schizencephaly a case report schizencephaly – a case report p. k. chhetri1, s. raut2 1assistant professor, 2junior resident, department of radiodiagnosis, college of medical sciences, bharatpur, chitwan district, nepal abstract schizencephaly is an uncommon congenital cerebral malformation that involves the cerebral mantle and consists of a cleft that extends through the entire cerebral hemisphere from the lateral ventricle to cerebral cortex. the condition is present at birth and present early in life. here we present an adult patient with schizencephaly presenting with first onset seizure. key words: schizencephaly, lateral ventricle,seizure imaging diagnosis introduction schizencephaly (split brain) is a gray matter-lined cerebrospinal fluid – filled cleft that extends from the ependymal surface of the brain through the white matter to the pia. there is no well-documented data on its incidence.1 two types are recognized, which have prognostic significance. in type i or closed-lip schizencephaly, the cleft walls are in apposition and type ii or open lip schizencephaly, in which the walls are separated. schizencephaly type ii occurs more commonly than type i.1 in either instance the cleft is lined by heterotopic gray matter. in most cases, the gray matter along the cleft is polymicrogyric; in some instances, it is more dysplastic than polymicrogyric. 2 the clefts can be unilateral or bilateral, symmetric or asymmetric and can appear anywhere in the brain, although they usually are perisylvian. in unilateral cases, perusal of the contralateral hemisphere is warranted, as subtle clefts of polymicrogyria are common.2 case report a 50 year old male patient was referred for ct scan of the head for a single episode of a generalized tonic clonic seizure. apart from mental retardation present since birth no other significant history could be elicited. a non contrast enhanced ct scan of the head was performed. axial (figure 1) and coronal (figure 2) ct scan shows the wide open lip schizencephaly with communication of the left lateral ventricle and the subarachnoid space on the left side. there is also absent septum pellucidum and partial thinning of the skull vault on the left side (temporoparietal region). figure 1 figure 2 correspondence: dr. p k chhetri e-mail:pramodchhetri@rediffmail.com case report, 54-56journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 54 discussion several theories have been proposed to explain the etiology of schizencephaly, although none is universally accepted. however, an ischemic episode occurring at the 7 th week of gestation has been hypothesized as an etiological factor. in the normal embryo, beginning7 th week of gestation, neuroblasts are generated in the germinal matrix. during the 8 th week these primitive cells begin to migrate along radially oriented glial cells to the cerebral cortical regions. during that critical period, any insult to the centripetal and centrifugal vessels in the region of germinal matrix may cause hypoxaemia and infarction with arrest of migration of these neuroblasts.3 conversely, another author favours a primary developmental abnormality to account for the combination of schizencephaly and absence of the cavum septum pellucidum.4 recently, mutations in the homebox gene, emx2 located on chromosome 10q2.6, have been reported in some patients with schizencephaly.2 presenting symptoms relate to the amount of involved brain. children with closed-lip schizencephaly typically present with hemiparesis or motor delay, whereas patients with open-lip schizencephaly usually present with hydrocephalus or seizures. patient with closed-lip schizencephaly are more likely to have mild to moderate neurologic deficit than those with openlip type. unilateral closed-lip schizencephaly is associated with the best neurodevelopmental outcome. patients with progressively larger clefts present with progressively greater neurologic deficits because progressively more brain is missing. nearly all patients with bilateral open-lip clefts have severe disabilities. 2 ct scans of closed-lip schizencephaly may show only a slight outpouching, or "nipple,"at the ependymal surface of the cleft. the full thickness cleft, or pialependymal seam, may be difficult to detect on ct scans but is easily discernible on mr studies. openlip schizencephaly has a larger, more apparent gray matter-lined csf cleft. 5 ct may show subependymal or parenchymal calcification in many cases, which suggests that one cause of schizencephaly may be intrauterine infection with cytomegalovirus. 6 mri is the imaging modality of choice because of its superior differentiation of gray matter and white matter and its ability to image in more than one plane. identification of gray matter lining the cleft is the pathognomic finding. 1 mri shows the abnormal appearance of the cortical mantle along the cleft and the cortex appearing thicker than normal owing to the presence of polymicrogyria. the contralateral hemisphere may also have developmental abnormalities, such as polymicrogyria and subependymal heterotopias. 6 mild hypoplasia of the corpus callosum is commonly seen. the septum pellucidum is absent or nearly completely absent in 70% to 90% of affected patients. of those with absence of the septum pellucidum, 30-50 % will have optic nerve hypoplasia on clinical examination. therefore, septo-optic dysplasia is, by definition, present in 20-45% of patients with schizencephaly.2 optic atrophy is usually easily recognizable clinically but is often difficult to confirm on imaging. in addition to the brain anomalies, in patients with openlip schizencephaly, csf pulsations from the lateral ventricles result in pressure effects on the inner table of the skull.2 p. k. chhetri et al. schizencephaly – a case report 55 references 1. bird cr, gilles fh. type 1 schizencephaly: ct and neuropathologic findings. am j of neuroradio 1987;vol 8,(3):451-4 2. robertson r, caruso pa, truwit cl et al disorders of brain development. in: magnetic resonance imaging of the brain and spine. scott w. atlas. 3 rd edition. lippincott williams & wilkins, 2002;356-60 3. chuang sh, fitz cr, chilton sj et al: schizencephaly; spectrum of ct findings in association with septo-optic dysplasia. presented at the 70 th scientific assembly and annual meeting of radiological society of north america washington dc november. radiology 1984;153:118 4. page lk, brown sb, gargano fp et al. schizencephaly: a clinical study for review. child brain 1975;1:348-58 5. anne g. osborn. disorders of diverticulation and cleavage, sulcation and cellular migraton. in: diagnostic neuroradiology. mosby, 1994;52-4 6. gunny rs, chong wkk. paediatric neuroradiology. in: grainger & allison`s diagnostic radiology. 5 th edition. volume ii. churchill livingstone elsevier, 2008;1660 journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 56 journal of college of medical sciences-nepal, 2014, vol-10, no-3 48 case report introduction transradialarterial puncture for diagnostic coronary angiography and percutaneous coronary intervention (pci)is gradually replacing femoral artery access in many cardiac centers. this is because of the significant reduction in the occurrence of accesssite complications as  well  as  patient  comfort  and  early  ambulation observed while selecting transradial over transfemoral puncture.clinically significant pseudoaneurysm occurs in  0.05%  to  1.0%  of  diagnostic  and  up  to  6%  of interventional  transfemoral  procedures.1,2  posttransradial catheterization pseudoaneurysm is rare, with an incidence <0.1% reported in a large caseseries.3 case report 62 years female with past history of diabetes and systemic  hypertension  had  undergone  diagnostic coronary angiography via radial access for evaluation radial pseudoaneurysm following diagnostic coronary angiography shankar laudari1, sachin dhungel1, laxman dubey1, guru prasad2, r bhattacharya2, s subramanyam2 dm residents1, professors2, department of cardiology, coms-th, bharatpur, nepal abstract the radial artery access has gained popularity as a method of diagnostic coronary catheterization compared to femoral artery puncture in terms of vascular complications and early ambulation. however, very rare complication like radial artery pseudoaneurysm may occur following cardiac catheterization which may give rise to serious consequences. here, we report a patient with radial pseudoaneurysm following diagnostic coronary angiography. adequate and correct methodology of compression of radial artery following puncture for maintaining hemostasis is the key to prevention. key words: coronary catheterization, pseudoaneurysm, radial artery correspondence: shankar laudari e-mail: lshankar2@hotmail.com and management of exertional chest pain and shortness for breath. the patient was on aspirin, clopidogrel, atorvastatin, nitrate  and metoprolol. bleeding and coagulation profiles were normal before the procedure. during angiography, single right radial artery puncture was done and coronary ostium hooked with diagnostic 5frenchtiger catheter. coronary angiography was suggestive of double vessel disease with 99% stenosis of  ramus  intermedius  and  90%  stenosis  of  left circumflex vessel. there was no local bleeding during and  after  the  procedure  but  she  presented  with  a pulsatile swelling of 2×2cm over distal wrist on the fourth day of intervention as shown in fig 1. systolic bruit was audible. allen’s test was negative. radial colour doppler(as shown in fig 2a and 2b) revealed the presence of pseudoaneurysm arising from the main right radial artery with continuous bidirectional blood flow in the neck of the pseudoaneurysm. there was turbulent blood flow within the lesion and in the radial artery which was patent. ulnar artery and palmar arch integrity were confirmed. 49 journal of college of medical sciences-nepal, 2014, vol-10, no-3 discussion the transradial access for cardiac catheterization has resulted  in  significant  reduction  of  vascular complications.4  complications  of  transradial catheterization  include  radial  artery  occlusion, nonocclusive injury, spasm, hand ischemia, nerve damage, bleeding and pseudoaneurysm formation.4 factors predisposing to the development of radial artery pseudoaneurysm include multiple puncture attempts, ongoing  systemic anticoagulation, inadequate hemostasis/postprocedure compression, vascular site infection and the use of larger catheter sheath sizes.5,6 our patient  had single radial artery  puncture and received antiplatelet therapy before the procedure but not affected by access-site infection. postprocedure hemostatic compression devices are frequently used for the prevention of pseudoaneurysm formation.7 in our patient, manual compression was done for about 30 minutes. potential problems may be incorrect and inadequate compression pressure. attending nurses and doctors should be vigilant for proper clinical observation and assessment over radial puncture  site  following  cardiac  catheterization. following  clinical  suspicion,  confirmation  of pseudoaneurysm with colour doppler study and subsequent intervention is of extreme importance for preventing evolution of a hematoma and associated complications.8 an individualized approach to management based on the severity of the pseudoaneurysm is recommended.4 for small defects, firm compression with a view to thrombose false aneurysm may suffice whereas larger aneurysms require surgical intervention.where there is evidence of adequate collateral arterial flow to the hand, ligation and excision of the pseudoaneurysm and fig 1:pseudoaneurysmal swelling over right distal wrist fig 2a fig 2b fig 2a and 2b: doppler ultrasound of pseudoaneurysm (longitudinal view). colour doppler imaging showing flow of blood from lower end of right radial artery to hematoma cavity through a narrow neck. journal of college of medical sciences-nepal, 2014, vol-10, no-3 50 radial artery may be permitted.9 management using thrombin injection has also been reported but is unlikely to  offer  significant  advantage  over  surgical intervention.8,9 conclusion although vascular complications like pseudoaneurysm following radial artery puncture are very rare, they are significant and may result in serious catastrophes. adequate  and  correct  optimal  postprocedure compression along  with vigilant  monitoring may minimize the risk of pseudoaneurysm formation. competing interests the authors do not have competing interests in the publication of this article. references 1. katzenschlager r, ugurluoglu a, ahmadi a. incidence of  pseudoaneurysm  after  diagnostic  and  therapeutic angiography. radiology 1995;195:463–6. 2. kresowik  tf,  khoury  md,  miller  bv. a  prospective study  of  the  incidence  and  natural  history  of  femoral vascular  complications  after  percutaneous  coronary angioplasty. j vascsurg1991;13:328–36. 3. sanmartin  m,  cuevas  d,  goicolea  j,  et  al.  vascular complications associated with radial artery access for cardiac catheterization. rev espcardiol 2004;57:581–4. 4. kanei  y,  kwan  t,  nakra  nc.  transradial  cardiac catheterization:  a  review  o f  access  site comp lications.  catheter  car d io vasc  i nter ven 2011;78:840–6. 5. gilchrist  ic.  laissez-faire  hemostasis  and  transradial injuries. catheter cardiovasc interv 2009;73:473–4. 6. lefevre t, morice mc, bonan r. coronary angiography using 4 or 6 french diagnostic catheters: a prospective, randomized study. j invasive cardiol2001;13:674–7. 7. liou m, tung f, kanei y, et al. treatment of radial artery pseudoaneurysm  using  a novel  compression  device. j invasive cardiol2010;22:293–5. 8. tahir  h,  luke  h,   j o hn  mc  d.  rad ial  ar ter y pseudoaneurysm  following  coronary  angiography  in two octogenerians. expclincardiol 2012;17: 260–62. 9. d’achille  a,  sebben  ra,  davies  rp.  percutaneous ultrasound-guided  thrombin  injection  for  coagulation o f  p ost-tr aumatic  p seud oaneur ysms.   austr alas radiol 2001;45:218–21. 1-43 1 prevalence and antimicrobial susceptibility pattern of methicillin-resistant staphylococcus aureus (mrsa) in cms-teaching hospital: a preliminary report r. k. sanjana 1, rajesh shah2, navin chaudhary2, y.i. singh 3 1assistant professor, 2lecturer, 3prof & head, dept. of microbiology, college of medical sciences-teaching hospital, bharatpur, chitwan district, nepal. abstracts aims: nosocomial infection is a major problem in the world today. methicillinresistant staphylococcus aureus (mrsa) strains, usually resistant to several antibiotics and also intrinsic resistance to ßlactam antibiotics, shows a particular ability to spread in hospitals and now present in most of the countries. the present study was carried out to investigate the prevalence of mrsa and their rate of resistance to different antistaphylococcal antibiotics. materials and methods: between april 2007 and december 2009, the clinical specimens submitted at the microbiology laboratory were processed and all staphylococcus aureus (s. aureus) isolates were included in this study. all isolates were identified morphologically and biochemically by standard laboratory procedures and antibiotic susceptibility pattern including oxacillin was determined by modified kirby bauer disc diffusion method. results: out of a total of 348 staphylococcus aureus strains isolated from various clinical samples, 138 (39.6%) were found to be methicillinresistant. among mrsa isolates, 86(62.3%) were from different inpatient departments, whereas, 52(37.7%) of the isolates were from outpatients. all mrsa were resistant to penicillin. more than 70% of the mrsa strains were resistant to cephalexin, ciprofloxacin and cloxacillin, while less than 10% of them were resistant to azithromycin, amikacin and tetracycline. many mrsa strains were multidrug resistant. however, no strains were resistant to vancomycin. conclusion: this preliminary report showed a high prevalence of mrsa in our hospital. to reduce the prevalence of mrsa, regular surveillance of hospital acquired infection and isolation is the need of the hour. key words: nosocomial infection, methicillin-resistant staphylococcus aureus (mrsa), multidrug resistant. correspondence: dr. r. k. sanjana e-mail: rajkumari_sanjana@yahoo.co.in , 1-6 original articlejournal of college of medical sciences-nepal, 2010, vol. 6, no. 1 2 introduction staphylococcus aureus is a leading cause of hospital acquired infection (hai) and over the past 50 years it has acquired resistance to previously effective antimicrobials including the penicillinase resistant ones like methicillin.1 today, methicillin resistant staphylococcus aureus(mrsa) has emerged as one of the most important nosocomial pathogens.2 the percentage of hospitals isolating mrsa in the developed countries has increased from 2% in the 70’s to 30% in the 90’s.3 moreover, half of s. aureus in many centres are methicillin resistant(multidrug resistant) posing major therapeutic challenge.4 mrsa causes more than 50% of hai and are more virulent than the methicillin sensitive strains.5,6 prompt diagnosis of mrsa infection is, therefore, important for patients, health care givers and for epidemiological purposes. hospital acquired infection (hai) gives an enormous burden to the health care system significantly affecting the patient’s morbidity and mortality. it results in prolongation of hospital stay and hence higher bed occupancy rate with an attendant increase in the cost of hospitalisation.7, 8 surveillance of mrsa related infections especially in the hospital set up is required and has been doing in the developed countries. not only that, the magnitude of the problem is yet to be quantified. this study is an attempt to assess the prevalence of methicillin resistant s. aureus (mrsa) infection and its antibiotic susceptibility pattern in this hospital. materials and methods this study was based on retrospective data of samples sent from different wards and opds of college of medical sciences-teaching hospital, bharatpur. total strains of 348 s. aureus were isolated from pus, urine, sputum, wound swab, aural swab, blood, throat swab and urethral swab during april 2007 and dec 2009. s. aureus was identified by conventional method. 9 the antimicrobial susceptibility test was carried out using kirby-bauer’s disc diffusion method modified and updated by clinical and laboratory standards institute guidelines (clsi). 10 each of the strain was screened for oxacillin resistance using american type culture collection (atcc) 43300 as the control. a standard inoculum was prepared by direct colony suspension in and comparing it with 0.5 mc. farland turbidity. using a sterile cotton swab and after removing the excess of the inoculum by pressing against the side of the tube, the suspension was inoculated on a mueller hinton agar medium by lawn culture method all over the surface of the medium. oxacillin disc (1µg), (hi media laboratories, pvt. ltd. mumbai) was applied along with other antimicrobials for testing sensitivity and the plates were examined after an over night incubation at 37 º c. zone of inhibition diameter (in mm) were measured and results were interpreted as sensitive, resistant as per recommendation of clinical and laboratory standards institute guidelines (clsi). other antimicrobials tested were chloramphenicol (30µg), tetracycline (30 µg), gentamicin (10µg ), erythromycin (15µg), cotrimoxazole (25µg), cephalexin (30µg ), ciprofloxacin (5µg), amikacin (30µg ), cefotaxime (30µg) and vancomycin (10µg ). results isolation of staphylococcus was maximum in pus samples. out of the 348 strains of s. aureus examined 138 (39.6%) were found to be methicillinresistant and of which 86 (62.3%) were from inpatient departments. amongst them only 9 (10.4%) of the journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 3 isolates were from intensive care units (icu). a total of 52 (37.7%) mrsa strains were from outpatients. maximum isolation of mrsa was from pus (53.3%), followed by wound swabs (44.4%), sputum (37.5%), aural swabs (33.3%) etc. (table1) shows detection of mrsa in different samples. all the strains of mrsa were found to be resistant to penicillin. (table -2) depicts the antibiotic susceptibility data for all the s. aureus isolates. among mrsa, resistance to cephalexin was 81.8%, ciprofloxacin -71.0%, cloxacillin -70.6%, erythromycin -58.0%, gentamicin -38.0%, cefotaxim -31.6%, cotrimoxazole -20.4%, while amikacin, azithromycin and tetracycline were resistant to less than 10% of the mrsa strains. many mrsa strains were multidrug resistant. no strain was resistant to vancomycin. however, 41.2% of methicillin sensitive s. aureus (mssa) were resistant to penicillin, 25.7% resistance to cephalexin, 25.4% resistance to ciprofloxacin, 16.6% resistance to cloxacillin, 14.5% resistance to erythromycin, 32.3 % resistance to gentamicin as compared with mrsa. mssa isolates also revealed higher susceptibility to cefotaxime, cotrimoxazole with a resistance rate of 9.3% and 9.8% of the strains respectively. none of the mssa was resistant to azithromycin. table1: isolation of mrsa from specimens of outdoor and indoor patients in cms-teaching hospital, bharatpur, nepal r.k. sanjana et al. prevalence and antimicrobial susceptibility..............................: a preliminary report opd ward & icu total s.no specimens s. aureus mrsa (%) s. aureus mrsa (%) s. aureus mrsa (%) 1 pus 60 32 53.33 80 53 66.25 140 85 60.71 2 urine 20 04 20.00 30 08 26.66 50 12 24.00 3 wound swab 09 04 44.44 10 06 60.00 19 10 52.63 4 sputum 08 03 37.50 15 06 20.00 23 09 39.13 5 aural swab 09 03 33.33 20 06 30.00 29 09 31.03 6 blood 18 02 11.11 34 03 08.82 52 05 09.61 7 throat swab 08 02 25.00 12 03 25.00 20 05 25.00 8 csf 00 00 00 01 00 00 01 00 00 9 urethral swab 04 01 25.00 03 01 33.33 07 02 28.57 10 bone cartilage 00 00 00 02 00 00 02 00 00 11 semen 03 01 33.33 02 00 00 05 01 20.00 total 139 52 37.68 209 86 41.14 348 138 39.65 4 discussion mrsa is a global phenomenon with a prevalence rate ranging from 2% in netherland and switzerland, to 70% in japan and hong kong.11, 12 in this study, the prevalence of mrsa was found to be 39.6%. prevalence of mrsa was higher among inpatients (41.1%) than outpatients (37.4%). this difference could be due to prolonged hospital stay, instrumentation and other invasive procedures. a comparable prevalence rate of 34.7%, 31.0% and 38.5% were also reported from assam, tamil nadu and delhi13, 14, 15 whereas, in some studies the rate is comparatively low. in a study in eastern part of nepal in dharan, the rate of mrsa was (26.4%),16 which was low as compared to this study. in another study in nagpur the rate of mrsa (19.5%) 17 was also low compared to our study. however, in another study it was very high (80.8%).18 analysis from previous studies revealed a relationship between methicillin resistance and table2: resistance to individual antimicrobials in mrsa and mssa isolated in cms-teaching hospital, bharatpur,nepal journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 mrsa mssa total s. no antimicrobials tested resistance (%) tested resistance (%) tested resistance (%) 1 penicillin g 126 126 100 189 78 41.25 315 204 64.76 2 cephalexin 22 18 81.81 69 25 36.23 91 43 47.25 3 ciprofloxacin 83 59 71.08 138 35 25.36 221 94 42.53 4 cloxacillin 136 96 70.58 187 80 42.78 323 127 39.31 5 erythromycin 62 36 58.06 124 18 14.51 186 54 29.03 6 gentamicin 21 08 38.09 65 21 32.30 86 29 33.72 7 cefotaxim 57 18 31.57 118 11 09.32 175 29 16.57 8 co-trimoxazole 44 09 20.45 132 13 09.84 176 22 12.50 9 ofloxacin 68 12 17.64 154 18 11.68 222 30 13.51 10 amoxyclav 28 04 14.28 84 07 08.33 112 11 09.82 11 azithromycin 52 05 09.61 158 00 00 210 08 03.80 12 amikacin 65 06 09.23 112 07 06.25 177 13 07.34 13 tetrcyclin 50 04 08.00 59 06 10.16 109 10 09.17 14 vancomycin 128 00 00 186 00 00 324 00 00 5 resistance to other antibiotics.19, 20 this study showed that all mrsa isolates were significantly less sensitive to antibiotics as compared with mssa isolates. many of the isolates were resistant to commonly used antistaphylococcal agents except vancomycin. anupurba et al. also observed that 32% of mrsa isolates are resistant to all commonly used antibiotics for s. aureus except vancomycin.21 because of the resistance of mrsa to all commonly used antibiotics, it is necessary to test newer group of antibiotics such as vancomycin and teicoplanin routinely. resistance to (cephalexin) was much higher (81.8%) in this study. this is comparable to the study done by namrata et al. in the eastern part of nepal who reported the resistant rate to be above (65%).16 resistance to quinolones (ciprofloxacin) was also high (71%) in this study . in the study reported by lahari sakia et al., the resistant rate was also high (87.5%) in assam.13 however, in the same institute, a previous study, in 2001, reported the resistant rate of ciprofloxacin to be only (22.8%).16 the rapid emergence of ciprofloxacin is probably due to the indiscriminate and empirical use of these drugs. mssa isolates shows higher susceptibility to penicillin and cloxacillin (100% vs. 41.3%) and (70.6% vs.43.0%) respectively than mrsa strains. the epidemiology of mrsa is gradually changing since its emergence was reported. initially there were occasional reports but now it has become one of the established hospital acquired pathogen. moreover, the association of multidrug resistance with mrsa had added to the problem. ß – lactam antibiotics like penicillin and cephalexin resistance were 100% and 81% respectively. resistance to amino glycosides was more in gentamicin (38%) than amikacin (9.2%) in this study, however, it cannot be recommended for empirical treatment of mrsa associated infections. vancomycin seems to be the only antimicrobial agent which showed 100% sensitivity and may be used as the drug of choice for treating multidrug resistant mrsa infections. however, regular monitoring of vancomycin sensitivity and routine testing of other newer glycopeptides like teicoplanin should be carried out. further, the regular surveillance of hospital associated infections including monitoring antibiotic sensitivity pattern of mrsa and formulation of definite antibiotic policy may be helpful for reducing the incidence of mrsa infection. conclusion this preliminary report showed a high prevalence of mrsa in our hospital. there is a need for surveillance of mrsa and its antimicrobial profile. the hospital infection control policy and guidelines that already exists should be strictly implemented and followed so as to enable the clinicians to deliver better and proper health care to the patients. references 1. duckworth g.j. diagnosis and management of methicillin resistant staphylococcus aureus infection. bmj1993; 307: 1049-52. 2. bradley jm, noone p, townstend de et al, methicillin resistant staphylococcus aureus in a london hospital. lancet 1985;1: 1493-5 3. gordon j. clinical significance of methicillin sensitive and methicilin resistant staphlococcus in uk hospitals and the relevance of povidone iodine in their control.postgrad med j 1993; 69 (suppl 3); 106-16. r.k. sanjana et al. prevalence and antimicrobial susceptibility..............................: a preliminary report 6 4. manual on antimicrobial resistance and susceptibility testing. who antimicrobial resistance monitoring programme. who geneva. 1997. 5. mathur sk, singal s, prasad kn, et al. prevalence of methicillin resistant staphylococcus aureus (mrsa) in tertiary care hospital. indian j med microbiology 1994; 12(2): 96-101. 6. udaya shankar c, harish bn, umesh kumar pm, et al. prevalence of methicillin resistant staphylococcus aureus in jipmer hospital – a preliminary report. indian j med microbiol 1997;15(3):137-8 7. burgner d, dalton d, hanlon m, wong m, et al. repeated prevalence surveys of paediatric hospitalacquired infection. j hosp infect 1996; 34(3):163-70. 8. leroyer a, bedu a, lombrail p, et al. prolongation of hospital stay and extra costs due to hospital acquired infection in a neonatal unit.j hosp infect 1997; 35(1):37-45. 9. baird d. staphylococcus. cluster forming gram negative cocci. mackie and mccartney practical medical microbiology. 4th ed, 2;1996;245-58. 10. clinical and laboratory standards institute. performance standards for antimicrobial susceptibility testing; 16th information supplement (m100-s16). clinical and laboratory standards institute, wayne, pa: 2006. 11. fluit ac, wielders cl, verhoef jf, et al. epidemiology and susceptibility of 3,051 staphylococcus aureus isolates from 25 university hospitals participating in the european sentry study. j clin microbiol 2001; 39:3727-32. 12. diekema dj, pfaller ma, schmitz fj, et al. survey of infections due to staphylococcus species: frequency of occurrence and antimicrobial susceptibility of isolates collected in the united states, canada, latin america, europe and the western pacific region for the sentry antimicrobial surveillance program, 1997-1999. clin infect dis 2001; 32:s114-32. 13. saikia l, nath r choudhary b, et al. prevalence and antimicrobial susceptibility pattern of methicillinresistant staphylococcus aureus in assam. indian j crit care med 2009; 13:156-8. 14. rajaduraipandi k, mani kr,panneerselvam k, et al. prevalence and antimicrobial susceptibility pattern of methicillin-resistant staphylococcus aureus. a multicentric study. ind j med microbiol 2006; 24:348. 15. mohanty s, kapil a, dhawan b, et al. bacteriological and antimicrobial susceptibility profile of soft tissue infections from northern india. ind j med sci 2004; 58:10-5. 16. kumari n, mohapatra tm, singh yi. prevalence of methicillin resistant staphylococcus aureus in a tertiary-care hospital in eastern nepal. j nepal med assoc.2008 apr-jun; 47(170):53-6. 17. tahnkiwale ss, roy s, jalgaonkar sv. methicillin resistance among isolates of staphylococcus aureus: antibiotic sensitivity pattern and phage typing. ind j med sci 2002; 56:330-4. 18. verma s, joshi s, chitnis v, et al. growing problem of methicillin resistant staphylocci: indian scenario. ind j med sci 2000; 54:535-40. 19. majumder d, bordoloi jn, phukan ac, et al. antimicrobiol susceptibility pattern among methicillin resistant staphylococci isolates in assam. indian j med microbiol 2001; 19:138-40. 20. vidhani s, mehndiratta pl, mathur md.study of mrsa isolates from high risk patients. indian j med microbiol 2001; 19:87-90. 21. anupurba s, sen mr, nath g, et al. prevalence of methicillin resistant staphylococcus aureus in a tertitiary care referral hospital in eastern uttar pradesh. indian j med microbiol 2003; 21:49-51 journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 unusual case of laryngeal foreign body unusual case of laryngeal foreign body s.n. ganguly1, n.s. reddy2, a. shrestha3, d. shah4, n. shakya5, s. acharya 6 1,2professor, 3lecturer, 4,5,6 residents department of ent , college of medical sciences, bharatpur, nepal abstract: the foreign bodies in respiratory tract have been major cause of morbidity and present as challenge to otolaryngologist. the spectrum of presentation varies widely from sudden death due to respiratory obstruction to accidental finding during routine investigation. one case of unusual presentation of laryngeal foreign body with loss of voice is described here. key words: respiratory obstruction laryngeal, foreign body,. introduction laryngeal foreign body is less common than bronchial foreign body and is potentially dangerous. the foreign bodies in respiratory tract usually occurs as an emergency. diagnosis is made by clinical and radiological examination. the foreign body in larynx needs quick intervention. due to delayed intervention, most of the complications including death may occur. laryngeal impaction of foreign body is rare, as most aspirated foreign bodies pass through laryngeal inlet and get lodged down in the airway. here we report a rare case of laryngeal foreign body presented as hoarseness of voice. case report: a female patient aged 29 years, from chirchisae nawalparasi-8 lumbini admitted to c.m.s .t.h. bharatpur on 27.02.09 with history of blood mixed sputum and change of voice for last 2 months. breathlessness was also there which was felt more when she lied down on supine position. she had also feeling of something moving in the throat. there was no history of trauma, fever, stridor or pain in the throat. indirect laryngoscopy and nasopharyngeal laryngoscopy (flexible) showed one thick black colour leech visible in glottic chink, which was moving. detailed history revealed that she used to go to the forest to bring wood. she used to drink river water present in the forest which may have contained leech. during interrogation it was found that she had taken many medicines for change of voice and feeling of something moving in throat. she was taken to o.t. and direct laryngoscopy was done. an alive leech which was seen coming out of laryngeal inlet which was grasped with forceps and pulled out.. it was about 5cm long and 1.5 cm thick. post procedure antibiotic was given and followed up. the patient regained her voice within 2 days and had no complaints. pathology foreign body can settle in hypopharynx (5%) larynx (2-9%), trachea (12%) or bronchus (83%). the correspondence: dr. s.n. ganguly e-mail:soumen_ganguli@yahoo.co.in case report, 45-46journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 44 airway obstruction may he partial or complete. partial obstruction occurs when the upper airways are partially occluded or obstruction is distal to carina. patient may present within weeks to months after foreign body aspiration. most foreign body lodge in periphery, distal to larynx or trachea. however foreign body having a sharp or irregular body gets lodged in larynx or trachea .1,2 discussion in 1897 gustav killer removed a foreign body from lower respiratory tract with a rigid bronchoscope. during 1st past of 20th century chevalier jackson perfected endoscopic technique the incidence of foreign bodies in the airway is around 0.60% among the total foreign bodies. this is due to protection of the airway with epiglottis, arytenoid and coughing reflex.3 foreign bodies are most common in children up to 3-4 yrs.1,3,4 the incidence is between 55-75% .this is because children in that age group are curious in nature, have strong oral tendency and no molar teeth. 