Clinical Outcome of Cooled Radiofrequency Ablation in Chronic Knee Pain Osteoarthritis: An Initial Experience from Nepal

Background: Cooled Radiofrequency ablation is a newer technique for management of chronic knee pain in osteoarthritis. The aim of the study is to evaluate the clinical outcomes in patients with chronic osteoarthritis in terms of pain scores for first six months of cooled radiofrequency ablation using ultrasound guidance. Methods: A cross-sectional study with retrospective review of database was evaluated to analyze the change in the Numerical Rating Scale from baseline scores at 1 day, 1 month and 6 months after the Cooled Radiofrequency ablation of genicular nerves around knee in patients with chronic knee osteoarthritis. Results: Median age was 71 years [ 61-73 years (IQR: 25-75)] with more female preponderance. Numerical Rating Scale (Mean ± S.D.) was significantly less at 1 day (1.87 ± 1.22), 1 month (3.03 ± 0.99) and 6 months (3.37 ± 1.098) from baseline values (6.77 ± 1.00). No soreness and numbness were noted.Conclusions: Cooled Radiofrequency using Ultrasound guidance for management of knee pain in chronic osteoarthritis is promising and reduces Numerical Rating Score significantly from baseline at 1 month and 6 months respectively.Keywords: Cooled radiofrequency ablation; genicular nerve; numeric rating scale

Patterns of Clinically Identifiable Congenital Defects in Neonates

Background: The study is aimed at highlighting the pattern of congenital defect in a tertiary care hospital. Congenital anomalies are recognized as a growing cause of neonatal morbidity and mortality in developing countries and a major cause of distress to parents.Methods: This was a prospective descriptive study conducted between September 2019 and August 2020 with the objective to determine the types of congenital anomalies among live born neonates at Manipal Teaching Hospital (MTH), Pokhara and to determine their immediate outcome. Neonatal and maternal characteristics were noted.Results: Twenty four out of 2515 live births had congenital anomalies during the study period, giving an incidence rate of 9.42 congenital anomalies per 1000 live birth per year. Single system involvement was seen in 79.2 % cases, remaining 5 (20.8%) neonates had involvement of more than one system; 54.2% of these newborns were discharged, 33.3% expired, 8.3% left against medical advice and 4.2% were referred out.Conclusions: This study highlights the importance of clinical examination of neonates to detect anomalies in our setting. Keywords: Congenital anomalies; incidence; newborn

Association of Iron Deficiency Anemia with Febrile Seizure in Children in a Tertiary Care Hospital

Background: Febrile seizure is the most common cause of seizure in children. Iron deficiency, by lowering seizure threshold, is proposed to be one of the risk factors for febrile seizure. Many studies have been done to determine the association of iron deficiency anemia with febrile seizure but the results are controversial. Hence, the present study was conducted to evaluate the association of iron deficiency anemia with febrile seizure in Nepalese children. Methods: A prospective age and sex matched case control study was performed in 68 cases of febrile seizures and 68 controls of febrile illness without seizure after calculating the sample size. The study was conducted from October 21, 2019 to October 20, 2020 in Pediatric ward and intensive care unit of College of Medical Sciences, Bharatpur, Nepal after obtaining ethical clearance from institutional review committee. Data entry was done in statistical packages for the social science version 20.Results: Mean of haematological parameters (haemoglobin and mean corpuscular volume) as well as mean of serum iron, ferritin and transferrin saturation were significantly less and total iron binding capacity was significantly high in cases as compared to controls (P <0.05). Iron deficiency anemia was significantly associated with cases (59.7%), with odds ratio of 2.5 (95% confidence interval =1.24 – 5.01) as compared to control (40.3%) (P <0.05).Conclusions: Iron deficiency anemia may be considered one of the risk factors for febrile seizure in children. Hence, Children with febrile seizure should be investigated and treated for Iron deficiency anemia.Keywords: Children; febrile seizure; iron deficiency anemia

Evaluation of Mannheim’s Peritonitis Index in Prediction of Mortality in Patients with Non-traumatic Hollow Viscus Perforation Peritonitis

