.003). Mean of Heart rate, systolic, diastolic and mean arterial blood pressures were not significant between the two groups. Incidence of nausea and vomiting was statistically significant between the two groups with a p value of 0.010. Hypotension and bradycardia was statistically not significant between the two groups. Conclusion: Tramadol was effective adjuvant to hyperbaric bupivacaine for intrathecal use to increase the duration of spinal anesthesia in patients undergoing lower abdominal surgeries.