1,3,4 laryngeal foreign bodies as such are very rare as most inhaled objects pass into bronchus.5 lima et al 6 in a review of 91 inhaled foreign bodies, found 11 to be true glottic. 5 out of 11 had fatal outcome and transient hypoxic encephalopathy occurred in 3 patients. rothman et al 2 found only 5 cases of laryngeal foreign bodies in a series of 225 patients. in most cases a history of choking followed by a transient cough was seen. a foreign body lodged in the larynx can cause laryngospasm and complete respiratory obstruction.7 ambu et al 8 have reported a case of one and half month neglected laryngeal foreign body in 3 years old boy. delay in diagnosis was because there was no symptom suggestive of a foreign body in airway passage. on plain x-ray of neck a bird bone was detected. tracheostomy was required due to granulation tissue. a part of bone was removed by direct laryngoscopy and remaining part through tracheostomy. metallic foreign bodies in the larynx are rare and safety pin is commonly detected. hussain et al 9 reported a case of open safety pin in the larynx in a 6 month old boy. vian et al 7 described the use of high frequency jet ventilation to maintain gaseous exchange in a 16 month old child who had impacted safety pin in the larynx which was removed by a tracheostomy. bhatt et al 10 reported an unusual foreign body in the larynx in an 18 month old baby who presented with two days history of fever, refusal of feeds and stridor. history of foreign body inhalation, cough and choking was absent. radiological investigation revealed the pathological finding. initial diagnosis of croup was made. the child was given antibiotics, adrenaline nebulization and parenteral fluid. general condition improved but stridor (inspiratory) persisted. ent consultation was sought and endoscopy revealed artificial fingernail lodged between the vocal cords. stridor improved after removal of foreign body. man et al 11 reported an unusual case of laryngeal impaction of cervical vertebra of a toad in an infant. this was diagnosed with c.t.scan as more conventional methods failed to diagnose. kansara et al 12 reported an unsual case of laryngeal foreign body presented with sudden loss of voice since 6 days. there was no history of trauma or fever. indirect laryngoscopy showed shiny material attached to left cord direct laryngoscopy was passed and with forceps the foreign body was carefully removed. s.n. ganguly et al. unusual case of laryngeal foreign body 45 bakshi et al 13 reported two interesting cases in which the diagnosis of foreign body in the larynx was not suspected preoperatively. a three and half year old female child was diagnosed as a case of bronchitis and was later found to have a metallic spring in the supraglottic region which was removed by direct laryngoscopy under general anesthesia. the other patient, a 32-year-old male, was diagnosed to have a fibrous lesion in the larynx one year previously, and on laryngoscopy a vegetable, speculated foreign body was found after excising the fibrous lesion on the left false cord. both the cases are symptom free 18 months after endoscopy. conclusion unusual foreign body like the case which we reported may miss the diagnosis as there was no history of respiratory symptom. moreover, the foreign body was radiolucent. complete detailed history helps to detect such case. it is important to diagnose the case as early as possible, so that there may not be any catastrophe. acknowledgement we are thankful to the superintendent of c.m.s-t.h, bharatpur, nepal for publication of this article. fig-1 …………………………………………………………………………………… black colour leech visible in the glottis. references: 1. diop em, tall a, diout r . laryngeal foreign body: management in children in senegal: arch pediatric. 2000;7:10-5. 2. rothman bf, beockman cr. foreign bodies in the larynx and tracheobronchial tree in children: a review of 225 cases. ann otol rhinol and laryngol 1980; 89:434-6 3. ricardo rf, walter sm. foreign body aspiration through tracheotomy. brazilian journal of otorhinolaryngology 2005;71: 234-6. 4. ellan m. tracheo-bronchical foreign bodies. otolaryngologic clinics of north america 2000;33:17-8. 5. kent se, watson mg. laryngeal foreign bodies. journal of laryngology and otology 1990;104:131-3 6. lima ja. laryngeal foreign bodies in children: a persistent life threatening problem. laryngoscope 1989;99:415-20 7. vain ss, dhara ss, sim ck. removal of foreign body using high frequency jet ventilation. anaesthesia 1991;46:741-3 8. ambu vk, narayanan p, rathnasingam v. neglected laryngeal foreign body. the journal of laryngology and otology 2001; 115:740-2 9. hussain ss, raine ch, caldicott ld et al. an open safety pin in the larynx: case report. the journal of laryngology and otology 1994;108:254-5 10. bhat na, oates j . an unusual foreign body in the larynx: a case report. the journal of layrngoloy & otology 1996;110:1164-5 11. man dw, engzell uc, hadgis c et al. an unusual laryngeal foreign body. in an infant j otolaryngol 1986; 115: 127-9 12. kansara ah ,shah hv, patel ma et al. unusual case of laryngeal foreign body indian journal of otolaryngology and head and neck surgery2007;59: 63-5. 13. jasmanti bakshi, mann sbs ,gupta ak. unusual presentation of laryngeal foreign bodies report of two rare cases. indian journal of otolaryngology and head and neck surgery 2007;59:252-4 . journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 46 fly leafs and instructions to author editorial wake-up calls dr. g. subramanyam director, prof. & head of the dept. of cardiology, college of medical sciences, bharatpur, chitwan (dist.), nepal worldwide data suggest that people are living longer than previously in developed countries. reports predict that if the present trend of increase in the life expectancy continues through this century, most babies born after 2000 will be able to celebrate their 100th birthday. however, researchers also have noticed an increased trend of the prevalence of obesity in wealthy countries and assume that it might slow down the trend of rising life expectancy. similarly increased life expectancy means increased prevalence of coronary artery diseases and this may also put some brakes in this trend. however, there is a greater advancement and achievement in the early recognition and treatment of coronary artery diseases especially in developed nations; it indicates that there is no stop in rising life expectancy. on the other hand, this scenario is markedly different in developing countries. the developing nations are just getting rid of infectious and communicable diseases as a result of some improvement in sanitation and living conditions, and also because of the easy availability of effective antibiotics and antimicrobial treatment. but there is also a rising trend in non-infectious conditions such as cardiovascular diseases and oncological conditions. this is not only because of some rise in life expectancy but also due to sedentary life style and diet containing high fat and carbohydrates. so, it seems the long life is still a distant privilege for the future generations in these countries until there is satisfactory development in the management of the major contributors of mortality and morbidity; cardiovascular, cerebrovascular and oncological diseases. nepal, being one of the representatives of latter group, is experiencing similar trend. so, the future generations of the nepal and other developing world will not be lucky enough to enjoy the privilege of long life. therefore, apart from strengthening the efforts against infectious diseases, there is a strong need in the advancement of facilities dealing with major determinants of mortality and morbidity in future scenario, such as coronary artery diseases and other cardiovascular conditions, cerebrovascular diseases, and oncological conditions. in addition, there is also a strong need for authentic researches on health related matters of the communities. so, it is high time to start higher education in super specialty such as cardiology, neurology and nephrology, and other areas of medicine. these courses, apart from emphasizing on clinical skills and community services as the main objectives, should produce high level researchers capable of carrying independent researches. in this regard, the steps taken by kathmandu university in starting dm and mch courses on various subjects at the college of medical sciences teaching hospital, bharatpur are timely and appreciable. kathmandu university has always been a pioneering institution in starting various innovative and practical courses in the country and such milestones will also be a leap in medical education. we fully agree with the idea that nepal needs to put brakes on the conventional development and should make leaps not only in economic but also in every aspect of development. the steps taken by kathmandu university should be encouraged and supported by the medical community. we are sure these measures taken by the university and the efforts taken by the persons behind these programs will be remembered forever not only by the medical community of the nation but also by the general public. as these courses are research based advance clinical degrees, priorities are on both advance research and clinical super specialty subjects. therefore, we hope these programs will produce not only highly skilled, community and service oriented specialists but also well trained researchers and strengthen the research wing of the medical science. we hope these efforts and steps will also make a wake up calls to various institutions in collaborating for the success of this historymaking effort of kathmandu university. editiorial editorial diagnostic imaging, present & future dr. p.k. deka, md, ficr prof & hod, radiodiagnosis, college of medical sciences, bharatpur, chitwan, nepal just a few decades ago when i joined radiology as a junior faculty member, little we could realised that many great discoveries are going to happened soon. there had been tremendous technologic explosions during the decades from 1970s through 1980s. during this past 30 years, the radiology & imaging has seen accelerated growth in technology with introduction of interventional radiology, nuclear medicine and an access to cross – sectional imaging. as a matter of fact technologies that are used today in the field of radiology & imaging did not exist a decade age. about one-third of radiologic imaging procedures and two-third of the relative value units involved in radiological imaging, especially ct, mri, us, interventional radiology or nuclear medicine were only in its experimental and nascent stages. the medical imaging is now increasing in sensitivity and specificity towards optimum precision. it is acquiring and displaying data in 3d/4d dimensions and on the verge of providing virtual presentation. functional imaging has become a reality. in the near future genetic and molecular marker imaging is going to be a part of imaging system. the futuristic developments shall make the progress in conventional radiology with picture achieving and communication system (pacs), ct, mri intervention radiology and nuclear medicine. remarkable progress in electronic and computer engineering shall benefit diagnostic imaging with further advances which will continue for years to come. introduced 30 years back ct has undergone numerous advances. a three dimensional reformatting and rotation of images has been introduced and this technique is becoming increasingly useful to the plastic surgeons, vascular surgeons and neurosurgery. introduced in 1998, the multi slices ct (msct) has rapidly evolved 2/4/8/16/32/64 slices. adaptive spiral ct has debuted on the block and with this technique perfusion study of several body region can be performed. ct has nearly peaked itself in its capacity and the one beat, three beat cardiac ct have reached their potential as commented by one sr. technologist. about 25 years ago, a diagnostic technique in which radio waves generated in a strong magnetic field were used to provide information about the hydrogen atoms in different tissues within the body was introduced, it is mri. since then there is a growth rate of about 10 percent per year, and the trend will continue due to new application of magnet and gantry design. at present, three tesla diagnostic mri is preferred by most institutions which deliver clear images of the body organs. the most important clinical areas those are currently significant for mri is neurosciences, oncology, ent and orthopaedics. during the next 10 years or so the newer areas of attention shall be the breast imaging, cardiology and interventional invasive procedures. mri will complement ct in future in assessing brain function and shall be a standard of care for all white matter brain diseases. ultrasonography (us) has fetched the status of the most popular cross-sectional diagnostic modality all over the world, especially, in the developing countries, it is the only cross-sectional modality available. as commented by a sr. sinologist the popularity of the present us is due to advances in resolution of images. with introduction of contrast in doppler techniques, us shall continue to be the predominant imaging modality in the present time. the other area of future imaging is the fusion imaging where two modalities provide a combined enhanced images. the common examples are in nuclear imaging with spect-ct and pet-ct. pet/ spect provides functional information about tissue properties, function and viability. the common application for pet-ct is in cancer staging of tumour, treatment planning and therapy. radiology and imaging training to the pgs and interns are perhaps far from adequate. sub-specialization is imperative. depth of knowledge is of course essential. a chest physician can read high-resolution ct scan better, a child specialist understand paediatric imaging better, so also a neurologist and neurosurgeon etc. with adjusted protocols radiologist will have to be a part of the system. radiology and imaging is one of the most powerful diagnostic approaches in clinical medicine to-day. so also the role of a radiologist! 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 formation of median nerve by three roots a case report formation of median nerve by three roots: a case report n. satyanarayana1, c.k. reddy2, p. sunitha3, n. jayasri4, v. nitin5, g. praveen6, r. guha7, a.k. datta8, m. m. shaik9 1, 5, 6lecturer in anatomy, 2associate prof in anatomy, pims, karimnagar, india, 3lecturer in physiology , 7,8professor in anatomy, 9lecturer in pharmacology, college of medical sciences, bharatpur, nepal, 4professor & head, dept of anatomy, caims, karimnagar abstract: during routine dissection of an adult male cadaver in the department of anatomy, college of medical sciences, bharatpur, nepal, the right median nerve was found to be formed by three roots. the finding was noted after thorough and meticulous dissection of the upper limbs of both sides (axilla, arm, forearm and palm). out of the three roots forming the anomalous median nerve, two were from lateral cord and one from medial cord of brachial plexus. however, the distribution of the anomalous median nerve was normal in arm, forearm and palm. the arterial pattern in the arm (axillary and brachial arteries) was also normal. key words: cadaver, median nerve, brachial plexus case report: during routine dissection of an adult male cadaver in the department of anatomy, college of medical sciences, bharatpur, nepal, anomalous median nerve with regard to its formation was found. dissection of both the upper limbs (axilla, arm, cubital fossa, forearm and palm) was done thoroughly and meticulously to find out the mode of formation, relations and distribution of the anomalous right median nerve and the status of the left median nerve. it was found that the right median nerve was formed by three roots, two coming from lateral cord and one from medial cord of brachial plexus. the uppermost or highest root was noted to be at the level of origin of coracobrachialis muscle. the second root was found to be immediately below the first one. these two roots were found to be passing obliquely in front of second and third part of axillary artery and joining individually with the medial root of median nerve and forming median nerve trunk, in front of third part of axillary artery. (figure no.-1) further distribution of the anomalous median nerve in the arm, forearm and palm was normal. the arterial pattern in arm was also normal. the left median nerve was also normal. discussion: the median nerve is normally formed by the union of two roots: lateral root of median nerve coming from the lateral cord (c5, c6, c7) of brachial plexus and medial root of median nerve coming from the medial cord (c8, t1) of brachial plexus. the two roots embrace the third part of the axillary artery, uniting anterior or lateral to it. some fibres from c7 often leave the lateral root in the lower part of the axilla passing correspondences: dr. n. satyanarayana e-mail: satyam_n19@yahoo.com case report, 47-50journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 47 distomedially posterior to the medial root, usually anterior to axillary artery, to join the ulnar nerve: they may branch from the seventh cervical ventral ramus. clinically they are believed to be mainly motor to the flexor carpi ulnaris. the median nerve enters the arm at first lateral to the brachial artery. near the insertion of the coracobrachialis, it crosses in front of (rarely behind) the artery, descending medial to it, to the cubital fossa, where it is posterior to the bicipital aponeurosis and anterior to the brachialis, separated by the latter from the elbow joint. it usually enters the forearm between the heads of the pronator teres, crossing to the lateral side of the ulnar artery and separated from it by the deep head of pronator teres.1 variations in the formation of median nerve were noted by some earlier workers. however, most of the variations as presented by them were related to anomalous relationship between median and musculocutaneous nerves. chauhan and roy (2002) reported formation of median nerve by two lateral and one medial root.2 same observation was reported by saeed and rufai (2003).3 satyanarayana and guha (2008) reported formation of median nerve by four roots (three lateral and one medial root).4 in other study, it was found that the lateral root was small and the musculocutaneous nerve was connected with median nerve in the arm.5 another study involving dissection of ten cadavers, mentioned failure of separation of musculocutaneous nerve from the median nerve and the latter therefore gave off the branches that should arise from musculocutaneous nerve, namely branches to coracobrachialis, biceps brachii and major part of brachialis.6 however the variation related to the formation of median nerve by more than two roots which were observed in the present study is rare as revealed by survey of literatures. such variation can be explained in the light of embryogenic development. the first indication of limb musculature is observed in the seventh week of development as condensation of mesenchyme near the base of the limb buds. with further elongation of the limb buds, the muscle tissue splits into flexor and extensor compartments. the upper limb buds lie opposite the lower five cervical and upper two thoracic segments. as soon as the buds form, ventral primary rami from the spinal nerves penetrate into the mesenchyme. at first, each ventral ramus divides into dorsal and ventral branches, but soon these branches unite to form named peripheral nerves which supply extensor and flexor group of muscles respectively. immediately after the above mentioned rearrangement of nerves, they enter the limb buds and establish an intimate contact with the differentiating mesodermal condensations and this early contact between the nerve and muscle cells is a prerequisite for their complete functional differentiation.7 over the years, two principal theories have emerged concerning the directional growth of nerve fibres-the neurotropism or chemotropism hypothesis of ramon y cajal.8 and the principle of contactguidance of weiss.9 the salient feature of chemotropism is that axonal growth cones act as sensors to concentration gradients of molecules in the environment and grow up the gradient towards the source, i.e. the target. journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 48 there is no doubt, however that contact guidance mechanisms operate in parallel with neurotropism. adhesion to the structures with which the growth cone contacts also plays a role. a group of cell surface receptors viz. neural cell adhesion molecule (n-cam) and l1 and the cadherins act as transcription factors which recognize and bind to components of the extracellular matrix. thus, both cell-cell and cell-matrix interactions may be involved in axonal pathfinding.10 over or under expression of one or multiple transcription factors as mentioned above have been found to be responsible for the variations in the formation, relation and distribution of the motor nerve fibers10. the variations could arise from circulatory factors at the time of fusion of the cords of brachial plexus.11 the variations in the formation of median nerve in the arm bear remarkable clinical significance. considering these variations rao advocated that the clinicians and surgeons should be aware of such variations while performing surgical procedure in this region.12 injury to such a variant nerve in the proximal arm may lead to a galaxy of manifestations including sensory, motor, vasomotor and trophic changes.3 the possible clinical implications of these variations relating either to the surgical approach to the shoulder joint and entrapment syndromes are important.13 anomalies of axillary or brachial artery are frequently related to unusual pattern of brachial plexus and median nerve.14 however, in our case no abnormal arterial pattern was detected. references: 1. williams pl, bannister lh, berry mm, et al gray’s anatomy. in: nervous system. 38th ed. london churchill livingstone, 1999; 1270. 2. chauhan and roy communication between the median and musculocutaneous nerve-a case report.journal of the anatomical society of india. 2002:52(1):72-5. 3. saeed and rufai,a.a.-median nerve and musculocutaneous nerves:variant formation and distribution. clinical anatomy.2003:16:453-7. 4. satyanarayana n and guha r -formation of median nerve by four roots. j college of medical sciences 2008;vol.5,no.1:105-7. 5. standring s, ellis h, healy jc, et al gray’s anatomy. in: general organisation and surface anatomy of the upper limb.39th ed. philadelphia elsevier churchill livingstone, 2005; 803-4. 6. guha r and palit s a rare variation of anomalous median nerve with absent musculocutaneous nerve and high up division of brachial artery. j interacad 2005; 9(3): 398-403. 7. saddler tw langman’s medical embryology. in: muscular system. 10th ed. philadelphia lippincott williams & wilkins, 2006; 146-7. 8. ramon y cajal s – accion neurotropica de los epitelios. algunos detalles sobre el mecanismo genetico de las ramificaciones nerviosas intraepiteliales sensitivas y sensoriales. trab lab invest biol 1919; 17:65-8. 9. weiss p – nerve patterns: the mechanics of nerve growth. growth (suppl 5) 1941; 163-203. 10. williams pl, bannister lh, berry mm, et al gray’s anatomy. in: embryology and development. 38th ed. london churchill livingstone, 1999; 231-2. 11. kosugi,k mortia. t,yamashita.h: branching pattern of the musculocutaneous nerve-jikeakai medical journal.1986;33:63-71. 12. rao ppv and chaudhary sc communication of musculocutaneous nerve with the median nerve. east afr med j 2000; 77(9):498-503. 13. venieratos d and anagnostopoulou s – classification of communication between musculocutaneous and median nerves. clin anat 1998; 11(5): 327-31. 14. basar r, aldur mm, celik hh, et ala connecting branch between the musculocutaneouos nerve and the median nerve. morphologie 2000; 84(266): 25-7. n. satyanarayana et al. unusual case of laryngeal foreign body: a case report 49 figure no.-1. shows formation of median nerve by three roots, two from lateral cord of brachial plexus joining individually with medial root of median nerve forming the median nerve trunk. lc= lateral cord, r1= root one, r2= root two, r3= root three, mn= median nerve, mcn= musculocutaneous nerve, un= ulnar nerve, aa= axillary artery, ba= brachial artery, bb=biceps brachii, cbm=coracobrachialis muscle. journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 50 51 journal of college of medical sciences-nepal, 2014, vol-10, no-3 introduction traumatic asphyxia is a rare condition presenting with cervicofacial cyanosis and edema, subconjunctival hemorrhage, and petechial hemorrhages of the face, neck, and upper chest that occurs due to a compressive force to the thoracoabdominal region1. it was first reported by olivier approximately 170 years ago in victims trampled by crowd in paris 2, 3. although the exact mechanism is controversial, it is probably due to thoracoabdominal compression causing increased correspondence: dr bikash sah e-mail: bikashsa01@gmail.com a case report of traumatic asphyxia sah b1, yadav b.n.2, jha s.3 1assistant professor, 2professor, 3additional professor, department of forensic medicine & toxicology b.p. koirala institute of health sciences, dharan. abstract: traumatic asphyxia is a condition presenting with cervicofacial cyanosis and edema, subconjunctival hemorrhage, and petechial hemorrhages of the face, neck, and upper chest that occurs due to a compressive force to the thoracoabdominal region. in this case report a 52 years old lady who was brought to the mortuary because of death due to traumatic asphyxia as a result of being stampeded by her own cows upon her chest was discussed. congestion on both the conjunctiva, cyanosis on chin and adjacent upper left side of neck found with a well demarcated area observed between the cyanosed area over face and the normal area of neck. hematoma was present in the chin and the adjacent neck region. apart from quickly eliminating organ pathologies and initiation of supportive therapy in a case of traumatic asphyxia, possibility of formation of hematoma in neck after few hours of getting injured should also be considered, as this type of hematoma may contribute to the cause of death. keywords: autopsy, cyanosis, hematoma, stampede, traumatic asphyxia intrathoracic pressure just at the moment of the event. the fear response, which is characterized by taking and holding a deep breath and closure of the glottis, also contributes to this process1, 4 this back pressure is transmitted ultimately to the head and neck veins and capillaries, with stasis and rupture producing characteristic petechial and subconjunctival hemorrhages 4. traumatic asphyxial deaths can occur in variety of situations, such as motor vehicle accidents, railway-related fatalities, elevator accidents, buildings journal of college of medical sciences-nepal, 2014, vol-10, no-3 52 was immediately resuscitated but could not be saved. postmortem examination was conducted approximately 8 hours after her death. death in this case was because of traumatic asphyxia contributed by neck hematoma. she was not known to have been suffering from any diseases that could have either caused or contributed to death. autopsy findings autopsy examination revealed distinct cyanotic, edematous, and multiple petechiae on the chin, upper left side of neck of the victim. bilateral subconjunctival hemorrhage was detected. a well demarcated area was observed between the congested area over face and the normal area of neck along with linear abrasion present on the left side of mid neck region (figure 1). left seventh, eighth, ninth and tenth ribs were fractured. internally, hematoma was present in the chin and the adjacent neck region; the lungs were congested and cut surface revealed oozing of frothy blood. the rest of the internal organs were unremarkable. figure 1: linear abrasion in the mid of the neck and contusion in the chin region. collapse, landslides and stampede. however, motor vehicle accidents are the most common cause of traumatic asphyxial deaths 2 . in patients with traumatic asphyxia, injuries associated with other systems may also accompany the condition. jongewaard et al. reported chest wall and intrathoracic injuries in 11 patients, loss of consciousness in 8, prolonged confusion in 5, seizures in 2, and visual disturbances in 2 of 14 patients with traumatic asphyxia 5. in this case report a female patient with traumatic asphyxia because of being stampeded by her own cows was discussed. case history in this case report, a 52-years-old female who was brought to the mortuary after death due to traumatic asphyxia was discussed. from the anamnesis of the patient, the lady was stampeded by her own cows on the evening of 9th march 2014. as per eyewitnesses, the mishap took place when she was about to put fodder for the cows. one cow suddenly turned her head and tried to hit the lady by her horns. sensing something wrong, the lady suddenly turned and tried to run away to save herself. however, due to sudden turning, she lost her balance and fell near the legs of the cow. three cows eventually stampeded upon her. she was then rescued and brought to the hospital (bp koirala institute of health sciences). as per her relatives, she was declared normal by the clinical examinations and radiological investigations (x-rays and ultrasonography) done by the attending doctor and because of no any organ pathology being detected, she was suggested to go back home the same day but because of request from the relatives, she was kept in observation for that day. next morning at about 9 am, she was not responding to the attending nurse. she 53 journal of college of medical sciences-nepal, 2014, vol-10, no-3 discussion traumatic asphyxia is a rare condition presenting with cervicofacial cyanosis and edema, petechial, and subconjunctival hemorrhages of the face, neck, and upper chest that occurs usually due to a compressive force to the thoracoabdominal region but has also been associated with asthma, paroxysmal coughing, protracted vomiting, and jugular venous occlusion 6, 7. however, for these signs to be present, the following two processes should occur simultaneously 8. the first is mechanical reflux of blood from chest into cervicofacial region. the second is vasomotor paralysis due to pressure on thoracic sympathetic nerves resulting in distension of vessels with desaturated blood. additionally, reflex closure of glottis, which occurs to brace against the impending force as the victim has warning of being crushed 9, 10, also augments the venous reflux. the venous reflux into cervico-facial region occurs through the competent venous valves of the internal jugular veins (ijvs), external jugular veins (ejvs) and vertebral veins (vvs). thus for better comprehension of cervico-facial congestion and petechiae, description of anatomical pathway of the ijv, ejv, vv and function of valves is undertaken. the ijvs are considered to be the main pathways of blood drainage from the brain, the superficial part of the face and the neck. it begins at the base of skull and then runs down the side of the neck along the carotid artery. at the root of the neck, ijv unites with the subclavian vein to form the brachiocephalic vein, which meets the superior vena cava. 11, 12 the ejvs mainly drains the scalp and the deep part of face. it begins near the mandibular angle, and then descends from the mandibular angle to the mid-clavicle superficial to the sternocleidomastoid. at the root of neck it ends in the subclavian vein 11, 12. the vvs along with the deep cervical veins (dcvs) represents the major non-jugular cerebrovenous drainage pathway. vv is formed in suboccipital triangle from where it goes through the canal formed by the foramina transversaria of cervical vertebra to open at the root of neck into the brachiocephalic vein. the dcv is also formed in the suboccipital region and ends in the lower part of vv.12 regarding the function of craniocervical venous valves, it has been proved that competent valves of the ijv 13, ejv 14 and vv15 prevent the retrograde flow of cephalic venous blood in these veins. however, the sudden thoraco-abdominal compression in traumatic asphyxia causes acute incompetence of these valves resulting in characteristic venous discoloration of the head and neck. in contrast to this, the congestion and petechiae are not seen over lower body due to the inferior vena cava compression as a result of valsalva maneuver produced subsequent to pre-impact fear response 16. in the present study, the case showed unusual facial congestion in the form of involvement of chin and adjacent neck region especially in the upper left neck region only. the reason for such left sided neck congestion may be due to compression of chest on left side. however, it showed well demarcated area between the congested area and normal area. this demarcation is characteristic of venous congestion caused by circumstances that are compatible with traumatic asphyxia such as entrapment beneath or within motor vehicles, or under heavy objects 17. abrasion present in the left side of mid neck region suggest the congestion in the chin and upper left neck region might be due direct trauma also. however, the congestion is at higher level than abrasion that is at the traumatic site. journal of college of medical sciences-nepal, 2014, vol-10, no-3 54 in this case, all the clinical examinations and investigations revealed no any abnormality that may lead to death. however, death occured within 24 hours of declaring that she was alright. the cause of death as per postmortem examination was found to be traumatic asphyxia contributed by compression of trachea by upper neck haematoma. the reason behind undetectable neck haematoma found at postmortem examination, by ultrasonography might be due to usg performed immediately after the incident while the haematoma contributing to cause of death might take some time for its formation and enlargement to the enough size to compress the trachea. fractured ribs which were not detected in x-ray might be due to proper approximation or they might be fractured at terminal stage resuscitation. conclusion when characteristic findings of traumatic asphyxia are detected in trauma patients, apart from quickly eliminating organ pathologies and initiation of supportive therapy, possibility of formation of hematoma in neck after few hours of sustaining injury should also be considered. the neck hematoma finding in this present study suggests that the clinicians should keep on reexamining such patient for neck hematoma for at least 24 hours of getting injured and also to make them aware that this type of hematoma may contribute to the cause of death. this knowledge will definitely help the clinician to save such patients by taking the needful steps. references 1. richards ce, wallis dn., asphyxiation: a review. trauma 2005;7:37–45. 