Background: Hollow viscus perforation peritonitis is one of the commonest surgical emergencies with high mortality and morbidity. The objective of this study was to evaluate the effectiveness of Mannheim’s peritonitis index in prediction of mortality in these patients.Methods: This is a retrospective, observational cohort study in these patients managed in a single-center from January 1, 2013 to December 30, 2019. Total index scores were plotted in the receiver operating characteristic curves to find out the cut-off point. Sensitivity, specificity, relative risk, positive and negative predictive values were calculated. The individual risk factors were analyzed for mortality as well.Results: Case records of 395 cases of non-traumatic hollow viscus perforation peritonitis were available, there were 33 mortalities (8.2%), mean score was 22.96 (+7.6) points (range 10-43 points). The sensitivity and specificity with score cut-off of 25 came to be 75.8% and 56.35%; positive and negative predictive value being 13.7% and 96.2%. Risk of patients for mortality with scores >25 was 3.62 times those with scores <25 for mortality. Mortality rate was 2.4% with scores <21, 8.9% with 21–29 and 20.9% with >29 respectively (p-value <0.05). Univariate analysis showed age >50 years, presence of organ dysfunction, diffuse peritonitis, non-colonic origin and character of exudates were significant factors; multivariate analysis showed only organ failure as significant.Conclusions: Mannheim peritonitis index is very useful in stratification of severity of the disease and prediction of mortality in patients with peritonitis, and should be included in management of all these patients.Keywords: Mannheim’s peritonitis index; perforation peritonitis

Assessment of Preparedness of Government of Nepal in COVID Designated Hospitals and Clinics for Pandemic Response

Background: Preparedness, readiness, and response status of any country is integral in identifying, managing, and preventing COVID-19 pandemic. The objective of this study is to assess the status of the Government of Nepal designated COVID hospitals and COVID clinics to respond against COVID-19. Methods: A cross sectional study was conducted with the focal persons of COVID hospitals and COVID clinics using a semi-structured questionnaire from April 26, 2020 to May 27, 2020 via face to face interview with onsite observation and telephonic interview in few unreachable health facilities. Results: Government of Nepal designated COVID hospitals and COVID clinics demonstrated efforts in establishing preparedness plans and committees such as COVID management core team (96.7% and 86%), provision of coordination with the government authority (both 100% ), preparedness response plan (93.3% and 84%), and infection prevention and control committee (63.3% and 65.6%) to respond to COVID-19 respectively. The participants reported differences in training provided to their health care workers with maximum COVID hospitals (80%) providing training on use of personal protective equipment and least (43.3%) on handling dead bodies. Only half of the COVID clinics (49.5%) had provision of triage systems.Conclusions: COVID hospitals and COVID clinics in Nepal demonstrated different status of COVID pandemic preparedness and readiness. In case of surge, Nepalese hospitals would struggle due to lack of trained workforce and infrastructure. Interdisciplinary, multi-sectoral collaboration with various focused strategies, including in-service training to staff, is paramount to increase preparedness and readiness. Keywords: COVID-19; Nepal; preparedness; readiness

Acute Myocardial Infarction and Diabetic Ketoacidosis: The Lethal Duo

Diabetes Ketoacidosis in association with acute myocardial infarction is quite frequent but is also associated with higher morbidity and mortality. These two can trigger each other, different hypothesis have been proposed to explain this phenomenon but still it is difficult to know which one appears first. We report a referred case to our centre with acute Myocardial Infarction and diabetic ketoacidosis promptly initiated treatment of diabetic ketoacidosis along with primary PCI. Keywords: Cardiogenic shock; diabetic ketoacidosis; metabolic acidosis; myocardial Infarction

Progress in Reducing Inequalities in Reproductive, Maternal, Newborn and Child Health Services in Nepal

Background: Equity has emerged as a cross-cutting theme in the health sector, and countries across the world are striving to ensure that all people have access to the health services they need without undue financial hardship and educational, social, cultural and geographical barriers. In this context, this analysis has attempted to analyse Nepal’s progress in reducing inequalities in reproductive, maternal, newborn and child health services based on economic status and place of residence.Methods: In this analysis, we have used data available from the web version of the Health Equity Assessment Toolkit, a data visualisation tool developed by the World Health Organisation. We have analysed the inequalities in terms of a composite coverage index which combines eight reproductive, maternal, newborn and child health interventions along the continuum of care.Results: Composite coverage of reproductive, maternal, newborn and child health services was 43% in 2001 which increased to 65% in 2016. The absolute difference in composite coverage of the services between the lowest and highest wealth quintiles decreased from 28-percentage points in 2001 to 8-percentage points in 2016. The difference in service coverage between the urban and rural settings reduced from 21-percentage points to six percentage points in the period. Among the eight various services, births attended by skilled birth attendants is the indicator with the highest scope for improvement. Conclusions: Inequalities based on wealth quintiles and residence places have narrowed from 2001 to 2016. Additional efforts in expanding skilled birth attendants and antenatal care service coverage among the poorest quintile and rural residents could further improve the coverage of the indicators at the national level and narrow down the inequalities.Keywords: Health services; inequality; maternal; Nepal; newborn and child health; reproductive health