2. conroy c, stanley c, eastman ba. asphyxia: a rare cause of death for motor vehicle crash occupants, am j forensic med pathol 2008;29:14–8. 3. lowe l, rapini rp, johnson tm. traumatic asphyxia. journal of the american academy of dermatology 1990;23(5):972–4. 4. williams js, minken sl, adams jt. traumatic asphyxia—reappraised. ann surg 1968;167(3):384–92. 5. jongewaard wr, cogbill th, landercasper j. neurologic conseq uences of traumatic asphyxia. j t rauma 1992;32(1):28–31. 6. richards ce, wallis dn. asphyxiation: a review. trauma 2005;7(1):37–45. 7. newquist mj, sobel rm. traumatic asphyxia: an indicator of significant pulmonary injury. american journal of emergency medicine 1990;8(3):212–5. 8. conwell he. traumatic asphyxia: report of four cases, j. bone joint surg. 1927;9:106–10. 9. lee mc, wong ss, chu jj, et al. traumatic asphyxia, ann thorac surg 1991;51:86–8. 10. wardrope j, ryan f, clark g, et al. the hillsborough tragedy, br med j 1991;303:1381–5. 55 journal of college of medical sciences-nepal, 2014, vol-10, no-3 11. morimoto a, takase i, shimizu y, nishi k. assessment of cervical venous blood flow and the craniocervical venous valve using ultrasound sonography. leg med (tokyo) 2009 ;11(1):10-7. 12. g. gabella, cardiovascular system, in: l.h. bannister, m.m. berry, p. collins, m. dyson, j.e. dussek, m.w.j. ferguson (eds.), gray’s anatomy: the anatomical basis of medicine and surgery, 38th ed. churchill livingstone harcourt publishers limited, london, 1995, 1451–626. 13. fisher j, vaghaiwalla f, tsitlik j, et al. determinants and clinical significance of jugular venous valve competence, circulation 1982;65:188–96. 14. lipton b. estimation of central venous pressure by ultrasound of the internal jugular vein. am j emerg med 2000;18:432–4. 15. chou ch, chao ac, hu hh, ultrasonographic evaluation of vertebral venous valves. am j neuroradiol 2002;23:1418–20. 16. thompson jr, illescas ff, chiu rc. why is the lower torso protected in traumatic asphyxia? a new hypothesis. ann thorac surg 1989;47:247–9. 17. byard rw, wick r, simpson e, et al. the pathological features and circumstances of death of lethal crush/ traumatic asphyxia in adults – a 25-year study. forensic sci int 2006;159:200–5. original articel prescribing indicators and pattern of use of antibiotics among medical outpatients in a teaching hospital of central nepal jeetendra kumar1, m. m. shaik2, m. c. kathi2, a. deka3, s .s. gambhir3 1assistant professor, 2lecturer, 3professor, department of clinical pharmacology, college of medical sciences bharatpur, chitwan, nepal abstract the study of prescriptions using prescribing indicators enables us to detect some common problems of prescribing and to focus subsequent efforts to correct them. this study was designed to define the extent and pattern of drug prescribing with emphasis on that of antibiotics among medical outpatients of teaching hospital of college of medical sciences bharatpur, nepal. the data contained on randomly selected original prescriptions of patients attending medical opd in between january2008 and june2008 were collected prospectively on duplex prescriptions and analyzed. a total of 955 drugs were prescribed to 339 patients. the average number of drugs per encounter was 2.81. drugs prescribed by generic name were 20.31% and those matched to national essential drugs list were 49.63%. encounters with antibiotics were 43.95%. antibiotics were the most frequently prescribed therapeutic class. azithromycin, ciprofloxacin and amoxycillin were three most frequently prescribed antibiotics. respiratory tract infection was the most common indication, for which antibiotics were given. selections of antibiotics were rational for most of the indications but bacteriological confirmation prior to institution of antibiotics were not done in any case. polypharmacy, inclination for branded products and overuse of antibiotics were revealed as problems requiring educational interventions and strict antibiotic policy as subsequent efforts to rectify them. key words: antibiotics, medical outpatients, prescribing indicators, teaching hospital. introduction the drug prescribing remains the end result of most of the medical consultations. this is one clinical skill that almost every physician practises regularly to transact the desired therapeutic goal. this is one important skill as the outcome of drug therapy depends much on this. drug is one of the most important components of the health care delivery system and account for a large percentage of its cost. these facts warrant the rational prescribing as an essence of a cost-effective medical care. rational prescribing refers to prescribing of right drug to the right patient, in the right dose, at right time intervals and for right duration. however, irrational prescribing has been widely reported both from the developed as well as the developing world1. the cost of irrational use of drugs consequent to irrational prescribing is enormous in terms of both scarce resources and adverse clinical consequences such ascorrespondence: dr. jeetendra kumar e-mail:drjktkhag2003@yahoo.co.in original article, 7-13journal of college of medical sciences-nepal, 2010, vol.6, no-2 7 ineffective or unsafe treatment, exacerbation or prolongation of existing illness, iatrogenic illnesses and emergence of resistance to antimicrobials. antibiotics have been found to be the most commonly prescribed and used class of drugs in several national and international studies.2,3,4,5 the emergence of antibiotic resistant bacterial pathogens on a large scale over last two decades is taken as an inevitable consequence of these over uses of antibiotics worldwide.6,7 strategies that optimize antibiotic use are therefore essential to minimize this microbial threat to suffering as well as to treating community of world. prescribing indicators are one of the core drug use indicators developed by world health organization (who) in a collaborative work with international network for rational use of drugs (inrud)8. these indicators can be used efficiently in many settings of drug use study to detect problems in drug prescribing such as polypharmacy, inclination for branded products, over use of antibiotics or injections and prescribing out of formulary or essential drugs list9. study of prescribing practices using prescribing indicators enables us to detect these problems and to prioritize and focus subsequent efforts to correct them. such studies accompanied with providing feedbacks to prescribers at regular intervals has been proved to be an effective strategy to optimize the use of antibiotics and other drugs and also to reduce the resistance related problems.8,9,10 various problems of prescribing including the overuse of antibiotics have been revealed in studies carried out in hospitals of other regions of nepal.2,3 polypharmacy, non-adherence to national formulary and inclination of prescribers for branded and fixed dose combination products were revealed in a previous study conducted among orthopedic outpatients in the teaching hospital of college of medical sciences bharatpur.11 however, the information on the prescribing practices of antibiotics and other drugs among medical outpatients in this hospital is lacking. this study was undertaken therefore with an objective to define the extent and pattern of drug prescribing with a special reference to that of antibiotics among medical outpatients in this hospital and to delineate areas of improvement. this study was attempted also to highlight the subsequent needed efforts by the prescribers to correct them and to make their practices more rational and cost-effective. this study will serve to generate the basic data for more comprehensive study in the future and for a comparative study by other investigators. materials and methods this cross-sectional descriptive study was conducted at the teaching hospital of college of medical sciences bharatpur. this is a tertiary care hospital located in the chitwan district of central nepal. patients were approached for their prescriptions at the pharmacy of the hospital on a prefixed day in each week in between january 2008 and june 2008. only freshly registered medical outpatients were selected randomly for this study. revisit cases and prescriptions with admission order were excluded from this study. all informations contained on each selected prescription were recorded on the duplex prescription papers having all the columns of an original prescription paper. each patient was explained the nature and purpose of study well before recording the data from his or her prescription. the data was collected prospectively by this method from 339 original prescriptions belonging to same number of patients selected for this study. prescriptions were analyzed strictly under who guidelines to get the value of each of prescribing indicators.8 analysis of prescriptions were done also journal of college of medical sciences-nepal, 2010, vol.6, no-2 8 to get the distribution of different therapeutic classes of prescribed drugs, the distribution of classes of antibiotics and frequently prescribed individual antibiotics. prescriptions were further analyzed to get the pattern of frequently prescribed individual antibiotics against different diagnosis. each of fixed dose combination drugs was counted as a single drug. antitubercular drugs and anti-protozoals such as metronidazole and tinidazole were not counted as antibiotics as per the instructions of who.8 prescribed drugs were compared with those included in the latest essential drugs list of nepal12 to measure the deviation from the national formulary. the number and the percentage were used to express the observed data. results a total of 339 prescriptions belonging to same number of patients contained a total of 955 drugs. the average number of drugs per encounter was 2.81. two hundred and thirty two patients (68.4%) were prescribed 2-3 drugs. more than three drugs were prescribed in 77(22.8%) patients. thirty (8.8%) patients received only one drug. only 194 (20.31%) drugs out of total 955 drugs were prescribed by generic name. drugs prescribed from essential drugs list of nepal were 474(49.63%). prescribing indicators are detailed in table-1. table 1: prescribing indicators among medical outpatients antibiotics were the most frequently prescribed therapeutic class followed by drugs for peptic ulcer syndrome, non-steroidal anti-inflammatory drugs, multivitamins and anti-histaminics. other commonly prescribed classes were anthelmintics, cough and cold remedies, anti-protozoals, bronchodilators and antihypertensives. among 149 patients who received antibiotic, only 9 patients were exposed to two antibiotics concurrently and rest of the patients were exposed with only one antibiotic. antibiotics constituted 16.54% of totally prescribed drugs. table2 shows the prescribing frequency of different therapeutic classes. table 2: therapeutic classes of drugs prescribed prescribing indicators no. % prescriptions analyzed 339 100 drugs prescribed 955 100 average number of drugs/encounter 2.81 encounters with an antibiotic 149 43.95 encounters with an injection 008 2.36 drugs prescribed by generic name 194 20.31 drugs prescribed from essential drugs list of nepal 474 49.63 s.n. therapeutic class no. % 1. antibiotics 158 16.54 2. drugs for peptic ulcer syndrome 147 15.39 3. nsaids 122 12.77 4. multivitamins 79 8.27 5. anti-histaminics 68 7.12 6. anthelmintics 58 6.07 7. cough & cold remedies 41 4.29 8. antiprotozoals 39 4.08 9. bronchodilators 35 3.66 10. antihypertensives 31 3.24 11. anti-emetics 24 2.51 12. antidepressants 24 2.51 13. anti-spasmodics 12 1.25 14. anti-diabetics 12 1.25 15. nasal decongestants 12 1.25 16. miscellaneous drugs (antiseptics, antivirals, anti-tb, steroids etc.) 93 9.73 total 955 100 jeetendra kumar et al, prescribing indicators and pattern of use.......................... 8 macrolides ranked the first among prescribed classes of antibiotics followed by fluoroquinolones and betalactams. figure-1 describes the prescribing frequency of different classes of antibiotics. figure 1: prescribing frequency of classes of antibiotics 64 44 32 8 10 0 10 20 30 40 50 60 70 n u m b e r o f d ru g s macrolides fqs penicliins cephalosporins miscellaneous five most frequently prescribed individual antibiotics in decreasing order were azithromycin, ciprofloxacin, amoxycillin, ofloxacin and norfloxacin. figure-2 details the prescribing frequency of individual antibiotics. figure 2: prescribing frequency of individual antibiotics antibiotics 53 24 21 11 9 24 0 10 20 30 40 50 60 azithromycin ciprofloxacin amoxycillin ofloxacin norfloxacin miscellaneous reasons for antibiotic institution in decreasing order were respiratory tract infections (rtis), urinary tract infections (utis), gastrointestinal infections (gitis), enteric fever and pyrexia of unknown origin (puo). azithromycin and amoxycillin were two most frequently prescribed antibiotics for respiratory tract infections. ciprofloxacin and norfloxacin were preferred for urinary tract infections. ciprofloxacin or ofloxacin were used to treat cases of enteric fever. further analysis of prescriptions containing two antibiotics revealed that amoxycillin and clarithromycin were those two antibiotics and they had been prescribed only for all those nine cases where helicobacter pylori infections were suspected as the cause of peptic ulcer syndromes. diagnosis was not mentioned at all in 14 cases and antibiotics were prescribed also for these cases. pattern of five most frequently prescribed antibiotics for different diagnosis has been detailed in table 3. table 3: pattern of five most frequently prescribed antibiotics for different diagnosis out of 135 patients for whom the diagnosis was mentioned, it was made only clinically in 112(75.16%) cases. clinical findings and the reports of laboratory investigations were employed to diagnose only 8 cases. clinical and radiological findings were combinedly considered to diagnose 5 cases and for another each 5 cases, decision was based on the reports of either laboratory investigations or radiological examinations. antibiotics were prescribed therapeutically in 103(69.12%) patients and prophylactically in d iag n osis n o.(% ) a zith ro m y cin c ip ro flo xacin a m ox y cillin o flo xacin rti 79 (53.02) 43 06 14 03 uti 17 (11.41) 02 06 xx xx giti 15 (10.07) xx 04 05 xx enteric fever 12 (8.05) xx 06 xx 06 puo 12 (8.05) 04 02 xx 02 not m entioned 14 (9.4) 04 xx 02 xx total 149 (100) 53 24 21 11 journal of college of medical sciences-nepal, 2010, vol.6, no-2 10 46(30.88%) patients. the therapeutic or the prophylactic use of antibiotics was ascertained only clinically. institution of antibiotic for therapeutic purpose was empirical in all 103(69.12%) patients and a prior bacteriological confirmation was not considered in even a single case. antibiotics were instituted by oral route in 150(94.94%) instances and parenteral route was preferred in 8(5.06 %) instances only. discussion the average number of drugs per encounter is the most commonly measured index that is used to assess the extent of polypharmacy. the value of this index observed in our study was 2.81. the same value for this index was observed in a previous study conducted among orthopedic outpatients in our hospital.11 our observed value represents a better figure in comparison to those reported in studies of eastern nepal2(5.3), india4(3.75), bangladesh13(3.81), iran5(3.43) and nigeria14(3.5). however this is not better than those reported in the studies of western nepal3(1.5), pakistan15(2.7), saudi arabia16(2.1) and sudan17(1.9). the who recommends that the average number of drugs per prescription should be less than two.8 the observed value in our study therefore may be taken as an evidence of existing polypharmacy. this index should be kept as low as possible to avoid the unfavorable outcomes of polypharmacy such as increased risk of drug interactions, increased cost of therapy, non-compliance and emergence of resistance in case of use of antimicrobials. five most commonly prescribed therapeutic classes in our study were antibiotics, drugs for peptic ulcer, nsaids, multivitamins and antihistaminics. antibiotics, nsaids, drugs for peptic ulcer and antihistaminics were reported as most common classes also in the study of western nepal.3 antibiotics, analgesics and antiinflammatory drugs and vitamins were most frequently classes observed in the study of eastern nepal.2 antibiotics and nsaids were reported as two most frequently prescribed classes also in the studies of saudi arabia16 and iran5. antibiotics were the most commonly prescribed group also in the indian study.4 our as well as other studies thus confirm the antibiotics as most widely prescribed and used class of drugs. in the studies of eastern and western nepal, antibiotics were prescribed in 84% and 59.9% of encounters respectively.2,3 in the studies conducted in bangladesh13, pakistan15, nigeria14 and united kingdom18 encounters with one or more antibiotics were found to be 72.5%, 52%, 54.8% and 77% respectively. our study revealed a better figure in this concern as encounters with an antibiotic were less than these reports i.e. only 43.95%. however this value is not better than that reported in a jordanian study19 where only 35.6% encounters contained antibiotics. this is a higher figure also in the context of suggestion made by the who that less than 30% of encounters should include one or more antibiotics.8 our study report thereby is an indication that antibiotics are overused in our hospital. but prescribers in our hospital seem to be rational regarding the use of antibiotics as in majority of cases only one antibiotic has been prescribed and only nine patients got two antibiotics concurrently. among those who got two antibiotics, peptic ulcer syndrome due to helicobacter pylori were suspected strongly and amoxycillin and clarithromycin were prescribed as a part of triple drug regimen to eradicate this microbe. prescribing azithromycin and amoxycillin for respiratory tract infections, jeetendra kumar et al, prescribing indicators and pattern of use.......................... 11 ciprofloxacin and norfloxacin for urinary tract infections and ciprofloxacin and ofloxacin for enteric fever cases also point towards a rational approach of prescribers. this is also favored by this fact that antibiotics were given only through oral route in about 95% instances. however, overuse of antibiotics should be discouraged as this contributes to emergence of resistance20. institution of antibiotics only on the basis of clinical diagnosis and without a prior bacteriological confirmation was observed in majority of cases of this study. this was practiced in an outpatient setting where bacteriological confirmation was not possible in one day. even after this fact, this kind of practice is not justified for the above mentioned reason and should be discouraged as far as possible. encounters with an injection in our study were found to be only 2.36%. this is a far below and favorable figure in comparison to that set forth by who in this concern i.e. less than 10%.9 this proves that prescribers in our hospital are more awared and rational regarding use of injections. drugs prescribed by generic name in our study were observed to be 20.31%. in a previous study conducted among orthopedic outpatients in our hospital, only 7.2% drugs were prescribed by generic name.11 therefore the finding of present study proves an improvement in our hospital regarding prescribing by generic name. however, our observed value is low in comparison to that observed in the study of eastern nepal where 29.3% drugs were prescribed by generic name.2 our finding is a remarkably low figure in comparison to those reported in the studies of western nepal 3(63.5%), india4(96.5%), iran5(97.2%) and sudan17(43.6%). prescribers in our hospital thus seem to be inclined towards branded products. the most likely reason behind this inclination might be either highly powered salesmanship of drug manufacturing companies to sell their products or the unawareness among prescribers for the advantages of generic prescribing. prescribing by generic name offers several advantages including less cost of therapy and less dispensing errors and this needs to be promoted among prescribers of our hospital. drugs prescribed from essential drugs list of nepal were 49.63% in the present study. the observed value in the previous study of orthopedic outpatients of this hospital in this regard was 46.2%.11 the observed value of present study thus appears to be slightly improved in comparison to previous one. however this is not better than those observed in the studies of western nepal3 and bangladesh13. apart from unawareness regarding benefits of prescribing from essential drugs list, the unavailability of hospital formulary or national list in the hospital or pharmacy seems to be reasons for the observed deviation. prescribing from such list is beneficial in terms of costeffectiveness and safety as drugs are selected with due regard to local disease prevalence, evidence of efficacy and safety and the cost. prescribing from such list should be encouraged to ensure rational use of medicines. conclusion there is a much scope for improvement consequent to this study. polypharmacy, non-adherence to national formulary, inclination for branded products and overuse of antibiotics are different problems that needs attention by prescribers. educational interventions emphasizing rational prescribing along with a multidirectional effort to create an updated local formulary and a strict antibiotic prescribing policy can help significantly to overcome these problems and to reduce the extent of resistance to antibiotics. journal of college of medical sciences-nepal, 2010, vol.6, no-2 12 acknowledgement we sincerely acknowledge the kind support of mr. p. khanal and mr. surya prasad ghimire at hospital pharmacy along with our fourth semester students in due course of data collection intended for this study. we extend our thanks to these valuable persons in our study. references 1. hogerzeil hv. promoting rational prescribing: an international perspective. br j clin pharmacol 1995; 39; 1-6. 2. rehana hs, nagarani ma, rehan m. a study on the drug prescribing pattern and use of antimicrobial agents at a tertiary care teaching hospital in eastern nepal. ind j pharmacol 1998; 30: 175-80. 3. shankar pr, dubey ak, rana ms, et al. drug utilization with special reference to antimicrobials in a subhealth post in western nepal. j nep health research council 2005; 3(2) oct.: 65-9. 4. kanakambal s, murgesh n, shanthi m. drug prescribing pattern in a tertiary care teaching hospital in madurai(tamilnadu). ind j pharmacol 2001; 33: 223. 5. sepehri g, meimandi ms. the quality of prescribing in general practice in kerman, iran. international j health care quality assurance 2005; 18(5): 353-60. 6. smith rd, coast j. antimicrobial resistance: a global response. bull world health organ 2002; 80: 126-33. 7. levy sb, marshall b. antibacterial resistance worldwide: causes, challenges and responses. nat med 2004; 10(12 suppl):122s-129s. 8. who. how to investigate drug use in health facilities: selected drug use indicators. geneva: world health organization 1993. who/dap/93.1 9. who. teacher’s guide to good prescribing. geneva: world health organization 2001. who/edm/par/2001.2. 10. zwar n, wolk j, sanson fr, et al . influencing antibiotic prescribing in general practice: a trial of prescriber feedback and management guidelines. fam pract 1998; 16: 495-500. 11. kumar j, shaik mm, kathi mc, et al. prescribing pattern and use of non-steroidal anti-inflammatory drugs among orthopedic outpatients in a teaching hospital of central nepal. jcms nepal 2008; 5(1): 80-6. 12. department of drug administration, his majesty’s government. national list of essential drugs nepal (third revision) 2002. 13. rahman z, nazneen r, begum m. evaluation of prescribing pattern of the private practitioners by the undergraduate medical students. bangladesh j pharmacol 2009; 4: 73-5. 14. odusanya oo. drug use indicators at a secondary health care facility in lagos, nigeria. j com med and primary health care 2004; 16(1): 21-4. 15. hafeez a, kiani ag, uddin s, et al. prescription and dispensing practices in public sector health facilities in pakistan: survey report. j pak med assoc 2004; 54: 18791. 16.irshaid ym, al-homrany ma, hamdi aa, et al. a pharmacoepidemiological study of prescription pattern in outpatient clinics in southwestern saudi arabia. saudi med j 2004; 25(12): 1864-70. 17. awad ai, himad ha. drug use practices in teaching hospital of khartoum state, sudan. euro j clin pharmacol 2006; 62(12): 1087-93. 18.warren mm, gibb ap, walsh ts. antibiotic prescription practice in an intensive care unit using twice-weekly collection of screening specimens: a prospective audit in a large uk teaching hospital. j hosp infect 2005; 59: 90-5. 19. al-niemat si, bloukh dt, al-harasis md, et al. drug use evaluation of antibiotics prescribed in a jordanian hospital outpatient and emergency clinics using who prescribing indicators. saudi med j 2008; 29(5): 743-8. 20. who. global strategy for containment of antimicrobial resistance. who/cds/csr/drs/2001.2. jeetendra kumar et al, prescribing indicators and pattern of use.......................... 13 pleomorphic adenoma of the upper lip a case report introduction the most common salivary gland tumor is pleomorphic adenoma (pa), which accounts for 6065% of such diseases. it mainly affects women in their fourth to sixth decade of life, and has a natural history of asymptomatic slow growth over a long period.1 it usually involves major salivary glands, most commonly being the tail of parotid. it also involves minor salivary glands. the lips are commonly affected sites, second only to the palate, and accounting for about 20-40 % of all intraoral pleomorphic adenoma. 2,3 the aetiology of pa is unknown. it is epithelial in origin, and clonal chromosome abnormalities with aberrations involving 8q12 and 12q15 have been described.4 this paper describes the diagnosis and management of an asymptomatic, slowly growing, pleomorphic adenoma in the upper lip of middle aged female. a brief review of the relevant literatures is also presented case report a 27-year old female presented in ent o.p.d. of this hospital with a complaint of painless, mobile lump in upper lip. the mass slowly increased in size during the past 3 years. at the time of presentation, nasal vestibule was almost obstructed by the mass as shown in fig-1. on examination, the mass was circumscribed, mobile, sessile, and rubbery in consistency and 4.55 cm in diameter as shown in fig2. the overlying mucosa was smooth with pinkishpurple color showing evidence of superficial vascularity. skin over the tumor was not fixed. there was no pain or bleeding on palpation. head and neck abnormalities were not noted on clinical examination. the medical history was unremarkable, and no other abnormalities were found on clinical examination. thus, the clinical diagnosis was benign minor salivary gland tumor. fnac showed the features of pleomorphic adenoma. correspondence: dr. a. shrestha email: dr_amar2003@yahoo.com case report, 51-53 pleomorphic adenoma of the upper lip: a case report a. shrestha1, n.s. reddy2, s. n. ganguly3 1lecturer, 2 prof. & head,3 professor department of ent, college of medical sciences, bharatpur, chitwan, nepal abstract: this case report describes a rare and unusual lesion found in 27 year old female, which was diagnosed as pleomorphic adenoma of the minor salivary glands in the upper lip. the tumor was a circumscribed, large firm mass, about 5 cm in diameter, almost obstructing the nasal vestibule and characterized by slow growth. complete excision was performed and the histopathological analysis showed pleomorphic adenoma. the tumor did not recur. a brief review of the relevant literature is also presented. keywords: pleomorphic adenoma; minor salivary gland tumors, nasal vestibule. journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 51 fig1 fig-2 the tumor was completely removed with lip splitting incision as shown in fig-3. during the surgical procedure, the lesion was excised without difficulty with clinically normal margin because the mass was fully encapsulated. subsequent follow up after one year showed no signs of recurrence. discussion kroll and hick 5 reviewed 4042 cases of pleomorphic adenomas of the salivary glands. of these, 445 originated in the minor salivary glands, only 16.9% were located in the upper lip and 2.9% in lower lip. pleomorphic adenoma in the upper lip exceeds that of the lower lip by the ratio of 6:1. the reason for this fig-3 fig-4 hstopathological analysis of the surgical specimen revealed pleomorphic adenoma and there was no evidence of malignancy. fig-4 is 7th post-operative day photo of the same patient. difference has been thought to be due to the differences in embryonic development between the upper and lower lips. pleomorphic adenoma arising from minor salivary glands of the lips tends to occur at an earlier age than it does at other sites. bernier 6 found that the peak incidence of pleomorphic adenoma of the lips was in journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 52 the third and fourth decades, with an average age of 33.2 years. there is a propensity for benign tumor to occur in the upper lip, whereas malignant lesions to predominate in the lower lip.3,7 owens and calcaterra8 found 90% of the upper lip tumors to be benign in reports in the literature. eveson and cawson3 documented 75% of upper lip tumors as benign. in the study by neville et al9, 92% of the upper lip tumors were monomorphic adenoma (canalicular adenoma and basal cell adenoma) and pleomorphic adenoma, whereas sporadic cases of adenoid cystic carcinoma, acinic carcinoma, and adenocarcinoma constitute the remainder. malignant tumors tend to predominate in the lower lip. owens and calcaterra8 found that 7 of the 13 malignant tumors in the lower lip were mucoepidermoid carcinoma. this finding was also consistent with the report from neville et al9, which confirmed mucoepidermoid carcinoma to be compose more than 80% of lower lip tumors. minor salivary gland tumor presents as soft or firm masses, with most having a nodular, exophytic component. ulceration of the nodular mass may occur, but the presence of ulcer provides no clue to the invasiveness of the tumor. those that are soft on palpation usually have large cystic cavities and an abundance of mucin. the more solid tumors, especially pleomorphic adenoma with bone and cartilage formation, are firm on palpation. differentiation between benign and malignant tumors is not possible without histopathology. however, suspicion of malignancy necessitates a biopsy before surgical treatment. when a lip mass is freely movable and submucosal, an excision of the mass with surrounding tissue may be adequate. on the other hand, a multilobulated mass fixed to the underlying tissue is more likely to be malignant. a wide local excision with a 1.5 cm margin and resection of 1 anatomic barrier beyond the tumor are necessary for surgical clearance. this will sacrifice the overlying and adjacent mucosa, the orbicularis oris muscle, and even the involved external skin of the lip. reconstruction is effected by local tissue advancement or abbe flaps. 10 references: 1. forty mj, wake mjc. pleomorphic salivary adenoma in an adolescent. br dent j 2000; 188: 545-6 2. chaudhry ap, vickers ra, gorlin rj. intraoral minor salivary gland tumors: an analysis of 1414 cases. oral surg 1961;14: 1194 3. eveson jw, cawson ra. tumors of the minor (oropharyngeal) salivary glands: a demographic study of 336 cases. j oral pathol 1985;14: 500 4. farina a, pelucchi s, grandi e, carinci f. histological subtypes of pleomorphic adenoma and age frequency distribution. br j oral maxillofac surg 1999;37: 154-5 5. krolls so, hicks jl. mixed tumors of the lower lip. oral surg 1973;35: 212 6. bernier jl. mixed tumors of lips. j oral surg 1946; 4: 193 7. waldron ca, el-mofty sk, gnepp dr. tumors of the intraoral minor salivary glands: a demographic and histologic study of 426 cases. oral surg oral med pathol 1988;66: 323 8. owens ot, calcaterra tc. salivary gland tumors of the lip. arch otolaryngol 1982;108: 45 9. neville bw, damm dd, weir jc, et al. labial salivary gland tumors. cancer 1988;61:2113 10. ord ra. management of intraoral salivary gland tumors. oral maxillofac surg clin north am 1994;6:499 a. shrestha et al. pleomorphic adenoma of the upper lip: a case report 53 63-69 journal of college of medical sciences-nepal, 2010, vol. 6, no. 1, 67-69 medical education correspondences: dr. p.r. shankar e-mail: ravi.dr.shankar@gmail.com the word ‘trek’ originated from a dutch word for travel and with the dutch migration to south africa came to be an afrikaans word meaning migration by oxcart. the term has been modified over the years to mean travel by foot for many days. nepal is one of the hotspots on the global trekking scene due to various factors. the wide range of landscapes ranging from the ‘terai’ the flat plains bordering india to the frigid heights of mt. everest and the friendly open nature of the people could be important reasons. treks and trekking styles: in this article the author plans to explore how trekking could be a metaphor for medical education and the practice of medicine. most treks in nepal start at relatively low elevations climb steadily up, cross a pass and then descend on the other side to a river valley. there are a variety of trekking styles which people choose according to their purse and inclinations. in the simplest style one or more trekkers usually set out carrying their own gear and organizing their own logistics. they spend the night at tea houses (lodges) which are common in the popular trekking areas. the trekker/s could walk with one or more porters who will carry the majority of the gear. if there are no tea houses the trekker/s camps out and the porter may cook for you. the last and the most expensive method is to trek with a retinue of porters, kitchen staff, guides and a head sherpa or sirdar. trekking as a metaphor for medicine and medical education p.r. shankar1, v. malhotra2 1department of medical education, kist medical college, imadol, lalitpur, nepal, 2department of physiology, k variyar medical college, salem, india abstract nepal is a favored trekking destination. over the years a number of trekking styles have emerged and the author sees similarities between trekking styles and methods of medical education. problembased learning strategies make students more involved in their own learning and teachers act as facilitators. trekkers and medical students mostly concentrate on the immediate trail or different subjects and are able to obtain an integrated and holistic view only occasionally. the nature of the doctor-patient relationship is changing with patients wanting to play a more active role in their treatment. workers in the trekking industry and doctors slowly rise through the ranks. often people take up jobs with more responsibilities and challenges which pay better. technology has invaded both trekking and healthcare and most of the money is made by middlemen. in addition to other areas medicine is focusing on preparing patients for the final exist key words: problem-based learning, doctor-patient relationship, medicine. 67 journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 ‘styles’ of medical education: looking at the medical education scene in south asia i see similarities with trekking styles. previously most medical schools used to be supported by the government. students were selected through a tough entrance exam and came from ‘ordinary’ families. fees were low. these students can be likened to the single trekkers who carry their own backpacks. trekkers carry guidebooks and maps while students use textbooks to guide them through the difficult terrain of medicine. teachers could be likened to ‘guides’ guiding the students (neophyte trekkers) over the difficult terrain ensuring they take the proper trail and eventually reach their destination. recently a number of medical schools have been opened in the private sector in south asia. these colleges admit self-financing students who have to pay high tuition and other fees. the self-financing students share many similarities with the group of trekkers who trek with a full retinue. both depend on others to smooth out and cushion their path over the rough terrain. also as they have invested a large amount of money both expect a smooth and easy journey to their destination. they expect their ‘guides’ to read and interpret the maps and other material and chalk out the easiest path to their destination. in the more traditional learning system, the teachers (guides) usually led the way across the terrain of medicine and students followed the path shown by the guide. with the increasing use of problem-based learning strategies the teacher no longer leads the expedition. he/she acts as a facilitator of the process and keeps watch from a respectable distance. the student is trained in leadership and other requisite skills and a group of students chart their own way across the difficult terrain. the guide (teacher) intervenes only in cases of difficulties. guiding patients: the landscape of medicine has dark alleys and cul de sacs bristling with death, suffering and despair. patients often get entangled in these fearful landscapes and the doctor guides the patient away from danger and disease to the balmy and sunny valleys of health and happiness. the doctor-patient relationship is steadily changing. previously patients expected their doctors to lead them out using their knowledge and experience and they used to blindly follow their doctor’s orders. today with increasing levels of literacy and economic well being patients expect to chart their own path out of the dark and dangerous valleys with the doctor providing help and knowledge and supporting the patients’ efforts. rising up the professional ladder: in nepal many guides start their career in low paying jobs with the trekking industry. they slowly rise up the ladder eventually rising to the post of head sherpa or trek leader. the same is true of doctors who start off as medical students, then work as interns, house officers, postgraduate trainees and finally become eligible to be consultants or faculty members. sherpas with trekking groups in nepal sometimes switch over to mountaineering expeditions. the greater risks and challenges are offset by the higher pay. doctors specialize and super specialize tackling more challenging and difficult cases for greater financial rewards. many guides developing close relationships with their clients. many are sponsored to do their higher education in the west. others migrate to developed nations taking better paying jobs in either the tourism or other sectors. many doctors from nepal migrate to developing countries. 68 inroads of technology: technology has made steady inroads into trekking and mountaineering. better trails, improved quality of lodges, better maps, global positioning systems, improved food and better shoes and trekking gear are a few examples. medicine is becoming dominated by technology and big healing teams. the individual family physician is becoming rarer in the west and even in cities of south asia. luckily the individual trekker is still commonplace despite big trekking companies and outfitters. advanced technology does not come cheap. with increasing investments businessmen and corporate houses are becoming common. doctors work for a fixed salary or a percentage of the profits. foreign trekkers pay a large amount to agencies in their countries for planning and organizing their treks. the foreign agency often subcontracts the logistics to an agency in nepal. this agency then hires sirdars, guides and porters. only a small percentage of the original fee paid goes into the pockets of the guides and porters. middlemen gain the most in the transactions. the guides and porters are paid well when compared to the low local nepalese wage standards. the same is true of the doctors who work in hospitals. life is a trek with ups and downs, happiness and sorrows. death is inevitable. what happens after death? do we continue our trek on a different plane? medicine along with religion has an important role in preparing people for the final exit which should be as far as possible without pain and suffering. medicine these days is increasingly focusing on dying with dignity and preparing patients for the unknown frontier. 69 p.r. shankar et al. trekking as a metaphor for medicine and medical education 1-43 introduction the rt was made available for use in 1920 when it was published along with the manual named psychodiagnostic.1 test consists of ten page-sized inkblots that represent the stimulus plates of the technique. number of surveys has been conducted in the usa, india and other countries to find out the psychological test to be highly accepted and widely used by the clinicians2 among the entire test the rt has always been found to have first place in usa, india and other countries.3 the interpretation of rorschach protocol in most of the symptoms is based on the number of responses given by the subjects. the test has psychometric qualities and is useful for personality assessment. it has also been used in many countries. in india extensive work has been done at central institute of psychiatry, ranchi.4 indian researchers have carried out normative studies on indian subjects. the norms, in the form of the rorschach indices, established by different indian researchers have been followed. in clinical setup, the rt is frequently and even regularly administered to resolve the diagnosis. these diagnostic indicators are generally called for the following major psychiatric illnesses or conditions: schizophrenia, psychosis, depression, hypomania, anxiety, obsession and organicity. apart from these psychiatric categories, many a times, the rt is advised to understand and study the personality structure of an individual or patient.5 patients correspondence: dr. b. yengkokpam e-mail: babkokpam@yahoo.com comparative study of consultant psychiatrist and clinical psychologist among psychiatric patients, using rorschach test b. yengkokpam1, s. k. shah1, g.r. bhantana1, p. giri 2 1 lecturer, 2 medical officer, department of psychiatry, college of medical sciences, bharatpur, nepal. abstract this comparative study among psychiatric patients attending college of medical sciences, teaching hospital, bharatpur, nepal was carried out to determine responses on rorschach test (rt). a total of 65 diagnosed psychiatric patients as per international classification of diseases (icd-10) criteria attending psychiatric opd between ages of 15 to 65 years, both male and female in the period of january 2009 to july 2009 were selected. rt was administered and results were tabulated as per diagnosis by clinical psychologist. out of total 65 patients who underwent rt, 41 were male and 24 were female in the ratio of 63:37. in clinical psychologist diagnosis38 were schizophrenia, 7 were psychotic depression, 6 were depression, 3 were mania, 1 was organic psychosis and 10 were underlying psychosis and in consultant psychiatrist diagnosis36 were schizophrenia, 5 were psychotic depression, 12 were depression, 8 were mania, 3 were organic psychosis, 1 was underlying psychosis. key words: rorschach test, international classification of diseases, psychotic depression, organic psychosis, underlying psychosis. , 14-17 original articlejournal of college of medical sciences-nepal, 2010, vol. 6, no. 1 14 are diagnosed as per icd-10 classification of mental and behavioral disorders by a consultant psychiatrist.6 materials and methods all the cases in this study have been selected from psychiatry outpatient department of college of medical sciences, teaching hospital, bharatpur, nepal, between january to july 2009. a total of 65 diagnosed psychiatric patients as per icd-10 criteria by a consultant psychiatrist between the ages of 15 to 65 years, both male and female were selected. patients were analyzed according to age, sex and symptoms. rt was administered by clinical psychologist and results were tabulated as per diagnosis. statistical analysis in the present research study obtained data have been scored by using standard scoring procedure of the tests. chi-square test has been computed to evaluate the difference between clinical psychologist and consultant psychiatrist. results table-1 shows that out of total 65 patients, who underwent rt, 41 were males and 24 were females in the ratio of 63:37, their age ranged from 15 to 65 years but they are divided into three age groups of 15 to 30, 31 to 46, 47 to 65 years. in the first age group from 15 to 30 years, 42 cases in which 28 were males and 14 were females, in the second age group 31 to 46 years, 20 cases in which 13 were males and 7 were females and in the third age group of 47 to 65 years and all the 3 cases of them were females. in table-2 comparison between clinical psychologist and consultant psychiatrist, symptom wise distribution: clinical psychologist diagnosis: a 38 were schizophrenia, 7 were psychotic depression, 6 were depression, 3 were mania, 1 was organic psychosis and 10 were underlying psychosis. consultant psychiatrist diagnosis: a 36 were schizophrenia, 5 were psychotic depression, 12 were depression, 8 were mania, 3 were organic psychosis and 1 was underlying psychosis. the difference between clinical psychologist b. yengkokpam et al. comparative study of consultant psychiatrist and clinical .............. using rorschach test 15 table1: age group of patients included in the study ages male % female % total % 15-30 28 43 14 21.5 42 64.5 31-46 13 20 7 10.5 20 30.5 47-65 0 0 3 5.0 3 5.0 total 41 63 24 37 65 100 table2: clinical psychologist diagnosis and consultant psychiatrist diagnosis diagnosissymptoms clinical consultant df χχχχχ 2 level of psychologist psychiatrist (degrees of (chi significance freedom) square) schizophrenia 38 (55.5%) 36 (55%) psychotic depression 7 (10.5%) 5 (7.5%) depression 6 (10%) 12 (18.5%) 5 29.11 0.01 mania 3 (5%) 8 (12.5%) organic psychosis 1 (1.5%) 3 (5%) underlying psychosis 10 (14.5%) 1 (1.5%) total 65 65 and consultant psychiatrist was found to be statistically significant at 0.01 levels (x2 = 29.11, p < 0.01). discussion psychiatric diagnoses were based on icd-10 criteria. recent research has revealed that norms cannot be used from one country to another and differences within the same cultural group are also to be found.7, 8 the rorschach norms were established by researchers in india differ considerably.9 most of these studies had a number of shortcomings the most important being the relatively small sample size from one center, which was not representative of the service. in the absence of reliable norms, mental health professionals in india are left with no alternative but to interpret. our aim in this study was to divide the patients in subgroups based on the age, sex and symptoms wise distribution. general background information and behavioral data that are generally considered to be of importance in finding symptoms could be illuminating for this purpose. differences in terms of such additional data would support the meaningfulness and validity of the suggested sub groupings. our results suggest that these patients display a rather complex pattern of psychological functioning, with emotional encumbrance and also a more complex psychological relation to symptoms itself. although psychological resources were higher in this group, there were also more psychological factors possibly counteracting. out of the sample of total 65 patients, who underwent rt, 41 were males and 24 were females in the ratio of 63:37. there are differences between clinical psychologist diagnosis and consultant psychiatrist diagnosis as shown in table-2. in clinical psychologist diagnosis 38 were schizophrenia, 7 were psychotic depression, 6 were depression, 3 were mania, 1 was organic psychosis and 10 were underlying psychosis. but in consultant psychiatrist diagnosis: a 36 were schizophrenia, 5 were psychotic depression, 12 were depression, 8 were mania, 3 were organic psychosis and 1 was underlying psychosis. the results of this study indicate that there were clinically meaningful in the diagnosis of a psychiatric disorder. acute schizophrenics are quick and impulsive as the normal inhibition is lifted in them. this trend is in agreement with some studies though one study observed longer rt in schizophrenics which may be attributed to differences in the sample characteristics. a chronic schizophrenic is likely to have a longer rt as compared to an acute schizophrenic. the rt of head injury and epilepsy patients was significantly more than the rt of the psychotic subjects, which is in agreement. in this study, we investigate the reliability, and diagnostic efficiency of the rt in relation to the accurate identification of patients diagnosed with icd10 criteria, schizophrenia or other psychotic disorder. finally, this variable could be employed for classification purposes in ways that were clinically meaningful in the diagnosis of a psychotic disorder. conceptual and methodological issues are discussed in relation to the assessment of psychosis.10 ilonen et al. reported out of twenty-seven patients with first-episode schizophrenia, 13 with bipolar i disorder, 28 with psychotic depression, 29 with nonpsychotic depression, and 60 healthy controls were recruited for the study. the schizophrenic was highly specific with a very low false positive rate. the lowest positive value of 4, however, may yield false positives, especially among manic patients. the depressive disorder patients identified severe non-psychotic depression but not psychotic depression, suggesting that these patient groups invoke different perceptualjournal of college of medical sciences-nepal, 2010, vol. 6, no. 1 16 cognitive processes in formulating and articulating their rorschach responses. anyway, both the schizophrenic and the depressive disorder patients based on the psychological organization and functioning that are known to play a clearly formulated role in schizophrenia and depression, respectively, provide a valuable addition for diagnostics characterized by overt symptoms.11 finally, it is important to consider that this research opens an area of interest for the study of human behavior in the definition of conduct. the present findings although preliminary, shed some light into this matter. furthermore, these results are concordant with diagnostic and semiologic instruments such are those suggested by kandel12 and kaplan13, among others. in the genesis of these clinical conditions we must consider genetic factors as well as environmental issues such as parental relations, social stressors, workrelated stressors, familiar stressors.14 references 1. rorschach h. rorschach psychodiagnostik. ernst bircher, bern 1921:12. 2. dubey bl. rorschach analysis of importance cases and their response to psychotherapy. indian j clin psychol 1977; 4: 145-9. 3. fiske dw, baughman ee. relationship between rorschach scoring categories and total number of responses. j.abnor soc psychol 1953; 48: 25-32. 4. shukla tr. psychodiagnostic efficacy of holtzman inkblot technique under indian conditiona normative study. indian j clin psychol 1976; 3: 189-98. 5. asthana hs. some aspects of personality structuring in indian social organization. j soc psychol 1956; 44:155-63. 6. who. icd-10 classification of mental and behavioral disorders 2002. 7. nascimento rsgf. the impact of education and /or socioeconomic conditions on rorschach data in a brazillian non patient sample. rorschiana 2004; 26: 45-62. 8. singh dk, singh a, singh ar. relevance of beck norms of rorschach inkblot technique on indian populationan exploratory pilot study on normal subjects. sis j projective psychol mental health 2004; 12: 49-52. 9. manickam lss, dubey bl. rorschach inkblot test in india, historical review and perspectives for future action. sis j projective psychol mental health 2004; 12: 61-78. 10. hilsenroth m j, fowlerjc, justin rp. an examination of reliability, validity and diagnostic efficiency. rorschach schizophrenia index 2006; 86: 180-9. 11. ilonen t, taiminen t, karlsson h, et al. diagnostic efficiency of the rorschach schizophrenia and depression indices in identifying first-episode schizophrenia and severe depression. psychiatr res 1999; 87: 183-92. 12. kandel es. neurociencias y conducta. prentice hall 1997: 7581. 13. kaplan hi, sadock bj. tratado de psiquiatria tomo i. ed intermedica 1997: 92-3. 14. nilson m, perfilieva e. enriched environment increases neurogenesis and improves spatial memory. j neurobiol 1999; 39: 569-78. b. yengkokpam et al. comparative study of consultant psychiatrist and clinical .............. using rorschach test 17 original articel original article correspondence: dr. y. r.khinchi e-mail: dr_khinchi@yahoo.com profile of neonatal sepsis y. r. khinchi1, anit kumar2, satish yadav3 1associate professor, 2second year md resident, 3third year md resident; department of pediatrics and neonatology, college of medical sciences, bharatpur, nepal abstract objective: to study the clinical presentation, investigational profile and outcome of neonatal sepsis in general and with special reference to inborn (intramural) or out born (extramural), sex and weight of the neonate. materials and method: retrospective descriptive study of neonates admitted during 2 years from july 2007 to june 2009 in special care neonatal unit of the department of pediatrics, college of medical sciences-teaching hospital, bharatpur, nepal. results: majority of neonates were out born and referred (72.2%) to this institution. significant number of babies was having sepsis in out born group (59%) as compared to inborn (35%). male sex was found to have more sepsis as compared to female. sepsis was observed to be inversely related to birth weight, 65% in low birth weight (lbw, <2.5kg) as compared to 42.6% in normal birth weight group (> 2.5kg). conclusions: high index of suspicion for diagnosis of neonatal sepsis is required specially in the presence of risk factors. prevalence of sepsis is inversely related to birth weight. more number of out born delivered babies developed sepsis. neonatal sepsis related morbidity and mortality can be significantly reduced by comprehensive obstetric and neonatal care at multiple levels right from community to health institutions. key words: neonatal sepsis, inborn, out born, low birth weight (lbw). introduction neonatal sepsis is the single most important cause of neonatal deaths in the community, accounting for half of them. if diagnosed early and treated aggressively with antibiotics and good supportive care, it may be possible to save most cases of neonatal sepsis1. surviving infants can have significant neurological sequelae as a consequence of cns involvement, septic shock or hypoxemia secondary to severe parenchymal lung disease2. neonatal sepsis is defined as a clinical syndrome of bacteremia with signs and symptoms of infection in the first four weeks of life. when pathogenic bacteria gain access into the blood stream, they may cause overwhelming infection without much localization , 1-6journal of college of medical sciences-nepal, 2010, vol.6, no-2 1 termed as septicemia or may get predominantly localized to the lungs resulting in pneumonia, or the meninges causing meningitis. early onset and late onset sepsis are defined on the basis of presentation within 72 hours or after 72 hours of life respectively. there are many risk factors for development of neonatal sepsis including low birth weight, unsafe place of delivery or unclean delivery, prolonged rupture of membranes more than 24 hours, maternal pyrexia, chorio-amnionitis, prolonged labor and perinatal asphyxia. the present study is carried out to determine the clinicoinvestigational profile and outcome of neonatal sepsis in general and specially in relation to place of delivery whether inborn or out born, sex, and weight of neonates admitted in special neonatal care unit of this institution. materials and methods this study included newborns admitted in special care neonatal unit of college of medical sciences teaching hospital, bharatpur, nepal from july 2007 to june 2009. this is a retrospective descriptive study. the case records of 411 newborns entitled for the study during this period was evaluated and categorized on the basis of septic or non septic; inborn (intramural: delivered in the study institution) or out born (extramural: delivered in other heath facility or home); sex and birth weight. the case records of these newborns was thoroughly studied and recorded for relevant information including history, clinical evaluation and available investigation either favoring primary diagnosis of neonatal sepsis including with co-morbid conditions or having some other exclusive alternate diagnosis other than sepsis. the diagnosis of neonatal sepsis was based on clinical profile and septic screen, x-ray chest and or blood culture whenever feasible and ruling out any other exclusive alternate diagnosis. neonates diagnosed as having neonatal sepsis on the basis of clinicoinvestigational evaluation with co-morbid conditions were also included as septic cases in the study. neonates taken against medical advice (lama) or referred or taken elsewhere on request or discharged on request before proper diagnosis were excluded from the study. all other neonates not fulfilling the diagnosis of sepsis as mentioned above were considered as having other alternate diagnosis and put in the category of non-septic cases. statistical analysis was done by evaluating p value. results total number of cases enrolled for the study was 411 which included 271 male and 140 female patients. there were 297 out born and 114 inborn neonates. clinical and investigational profile of inborn and out born neonates is shown in the table-1. septic group included 215 patients as compared to 196 in non-septic group (table-2). neonatal sepsis accounted for 175 (59%) in the out born and 40 (35%) in the inborn category (p<0.05, table-3). there was significant difference for prevalence of sepsis between male (65.1%) and female (34.9%) neonates (p<0.05, table2). early onset sepsis was responsible for 131 cases whereas late onset sepsis was observed in 84 neonates (p<0.05, table-4). sepsis was significantly (p<.000, table-5) much higher (69.7%) in very low birth weight/ extremely low birth weight (<1.5kg), followed by (64.3%) in lbw (< 2.5 kg) than normal birth weight (>2.5kg) babies (42.6%). journal of college of medical sciences-nepal, 2010, vol.6, no-2 2 discussion sepsis is the commonest cause of neonatal morbidity and mortality. it is responsible for about 30-50% of total neonatal deaths3,4. sepsis related morbidity and mortality is largely either preventable or treatable with rational antimicrobial and supportive therapy. lbw is a strong risk factor for neonatal sepsis due to multiple reasons. unsafe delivery or unclean delivery at inappropriate place is another important predisposing factor for sepsis. earliest clinical features of neonatal sepsis are often subtle and non specific therefore a high index of suspicion is needed for early diagnosis specially so if risk factors are also present. in the present study majority of neonates presented (table-1) with refusal to feeds (74%), tachypnea or respiratory distress (75%) and fever (69%). in a study done in the tertiary care center in bangladesh poor feeding, respiratory distress and fever was reported in 22.2%, 27.8% and 44.4% cases respectively5. in the same study they documented hypothermia in 11.1%, apnea in 16.7%, cyanosis in 11.1%, convulsions in 11.1% and jaundice in 50% as compared to our findings 11.6%, 15%, 41%, 20.4%, and 40% respectively. clinical features and further course in neonatal sepsis depends on various factors like birth weight, place of delivery, age of newborn, intervention in preventable factors for sepsis, availability, accessibility, affordability and timely referral of baby to an appropriate center. therefore variation in different parameters may be observed in various studies. though the gold standard for the diagnosis of sepsis is positive blood culture but in our setup due to limitation of affordability, limited blood sample from newborn, prior use of antibiotics before admission and other factors, diagnosis is mainly clinical supported by septic screen and xray chest. csf examination and neuroimaging or other relevant investigations were done whenever clinically indicated. neonatal sepsis was diagnosed in 52.6% of neonates during the previous study done from january 06 to june 07 in this institution which is comparable to present data (52.3%), reflecting that there is no change in factors having impact on prevention of neonatal sepsis in this region at all levels right from community to health facilities6. male neonates were reported to be affected more with sepsis as compared to females in some studies7,8. this is in concordance with our study as well (p<0.05, table-2). bias for male sex, place of study, sample including other factors may be responsible for increased number of male cases in these studies. there was statistically significant difference (p<0.05, table-3) in sepsis cases born in the study institution (inborn) as compared to those brought from outside (out born). in inborn category 35% had sepsis as compared to 59% in out born group. this is because of the fact that intramural deliveries in the study institution are conducted with preventive aspects with adequate perinatal care whereas in extramural including home deliveries there may be various predisposing and risk factors including unsafe or unclean environment, limited skilled manpower and inadequate facilities etc. early onset sepsis was documented significantly more as compared to late onset sepsis (p<0.05, table4). early onset neonatal sepsis in general is more common because of various high risk perinatal factors for sepsis operate during this period. lbw is a strong risk factor contributing to sepsis. in this study birth weight is inversely related to y. r. khinchi et al, profile of neonatal sepsis 3 development of sepsis which is statistically highly significant (p<0.000, table4). this is in concordance with other studies where low birth was found to be important risk factor for sepsis 6,9. lbw babies are mostly also premature and are predisposed to sepsis due to multiple reasons like immune incompetence at various levels of defense, more subjected to invasive interventions etc. mortality due to sepsis in inborn was 7.5% as compared to 11% in out born with overall mortality of 10.2% (table-1) which is comparable to other hospital based study6. these data are low as compared to overall mortality which is reported to be in the range of 30-50% of total neonatal deaths in the community and rural india3,4. this wide difference in mortality may be due to the fact that our data are hospital based where we get selected referred out born babies and due to less neonatal sepsis in inborn neonates because deliveries are conducted with proper antenatal and perinatal services in this institution. conclusions high index of suspicion for diagnosis of neonatal sepsis is required specially in the presence of risk factors and baby presenting with non specific clinical features. prevalence of sepsis is inversely related to birth weight. more number of out born delivered cases develops sepsis due to lack of poor knowledge, accessibility, affordability or inadequate perinatal services in the community setup. neonatal sepsis related morbidity and mortality can be significantly reduced with good maternal nutrition and health status which is known to improve the birth weight of newborn along with encouraging institutional deliveries where adequate obstetric and neonatal services are available. references 1. management of neonatal sepsis, iap-nnf (indian academy of pediatricsnational neonatology forum) guidelines 2006 on level ii neonatal care: 159-86. 