A Comparative Study of Raja Isteri Pengiran Anak Saleha and Alvarado Scores to Diagnose Acute Appendicitis

Background: Acute Appendicitis is a clinical diagnosis with atypical presentation in young, elderly, females, genitourinary and gynecological conditions. Delayed appendectomy increases the risk of appendicular perforation, sepsis morbidity and mortality. Literature reports as high as 20-40% negative appendectomy. Raja Isteri Pengiran Anak Saleha score has come with higher sensitivity and diagnostic accuracy than Alvarado score in Asian population. This study aims to compare RIPASA and Alvarado score for diagnostic accuracy.Methods: Appendectomy patients at Patan Hospital from April to September 2014 were compared on raja isteri pengiran anak saleha (cut-off value 7.5 out of 15) and Alvarado score (cut-off value 7 out of 10). Final diagnosis was histopathology based. Microsoft Excel and SPSS 17 were used for analysing sensitivity, specificity and diagnostic accuracy of both scores. The study included patients who underwent appendectomy with histopathology report and excluded those with conservative management, generalized peritonitis, appendicular lump and abscess.Results: There were 88 appendectomy patients with median age 26 (18.25, 35) years, and male 52 (59.1%). Negative appendectomy was 10 (11.36%). Sensitivity and specificity of Raja Isteri Pengiran Anak Saleha 98.71% and 80.00% respectively, and for Alvarado 52.56% and 70%.The Raja Isteri Pengiran Anak Saleha score had statistically significant sensitivity (p=0.000). Positive Predictive value, Negative Predictive Value and diagnostic accuracy were 97.46%, 88.89% and 96.6% for RIPASA and 93.18%, 15.19% and 54.4% for Alvarado respectively.Conclusions: The Raja Isteri Pengiran Anak Saleha score had better diagnostic accuracy compared to Alvarado score for diagnosis of Acute Appendicitis.Keywords: Acute appendicitis; alvarado score; RIPASA score

Robsons Ten Group Classification of Cesarean Section at a Tertiary Center in Nepal

Background: Increasing trend in Ceasarean birth is the issue of both demand and supply side. One of the recommended tools to characterize every pregnancy admitted for childbirth is Robson ten-group classification system that may evaluate obstetric practice. The aim of the study was to assess the cesarean section pattern based on Robson’s classification in a central referral hospital.Methods: A retrospective census of childbirths at Paropakar Maternity and Women’s Hospital in Kathmandu performed from September 2018 to February 2019 based on obstetric record. Robson ten-group classification system was the research tool to collect data and Robson Classification Report Table was used to evaluate the data.Results: There were 10500 births with 34% (32-35%) overall cesarean section rate. Excluding spontaneous and induced labor the supposedly total prelabor CS is 14.5%. Group 1+2+3 size is 81% and 21% CS; 5+10 had 11.3% and 23.3% respectively. Prelabor CS (2b+4b) is 3.54% and additional 11% from malpresentation and preterm. Group CS rate from Class 5 onwards, and ratio of 1 and 2 are as recommended by Robson; 67% of CS were not picked up by Robson class due to indications evolved as the labor progresses and the attributes not pre-classified.Conclusions: The assessed quality of data and the type of obstetric population by Robson reference values prove this study as a representative research. But the indications of cesarean sections can be predicted for only one-third of pregnancy attributes classified by Robson class. To supplement this tool to reduce rising cesarean birth requires audit of indications at decision making level.Keywords: Cesarean section; indication; prediction; robson classification

Management of Stroke During COVID-19 Pandemic: The Challenges in Nepal

The COVID-19 pandemic has significantly affected health care delivery globally. COVID-19 is associated with varied neurological manifestations including acute ischemic stroke. In densely populated South Asian nations like Nepal that have suboptimal baseline health care systems, we foresee unique challenges during this pandemic to ensure effective stroke management as well as the safety of health care workers involved in the management of stroke patients. Keywords: COVID-19; health care workers; safety; stroke management.