2. chaiko b and sohi i, early onset neonatal sepsis. indian journal of pediatrics, 72: 2005: 23-6. 3. bang at, bang ra, bactule sb et al. effect of homebased neonatal care and management of sepsis on neonatal mortality: field trial in rural india. lancet 1999: 354: 1955-86. 4. stoll bj, the global impact of neonatal infection. clin perinatol 1997: 24: 1-21. 5. ahmed nu, chowdhary a, hoque m et al. clinical and bacteriological profile of neonatal septicemia in a tertiary level pediatric hospital in bangladesh. indian pediatrics 2002: 39: 1034-39. 6. khinchi yr, shreshta d, sarmah bk et al. a study of morbidity and mortality profile of neonates admitted in tertiary care hospital in central nepal. journal of college of medical sciences, nepal, 2008: 5: 70-5. 7. jain nk, jain vm, maheshwari s. clinical profile of neonatal sepsis. kumj: 2003: 1: 117-20. 8. who young infant study group. bacterial etiology of serious infection in young infants in developing countries: results of multicenter study. pediatr. dis. j. 1999: 18 s17-22. 9. jeeva sankar m, agrawal r, deorari ak et al. sepsis in newborn. indian j pediatr 2008: 75: 261-66. journal of college of medical sciences-nepal, 2010, vol.6, no-2 4 table-1: profile of neonatal sepsis: feature inborn (40) out born (175) total (215) (%) refusal to feeds 28(70%) 132(75%) 160(74%) poor activity and cry 21(52%) 67(38%) 88(41%) tachypnea / respiratory distress 32(80%) 129(73%) 161(75%) fever 26(65%) 122(69%) 148(69%) jaundice 28(70%) 59(33%) 87(40%) apnea 9(22%) 24(13%) 33(15%) hypothermia 2(5%) 23(13%) 25(11.6%) cyanosis 12(30%) 78(44.5%) 90(41%) crt(capillary refill time) > 3 sec 9(22.5%) 82(46.8%) 91(42.3%) bleeding/ patechie/ purpura 12(30%) 36(20.5%) 48(22.3%) convulsions 8(20%) 36(20.5%) 44(20.4%) umbilical sepsis / skin infections 2(5%) 31(17.7%) 33(15.3%) chest x-ray suggestive of respiratory infection 24(60%) 68(38.8%) 92(42.7%) clinical and chest x-ray with empyema 1(0.57%) 1(0.46%) positive septic screen (crp/cbc/pbf) 26(65%) 109(62.2%) 135(62.7%) positive blood culture (out of 22 samples sent) 1(0.57%) 1(0.46%) meningitis (csf: cell count/gram stain/biochem.) 5(12.5%) 28(16%) 33(15.3%) ct scan showing complications (meningitis cases) 2(1.14%) 2(0.93%) mortality due to sepsis 3(7.5%) 19(11%) 22(10.2%) table-2: distribution of cases according to sex and septic/ non-septic: sex septic non-septic total male 140 (65.1%) 131 (66.8%) 271 female 75 (34.9%) 65 (33.1%) 140 total 215 196 411 (p value <0.05) table-3: distribution of cases according to place of delivery: sepsis cases septic non-septic total out born (extramural) 175 (59%) 122 (41%) 297 inborn (intramural) 40 (35%) 74 (65%) 114 total 215(52.3%) 196(47.6%) 411 (p value <0.05) y. r. khinchi et al, profile of neonatal sepsis 5 table-4: distribution of sepsis cases according to onset of neonatal sepsis: place of delivery early onset sepsis late onset sepsis total inborn (intramural) 32 (80%) 8 (20%) 40 out born (extramural) 99 (56%) 76 (44%) 175 total 131(60.9%) 84(39%) 215 (p value <0.05) table-5: neonatal sepsis according to birth weight: weight group septic non septic total 2.5kg or more 102(42.6%) 137(57.3%) 239 low birth weight (1.5kg to < 2.5kg) 83(64.3%) 46(35.6%) 129 very/extremely low birth weight (<1.5 kg) 30(69.7%) 13(30.2%) 43 all weight group 215(52.3%) 196(47.6) 411 (p value <0.000) journal of college of medical sciences-nepal, 2010, vol.6, no-2 6 1-43 , 35-43 correspondences: munvar miya shaik e-mail: munvar.shaik@gmail.com introduction the wisdom tooth (or third molar) is usually the last tooth to erupt into the mouth anytime after about 16 years of age. frequently, there is not enough room comparative study of tramadol and ketorolac in the pain management of third molar tooth extraction m.m. shaik1, j. kumar2, s. mobina3, n. satyanarayana4, p. sunitha5 1lecturer in pharmacology, 2assistant professor in pharmacology, 4lecturer in anatomy, 5lecturer in physiology, college of medical sciences, bharatpur, nepal 3junior resident, st joseph’s dental college, eluru, andhra pradesh, india abstract objective: clinical comparison of efficacy, duration of action, onset of action, side effects of two most commonly used analgesics tramadol and ketorolac after the third molar tooth extraction. materials and methods: the present study was carried out at department of oral surgery, mamata dental hospital, khammam, india. 150 patients were randomly selected and divided into two groups. group a received 50 mg of tramadol orally and group b received 10 mg of ketorolac orally. in both groups dose was repeated for next 24 hrs. visual scale analog was used for the collection of pain intensity from the patients. results: in group a, the analgesia started within 1hour and at the end of 24 hours, pain intensity was 2.12 out of 10 on visual analog scale. in group b, analgesia started within 30 mins and at the end of 24 hours, the pain intensity was 2.98 on visual analog scale. sedation associated with dizziness and muscle relaxation was observed with tramadol in 5% of patients and sweating in 8% patients. while in case of ketorolac, 33% of patients suffered with side effects. among them 33% patients suffered with bleeding at the site of tooth extraction and 20% patients suffered with epigastric pain. the analgesic effect of 50 mg tramadol lasted up to 6 hours and that of ketorolac lasted for 5 hour. conclusion: the study shows that tramadol is a suitable and safe analgesic for the relief of post-extraction pain and is more effective than ketorolac with prolonged analgesia and minimal side effects. key words: tramadol, ketorolac, third molar tooth extraction, in the mouth to accommodate the erupting wisdom teeth and therefore, they might not always come into the mouth normally. wisdom teeth are usually either impacted forwards into the tooth in front or backwards into the jaw bone. an impacted wisdom tooth causes infection in the gum surrounding the tooth leading to original articlejournal of college of medical sciences-nepal, 2010, vol. 6, no. 1 35 pain and swelling. sometimes cysts also formed due to impacted wisdom tooth. to avoid these problems it is always better to remove the tooth. however, the management of pain consequent to tooth extraction is always a major concern for the individual.1, 2 the way pain is experienced is a reflection of the individual’s emotional, motivational, cognitive, social, and cultural circumstances. the pain of tooth extraction is likely to be the most severe pain that an individual experiences during his or her life.3 many individuals rate the pain of tooth extraction as very severe or intolerable. the pain of tooth extraction varies among individuals, and each extraction of an individual may be quite different. management of post-extraction pain relieves suffering and leads to earlier mobilization, shortened hospital stay, reduced hospital costs and increased patient satisfaction.4,5,6 tramadol is an atypical centrally-acting analgesic because of its combined effects as an opioid agonist and a serotonin and noradrenaline reuptake inhibitor. the risk of respiratory depression is significantly lower at equianalgesic doses and does not depress the hypoxic ventilatory response. it has limited effects on gastrointestinal motor function. nausea and vomiting are the most common side effects and tramadol does not increase seizure incidence when compared to other analgesic agents. tramadol has been used clinically and evaluated during the past 20 years with broad indications leading to its widespread use.7 ketorolac tromethamine is a member of the pyrrolo-pyrrole group of nonsteroidal antiinflammatory drugs (nsaids) which was previously reported for the short term management of moderate to severe pain. the primary molecular basis for antiinflammatory, antipyretic and analgesic effects of ketorolac is the inhibition of prostaglandin synthesis by competitive blocking of the enzyme cyclooxygenase (cox). the present study was conducted keeping in view giving the quicker, prolonged and safer post-extraction analgesic after third molar tooth extraction for quicker recovery of the patient from the post-extraction pain. this study was the clinical comparison of efficacy, safety and patient satisfaction of clinically widely used analgesics, tramadol and ketorolac. there were some reports published the comparing the parenteral tramadol and ketorolac in maxiofacilary surgery.8,9 materials and methods one hundread and fifty patients from routine admissions with tooth extraction were selected randomly during the period of 10 months from july 2008 to april 2009 in the department of oral surgery, mamata dental hospital affiliated to mamata dental college, khammam, india. the inclusion criteria were: age in between 18 to 60, undergoing into third molar tooth extraction, alertness and stability. the exclusion criteria were: history of drug or substance abuse, allergy to opioids or any other contraindication for the use of opioids, end stage renal disease, history of seizure or any abnormal laboratory tests that could interfere with our results. the methodology and procedure of study had been cleared by the ethical committee and clinical research review committee, mamata dental college. all the individuals were well informed about the study, methodology and also about the visual analog scale prior to tooth extraction. the individuals were unawared of the analgesic which they had taken during the study. the drugs ketorolac and tramadol were journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 36 procured from the hospital pharmacy and they have been assigned a code. patients were randomly assigned in either treatment groups with an assigned code. the patients were divided into two groups containing 75 patients in each group. all the codes of administered drugs were disclosed only after the pain assessment. the group ‘a’ received tramadol 50mg oral dose before the extraction and dose repeated after 6 hours. the group ‘b’ received ketorolac 10mg oral dose before the extraction and dose was repeated after 6hrs. pain assessment was done by verbal rating using visual analog scale.10, 11 [0 – no pain, 2 mild pain, 4 tolerable, 6 – distressful pain, 8 – severe pain and 10 – totally disabling pain]. the pain assessment was started after the tooth extraction at time points of 30 min, 1, 2, 3, 4, 5, 6, 12, 18 and 24 hrs. the patient’s vital signs including heart rate, respiratory rate and blood pressure were recorded at every time point after the assessment of pain intensity. statistical analyses were performed using chi-square test. results the majority of the patients scored an average pain intensity of ‘8.07’ on visual analog scale as the maximum pain felt by them in their life time. the analgesic effect for group ‘a’ who were taken tramadol started within 1st hour and reached the maximum analgesic effect in 3 hours. the average rating of pain intensity is ‘1.12’ on visual analog scale for the maximum analgesic effect felt at 3rd hour and with the first dose the analgesic effect sustained for 6 hours. the analgesic effect of tramadol has been increased for every six hours and at the end of the 24 hours, the patients scored the pain intensity of ‘2.12’ on visual analog scale. the analgesic effect for group ‘b’ who were taken ketorolac started within 30 mins and showed its’s maximum analgesic effect in 1st hour itself. the pain intensity scored on visual analog is 2.45 at 1st hour. but the effect was not sustained till the next dose. the patients felt the pain in the 5th hour itself. the patients scored ‘6.94’ in 5th hour and ‘7.34’ in 6th hour on visual analog scale. after the second dose, the pain intensity was observed for every 6 hrs. at the end of 24 hours, the patient scored ‘2.98’ on visual analog scale. the ‘p’ values were less than 0.05 and were considered statistically significant (table 1). according the observations, the analgesic effect is reached quickly in group ‘b’ who received ketorolac. however, the duration of analgesia is more in group ‘a’ patients who received tramadol (figure 1). many patients in group who received ketorolac complained of pain before the dosing schedule time i.e. 6 hours. the adverse effects in group ‘a’ who took tramadol were minimum and they were shown only in 8% of the patients. major adverse effects seen in this group are sweating (8%), sedation (5%) and decrease in blood pressure (4%). but in group ‘b’ who were on ketorolac, adverse effects were observed in 33% patients. 33% patients reported the bleeding at the extraction site and 20% patients reported the epigastric pain. the intensity of adverse effects here increased as dose increased. with the first dose of ketorolac, only 8% patients reported both epigastric pain and the bleeding at the extraction site. (table 2) discussion inspite of the spectacular advances in modern medicine, no single drug satisfied all the criteria of an ideal post extraction analgesic. post extraction analgesia can increase the patients comfort, decrease m m shaik et al. comparative study of tramadol and ketorolac in the pain management of third molar tooth extraction 37 the pain and stress after tooth extraction. the present study was designed to assess and compare the efficacy, safety and the patient satisfaction of two most commonly clinically used analgesics tramadol and ketorolac. tramadol is a newer opioid with better analgesic action without the risk of developement of tolerance and physical dependence. now it has been using very commonly for chronic pain. from the literature it has been considered as safest postoperative analgesic. 5, 12 ketorolac is a most commonly used nsaid for the short term management of pain. main focus was on the study of pain intensity and the adverse effects of both the commonly used analgesics, tramadol and ketorolac. safety of therapy was based on the frequency of side effects and evolution of vital signs recorded during the study. from the current study it has been proved that both the drugs are giving better analgesic effect. ketorolac is showing its analgesic effect very rapidly but the action sustained only up to 4 hours (figure 1). where as tramadol’s analgesic effect started after 1 hour and sustained for the longer time i.e. more than 6 hours (figure 1). the patients who received ketorolac also reported severe adverse effects like epigastric pain, bleeding at the tooth extraction site, nausea and sweating. tramadol had a bit marked effect on blood pressure and also caused sweating in few patients (figure 2(a), 2(b), 2(c), 2(d). conclusion the overall study profile proved that tramadol is a suitable and safe analgesic with longer duration of action and less adverse effects for relief of postextraction pain after third molar extraction and is more effective than ketorolac with a long sustained analgesic action. the percentage of side effects was minimal. references 1. oladimeji a akadiri, ambrose e obiechina.: assessment of difficulty in third molar surgery-a systematic review. oral maxillofac surg. 2009 (apr); 67 (4):771-4. 2. capuzzi p ontebugnoli l m vaccaro m a.: extraction of impacted third molars. a longitudinal prospective study on factors that affect postoperative recovery. oral surg oral med oral pathol. 1994 (apr).; 77 (4) : 341-3. 3. hussain al-khateeb taiseer; alnahar amir.: pain experience after simple tooth extraction, journal of oral and maxillofacial surgery. 2008 (may).; (66), 911-7 4. de beer jde v, winemaker mj, donnelly ga, et al.: efficacy and safety of controlled-release oxycodone and standard therapies for postoperative pain after knee or hip replacement. can j surg. 2005; 48:277. 5. recart a, duchene d, white pf, et al.: efficacyand safety of fast-track recovery strategy for patients undergoing laparoscopic nephrectomy. j endourol 2005; 19:1165. 6. watcha mf, issioui t, klein kw, et al.: costs and effect of rofecoxib, celecoxib, and otolaryngologic surgery. anesth analog.; 2003; 96: 987 7. pozos-guillén ade j, martínez-rider r, aguirrebañuelos p, et al.: analgesic efficacy of tramadol by route of administration in a clinical model of pain. proc west pharmacol soc. 2005; 48: 61-4. 8. zackova m, taddei s, calò p, et al.: ketorolac vs tramadol in the treatment of postoperative pain during maxillofacial surgery. minerva anestesiol. 2001 (sep);67(9):641-6. journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 38 9. ong ks, tan jm.:preoperative intravenous tramadol versus ketorolac for preventing postoperative pain after third molar surgery. int j oral maxillofac surg. 2004(apr);33(3):274-8. 10. melzack r.:the mc gill pain questionnaire: major properties and scoring methods. 1975;277 – 99 11. seymour ra.:the use of pain scales in assessing the efficacy of analgesics in post-operative dental pain eur j clin pharmacol. 1982;23(5):441-4. 12. stamer um, maier c, grond s, veh-schmidt, klaschik e, lehman ka.: tramadol in the management of postoperative pain: a double-blind, placebo-and active drug-controlled study. eur j ana. 1997;12(6):646-54. tramadol ketorolac time intervals at which pain intensity is measured mean ± sd mean ± sd maximum pain 8.07±0.12 8.07±0.12 1st dose 30 min 6.16±0.34 4.32±0.18 1 hr 3.75±0.56 2.45±0.48 2 hr 1.65±0.82 3.09±0.94 3 hr 1.12±0.34 3.93±0.71 4 hr 2.89±0.29 5.65±0.41 5 hr 4.16±0.73 6.94±0.47 6 hr 5.41±0.48 7.34±0.12 2nd dose 12 hr 3.89±0.72 4.12±0.53 3rd dose 18 hr 3.12±0.41 3.89±0.64 4th dose 24 hr 2.12±0.27 2.98±0.29 p-value < 0.05 table 1: comparison of pain intensities of tramadol and penatazocine m m shaik et al. comparative study of tramadol and ketorolac in the pain management of third molar tooth extraction 39 figure 1: graphical representation – comparison of pain intensities of tramadol and ketorolac journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 40 tramadol ketorolac adverse effects no of patients with side effects* percentage (% ) no of patients with side effects* percent age (% ) after 1st dose sedation 2 2.67 0 0.00 sweating 2 2.67 1 1.33 bleeding at tooth extraction site 0 0.00 3 4.00 nausea 0 0.00 1 1.33 diarrhoea 0 0.00 1 1.33 epigastric pain 0 0.00 4 5.33 decrease in b.p. 1 1.33 0 0.00 after 2nd dose sedation 3 4.00 0 0.00 sweating 4 5.33 3 4.00 bleeding at tooth extraction site 0 0.00 6 8.00 nausea 2 2.67 3 4.00 diarrhoea 1 1.33 2 2.67 epigastric pain 1 1.33 6 8.00 decrease in b.p. 3 4.00 1 1.33 3rd dose sedation 4 5.33 0 0.00 sweating 6 8.00 4 5.33 bleeding at tooth extraction site 1 1.33 14 18.67 nausea 2 2.67 6 8.00 diarrhoea 1 1.33 2 2.67 epigastric pain 1 1.33 10 13.33 decrease in b.p. 3 4.00 2 2.67 4th dose sedation 4 5.33 0 0.00 sweating 6 8.00 5 6.67 bleeding at tooth extraction site 1 1.33 25 33.33 nausea 2 2.67 9 12.00 diarrhoea 1 1.33 2 2.67 epigastric pain 1 1.33 15 20.00 decrease in b.p. 3 4.00 3 4.00 p-value < 0.05 table 2: side effects distribution of tramadol and pentazocine * each group contains total number of 75 patients m m shaik et al. comparative study of tramadol and ketorolac in the pain management of third molar tooth extraction 41 figure 2(a): graphical representation – comparison of adverse effects of tramadol and ketorolac after 1st dose figure 2(b): graphical representation – comparison of adverse effects of tramadol and ketorolac after 2nd dose journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 42 figure 2(d): graphical representation – comparison of adverse effects of tramadol and ketorolac after 4th dose m m shaik et al. comparative study of tramadol and ketorolac in the pain management of third molar tooth extraction 43 1-43 introduction: the liver injury due to acute and chronic ethanol abuse has been proved to be dependent on its oxidative effect at the cytosolic, peroxisomal and microsomal levels.1 but despite extensive investigations, the molecular mechanism leading to the hepatic damage still needs to be clarified. based on technologically advanced procedures, it has been demonstrated that a group of reactive species known as free radicals might be taking a major role in the pathogenesis of tissue changes during hepatic ethanol loading. a free radical has been defined as a chemical species, capable of independent existence that contains unpaired electrons. they are energetically unstable, highly reactive and short lived.2 drugs including alcohol may exert toxic effect by promoting free radical formation during their metabolism and a decline of some of the antioxidant defences like reduced glutathione, vitamin c, vitamin e, vitamin a, etc. thereby increasing the ratio between pro-oxidant and antioxidant reaction resulting to a condition known as oxidative stress.3 polyunsaturated fatty acids within the cell membranes and lipoproteins are particularly susceptible to oxidative attack often as a result of metal ion dependent hydroxyl radical formation. long chains of lipid peroxides may be formed causing serious disruption of cell membrane correspondence: dr. a. r. singh e-mail: dr.drarsingh@rediffmail.com study of effect of ethanol on antioxidant vitamin a and c in rat liver a. r. singh1, sushil kumar2, roshan takhelmayum2, j. n. sihna3 1asst. prof, 2lecturer, 3prof and head, department of biochemistry, college of medical sciences and teaching hospital, bharatpur, nepal. abstract: objective: to see the effect of consumption of locally distilled alcohol (country liquor) continuously for few months on hepatic vitamin a and c status in albino rats. materials and methods: the study was conducted in 36 male wistar strain albino rats for 3-4 months old consisting six groups of six animals each. results: the first observation was weight gain among the series of alcoholic animals when compared to the control and alcoholic fed animals supplemented with vitamin a and c, p-value by t-test between the mean values of the initial weight and final weight was < 0.01 (0.006), significant. conclusion: it was found that the major effect on hepatic vitamin a and c contents were observed more distinctly in mitochondrial fractions when compared with the rest fractions. supplementation of vitamins helped to protect loss of the vitamins which delayed the aging process at age 9-10 months in our study. key words: albino rats, alcoholic, hepatic, vitamin a original article, 29-34journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 29 function.4, 5 proteins exposed to free radical attack may fragment, cross link or aggregate. the consequences include interference with ion channels, failure of cell receptor, etc. free radical damage to dna may cause destruction of bases, deoxyribose sugar and single or double strand breaks6 and is implicated in mutagenesis, carcinogenesis and even cell death.7 antioxidants delay and protect against oxidative damage produced by free radicals. vitamin a and c belong to nutrient antioxidants. vitamin a is a lipid soluble antioxidant and membrane bound. it can suppress free radical induced lipid peroxidation under conditions of low partial pressure of oxygen in most tissues. vitamin c, a water soluble antioxidant which acts as free radical scavenger could improve liver functions in alcoholic patients8, 9 and that also maintains the vitamin e level. it has been reported that both vitamins may behave as pro-oxidants if aqueous phase antioxidant fall short.10 the present study was undertaken to see whether the nutritional antioxidants like vitamin a and vitamin c have got any definite role in checking liver injury in alcoholics. materials and methods: the study was carried out in the department of biochemistry, regional institute of medical sciences (rims), imphal, manipur. albino rats (wistar strain), 3-4 months old procured from national institute of nutrition, indian council of medical research (icmr), hyderabad reared in the central animal house, rims, imphal were the animals used for the study. diet chart formulation was done according to the method given for preparation of pellet diets as published in laiis centre, news (nov, 1984). ethical clearance was obtained from the institutional ethical committee for conducting the animal experiment. thirty six male albino rats with average mean weight of 165 gm were selected and divided into six groups. the first group was given only normal diet and served as control no. 2. the second, third, fourth and fifth were given alcohol over and above normal diet. the sixth group was given both alcohol and nutrient antioxidant along with normal diet. an additional group (control-1) of six albino rats (3-4 months old) with an average mean weight of 165 gm were sacrificed at the very beginning of the study for determining antioxidant levels in various subcellular fractions. determination of antioxidant level in alcoholic group was done by sacrificing the second, third, fourth and fifth groups after one week, one month, three and six months respectively. the first (control no. 2, c 2 ) and the sixth groups were sacrificed after sixth months only to determine the hepatic antioxidant levels. all the chemicals and reagents used for the study were of analytical grade and alcohol used for feeding animals was collected from a local distiller. this sample contains 37.95% alcohol as per analysis method given by department of food and technology and biochemical engineering, jadavpur university, calcutta. four hundred i.u. of vitamin a (retinol procured from eupharma lab. ltd. mumbai), and 4 mg of vitamin c (ascorbic acid from abbott lab. india) were supplemented to the sixth group per day per animal. for collection of rat liver, the abdomen was cut and tissue was dissected and then a homogenate was prepared in 20% 0.25 m sucrose solution using potter elvehjem type homogenizer. differential centrifugation of the homogenate was done in high speed refrigerated centrifuge machine (beckman’s avanti-30) to separate the various sub-cellular fractions. all the sub-cellular fractions and 15000 x g, 1 hr supernatant were used journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 30 for study of antioxidant levels in them. methods of natelson s11 were used to estimate the levels of vitamin a and vitamin c. results: in table 1, the sixth group and the first group (c 2 ) show mean body weight of 201 and 204 gm respectively showing a weight gain of 36 gm and 39 gm within a span of six months. the alcoholic group, on the other hand showed a better rate of weight gain showing the increase of 15 gm, 30 gm, 39 gm and 75 gm when recorded after one week, one month, three months and six months respectively. table 1. comparative body weight changes in different groups of animals. animal groups/ duration initial weight in grams (mean) final weight in grams (mean) weight changes in grams (mean) 1 week alc (2nd gr) 165 180 15 1 month alc (3rd gr) 165 195 30 3 months alc (4th gr) 165 204 39 6 months alc (5th gr) 165 240 75 6 months alc+ao (6th gr) 165 201 36 6 months controlc2 (1 st gr) 165 204 39 p-value by t-test between mean values of initial weight and final weight <0.01 (0.006), significant. alc= alcoholic and ao= antioxidant table 2 shows vitamin a distribution in all the subcellular fractions though the nuclear fraction and light mitochondrial fraction show slightly higher level. effect of alcohol loading in the level of vitamin a can be seen in the subcellular fractions are all significant. heavy mitochondrial fraction shows the greatest fall (p <0.001). rearing the animal for six months showed decrease in the level of vitamin a in nuclear fraction, heavy and light mitochondrial fractions in the first (control 2, c 2 ) and sixth groups (alcohol and antioxidant). table 2: comparative study of vitamin a concentration in various subcellular fractions of alcoholic rat liver. alcohol s.f. control-1 mean±sd 1 week mean±sd 1 month mean±sd 3 months mean±sd 6 months mean±sd alcohol antioxidant 6 months mean±sd control c2 mean±sd h 68.80±5.00 71.35±0.74 66.75±1.68 60.20±2.62* 52.27±2.99* 76.62±2.98** 68.67±0.79 n 18.36±0.99 18.35±0.63 14.45±1.73* 14.53±1.69* 13.83±1.47* 22.40±2.60* 17.00±1.81 m1 16.67±0.47 17.14±0.38 12.76±1.39 ** 12.50±1.41** 12.16±1.39** 20.69±2.59* 14.18±1.51* m2 18.28±0.34 18.11±0.43 14.27±1.74 ** 14.26±1.74* 13.77±1.52** 17.05±1.02 17.09±0.74* sup 15.31±0.67 15.88±1.03* 13.67±1.95 12.82±1.35* 12.73±1.29* 17.46±0.52** 15.17±0.85 a. r. singh et al. study of effect of ethanol on antioxidant vitamin a and c in rat liver 31 values expressed as mg/g liver. *p <0.05 **p <0.001 s.f. = subcellular fraction, h= homogenate, n= nuclear fraction, m 1 = heavy mitochondrial, m 2 = light mitochondrial, sup= supernatant. the quantity of vitamin c recovered as sum of all the fractions seems to be much higher than that of the whole homogenate. the recovery is higher in the soluble fraction than that of the whole homogenate. on alcohol loading, vitamin c level decreases in the soluble fraction and on antioxidant supplementation in the sixth group, the level of vitamin c increases significantly in 15000 x g, 1 hr. supernatant. sacrificing the animals after 6 months decreases in level of vitamin c in 15000 x g, 1 hr supernatant and the decrease is similar in both alcoholic and non alcoholic groups, suggesting a negligible role of alcohol in changing the hepatic vitamin c level (table 3). the changes must be simply because of aging. table 3: comparative study of vitamin c concentration in various subcellular fractions of alcoholic rat liver. alcohol s.f control-1 mean±sd 1 week mean±sd 1 month mean±sd 3 months mean±sd h 201.17±6.65 189.33±4.84* 189.33±4.84** 186.50±3.45* 1 n 44.95±2.44 44.70±2.51 43.75±0.76 43.75±0.76* m1 43.47±1.00 43.47±1.00 43.75±0.76 43.75±0.76 m2 43.47±2.07 43.75±0.76 44.70±2.51 44.70±2.51 sup 220±10.73 206.33±4.97* 207.33±2.51 267.33±13.54* 2 values expressed as mg/g liver. *p <0.05 **p <0.001 s.f. = subcellular fraction, h= homogenate, n= nuclear fraction, m 1 = heavy mitochondrial, m 2 = light mitochondrial, sup= supernatant. discussion: in this study, we found that alcoholic animals had a better weight gain when compared to control and alcoholic groups supplemented with antioxidant vitamins. alcohol when given in reduced dose, instead of causing any harmful hepatic changes, might have simply stimulated the whole organ system thereby increasing different vital functions leading to better appetite and food intake. this may be one of the possible reasons of getting higher weight gain in alcoholic group.12 the rapid increase in weight may not be a good sign of healthiness because most of chronic alcoholics are always on higher side of expected normal weight. the cause of the increased body weight may be due to increased deposits of hepatic lipids and also other adipose tissues. alcohol has extra calories of its own and if taken regularly becomes an appetizer. the fall in vitamin a content in the alcoholic liver may be due to its utilisation in trying to control the ethanol mediated free radical generation. the low recovery from the subcellular fractions may be explained on the basis of the loss of certain naturally occurring protective antioxidant, after cell fractionation which in turn leading to the mobilisation of more of the vitamin a from the hepatic store in the alcoholic animals. due to the lack of ethanol mediated free radical journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 32 generation in non alcoholic animals (control), naturally occurring protective antioxidants may still be present unaffected and thus recovery after cell fractionation may still be maintained at 100%. the complete recovery of vitamin from the subcellular fractions in alcoholic animals supplemented with the antioxidant vitamin shows the importance of vitamin a in counteracting the generation of free radicals or quenching the free radicals already generated. one week ethanol feeding seems, to have no impact on the antioxidant status of the animal. only light mitochondrial fraction shows just significantly decreased level. maria et al, 1982 reported the changes in the structure of mitochondria in ethanol fed rats.13 further, one month of ethanol loading, affected all the subcellular fractions. the homogenate however, still maintain the vitamin level suggesting the presence of naturally occurring protective antioxidant. the sudden significant decrease of the vitamin level in the subcellular fractions explains the loss of the said natural antioxidant during the cell fractionation initiated by the ethanol mediated free radicals. after three months the alcoholic animals show the same pattern of changes as that of one month already discussed. here the only change is that homogenate show a significant decrease in its vitamin a content. after six months of ethanol loading, the light mitochondrial fraction shows a further fall in hepatic vitamin a content supporting the earlier views that a drastic structural change may be related to its increase fall of the vitamin. when antioxidant vitamin is given along with the alcohol for six months, the antioxidant status in the hepatic subcellular fractions show a dramatic improvement. all the subcellular fractions shows significantly increased level of the vitamin except that of light mitochondrial which has been considered as the most sensitive fraction in terms of its capacity to hold this vitamin because of its ethanol sensitive structural changes, the extent of the decrease however, is not significant. in short, a conclusion may be drawn for the antioxidant vitamin a as having an important role in checking the level of hepatic antioxidant levels during ethanol loading thereby helping in the prevention of ethanol mediated hepatic injury. aging also seems to affect the vitamin a status of two mitochondrial fractions sparing rest of the fractions. vitamin c is mainly recovered from soluble fraction and is not affected by the progress of alcohol loading. the aging process seems to be the major factor in changing vitamin levels in soluble fraction of the cells. the study reaffirms that antioxidant supplementation seems to be useful in maintaining the vitamin levels affected by process of aging and alcohol. conclusion: from all the findings, it is suggested that antioxidant vitamin supplements will be beneficial to alcoholic population but for it to be recommended, a thorough trial study in human alcoholics with a well control dietary chart and proper assessment of health status at different stages of aging be very much needed. references: 1. lieber cs. biochemical and molecular basis of alcoholinduced injury to liver and other tissues. n engl j med 1988; 319: 1639-50. 2. halliwell b, gutterrigde jmc. oxygen toxicity, oxygen radicals, transition metals and disease. biochem j 1984; 219: 1-14. 3. bast a, haenen gr, doelman cj. oxidants and antioxidants, state of art. am j med 1991; 2-13. a. r. singh et al. study of effect of ethanol on antioxidant vitamin a and c in rat liver 33 4. aust sd, morehous la, thomas ce. role of metal in oxygen radical reactions. free radic biol med 1985; 1: 3-6. 5. sevenian a, hachstein p. mechanisms and consequences of lipid peroxidation in biological systems. annu rev nutr 1985; 5: 365-75. 6. aruoma ol, halliwell b, dizdaroglu m. iron ion dependent modification of bases in dna by the superoxide radical generation system hypoxanthine/ xanthine oxidase. j biol chem 1989; 264: 13024-8. 7. scholes rj. radiation effect on dna. br j radiol 1983; 56: 221-32. 8. feher j, lengyel g, blazovics a. antioxidant and toxic liver disease. in: proceeding of international symposium of free radicals in medicine and biology, udaipur (rnt medical college), india; 1997: 15-6. 9. stocker r, frei b. endogenous antioxidant defences in human blood plasma. in: oxidative stress, oxidants and antioxidants. ed sics h. london: academic press; 1991: 213-42. 10. hennekens ch, gasiano jm, manson je, et al. antioxidant vitamins cardiovascular disease hypothesis is still promising but still unproven: the need for randomised trial. am j clin nutr 1985; 62: 137780. 11. natelson s. estimation of vitamin a, vitamin c and alpha-tocopherol. in: charles c, thomas wb. techniques of clinical chemistry. 3rd ed, usa: illionois; 1971: 162-758. 12. bharthi pg. nutrition and food. in: health and nutrition. 9th ed. london: churchil livingstone; 1998: 88-94. 13. tateo k, shinzo k, charles sl. lipid peroxidation and antioxidant defence systems in rat liver after chronic ethanol feeding. hepatolog. new york: academic press; 1989: 815-21. journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 34 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 1-43 introduction encephalitis refers to acute inflammatory process affecting the brain. aes may present as encephalitis, meningoencephalitis or meningitis and may be caused by viruses, bacteria, mycobacteria, rickettsia and rarely by toxoplasma. viral infections are most common and important cause of encephalitis. je and dengue are more prevalent in south east asia1. as a part of efforts to control je the world health organization (who) is providing a set of standards for je surveillance, which require the identification of patients with aes.2,3 according to clinical case definition by who, aes is defined as acute onset of fever and a change in mental status including symptoms such as confusion, disorientation, or inability to talk and/ or new onset of seizures excluding febrile convulsions in a person of any age at any time of year.4 cerebral malaria and non infectious causes of encephalopathy are required to be excluded while considering aes. confirmation of diagnosis of je is usually done by je specific titers of igm antibodies in serum and or in csf during acute illness of suspected aes case.2 je is caused by a zoonotic flavivirus which is one of the common causes of aes. it is difficult to eradicate study of acute encephalitis syndrome in children y. r.khinchi1, a. kumar2, s. yadav3 1associate professor, 2second year md resident, 3third year md resident; department of pediatrics and neonatology, college of medical sciences, bharatpur, nepal abstract objective: to determine the profile and outcome of children admitted with acute encephalitis syndrome (aes) and to find out the prevalence of japanese encephalitis (je) igm antibodies positive cases among these patients with their case fatality rate (cfr). materials and methods: study consist of retrospective analysis of hospital records of children up to 15 years of age admitted with diagnosis of aes in pediatric wards of college of medical sciencesteaching hospital, bharatpur from january 2007 to december 2008. results: during two years, 61 patients of aes were admitted. male and female patients were 33 and 28 respectively. meningitis accounted for 29 and encephalitis for 32 patients. je igm seropositive cases contributed for 18% of all aes cases. case fatality for je was 16.6%. conclusions: japanese encephalitis is endemic in catchment area of the hospital. je has significant morbidity and mortality which can be prevented by immunization and mortality can be reduced if supportive interventions are provided in time. key words: aes, je, cfr. correspondence: dr. y. r.khinchi e-mail: dr_khinchi@yahoo.com , 7-13 original articlejournal of college of medical sciences-nepal, 2010, vol. 6, no. 1 7 je because it is transmitted from natural reservoirs like pigs, waddling birds which are important amplifying hosts and man is involved as an accidental host. je has been controlled effectively through vaccination programs in several asian countries like japan, korea, china and thailand.5 culex tritaeniorhyncus is the principle vector of je in nepal, as the species is abundantly found in the rice field ecosystem of the endemic areas during the transmission season. increase in je cases is observed after the rainy season peaking between august and september.6 je was first observed in nepal in 1978 as an epidemic in rupandehi district of the western development region and morang of eastern region.6 between 1978 and 2004 around 27000 cases reported with approximately 5000 deaths. from 2004 to 2006, 1323 cases of je were confirmed in lab. total 24 tarai districts are endemic with cfr ranging from 5-29% with 10% as an average. average case fatality in all ages is about 20% in nepal.6 cfr and morbidity due to je can be reduced significantly by early diagnosis and appropriate supportive care.5 present study is carried out with the objective to evaluate the clinical profile of hospitalized pediatric aes cases, to determine the prevalence and outcome of meningitis or encephalitis presentation of aes and to document what proportion of these cases are serology proven je with case fatality. materials and methods this study is carried out in children with clinical diagnosis of aes admitted in pediatric wards of college of medical sciences teaching hospital, bharatpur, nepal for 2 years from january 2007 to december 2008. this is a retrospective descriptive study done on 61 patients up to 15 years of age diagnosed as aes according to who case definition admitted during two years. case records of these patients were analyzed in detail and data recorded for history, examination, investigation and outcome. patients were categorized on the basis of predominant clinico-investigational picture suggestive of meningitis or encephalitis. surveillance of je is being done by who in endemic areas through detection of je igm antibodies in acute stage of aes patients either in serum or serum and csf samples. college of medical sciencesteaching hospital is one of the je surveillance center recognized by who, nepal. blood and or csf samples of all clinical aes cases from our institution are routinely being sent to who program for immunization preventable diseases (who ipd) field office, hetauda as per requirement suggested by who for confirmation by je igm (elisa) which is processed at nepal public health laboratory teku, kathmandu. reports of these cases were correlated later with respective patient when received through who ipd field office, hetauda. all pediatric patients upto 15 years of age fulfilling the standard who case definition of aes as mentioned above were included in the study. exclusion criteria included patients presented like aes picture but with clinico-investigational diagnosis confirmative of cerebral malaria, reye syndrome or other non infectious encephalopathy. statistical significance was analyzed by deriving p value. results there were 61 cases of aes pediatric patients up to 15 years of age during two years of study period fulfilling the who definition. profile of these cases is shown in table-1. age distribution of these cases was 14, 16 and 31 in less than 1 year, 1 to 5 year and 5 to journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 8 15 years respectively. male and female patients were 33 and 28 and this was statistically insignificant (p>0.05, table-2). meningitis and encephalitis cases were 29 and 32 respectively. encephalitis was documented significantly more in male as compared to female (p<0.015) whereas meningitis was more commonly observed in female (table-3). out of total 61 cases of aes, 30 were discharged home, 13 expired, 9 were referred most often on request and another 9 left against medical advice (lama). statistically significant patients of meningitis (p<0.0003) and encephalitis (p<0.04) were discharged home as compared to lama, referred or expired (table-4). excluding lama and referred cases there was statistically less mortality in meningitis (p<0.05) as compared to high mortality in encephalitis patients (table-5). serology for je igm (elisa) was positive in 11 cases as per documented reports received from who field office out of 61 total cases of aes. most of these patients (72.7%) were from nawalparasi (8 out of 11) and one each from chitwan, tanahu and makwanpur districts. in year 2007, one, 3 and 4 cases were documented in august, september and november respectively, whereas in 2008, 2 cases occurred in july and 1 in august. igm seropositive cases consisted of 18% of all aes patients (table-6). among 11 seropositive cases male patients were 7 (63.6%) as compared to 4 (36.3%) female cases. no je seropositive case was found in less than 1 year, only 2 (18.1%) cases belonged to 1 to 5 years age group and maximum 9 (81.8%) patients were between 5 to 15 years of age. table-6 shows that statistically highly significant less number of patients had positive je igm serology in year 2008 (p<0.00004) as compared to year 2007 (p<0.0157). among those 11 cases positive for je igm, 6 (54.5%) were discharged home, 2 (18.1%) were taken lama, none was referred and remaining 3 (27.2%) expired in the hospital. discussion the je is the single largest cause of viral encephalitis in the world7. to monitor je surveillance, who has given clinical case definition of aes so that these cases are subjected for confirmative diagnosis by igm captured elisa in blood and or csf and preventive and supportive interventions can be planned and implemented in endemic or epidemic situations. je is a significant health problem throughout asia. epidemics of je are documented in southeast asia and most of the indian subcontinent. in 2005, there was a severe epidemic of je in the eastern uttar pradesh, as well as in the adjoining areas of the neighboring state of bihar and in nepal.7 the clinical disease presents with a prodromal stage, an acute encephalitic stage with varying grades of coma, convulsions and neurological deficits with high mortality or convalescent stage of recovery often with sequelae. clinical profile of aes patients in this study (table1) included vomiting, seizures, glasgow coma scale (gcs) <8, meningeal irritation signs, neurological deficit in 49.1%, 90.1%, 29.5%, 49.1% and 16.2% respectively. study done by gupta n et al. observed vomiting in 41.4%, seizures in 79.3%, altered sensorium in 51.7%, signs of meningeal irritation in 17.2% and neurological deficit in 34.5% of their cases in the study done in hospitalized patients suspected of je.8 some of these findings are comparable with present study. in another study done to determine the etiology of febrile encephalopathy by rayamajhi et al. seizures was documented in 58% of cases which is less than our data.9 kumar et al. described vomiting in 6.5%, y. r.khinchi et al. study of acute encephalitis syndrome in children 9 meningeal signs in 35.1%, gcs <7 in 44.1%, extrapyramidal features in 31.1% and convulsions in 98.7% in hospitalized patients during je epidemic in 2005 which occurred in eastern uttar pradesh and adjoining areas of india. these all patients were igm positive for je.7 differences in clinical picture may be variable depending on various factors like sample size, demographic and epidemiological differences as well as study objective including whether done entirely on encephalitis, investigation of je epidemic or as per who case definition of aes surveillance. prevalence of meningitis and encephalitis (table-3) was 47.5% and 52.4% respectively among 61 cases of aes. prevalence of je patients presenting with encephalitis form ranged between 60 to75% and presenting with meningitis form consisted up to 5 to 10% cases.10 though these data cannot be compared with our observations which were covering all patients of aes, whereas the data in the reference cited above are for je cases but still this suggest that patients may present in either way. number of aes patients discharged home (58.6%) was significantly more in meningitis (total 29) group (table-4, p<0.0003) as compared to lama (17.2%), referred (17.2%) or expired (6.8%). out of 32 cases of aes diagnosed as encephalitis 40.6% were discharged home, 12.5% taken lama, 12.5% referred and 34.3% patients expired (table-4, p<0.41). high mortality in this group is consistent with universal observations of more number of deaths in encephalitis including je. encephalitis in this study was statistically more frequent in 2007 and meningitis was more common in 2008 (table-3, p<0.015). there was significantly less number je igm positive cases documented in 2008 (table-6, p<0.00004) as compared to 2007 (table6, p<0.0157). less number of je igm positive cases (3, 9.3%) in the year 2008 as compared to 2007 (8, 27.5%, table-6) may be because of the fact that effective active immunization campaign involving our institution also by who ipd with sa14-14-2 vaccine to all children up to 15 years of age before rainy season in 2008 was undertaken in je endemic areas identified based on surveillance done in 2007. in this study most of the cases were confined to nawalparasi district and occurred after rainy season in september and november in 2007 and july and august in 2008. other studies also documented prevalence of disease during these months8,11. this is because of increase mosquito density during post monsoon period. among 11 seropositive cases 7 (63.6%) were male as compared to 4 (36.3%) female patients. similar trend was also observed in other studies.9,11 this may be attributed partly because male children are more likely to go out doors or to agriculture area where mosquito vector of the disease is abundant. most often affected (81.8%) children were between 5 to 15 years of age in the present study which is more or less comparable to other studies.8,9 this may be correlated to more ambulation in this age group like playing outdoors, going to school or agriculture rice fields predisposing them to vector mosquito bite. after excluding lama and referred cases there were 9 patients seropositive for je igm who stayed in hospital till final outcome. out of these 6 were discharged home whereas 3 died in the institution during two years of study period. out of those 6 patients who survived 4 were asymptomatic, 1 developed motor deficit with extrapyramidal features and another one had dysphasia on discharge. cfr is the number of deaths/ number of cases diagnosed per year.12 cfr in journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 10 this study was 16.6%. cfr due to je in nepal ranged from 9.8% to 46.3% from 1978 to 2003. during recent years cfr has declined and contained below 20% which is comparable to this study.6 cfr according to the study conducted over wide geographical area covering south asia, southeast asia, china, pacific rim and north australia was between 20-30%.10 other studies reported cfr for je as 8.3% by rayamajhi a et al. and 12.5% by shrestha sr et al., which is less than our study.9,11 these differences may be due to severity of disease at presentation, delay in referral, different geographical and epidemiological factors. conclusions je confirmed by je igm serology contributed to significant cases of aes in children up to 15 years of age. je is endemic in catchment region of this institution. male were found to be at more risk for je and significant number of patients were between 5 to 15 years. cfr for je in this institution is comparable to global results. je has significant morbidity and mortality which can be prevented by highly effective live attenuated single dose vaccination or other preventive measures. sequelae and mortality can be reduced if patients are referred in time for supportive interventions at proper place. acknowledgements we are highly thankful to dr umesh k. shukla, surveillance medical officer, who ipd field office, hetauda for his help in je surveillance and providing data of samples collected from our patients. we are also thankful to mr naresh manandhar, assistant professor, department of community medicine of this institution for his kind help in statistical analysis. references 1. mishra u k, tan c t, jayanti k. seizures in encephalitis. neurology asia; 2008:1-13. 2. fidan j, emsley h, fischer m et al. the incidence of acute encephalitic syndrome in western industrialized countries. virology journal 2008, 5: 134 (http:// www.virologyj.com/content/5/1/134; assessed on 12.2.2010) 3. who-recommended standards for surveillance of selected vaccine preventable diseases (http:// www.who.int/vaccine-documents/docspdf/843.pdf; assessed on 10.2.2010) 4. solomon t, thao tt, lewthwaite p et al. a cohort study to assess the new who japanese encephalitis surveillance standards. bulletin of the world health organization 2008;86:178-86 5. rao pn. japanese encephalitis. indian pediatrics 2001; 38:1252-64. 6. bista m b, shrestha j m. epidemiological situation of japanese encephalitis in nepal. j nep med assoc; 44: 51-6. 7. kumar r, tripathi p, singh s et al. clinical features in children hospitalized during the 2005 epidemic of japanese encephalitis in uttar pradesh, india. clinical infectious diseases, 2006; 43:123-31. 8. gupta n, chatterjee k, karmakar s et al. bellary, india achieves negligible case fatality due to japanese encephalitis despite no vaccination: an outbreak investigation in 2004. indian j pediatr 2008; 75(1):31-7. 9. rayamajhi a, singh r, prasad r et al. clinicolaboratory profile and outcome of japanese encephalitis in nepali children. annals of tropical pediatrics: international child health. 2006; 26, 4:293301. y. r.khinchi et al. study of acute encephalitis syndrome in children 11 10. solomon t. current concepts: flavivirus encephalitis. n eng j med 2004; 351:370-8. 11. shreshta sr, awale p, neupane s et al. japanese encephalitis in children admitted at patan hospital. j nepal paediatr. soc. 29, 1:17-21. 12. joshi ab, banjara mr, bhatta lr et al. status and trend of japanese encephalitis epidemics in nepal: a fiveyear retrospective review. journal of nepal health research council, 2004; 2, 1:59-64. table-2: distribution of aes cases according to age, sex and year: table-1: profile of acute encephalitis syndrome (aes) cases (61): journal of college of medical sciences-nepal, 2010, vol. 6, no. 1 12 feature number (%) fever 61(100%) altered sensorium 61(100%) vomiting 30(49.1%) headache/ excessive cry 27(44.2%) seizures 55(90.1%) glasgow coma scale (gcs) < 8 18(29.5%) extrapyramidal features 8(13.1%) signs of meningeal irritation 30(49.1%) neurological deficit 10(16.2%) fundoscopy normal 47(77%) suggestive of papilledema 2(3.2%) not required (anterior fontanel was open and flat) 12(19.6%) csf suggestive of bacterial meningitis (cell counts/ biochemistry/gram stain or c/s) 25(40.9%) suggestive of viral meningitis/ encephalitis (cell counts/biochemistry/neg. gram stain/sterile c/s) 22(36%) normal csf/ refused for lumber puncture 14(22.9%) age 2007 (aes 29) 2008 (aes 32) 2007 & 2008 total (61) male female male female male female <1 yr 4(13.7%) 2 (6.8%) 6 (18.7%) 2 (6.2%) 10 4 14(22.9%) 1 to 5 yr 2 (6.8%) 3 (10.3%) 7 (21.8%) 4 (12.5%) 9 7 16(26.2%) 5 to15 yr 8(27.5%) 10(34.4%) 6 (18.7%) 7 (21.8%) 14 17 31(50.8%) total 14(48%) 15(51.7%) 19(59.3%) 13(40.6%) 33 28 61 p value p >0.05 p >0.05 table-3: distribution of total cases of meningitis / encephalitis according to sex in 2 yrs table-4: outcome of encephalitis/ meningitis (aes) cases in 2 years table-5: outcome of encephalitis/ meningitis (aes) excluding lama/ referred cases table-6: aes cases according to serology for je igm y. r.khinchi et al. study of acute encephalitis syndrome in children 13 diagnosis 2007 and 2008 total (aes) male (33, 54%) female (28, 46%) 61 meningitis 11 (33.3%) 18 (64.2%) 29 (47.5%) encephalitis 22 (66.6%) 10 (35.7%) 32 (52.4%) p value p < 0.015 diagnosis encephalitis (32, 52.4%) meningitis (29, 47.5%) aes (61) discharged 13 (40.6%) 17 (58.6%) 30 (49.1%) lama 4 (12.5%) 5 (17.2%) 9 (14.7%) referred 4 (12.5%) 5 (17.2%) 9 (14.7%) expired 11 (34.3%) 2 (6.8%) 13 (21.3%) p value p <0.41 p <0.0003 p <0.0001 diagnosis encephalitis (24, 55.8%) meningitis (19, 44.1%) total (43) discharged 13 (54.1%) 17 (89.4%) 30 (69.7%) expired 11 (45.8%) 2 (10.5%) 13 (30.2%) p value p>0.05 p<0.05 43 year je igm positive je igm negative total aes (61) p value 2007 8 (27.5%) 21 (72.4%) 29 (47.5%) p<0.0157 2008 3 (9.3%) 29 (90.6%) 32 (52.4%) p<0.00004 2007-08 11 (18%) 50 (81.9%) 61 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 29 original article journal of college of medical sciences-nepal, 2014, vol-10, no-3 correspondence: dr. atanu pan e-mail: atanu8k@yahoo.co.uk status of glucose metabolism including insulin resistance and beta cell function in overtly iron loaded thalassemia patients pan a1, nag ss2, mondal bc2, anindya dasgupta a,3 piyali mitra p4 1college of medical sciences department of paediatrics,bharatpur,nepal, 2department of pediatrics, 3department of biochemistry and 4department of pathology, burdwan medical college, burdwan, india. abstract background abnormality of glucose metabolism is a frequent complication in thalassemia patients. both insulin deficiency and insulin resistance has been proposed in its pathogenesis. some form of abnormality in glucose metabolism is expected at an earlier age in these patients in developing countries like india and nepal where iron overload is excessive due to lack of chelation therapy. materials and methods fasting serum glucose and fasting serum insulin (fsi) were measured in 40 beta-thalassemia major patients, 40 ebetathalassemia patients and 40 controls, all aged between 5 and 12 years. 2 hours after an appropriate dose of oral glucose feed (children ingested 1.75 g/kg body weight maximum 75 gram dissolved in 250 to 300 ml water) blood samples were drawn again to measure post prandial serum glucose. iron overload was assessed by measuring liver size, spleen size, total amount of packed cells transfused and serum ferritin. insulin resistance (ir), insulin sensitivity (%s) and beta cell functions (%b) were derived from the measured laboratory parameters using the latest version of homeostatic model assessment(homa) calculator software. results no one had impaired glucose metabolism or diabetes mellitus beta-thalassemia major patients showed evidence of insulin resistance in the form of significantly higher fasting serum insulin (p value 0.002), ir (p value 0.003), %b (p value 0.017) and significantly lower %s (0.002) when compared with controls. fsi showed positive correlation with total amount of packed cells received (r=0.372, p=0.018), serum ferritin (r=0.345, p=0.029) and spleen size (r=0.427, p=0.006). similarly, ir also showed positive correlation with total amount of packed cells received (r=0.388, p=0.013), serum ferritin (r=0.336, p=0.034) and spleen size (r=0.425, p=0.005). %s showed negative correlation with all these parameters. %b didn’t show any statistically significant correlation with these parameters.ebetathalassemia patients didn’t have any statistically significant difference in fsi, ir, %s and %b than controls. conclusion insulin resistance develops as the earliest abnormality in glucose metabolism in overtly iron loaded beta thalassemia major patients at an early age. ebetathalassemia patients with milder phenotype do not develop dysfunction of glucose metabolism at such an early age. key words : glucose metabolism, insulin resistance, insulin sensitivity, beta cell function,beta- thalassemia major, ebeta- thalassemia. journal of college of medical sciences-nepal, 2014, vol-10, no-3 original article 30 introduction the thalassemias are a heterogenous group of singlegene  disorder  characterized  by  reduced  rate  of production of normal haemoglobin due to absent or reduced synthesis of one or more types of globin polypeptide chains resulting in chronic haemolytic anaemia. blood transfusion is the mainstay of care of individuals with thalassemia which improves anemia and suppresses  ineffective  erythropoiesis.  regular transfusions have prolonged and improved quality of life of patients with this disease.1,2 however, in absence of iron chelation therapy, blood transfusions increase iron overload. it is pronounced if transfusions are not optimum and regular due to gdf-15 (secreted from enormously  expanded  and  active  bone  marrow) mediated  increase  in  iron  absorption.  so,  blood transfusions, whether adequate or inadequate, leads to iron overload in various organs like heart, liver, pituitary, thyroid, parathyroid, pancreas etc. sixty percent of thalassemic patients have hypofunction of at least one endocrine gland.3disturbances of glucose metabolism are frequent in these patients. however, there is no consensus regarding etiology of abnormal glucose metabolism. though insulin deficiency has been proposed as the causative factor, some studies report presence of insulin resistance and hyperinsulinemia. evidence of insulin resistance has also been noted in thalassemics without any abnormality in serum glucose.4 in india and nepal, chelation is suboptimal in most of the  patients  due  to  economic  constraints.  even compliance  to  transfusion  is  often  not  optimal.5 therefore, there is a possibility that our patients may develop  some  form  of  derangement  in  glucose metabolism at an earlier age.e beta thalassemia is a common variety of thalassemia found in eastern part of india, besides beta- thalassemia major; but no study is available regarding glucose metabolism status in them.keeping these in mind, we planned our study to evaluate the status of glucose metabolism in terms of incidence of diabetes, impaired glucose tolerance and parameters related to insulin resistance in thalassemia patients (both beta thalassemia  major and  e beta thalassemia) who do not receive chelation therapy. materials & methods thalassemia patients attending burdwan medical college and hospital and college of medical sciences bharatpur for treatment were included in this study. they were divided into two groups – beta thalassemia major and e beta thalassemia; 40 patients from each group were selected. patients aged between 5 and 12 years,  diagnosed  by  electrophoresis  or  high performance liquid chromatography, were included in the study. exclusion criteria were: patients receiving chelation therapy, patients infected with hepatitis b and c viruses and patients whose 1st degree relatives (non-thalassemic)  and  who  were  suffering  from diabetes. 40 beta- thalassemia major patients (group 1) and 40 e-beta thalassemia patients (group 2) who satisfied these criteria were selected for the study. we also involved 40 controls (group 3), who were selected randomly  from  healthy  siblings  of  patients  (nonthalassemic)  attending  pediatric  out  patient department  for  minor  ailments.  the  study  was conducted after obtaining informed consent from parents of cases and controls and permission from institutional ethical committee. following an overnight fasting  for  8  hours,  a  venous  blood  sample  was collected next day to estimate fasting plasma glucose, fasting serum insulin and serum ferritin. then the patients were given a feed of glucose solution using dose of 31 original article journal of college of medical sciences-nepal, 2014, vol-10, no-3 1.75 gm glucose per kg body weight.  after 2 hours, another blood sample was collected for post prandial plasma glucose estimation. blood glucose level was assayed  by  glucose  oxidase-  peroxidase  (godpod) method, serum insulin and serum ferritin by non competitive elisa method. insulin resistance (ir), insulin sensitivity (%s) and beta cell functions (%b) were  derived  from  the  measured  laboratory parameters using the latest versionof homa calculator software.in  our  study,  we  have  used  the  homa calculator  2.2.2  software  developed  by  oxford university. finally, all the data were analysed using spss software version 17.0. results in our study no one from any group had qualified to be labeled as suffering from diabetes mellitus (dm) or having impaired glucose tolerance. fasting serum insulin, insulin resistance and beta cell function (%b) all were significantly higher in group 1, when  compared  to  group  2  and  group  3.  insulin sensitivity (%s) was significantly lower in group 1, compared to other groups. no significant difference was noted between groups 2 and 3 in any of these parameters [table 1]. table 1: demographic, clinical and biochemical parameters among various groups pa ra meters mea n±sd p va lues group 1 β tha l. ma jor group 2 eβ tha la ssemia group 3 control p1-2 p1-3 p2-3 liver size(cm) 6.78±2.02 2.61±1.07 <0.001 spleen size(cm) 10.60±3.81 5.64±1.27 <0.001 fbs(mg/dl) 89.35±5.71 87.72±5.62 88.27±5.31 0.204 0.386 0.654 ppbs(mg/dl) 118.10±7.06 116.73±6.14 115.97±5.15 0.356 0.128 0.556 sfi(ng/ml) 9.25±1.64 8.09±0.71 8.24±1.07 <0.001 0.002 0.494 ir 1.19±0.22 1.05±0.09 1.07±0.16 <0.001 0.003 0.449 %s 86.02±13.84 96.58±8.29 95.69±12.89 <0.001 0.002 0.713 %b 109.61±14.57 104.88±13.64 101.32±15.95 0.137 0.017 0.287 serum ferritin 4360.00±1705.01 2036.77±415.84 68.97±15.04 <0.001 <0.001 <0.001 p 1-2  is p value  when groups 1 and 2 are compared for significance, p 1-3   between groups 1 and 3 and  p 2-3 between groups 2 and 3. journal of college of medical sciences-nepal, 2014, vol-10, no-3 original article 32 discussion result  of  our  study  reflects  the  ground  reality  of condition  of  most  of  the  thalassemic  patients  in developing countries including ours where iron chelation therapy is suboptimal or not done at all. regular blood transfusion is also not done in some cases. this is reflected by very high serum ferritin levels in them. in our study no one among the cases or controls had diabetes  mellitus(dm)  or  impaired  glucose tolerance(igt). the reported incidence of impaired glucose tolerance and diabetes mellitus vary from 019.5%  (4-11)  to  0-24%    respectively  in  different studies.4-5, 7-11though diabetes has been observed as early as 5.5 years5, but mean age of onset of dm and igt is late adolescence onwards, as found in different studies.9,12 findings of various studies are given in table in group 1, fsi and ir showed positive correlation with some parameters related to iron overload like total amount of packed cells received, serum ferritin and spleen size. %s showed negative correlation with these parameters. %b, though, was significantly higher among patients of group 1; it didnot show any correlation with these parameters [table 2]. table 2: correlation of fsi, ir, %s and %b with various clinical and biochemical parameters among patients of beta thalassemia major total amount of  packed cells received liver size spleen size serum ferritin fsi r 0.372 0.237 0.427 0.345 p 0.018 0.140 0.006 0.029 ir r 0.388 0.248 0.425 0.336 p 0.013 0.123 0.006 0.034 %s r 0.421 0.287 0.465 0.392 p 0.007 0.073 0.002 0.012 %b r 0.127 0.019 0.052 0.009 p 0.434 0.909 0.751 0.955 3.we worked with thalassemic patients with lower age group of 5 to 12 years. these patients, if followed up, might eventually turn out to have deranged glucose metabolism. apart from iron overload, development of impaired glucose metabolism is also influenced by various other factors. viral hepatitis affects glucose metabolism in these patients in various ways. diabetes has been precipitated shortly after an episode of acute viral hepatitis in these patients.13 chronic viral hepatitis has a diabetogenic effect.14 some workers have found that iron induced hepatic damage is accentuated by hcv infection.15 hepatic cirrhosis is another liver related condition implicated as causal factor.14 besides these,  other  factors postulated  include  pancreatic autoimmunity demonstrated by islet cell antibodies,16 possible genetic factors9and family history of diabetes.17 in this study, our aim was to ascertain the sole effect of 33 original article journal of college of medical sciences-nepal, 2014, vol-10, no-3 that  insulin  resistance  develops  before  any derangements in glucose level appear. this raised insulin level helps to counteract insulin resistance and maintain glucose homeostasis.  with continuation of disease process, pancreatic beta cell damage starts leading to lowering of insulin level and increase in glucose level. dmochowski k et al21postulated that decreased hepatic uptake of insulin is the major factor for developing insulin resistance. presence of insulin resistance has been shown also by hafez m et al10 and pappas s et al18.however, insulin resistance has not been found in some studies. in our study, fsi and ir correlated with parameters related to iron overload like total amount of packed cells received, serum ferritin and spleen size revealing role of iron overload as risk factors for development of insulin resistance. in our study, insulin sensitivity in cases was found to be significantly lower than the controls (p value 0.001) by  independent  t  test.  some  workers  have  found similar results19, 21. %s correlates negatively with total amount of packed cells received, spleen size and serum ferritin. as we know insulin sensitivity is the reverse of insulin resistance, this finding is expected. on the other hand, we found beta cell function to be significantly higher in cases than controls. there is dearth of literature regarding beta cell function. jaruratanasirikul s et al12 showed a higher but not significant beta cell function  index  in  patients with  a  normal  glucose tolerance test than those with an abnormal glucose metabolism having liver and pancreatic cell damage. suverna j et al4 found beta cell function index to be higher in cases as compared to controls but was not statistically significant (p = 0.077). however, to the contrary  of  our  findings,  hafez  m  et  al20  found significantly lower mean homa beta cell function iron overload. so, we excluded these confounding factors as much as possible during selection of cases as per inclusion and exclusion criteria. this may be another reason why we did not find any case with impaired glucose metabolism. a study from india did not find any case with dm or igt in the age group of 8 to 15 years.4this similarity in result may be due to common genetic factors in this region of world which needs further exploration. the conventional method of detecting glucose metabolism abnormalities is glucose tolerance test. recently, soliman at et al18 used continuous glucose monitoring system and found  it  to  be  more  sensitive  in  detecting  such abnormalities. though we could not detect dm or igt among our patients, evidence of insulin resistance was detected in the form of higher fsi and ir in patients with beta thalassemia major, when compared with controls. cario h et al19 found that patients with impaired glucose tolerance had hyperinsulinemia and delayed peak insulin during glucose tolerance test. hafez m et al 20did not mention on fasting plasma insulin levels but found mean postprandial insulin to be significantly higher (p<0.0001) in cases with impaired glucose metabolism. higher fasting plasma insulin levels were also detected in the study by suverna j et al 4 among beta thalassemia major patients having no derangement in glucose metabolism. some other studies also demonstrated increased  insulin  level  following  oral  glucose  or intravenous tolbutamide administration. dmochowski k et al21 progressively analysed  seven thalassemic patients with decreased insulin sensitivity and found that the insulin sensitivity remained the same but the integrated  insulin  response  decreased.  so  they postulated that insulin resistance persists but at the same time a progressive reduction in circulatory insulin level occur which ultimately lead to diabetes. so, it appears journal of college of medical sciences-nepal, 2014, vol-10, no-3 original article 34 (p=0.007) among cases than controls. the present study not only rules out hyposecretion of insulin in our patients, but may also indicate beta cell hyperfunction to explain rise of insulin level in the face of insulin resistance.  over  time,  further  iron  overload  may increase insulin resistance and may also initiate damage to pancreatic beta cells with subsequent hyposecretion of insulin to give the full picture of impaired glucose metabolism.  unlike  pancreas,  liver  is  rich  in reticuloendothelial cells where iron is stored. this might explain earlier liver damage and appearance of insulin resistance than hyposecretion of insulin. fsi, ir, %s, %b was found to be significantly lower among ebt patients compared to btm. it is known that ebt is a very heterogenous disease with variable clinical manifestations ranging from mild thalassemia intermedia with little or no symptoms to a very severe transfusion dependent thalassemia major syndrome. our pool of e beta thalassemia patients have milder phenotype reflected by low transfusion requirement and not very high serum ferritin. so they are not overtly loaded with iron yet. this may be the reason that they do not show any statistically significant difference in terms of insulin related parameters when compared with control group. our beta thalassemia major patients showed evidence of insulin resistance but did not have overt impaired glucose tolerance or diabetes mellitus in spite of being heavily iron overloaded. from our study, it is evident that  insulin  resistance  develops  as  the  earliest abnormality in glucose metabolism in beta thalassemia major patients. iron overload plays a significant role in its development. these patients should be monitored periodically to assess status of glucose metabolism. e beta thalassemia patients, who form a significant part of thalassemics in eastern part of india, have milder clinical manifestation reflected by low transfusion requirement and low serum ferritin. this group of patients  does  not  show  any  evidence  of  insulin resistance or abnormality in serum glucose level. chelation therapy should be started in all thalassemia patients so that iron overload related problems can be retarded. table 3: findings of some of the related studies *12 patients were identified having igm using continuous glucose monitoring system in the same study group. insulin resistance found in 3(out of 16) patients.¥ indicates mean age. € indicates lowest age of onset. study study  group(yrs) sample  size ferritin patients with  igm igm  onset(yrs) ir reference present study 5-12 4 4360±1705 0 present suverna j et al 8-15 30 7623±2381 0 present 4 gulati r et al 3-22 37 4920±2758 3 5.5-18 5 jaruratanasirikul s et al 13.6±3.9 48 5206±3291 6 11 to? 12 chern jps et al 2-36 89 3107.3±2530.7 23 7-27 11 khalifa as et al 10-31 56 3648±2219 12 18.33¥ 9 arrigo t et al 17-42 29 4 18€ absent 10 soliman ta et al* 14-22 16 5 absent 18 35 original article journal of college of medical sciences-nepal, 2014, vol-10, no-3 contributions dr  atanu  pan  and  dr  badal  chandra  mandal conceptualized the study and reviewed the manuscript critically. ap and ssn collected the data, searched literature and drafted the manuscript. ad and pm helped in performing the investigations, searching the literature and also reviewed the manuscript. acknowledgement the authors are grateful to kaustav nayek, associate professor, department of pediatrics, burdwan medical college for his inputs during conceptualization of the study. the authors are also thankful to the institutional ethical committee for granting permission to carry out and publish the result of the study. references 1. pignati  cb,  rugolotto  s,  de  stefano  p,piga a  ,et  al. survival and disease complications in thalassemia major. ann n y acad sci 1998; 30(850):227-31. 2. olivieri n , koren g. survival in medically treated patients with homozygous thalassemia. new eng j med 1994; 331(9):574-8. 3. aydinok  y,  darcan  s,  polat  a,  et  al.  endocrine complications in patients with beta thalassemia major. j trop pediatr 2002;48:50-4. 4. suvarna j,  ingle  h,  deshmukh ct.  insulin  resistance and beta cell function in chronically transfused patients of thalassemia major. indian paediatr 2006; 43(5):313400. 5. gulati r, bhatia v, agarwal ss. early onset of endocrine abnormalities in beta-thalassemia major in a developing country. j pediatr endocrinol metab. 2000 jun;13(6):651-6 6. italian working group on endocrine complications in non-endocrine  diseases.  multicentre  study  on prevalence of endocrine complications in thalassaemia major. clin endocrinol 1995; 42: 581-6. 7. flynn  dm,  fairney a,  jackson  d,  et  al.  hormonal changes in thalassaemia major. arch dis child 1976; 51: 828- 36. 8. el-hazmi ma, al-swailem a, al-fawaz i,et al. diabetes mellitus in children suffering from beta-thalassaemia. j trop pediatr 1994;40:261-6. 9. khalifa as, salem m, mounir e, et al. abnormal glucose tolerance in egyptian beta thalassemic patients: possible association in genotyping. pediatr diabetes 2004; 5: 12632. 10. arrigo t, crisafulli g, meo a, et al. glucose tolerance, insulin  secretion  and  per ipheral  sensitivity  in thalassaemia major. j pediatr endocrinol metab. 1998;11 suppl 3: 863-6. 11. chern jps,  lin kh, lu my, et al. abnormal glucose tolerance  in  transfusion  dependent  beta  thalassemic patients.diabetes care 2001; 24(5):850-4. 12. jar uratanasirikul  s  ,  chareonmuang  r, wongcharnchailert  m,  et  al.  prevalence  of  impaired glucose  metabolism  in  beta-thalassemic  children receivinghypertransfusions  with  a  suboptimal  dosage of iron-chelating therapy. eur j pediatr 2008; 167:873–6. 13. de sanctis v, zurlo mg, senesi e,et al. insulin dependent diabetes in thalassemia. arch dis child 1988; 63:58–62, 14. labropoulou-karatza c, goritsas c, fragopanagou h,et al: high prevalence of diabetes mellitus among adult bthalassemic  patients  with  chronic  hepatitis  c.  eur jgastroenteol hepatol  1999; 11:1033–6. 15. piperno a, fargion s, d’alba r, et al. liver damage in italian  patients  with  hereditary  hemochromatosis  is highly influenced by hepatitis b and c virus infection.j hepatol 1992; 16:364 –8. journal of college of medical sciences-nepal, 2014, vol-10, no-3 original article 36 16. monge l, pinach s, caramellino l,et al. the possible role of autoimmunity in the pathogenesis of diabetes in beta-thalassemia major. diabetes metab 2001; 27:149-54. 17. saudek cd, hemm rm, peterson cm. abnormal glucose tolerance in beta thalassaemiamajor. metabolism 1977; 26: 43-52. 18. soliman at,  yasin  m,  el-awwa  a,et  al.detection  of glycemic  abnormalities  inadolescents  with  beta thalassemia  usingcontinuous  glucose  monitoring  and oral glucosetolerance in adolescents and young adults with beta thalassemia major: pilot study. indian j endocr metab 2013;17:490-5. 19. cario h, holl rw, debatin km,et al. insulin sensitivity and  beta-cell  secretion  in  thalassaemia  major  with secondary  haemochromatosis:  assessment  by  oral glucose tolerance test. eur j pediatr 2003; 162: 139-46. 20. hafez  m,  youssry  i,  el-hamed  fa,et  al.  abnormal glucose tolerance in beta-thalasemia: assessment of risk factors.hemoglobin 2009; 33(2):101-8. 21. dmochowski  k,  finegood  dt,  francombe  w,  et  al. factors determining glucose tolerance in patients with thalassemia major. j clin endocrinol metab 1993; 77: 478-83. ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-18 | no 4 | oct-dec 2022 315 ultrasound evaluation of normal thyroid size journal of college of medical sciences-nepal, vol-18, no 4, oct-dec 2022 issn: 2091-0657 (print); 2091-0673 (online) open access doi: 10.3126/jcmsn.v18i4.50275 prabhat basnet,1 ashutosh kumar singh,2 hari prasad upadhyay,3 rajib chaulagain4 1department of radiology, college of medical sciences, bharatpur, nepal, 2department of oral and maxillofacial surgery, institute of medicine, kathmandu, nepal, 3department of statistics, birendra multiple campus, chitwan, nepal, 4department of oral pathology, chitwan medical college, chitwan, nepal. original research article correspondence: dr. prabhat basnet, department of radiology, college of medical sciences, bharatpur, chitwan, nepal. email: pbasnet99@gmail.com. phone: +977-9848023405. abstract introduction normal thyroid size determination is very important for the accurate diagnosis of various thyroid disease. there are different thyroid pathologies which lead to increase in size of the thyroid gland, therefore it is essential to know the accurate dimension of the thyroid gland. this study was aimed to evaluate the normal range of thyroid gland dimensions. methods the study was a descriptive cross-sectional study conducted on 115 patients, in department of radiology and imaging, college of medical sciences, bharatpur, nepal. all ultrasound examinations were performed using toshiba aplio 500 superficial probe. the data was analyzed using statistical package for the social sciences (spss) version 16 (spss, inc., an ibm company, chicago, il). descriptive statistics was used to analyze the data. results among the 115 patients who participated in the study, 24 (20.9%) were male and 91 (79.1%) were female. the mean length of the right lobe was more (3.67±0.338 mm) than in the left lobe (3.45±.423 mm). the overall mean volume of thyroid gland was 6.71±2.05 ml. the mean volume of thyroid gland in males was 7.91±2.91 ml and in females was 6.40±1.63 ml. conclusions the present study estimated the normal dimension of thyroid gland. the normal dimension of thyroid gland volume was found to be more in male than in female. the mean total volume was found to be similar to the earlier published study from nepal. keywords: measurement; thyroid gland; ultrasound; volume. jcms | vol-18 | no 4 | oct-dec 2022316 introduction the thyroid gland is an endocrine gland located within the lower neck, draped anteriorly around the trachea. the two thyroid gland lobes, right and left lobes are connected together by a thin structure known as isthmus. the major role of thyroid gland is production, storage and release of thyroid hormones which are very vital in development and growth of humans.1-3 the thyroid gland’s shape, size and volume varies remarkably among individuals. many physiological as well as pathological factors affect the thyroid gland dimensions. studies have reported that thyroid glands are affected by age, gender and race.3,4 spatiotemporal variation in the size and volume of thyroid gland have also been reported. studies have shown it to be larger and heavier in females.5 in pathological conditions such as goiter, thyroiditis, the alterations in dimensions of thyroid gland have been reported.6 the standard size, shape and weight of thyroid gland and associated variations is necessary for the head neck surgeons. often the estimation of thyroid volume is helpful in monitoring the efficacy of medicine in goiter, thyroiditis and thyrotoxicosis. moreover, the baseline dimensions are important for personnel exposed to radiations in order to provide the protection against the radiation hazards.1,6,7 there is paucity of literatures determining the normal thyroid gland dimensions in nepalese. till date published literatures have determined the volume of thyroid gland6 and the thickness of thyroid isthmus among nepalese8, there is no consensus on the length, breath and width of the thyroid gland among nepalese and no studies have been reported from chitwan. this study was aimed to determine the dimensions of thyroid gland by ultrasound. methods this was a hospital-based descriptive crosssectional study done in the department of radiology and imaging of college of medical sciences, bharatpur, chitwan, for the period of three months (march, 2021 to may 2021). in this study using a convenience sampling method, altogether 115 patients were included. ethical approval was obtained from ethical committee of college of medical sciences, bharatpur, nepal (comsth-irc/2021-54). the objectives of the study and the procedure was well explained to the patients and written consent was obtained from the patients who participated in the study. the patients who were referred to the department for ultrasonography examination for reasons other than thyroid ultrasound scan and who consented to participate in the study were included in the study while female patients who were during menstruation, pregnancy or who have delivered within the last twelve months were excluded. patients with swelling in the anterior region of the neck and clinical evidence of thyroid disease and those who had history of previous thyroid surgery were also excluded. a single consultant radiologist performed the thyroid measurement, with an ultrasound machine, aplio 500 toshiba machine with superficial probe of frequency 7-10mhz. before doing ultrasound, the patients were instructed to remove jewelry and tie towel across the chest. then they were asked to lie in the supine position and a pillow was placed under the patient’s shoulder. this was done to aid in the extension of the neck. a coupling gel was applied over the anterior region of the neck and the transducer was placed over the thyroid gland region. the images were taken in transverse and longitudinal planes. the measurements of craniocaudal (l) and sagittal (d) dimensions were carried out on the longitudinal image while basnet et al. ultrasound evaluation of normal thyroid size. ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-18 | no 4 | oct-dec 2022 317 basnet et al. ultrasound evaluation of normal thyroid size. the mediolateral diameter (w) was obtained from the transverse image. the measurement of right and left lobes was taken and analyzed separately. all measurements were carried out by single radiography consultant to avoid individual variation. the thyroid gland volume was calculated using the rotation ellipsoid method: volume = l × d × w × 0.52 (correction factor) where: l = craniocaudal dimension w = mediolateral dimension d = sagittal dimension the isthmus volume was calculated as: volume of isthmus = l × d × w × 0.479. in addition, the volume of the right and left lobes was summed to obtain the total thyroid volume. the isthmus was not included in the sum. statistical analyses were performed using statistical package for the social sciences (spss) version 16 (spss, inc., an ibm company, chicago, il). descriptive statistics was used to analyze the data and the results was presented using frequency, percentage, mean, and standard deviation (sd). the results were presented in form of tables. results total 115 patients were enrolled in our study. male patients were 24 (20.9%) and female patients were 91 (79.1%) (table 1). table 1. characteristics of participants. variables frequency (%) mean age (years) ± sd 30.57±11.611 gender male 24 (20.9) female 91 (79.1) table 2 showed the descriptive statistics of length, breadth, depth and volume of each lobe and isthmus. mean length of thyroid lobe was higher in right lobe (3.67±0.338 mm) than in the left lobe (3.45±.423 mm) while the breadth was slightly higher in left lobe (1.52±0.224 mm). the mean volume of right lobe was higher (3.42±1.197 ml). table 2. dimensions and volume of right lobe, left lobe and isthmus. variables right lobe mean ± sd left lobe mean ± sd isthmus mean ± sd length (cm) 3.67±0.338 3.45±.423 1.45±0.403 breadth (cm) 1.50±0.256 1.52±0.224 0.29±0.090 depth (cm) 1.16±0.200 1.17±0.192 0.25±0.084 volume (ml) 3.42±1.197 3.30±1.065 0.06±0.063 the overall mean volume of thyroid gland was 6.71±2.05 ml. the mean volume of thyroid gland for both lobes in males and females were 7.91±2.91 ml and 6.40±1.63 ml respectively (table 3). table 3. total volume of thyroid gland. volume (ml) mean ± sd male (ml) 7.91±2.91 female (ml) 6.40±1.63 total volume (ml) 6.71±2.05 discussion the thyroid gland, a vital endocrine gland, plays a critical role in regulating metabolic functions including heart rate and cardiac output, lipid metabolism, heat regulation, and skeletal growth. it is due to the release of thyroid hormones triiodothyronine and thyroxine (t3 and t4). apart from this thyroid gland also consists of parafollicular cells that synthesize calcitonin.9 the thyroid gland examination is a routine clinical examination done. this may be due to the increase in the prevalence of thyroid disorders. the thyroid disorders are more common in females than in males.10 it is said that the thyroid nodules often missed do not show obvious symptoms. thus, careful preoperative jcms | vol-18 | no 4 | oct-dec 2022318 assessment is necessary for diagnosis and treatment planning.1,10,11 in addition to this, studies have also shown morphometric variations of thyroid gland. the variations have been observed in relation to age, gender, race and ethnicity.2,3,7,12-14 apart from this seasonal variation in the release of thyroid hormone have been reported.15-17 this study also focused on the dimension of the thyroid gland. the thyroid gland has been studied using various modalities such as ct, mri, ultrasound. anatomist have also observed the thyroid gland dimension based on cadaver.5,18,19 the present study used ultrasound to measure the dimension of thyroid gland. this is method is widely used due to its non-invasive, less expensive and lack of release of any harmful ionizing radiation.1,4,20,21 due to this nature it is also used for diagnostic and therapeutic interventional procedures related to thyroid gland.10 this study found the length of the right lobe was higher than the left lobe. only slight discrepancy between the right and left lobe in relation to the breadth and depth was observed. in contrast to the present study, lee et al reported longer length of thyroid gland. however, they also reported the right lobe length to be longer than left lobe.22 in their study the mean width of right lobe and left lobe was 15.7±2.6 mm and 15.2±3.1 mm while the mean thickness was 20.9±3.4 mm and 18.9±3.4 mm.22 this measurement was greater than the present study. the difference in the measurement may be associated with variation of body size, study location and sample size. in the present study the right thyroid lobe volume was greater than the left thyroid lobe volume. the mean volume of right lobe was 3.42±1.197 ml while the left lobe was 3.30±1.065 ml. the mean total volume of the thyroid gland was 6.71±2.05 ml. this finding is similar to the study conducted by yousef et al,23 turcios et al24 and kayastha et al.6 in a similar study done among nepalese patients, kayastha et al reported the mean volume of thyroid gland as 6.629 ± 2.5025 ml.6 yousef et al observed the total mean thyroid volume as 6.44 ± 2.44.23 turcios et al reported the total volume as 6.6 ± 0.26 ml. this value was slightly lower than the present study. this may be due to the variation of geographical location, sample size, the supplementation of iodine. hegedus et al measured the thyroid gland of 111 health people and found the mean total volume of thyroid glands slightly higher than the present study.17 in contrast to the present study, another study done in nigeria reported the total mean thyroid gland volume to be 6.03±2.49 ml.25 the reduction in volume may be attributed to the geographical location. studies have also reported variation in gender stating the thyroid gland to be larger and heavier in females. apart from this the size also varies during menstruation and pregnancy in female.5 the thyroid gland also undergoes physiological changes during pregnancy and menstruation in females.26 this study also observed variations among the gender. it was 7.91±2.91 ml in males and 6.40±1.63 ml in females. in agreement with the present study, salaam et al also reported the thyroid volume higher in male than in female.25 hegedus et al in their study observed the thyroid volume to be slightly greater in females.17 in the present study the volume of isthmus was 0.06±0.063 ml. this volume was not incorporated in the mean total volume of thyroid gland as its mean thickness in the present study was 0.29±0.090 cm. this was below three mm thickness.27 the mean thickness was slightly lesser than reported by kayastha et al.8 there are limitations of present study. there was non-uniform distribution of gender which have also caused slight increase in variation in the total volume in male. this study was based basnet et al. ultrasound evaluation of normal thyroid size ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-18 | no 4 | oct-dec 2022 319 on patients coming to single tertiary care centre of nepal so the results cannot be generalized. the study did not observe other physiological factors that might have impact on the dimension of thyroid gland. conclusions the present study evaluated the dimension of thyroid gland using ultrasound. the mean thyroid volume was found to be more in male basnet et al. ultrasound evaluation of normal thyroid size. than in female. the mean total volume was found to be similar to the earlier published study from nepal. acknowledgements the authors would like to acknowledge all the participating patients in this study. conflict of interest: none references 1. john a, ali a, shaheen m, akram m. thyroid volume measurements in normal adult females of gujrat, pakistan: thyroid volume measurements. pakistan biomedical journal. 2022:158-161. 2. çolak e, özkan b. sonographic evaluation of normal thyroid volume and thyroid isthmus depth among infants in the west coast of turkey. endokrynologia polska. 2022;73(2):325-329. 3. muguregowda ht, krishna g, prakash k. morphological variations of the thyroid gland: an insight on embryological and clinicoanatomical considerations. thyroid research and practice. 2019;16(3):100. 4. idigo fu, okon ie, okeji mc, anakwue a-mc. normative thyroid volume by ultrasonography in a nigerian pediatric population. journal of diagnostic medical sonography. 2019;35(1):17-21. 5. tanriover o, comunoglu n, eren b, et al. morphometric features of the thyroid gland: a cadaveric study of turkish people. folia morphologica. 2011;70(2):103-108. 6. kayastha p, paudel s, shrestha dm, ghimire rj, pradhan s. study of thyroid volume by ultrasonography in clinically euthyroid patients. journal of institute of medicine nepal. 2011;32(2):36-43. 7. ittermann t, richter a, junge m, et al. variability of thyroid measurements from ultrasound and laboratory in a repeated measurements study. european thyroid journal. 2021;10(2):140-149. 8. kayastha p, paudel s, ghimire rk. ultrasound measurement of thyroid isthmus thickness in clinically euthyroid subjects. nepalese journal of radiology. 2018;8(2):26-29. 9. nilsson m, fagman h. development of the thyroid gland. development. 2017;144(12):2123-2140. 10. wu y, zhou c, shi b, zeng z, wu x, liu j. systematic review and meta-analysis: diagnostic value of different ultrasound for benign and malignant thyroid nodules. gland surg. 2022;11(6):1067-1077. 11. urfali fe, erarslan s, özkul b, korkmaz m, sermin t. relationship of thyroid gland elasticity with age, gender and thyroid gland volume in the shear-wave ultrasound elastography. the european research journal. 2022;8(1):118-121. 12. rustamovna tn. comparative characteristics of ultrasound thyroid gland size and parameters of physical development of children 12 years of age. research journal of trauma and disability studies. 2022;1(9):148-154. jcms | vol-18 | no 4 | oct-dec 2022320 citation: basnet p, singh ak, uphadhayay hp, chaulagain r. ultrasound 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clin endocrinol metab. 1983;56(2):260-263. 18. joshi s, joshi s, daimi s, athavale s. the thyroid gland and its variations: a cadaveric study. folia morphologica. 2010;69(1):47-50. 19. rajini t, ramachandran a, savalgi gb, venkata sp, mokhasi v. variations in the anatomy of the thyroid gland: clinical implications of a cadaver study. anatomical science international. 2012;87(1):45-49. 20. souza lrmfd, sedassari nda, dias el, et al. ultrasound measurement of thyroid volume in euthyroid children under 3 years of age. radiologia brasileira. 2021;54:94-98. 21. viduetsky a, herrejon cl. sonographic evaluation of thyroid size: a review of important measurement parameters. journal of diagnostic medical sonography. 2019;35(3):206-210. 22. lee d-h, cho k-j, sun d-i, et al. thyroid dimensions of korean adults on routine neck computed tomography and its relationship to age, sex, and body size. surgical and radiologic anatomy. 2006;28(1):25-32. 23. yousef m, sulieman a, ahmed b, abdella a, eltom k. local reference ranges of thyroid volume in sudanese normal subjects using ultrasound. journal of thyroid research. 2011;2011. 24. turcios s, lence-anta jj, santana j-l, et al. thyroid volume and its relation to anthropometric measures in a healthy cuban population. european thyroid journal. 2015;4(1):55-61. 25. salaam aj, danjem s, abdul s, angba ha, ibinaiye p. determination of normal thyroid gland volume on ultrasound in normal adults in jos, north central nigeria. international journal of scientific and research publications (ijsrp). 2020;10:p9708. 26. cignini p, cafà ev, giorlandino c, capriglione s, spata a, dugo n. thyroid physiology and common diseases in pregnancy: review of literature. j prenat med. 2012;6(4):64-71. 27. chaudhary v, bano s. thyroid ultrasound. indian journal of endocrinology and metabolism. 2013;17(2):219. basnet et al. ultrasound evaluation of normal thyroid size ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-19 | no 1 | jan-mar 2023 123 retrospective study of autologous arteriovenous fistula creation as vascular access for hemodialysis journal of college of medical sciences-nepal, vol-19, no 1, jan-mar 2023 issn: 2091-0657 (print); 2091-0673 (online) open access doi: 10.3126/jcmsn.v18i4.50275 bijay sah,1 lokesh shekhar jaiswal,1 rakesh kumar gupta1 1department of surgery, b.p. koirala institute of health sciences, dharan, nepal. original research article correspondence: dr. bijay sah, department of surgery, b.p. koirala institute of health sciences, dharan, nepal. email: bijaysah@hotmail.com. phone: +977-9841410061. abstract introduction an autologous arteriovenous fistula (avf) creation is a common vascular procedure for hemodialysis (hd) patients. this surgical procedure aim is to design a vascular conduct that withstands hemodialysis for a durable period. however, the functional outcome of this procedure varies and depends on patients’ various predictors. . methods a retrospective observational study was carried out to evaluate the functional outcome of avf creation at the cardiothoracic vascular surgery unit of the surgery department of b.p koirala institute of health sciences from february 2019 to february 2020. the medical file of the patients was studied, relevant data entered and analyzed in spss statistical software. results there were a total of 112 autologous avf created during the study period. the mean age of the patients was 48.66±15.64 years. there were 75(67%) males and 37(33%) females. the most common limb of fistula creation was left non-dominant upper limb 95(84.8%) and right upper limb 17(15.2%). the most common type of avf was radiocephalic fistula 66(58.9%) and brachiocephalic fistula 46(41.1%). there were 92(82.1%) mature fistula at eight weeks follow-up. these include 54(48.2%) radiocephalic fistulas and 38(33.9%) brachiocephalic fistulas. there were 20(17.8%) delayed matured fistulas at 12 weeks (12 radiocephalic and 8 brachiocephalic avf). conclusions the creation of an autologous avf for hemodialysis in the upper limb has fewer complications and the maturation of the avf depends on the vessel’s diameter. radio-cephalic and brachiocephalic avf usually matures between six to eight weeks duration. keywords: arteriovenous fistula (avf); autologous vascular access; end stage renal disease (eskd); haemodialysis vascular shunts. jcms | vol-19 | no 1 | jan-mar 2023124 introduction autologous arteriovenous fistula (avf) creation is a common procedure for hemodialysis patients considered as gold standard vascular access.2 avf is the backbone of hemodialysis patients and improves the quality of life as compared to other forms of access.3,4 the national kidney foundation guidelines recommend assessment and creation of autologous avf for long-term hemodialysis patients with end-stage kidney disease (eskd) when egfr is 15 to 20 ml/1.73 min2 with progressive poor renal function.1 avf creation, its maturation rate, and long-term patency is influenced by various factors. size of the vessels, its inflow and outflow rate plays an important role in placement and development of avf.5,6 preoperative clinical examination and duplex ultrasound in selected high-risk patients is important in selecting types and location of av fistula. it also establishes any abnormalities in the arterial and venous network of upper limb, especially in patients with vascular disease and diabetes where clinical examination alone can be inadequate .7,8 a period of six to eight weeks after autologous fistula creation is a frivolous interval where the fistula heals and matures for hemodialysis procedure.6,7 the ideal fistula access must be a minimum of six millimeter in diameter, have six-millimeter depth from skin and should have blood flow greater than 600 ml/min. 9 after description of autologous avf procedure by cimino and brescia in 1966, there has been lots of modifications and configurations in the procedure with variable outcomes.7,10 radiocephalic and brachiocephalic avfs are the two most common types of avfs for hemodialysis.9,12,13 aim of the article is to identify some of the important details that determine the maturation of the procedure. methods this was a single-center, retrospective observational study, conducted by reviewing the medical files of the patients with inclusion criteria as end-stage renal disease (eskd) and avf creation, under cardiothoracic vascular surgery unit of b.p koirala institute of health sciences from february 2019 to february 2020 . the patients with small size vessels or unfit for the procedure were excluded. the study was conducted after obtaining clearance from the institutional review committee of b.p. koirala institute of health sciences (irc/1776/020). preoperative assessment: all the eskd patients routinely underwent complete general examination and focused local assessment of veins and artery of the upper limbs from distal to proximal for type and location of avf creation. a two-minute tourniquet test for venous distensibility, an allen test for palmar arch patency and tests for central venous occlusion were carried out. whenever in doubt, vessel mapping for vascular access was performed and vessels marked preoperatively. patients having inadequate vessel size (artery diameter <1.5mm and vein diameter <2mm) and the recent prick or injury to the vessels were followed up later. avf creation was planned after a written consent under adequate local anesthesia using 2% xylocaine injection and followup at one week, and then monthly for three months. surgical techniques once the suitable vein and artery was selected in the wrist or elbow, the next important step was to design or create the fistula. forearm was preferred than arm for avf site whenever suitable. the radial artery and cephalic vein in the wrist were exposed by a single two to three centimeters transverse incision. the dissection sah et al. retrospective study of autologous arteriovenous fistula creation as vascular... ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-19 | no 1 | jan-mar 2023 125 sah et al. retrospective study of autologous arteriovenous fistula creation as vascular... was confined to the cephalic vein and care taken not to injure the adjacent superficial radial nerve. the vein was looped and any side branched fixed. the radial artery situated deep to and medial to the brachioradialis tendon was then dissected and proximal and distal control of around 6 to 10mm long taken. the distal end of the cephalic vein was secured and divided and the appropriate length was brought closer to the artery. after regional heparin and a broad-spectrum antibiotic, the radial artery was clamped and an arteriotomy of five to six millimeters was made. the end of the vein prepared was then anastomosed to the side of the artery (side to end anastomosis) using a running 7-0 double arm polypropylene suture. the soft clamp was then released in the order of vein clamp or loop, distal, and then proximal arterial clamps. once the hemostasis was completed, the vein was palpated for a good thrill which confirms good fistula outflow and outcome. the skin was then sutured using 3-0 absorbable subcutaneous sutures and loose dressing was applied. for patients without radiocephalic av fistula possibility, brachiocephalic av fistula was the ideal vascular access. the transverse incision was given from the cephalic vein to the brachial artery at the elbow crease. the cephalic vein was dissected and adequate length to meet the artery was prepared. sometimes, the median antecubital vein if appropriate was used, leaving the cephalic vein. exploration of the brachial artery which was often beneath the flexor retinaculum of the brachioradialis muscle was carried out combining electrocautry and sharp dissection. major variations of the brachial artery were found and therefore adequate exposure of the artery with proximal and distal control was taken and prepared for arteriotomy after regional heparin and antibiotics. the procedure was completed with a 7-0 double arm polypropylene suture, the technique of anastomosis, hemostasis, and wound closure being similar to radiocephalic av fistula. statistical analysis the statistical analysis was performed using spss software 16 (usa). categorical variables were analyzed as mean values with standard deviation (±sd) and continuous values were shown as frequency (n) and percentages (%). results there was a total of 112 autologous avf created during the study period. the mean age of the patients was 48.66±15.64 years. there were 75(67%) male and 37(33%) female (table 1). the most common limb of avf creation was left non-dominant upper limb 95(84.80%) and right upper limb 17 (15.20%). the most common type of fistula was radiocephalic fistula 66(58.9%) and brachiocephalic fistula 46(41.1%). table 1. demographic profile of the patients. s. n variables n (%) 1 age 48.66 ± 15.642 2 gender male female 75 (67%) 37 (33%) 3 limbs left upper limb avf right upper limb avf 95(84.8%) 17(15.2%) 4 fistula type radiocephalic avf brachiocephalic avf 66 (58.9%) 46 (41.1%) 5 artery size (mm) 2.0 mm 2.5 mm 3.0 mm 2 (1.8%) 57 (50.9%) 53 (47.3%) 6 vein size (mm) 2.5 mm 3.0 mm 58 (51.8%) 54(48.2%) jcms | vol-19 | no 1 | jan-mar 2023126 7 causes of eskd hypertension diabetes mellitus chronic glomerulonephritis hypertension +diabetes mellitus other causes 14 (12.5%) 17 (15.2%) 36 (32.1%) 15 (13.4%) 30 (26.8%) 8 risk factors hypertension diabetes mellitus ischemic heart disease peripheral vascular disease multiple factors 17(15.2%) 23(20.5%) 18(16.1%) 18(16.1%) 36(32.1%) 9 temporary catheter use 52(46.4%) there were 92(82.1%) mature fistula at eight weeks follow-up (table 2). these include 54(48.2%) radiocephalic fistula and 38(33.9%) brachiocephalic fistulas. there were 20(17.8%) patients with delayed maturation of avf at 12 weeks (12 radiocephalic and 8 brachiocephalic fistulas). the most common complication was wound infection in three fistulas (2.70%). the mean anastomosis artery size was 2.73 ± 0.27mm while the mean vein size was 2.74 ± 0.25mm. the most common cause of the end-stage renal disease was chronic glomerulonephritis 36 (32.1%). the most common risk factor present was diabetes mellitus 23(20.5%) and there were multiple risk factors present in 36(32.1%) patients. there were 52(46.4%) patients with previous temporary hemodialysis catheter. figure 1. shows vein section of a non-functional avf. discussion the mature autologous avf serves as a lifeline for hemodialysis patients. the national kidney foundation guidelines recommend the early creation of autologous avf in patients with endstage renal disease with rapid decrease rate of egfr approximately >10 ml/min/year.1 early creation of autologous avf in progressive renal failure patients improves in the quality of life and prolongs survival. 3,7 majority of the eskd patients in our community remains on hemodialysis life long, as renal transplantation is not possible in most of the centers of the country. an autologous avf has much benefit over dialysis catheters or grafts in terms of costs, hospital stay and mortality. 14 table 2. functional outcome (maturation rate) at 8 and 12 weeks. fistula types maturation of avf total 8 weeks 12 weeks radiocephalic avf 54 (48.2%) 12(10.7%) 66(58.9%) brachiocephalic avf 38 (33.9%) 08(7.2% 46(41.1%) total 92(82.1%) 20(17.9) 112(100%) sah et al. retrospective study of autologous arteriovenous fistula creation as vascular... ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-19 | no 1 | jan-mar 2023 127 a period of six to eight weeks after avf creation is a frivolous interval where the fistula heals and matures for hemodialysis procedure. the fistula undergoes adaptation and remodeling due to increased flow. the ideal autologous fistula must be a minimum of six millimeter in diameter, have six-millimeter depth from the skin and should have blood flow greater than 600 ml/min. 5,6,8 hemodialysis initiation without avf creation has been seen in up to 93% of the patients and has major complications.11 in our study, 52(46.4%) patients began hemodialysis with central venous catheter. an ipsilateral autologous fistula was constructed in more than 50% of these patients with an internal jugular catheter. however, subclavian catheter and ipsilateral avf creation was avoided because of the risk of hand swelling and acronecrosis. the preoperative assessment of the upper limbs is an essential part in selection of the type and location of avf, combined with duplex ultrasound in selected patients.15 the vessels were assessed for caliber, distensibility and continuity. the study done by silva et al. 16 showed that the maturation rate of autologous fistula improved fourfold with the routine noninvasive assessment of the arterial inflow and venous outflow rate. the size and quality of the vessels possess significant role in the development of the fistula. our study showed that the mean artery size was 2.73-mm and vein size was 2.74-mm which was small-caliber vessels. the maturation rate in the study was 92 (82.1%) at eight weeks and 20 (17.8%) at 12 weeks. goh et al.17 showed that radiocephalic fistula had fewer complications like steal syndrome and maturation rate was only 55% with a vessels of small caliber (<2.5-mm). there were two (1.7%) fistulas which needed assessment with duplex ultrasound after eight weeks and diversion of venous flow and stenosis was seen in both the fistulas. the diverting venous branch was ligated and the stenotic vein was dilated to maximize flow which improved in fistula function. the fistula tends to mature after correction in few similar patients while in some, more proximal fistula needs to be created.12 there seems to be an international difference in the type and location of autologous avf creation and a shift from lower arm to upper arm avf is seen in many centers due to better maturation of upper arm avf (34% vs 59%). 7 the upper arm brachiocephalic avf has been recommended in diabetic, females and older hemodialysis patients where there is high risk of fistula failure. huben et al. 18 demonstrated major complications like steal syndrome and hand ischemia in seven percent of diabetic, females, and peripheral vascular disease patients. our study didn’t show any such complications as the high-risk patients were preoperatively carefully assessed by duplex ultrasound study and surgery was planned to minimize adverse effects. thamer et al.19 in the cost analysis study of the procedure found that there was a financial burden when fistula failed to mature on time and revision surgery was needed. there are complex modifiable and nonmodifiable factors that affected the long-term patency of the autologous avf. 20 modifiable factors like smoking, obesity, early referral, ultrasound imaging, anastomosis type and flow assessment have been found to affect the patency of fistulas. non-modifiable factors for avf patency were increase age, diabetes, hypotension, arterial diameter, arteriosclerosis, venous diameter and venous distensibility. 20–22 a systematic review done by tanner et al. 17 on drug treatments to increase the patency of fistula showed that clopidogrel of 75mg/day showed a beneficial effect. however, the random-effect meta-analysis on the use of the drug showed no benefit.18 there have been several modifications and configurations of the operative technique. all our procedures were done by artery side to vein end anastomosis with a continuous double arm 7-0 polypropylene suture. this technique sah et al. retrospective study of autologous arteriovenous fistula creation as vascular... jcms | vol-19 | no 1 | jan-mar 2023128 has less complication than interrupted suturing. kanko et al. 24 described the diamond-shaped technique in 67 patients and found an 89% patency rate in six months. early failure within four weeks of the procedure is seen in 29% of patients and emphasis has been made on surgical technique improvement.20,25 the proper skin incision without crossing the arterialized vein, felicitous handling of the vessels, and correct anastomosis angle with minimal shear stress distribution is advised, with high quality instruments and surgical loupes.9,26 fistula with feeble thrill and low outflow has more chances of thrombosis.11 heparin and a broad-spectrum antibiotic are routinely used in many centers and ours too as it prevents early thrombosis and infection. few patients experience hand and finger edema after avf creation which usually subsides by elevation of the limb.25–27 if the swelling progress to the extent of limiting the mobility, central stenosis should be suspected especially in patients with previous central venous catheters and devices (pacemakers).18 a duplex ultrasound study or venogram should be performed if such symptoms persist, as it can lead to discoloration of the limb. endovascular treatment has a high success rate and should be the first choice in such symptomatic patients. 20,28 severe pain and coldness after avf creation is usually rare and if present, one should consider steal syndrome, especially in brachiocephalic avf. 11 when the arteriotomy is more than 6-mm in the brachial artery, steal syndrome can develop with loss of the extremity function. revision surgery is usually required.25,29 distal pulses and saturation in the arms are routinely inspected after the procedure and any curiosity is confirmed by duplex scan immediately. severe calcifications of the fistula especially in older patients can cause thrombosis and threaten the long-term patency of the avf. 30 the study on pre-existing and postoperative intimal hyperplasia found no association in fistula longterm outcome. 31 siddiqui et al. 26 review on factors affecting avf maturation recommended more research studies on the basic biology of avf maturation. once the fistula is created, flow in the avf increases and vascular remodeling and vasodilatation takes place in a nonpathological vessel. wedgewood et al.32 studied flow rate in the radial artery and showed that flow increased immediately after the creation of the fistula. endothelial cell has important role in remodeling and the forward blood flow elicitate cytoskeletal remodeling in the vessels. 2 although, there has not been much development in the research of autologous avf stenosis, it is thought that deposition of fibrin and thrombocyte activation initiated delayed stenosis of the access as shown in a histogram of one non-functional radiocephalic fistula (figure 1). another factor might be the repeated iatrogenic remodeling from the puncture or cannulation of the vessel causing thrombosis of the access. 9 an autologous radiocephalic and brachiocephalic fistula with end to side anastomosis provide the best long-term access. occasionally, when the basilic or cephalic veins are not suitable, complex vascular access becomes necessary with brachial vein transposition or translocation of suitable veins. 25,31 an autologous avf creation needs more experience and a three-dimensional picture of the after the procedure should be in the back of the mind while creating the fistula.20,34 conclusions the creation of an autologous avf for hemodialysis in the upper limb has fewer complications and the maturation of the avf depends on the vessel’s diameter. radio-cephalic and brachiocephalic avf usually matures between six to eight weeks duration. sah et al. retrospective study of autologous arteriovenous fistula creation as vascular... ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-19 | no 1 | jan-mar 2023 129 references 1. lok ce, huber ts, lee t, et al. kdoqi clinical practice guideline for vascular access: 2019 update. american journal of kidney diseases 2020; 75: s1-s164.https://doi.org/10.1053/j. ajkd.2019.12.001 pmid:32778223 2. alencar de pinho n, coscas r, metzger m, et al. vascular access conversion and patient outcome after hemodialysis initiation with a nonfunctional arteriovenous access: a prospective registry-based study. bmc nephrology 2017; 18: 1-11.https://doi.org/10.1186/ s12882-017-0492-y pmid:28222688 3. liyanage t, ninomiya t, jha v, et al. worldwide access to treatment for end-stage kidney disease: a systematic review. the lancet 2015; 385: 19751982.https://doi.org/10.1016/s01406736(14)61601-9 pmid:25777665 4. thant kz, quah k, ng tk, et al. retrospective review of arteriovenous fistula success rate in a multi-ethnic asian population. journal of vascular access 2016; 17: 131-137.https://doi.org/10.5301/ jva.5000495 pmid:26797904 5. allon m, imrey pb, cheung ak, et al. relationships between clinical processes and arteriovenous fistula cannulation and maturation: a multicenter prospective cohort study. american journal of kidney diseases 2018; 71: 677-689. https://doi.org/10.1053/j. ajkd.2017.10.027 pmid:29398178 6. bashar k, conlon pj, kheirelseid eah, et al. arteriovenous fistula in dialysis patients: factors implicated in early and late avf maturation failure. surgeon 2016; 14: 294-300.https:// doi.org/10.1016/j.surge.2016.02.001 pmid:26988630 7. ethier j, mendelssohn dc, elder sj, et al. vascular access use and outcomes: an international perspective from the dialysis outcomes and practice patterns study. nephrology dialysis transplantation 2008; 23: 3219-3226. h t t p s : / / d o i . o r g / 1 0 . 1 0 9 3 / n d t / g f n 2 6 1 pmid:18511606 8. georgiadis gs, argyriou c, kantartzi k, et al. which is the most powerful adverse factor for autologous access patency between diabetes and high arterial calcification burden? renal failure 2018; 40: 455-457.https://doi.org/10.1080/08860 22x.2018.1497518 pmid:30278807 9. lew sq, nguyen bn, ing ts. hemodialysis vascular access construction in the upper extremity: a review. journal of vascular access 2015; 16: 87-92.https://doi.org/10.5301/ jva.5000299 pmid:25198804 10. brescia mj, cimino je, appell k, et al. chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. 1966. journal of the american society of nephrology : jasn 1999; 10: 193-199. pmid: 9890327 11. al-jaishi aa, liu ar, lok ce, et al. complications of the arteriovenous fistula: a systematic review. journal of the american society of nephrology 2017; 28: 1839-1850. https://doi.org/10.1681/asn.2016040412 pmid:28031406 12. lauvao ls, ihnat dm, goshima kr, et al. vein diameter is the major predictor of fistula maturation. journal of vascular surgery 2009; 49: 1499-1504. https://doi.org/10.1016/j.jvs.2009.02.018 sah et al. retrospective study of autologous arteriovenous fistula creation as vascular... jcms | vol-19 | no 1 | jan-mar 2023130 pmid:19497513 13. oprea a, molnar a, vlăduțiu d, et al. correlation between preoperative vein and artery diameters and arteriovenous fistula outcome in patients with endstage renal disease. medicine and pharmacy reports 2018; 91: 399-407. https://doi.org/10.15386/cjmed-1080 pmid:30564015 14. konner k, nonnast-daniel b, ritz e. the arteriovenous fistula. journal of the american society of nephrology 2003; 14: 1669-1680. https://doi.org/10.1097/01. a s n . 0 0 0 0 0 6 9 2 1 9 . 8 8 1 6 8 . 3 9 pmid:12761270 15. huynh ttt, garza bn, geer j, et al. the role of preoperative duplex ultrasound vessel mapping in determining primary failure of pediatric hemodialysis arteriovenous fistula. journal for vascular ultrasound 2019; 43: 63-68. https://doi. org/10.1177/1544316719831508 16. silva j, hobson rw, pappas pj, et al. a strategy for increasing use of autologous hemodialysis access procedures: impact of preoperative noninvasive evaluation. journal of vascular surgery 1998; 27: 302-308.https://doi.org/10.1016/s07415214(98)70360-x pmid:9510284 17. goh ma, ali jm, iype s, et al. outcomes of primary arteriovenous fistulas in patients older than 70 years. journal of vascular surgery 2016; 63: 1333-1340. https://doi.org/10.1016/j.jvs.2015.12.044 pmid:27109796 18. huber ts, larive b, imrey pb, et al. access-related hand ischemia and the hemodialysis fistula maturation study. in: journal of vascular surgery. mosby inc., 2016, pp. 1050-1058.e1. https://doi.org/10.1016/j.jvs.2016.03.449 pmid:27478007 19. thamer m, lee tc, wasse h, et al. medicare costs associated with arteriovenous fistulas among us hemodialysis patients. american journal of kidney diseases 2018; 72: 10-18. h t t p s : / / d o i . o r g / 1 0 . 1 0 5 3 / j . ajkd.2018.01.034 pmid:29602630 20. smith ge, gohil r, chetter ic. factors affecting the patency of arteriovenous fistulas for dialysis access. journal of vascular surgery 2012; 55: 849-855. https://doi.org/10.1016/j.jvs.2011.07.095 pmid:22070937 21. kordzadeh a, askari a, hoff m, et al. the impact of patient demographics, anatomy, comorbidities, and perioperative planning on the primary functional maturation of autologous radiocephalic arteriovenous fistula. european journal of vascular and endovascular surgery 2017; 53: 726-732 https://doi.org/10.1016/j.ejvs.2017.01.015 pmid:28389252 22. tanner nc, da silva a. medical adjuvant treatment to increase patency of arteriovenous fistulae and grafts. cochrane database of systematic reviews; 2015. epub ahead of print 16 july 2015. doi: 10.1002/14651858.cd002786. pub3.https://doi.org/10.1002/14651858. cd002786.pub3 pmid:26184395 23. dember lm, beck gj, allon m, et al. effect of clopidogrel on early failure of arteriovenous fistulas for hemodialysis. jama 2008; 299: 2164. https://doi.org/10.1001/jama.299.18.2164 pmid:18477783 24. kanko m, sen c, yavuz s, et al. evaluation sah et al. a retrospective study of autologous arteriovenous fistula creation as vascular... ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-19 | no 1 | jan-mar 2023 131 of arteriovenous fistulas made with the diamond-shaped anastomosis technique. medical science monitor; 18. epub ahead of print 2012. doi: 10.12659/ msm.883337.https://doi.org/10.12659/ msm.883337 pmid:22936197 25. lee sj, park sh, lee bh, et al. microsurgical approach for hemodialysis access. medicine 2019; 98: e14202.https:// doi.org/10.1097/md.0000000000014202 pmid:30681593 26. siddiqui ma, ashraff s, carline t. maturation of arteriovenous fistula: analysis of key factors. kidney research and clinical practice 2017; 36: 318-328.https://doi.org/10.23876/j. krcp.2017.36.4.318 pmid:29285424 27. quencer kb, oklu r. hemodialysis access thrombosis. cardiovascular diagnosis and therapy 2017; 7: s299-s308. https://doi.org/10.21037/ cdt.2017.09.08 pmid:29399534 28. chawla a, diraimo r, panetta tf. balloon angioplasty to facilitate autologous arteriovenous access maturation: a new paradigm for upgrading smallcaliber veins, improved function, and surveillance. seminars in vascular surgery 2011; 24: 82-88.https://doi. org/10.1053/j.semvascsurg.2011.05.010 pmid:21889095 29. parmar j, aslam m, standfield n. preoperative radial arterial diameter predicts early failure of arteriovenous fistula (avf) for haemodialysis. european journal of vascular and endovascular surgery 2007; 33: 113-115. https://doi.org/10.1016/j.ejvs.2006.09.001 citation: sah b, jaiswal ls, gupta rk. retrospective study of autologous arteriovenous fistula creation as vascular access for hemodialysis. jcms nepal. 2023; 19(1); 123-31. pmid:17030130 30. jankovic a, damjanovic t, djuric z, et al. calcification in arteriovenous fistula blood vessels may predict arteriovenous fistula failure: a 5-year follow-up study. international urology and nephrology 2017; 49: 881-887.https://doi.org/10.1007/ s11255-017-1515-0 pmid:28124305 31. tabbara m, duque jc, martinez l, et al. pre-existing and postoperative intimal hyperplasia and arteriovenous fistula outcomes. american journal of kidney diseases 2016; 68: 455-464. h t t p s : / / d o i . o r g / 1 0 . 1 0 5 3 / j . ajkd.2016.02.044 pmid:27012909 32. wedgwood kr, wiggins pa, guillou pj. a prospective study of end-toside vs. side-to-side arteriovenous fistulas for haemodialysis. british journal of surgery 1984; 71: 640-642. https://doi.org/10.1002/bjs.1800710831 pmid:6743990 33. woodside kj, bell s, mukhopadhyay p, et al. arteriovenous fistula maturation in prevalent hemodialysis patients in the united states: a national study. american journal of kidney diseases 2018; 71: 793-801.https:// d o i . o r g / 1 0 . 1 0 5 3 / j . a j k d . 2 0 1 7 . 1 1 . 0 2 0 pmid:29429750 34. kritayakirana k, narueponjirakul n, uthaipaisanwong a, et al. the effect of artery and vein size on forearm hemodialysis arteriovenous graft patency. annals of vascular diseases 2019; 12: 21-24.https://doi.org/10.3400/ avd.oa.18-00105 pmid:30931052 sah et al. a retrospective study of autologous arteriovenous fistula creation as vascular... ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-18 | no 4 | oct-dec 2022 321 clinicopathological study of upper gi malignancy in tertiary care centre of nepal journal of college of medical sciences-nepal, vol-18, no 4, oct-dec 2022 issn: 2091-0657 (print); 2091-0673 (online) open access doi: 10.3126/jcmsn.v18i4.48924 ajay kumar gautam,1 khus raj dewan,1 bhanumati saikia patowary1 1department of gastroenterology, college of medical sciences teaching hospital, bharatpur, chitwan, nepal. original research article correspondence: dr. ajay kumar gautam, department of gastroenterology, college of medical sciences-teaching hospital, bharatpur, chitwan, nepal. email: himaliphul@gmail.com. phone: +977-9841352924. abstract introduction upper gastrointestinal malignancies are among the most common causes for cancer related morbidity and mortality. these cancers rapidly progress to advanced stages even in the absence of significant symptoms, thus leading to delayed diagnosis and dismal prognosis. the aim of this study was to determine the prevalence, type and clinicopathological characteristics of upper gastrointestinal tumors. methods this was a three year cross-sectional study involving 66 patients of upper gastrointestinal cancer. the study was conducted from march 2018 to february 2021 at the college of medical sciencesteaching hospital, nepal. relevant clinical information, endoscopic pattern and histological characterization were recorded. spss version 25.0 was applied for statistical analysis. results total 66 patients were enrolled into this study. the mean age of the population was 59.13± 13.38 years with male predominance (m:f-1.36:1). common presenting symptoms were abdominal pain (76%), significant weight loss (61%), vomiting (40%). about 77% of the tumors were located in the stomach, 17% in the esophagus and 6% in the first and second part of the duodenum. most common endoscopic pattern of upper gastrointestinal lesion was ulceroproliferative type (53%). tissue histology showed adenocarcinoma as the commonest histological pattern with 82% followed by squamous cell carcinoma 10%. conclusions these malignancies can rapidly progress to advanced stages even in the absence of serious symptoms and endoscopy is needed in suspected patients to avoid delayed diagnosis and improve the disease outcome. keywords: upper gastrointestinal malignancies; histopathological types; endoscopy. jcms | vol-18 | no 4 | oct-dec 2022322 introduction gi malignancies constitute one of the major tumor burdens to world and are among the most lethal of all malignancies.1 malignant tumors of the oesophagus are one of the commonest types of cancer (sixth and ninth among cancers in men and women).2 gastric cancers are the commonest upper gastrointestinal (ugi) malignancy and are the second most common cause of cancer related death worldwide.3 despite advances in diagnosis and treatment, gastrointestinal (gi) malignancies are known for frequently progressing to advanced stages even in the absence of serious symptoms, thus leading to delayed diagnoses and dismal prognoses.4 since there are very few studies in nepal regarding upper gastrointestinal malignancies, this study is being conducted on such patients presenting to the college of medical sciences and teaching hospital, nepal to study prevalence, clinical features as well as endoscopic and histological patterns. methods this was a three year cross–sectional study involving 66 patients with upper gastrointestinal tumor. the study was conducted from march 2018 to february 2021 at the college of medical sciences-teaching hospital,bharatpur,nepal. relevant clinical information such as age, gender, clinical presentations (like unexplained recent weight loss, abdominal pain or swelling, dysphagia, haematemesis or melaena and anaemia), smoking history, alcohol use, spices were obtained from the patients. upper gi endoscopy was performed in all the patients with pentax epk 700 model / sonoscape hd 500 endoscope under 10% xylocaine anaesthetic spray of the oropharynx. the locations of the tumor were determined and recorded. endoscopically lesions were classified as ulcerative, ulceroproliferative, polypoid and other types. tissue biopsies were taken from the suspected lesions for histological confirmation and characterization. the tumors were classified by the predominant histological appearance into oesophageal squamous cell carcinoma/ adenocarcinoma or gastric squamous cell carcinoma/adenocarcinoma, lymphoma or gist. further categorizations into differentiated, moderately differentiated, undifferentiated or poorly differentiated carcinomas were made. an ethical clearance for this study was obtained from the ethical and research committee of college of medical sciences and teaching hospital, bharatpur and all the patient’s written consent were obtained for the study. statistical analysis: collected data were stored in an electronic database (msexcel sheet). statistical analysis was performed with statistical software (spss 25.0 for windows). results were statistically analyzed using descriptive and chi square test. results during the study period 66 patients of upper gastrointestinal malignancy were evaluated. the mean age of the study population was 59.13 years ± 13.38 years (age ranged from 25 years to 88 years). majority of patients (54.5%) were in the age group 60 years and above followed by age group 40-59 years (41%) and 18-39 years (4.5%). 50% male and 60% female were 60 years old and above. table 1. distribution of the age (n = 66). age group total percent 18-39 years 3 4.5% 40-59 years 27 41% 60 and above 36 54.5% total 66 100% mean age = 59.13 years ± 13.38; minimum age = 25 years, maximum age = 88 years gautam et al. a clinicopathological study of upper gi malignancy in tertiary care centre of nepal ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-18 | no 4 | oct-dec 2022 323 gautam et al. clinicopathological study of upper gi malignancy in tertiary care centre of nepal. in this study 38 (58%) males and 28 (42%) females. the male to female ratio was 1.36:1. the risk factors identified in this study included; smoking in 35 (53%) cases which is followed by alcohol in 33 (50%) cases, with smoked meat consumer 16 (24%) and spicy meal taker 19 (29%). whereas more than 1 risk factors were present in 35 (53%) of cases.this study showed abdominal pain as a presenting symptom in 76 % of patients followed by significant weight loss in 61% of patients, vomiting (40%), loss of appetite in 46% of patients, along with melena (20%), dysphagia (15%), hematemesis (6%) and other symptoms (8%) including ascites, diarrhea etc. in this study, 43 (64%) patients presented with anemia, 8 (12%) patients presented with abdominal lump and there were enlarged left supraclavicular lymph nodes in only 6 (9%) patients. duration of illness was less than 3 months in 34(52%) cases and more than 3 months in 32 (48%) cases. majority of these tumors were located in the stomach (77%), followed by 17% in the esophagus and 6% in the duodenal. of those located in the stomach, most common location was body of stomach with 26 (51%) cases, followed by 18 (35%) cases in antrum and 7 (14%) of cases in fundus. within esophagus, middle 1/3rd was most common location with 7 (64%), followed by 4 (36%) in lower 1/3rd of esophagus. in duodenal, 3 (75%) cases were seen in d1 and 1 (25%) case was in d2. table 3. showing frequency of upper gi cancer according to location (n=66). location frequency percent esophagus upper 1/3rd middle 1/3rd lower 1/3rd total 0 7 4 11 (16.6%) 64% 36% stomach fundus body antrum total 7 26 18 51 (77.3%) 13.7% 51% 35.3% duodenum d1 d2 total 3 1 4 (6.1%) 75% 25% in this study most common macroscopic/gross appearance of cancer was ulceroproliferative type, which was seen in 35 (53%) cases, followed by 11 (16.6%) cases of ulcerative type, 4 (6%) cases of gastric outlet obstruction, 6 (9%) cases of protruding lesion, 7 (10.6%) cases of polypoid type, whereas other lesion types including fungating were seen in 3 (4.5%) cases. among table 2. presentation of upper gi cancer according to location of lesion (n=66). signs/symptoms oesophageal cancer stomach cancer duodenal cancer total p-value pain abdomen 2 45 3 50 0.020* weight loss 9 29 2 40 0.264 vomiting 2 22 2 26 0.592 loss of appetite 6 22 2 30 0.775 melena 0 12 01 13 0.139 dysphagia 9 1 0 10 <0.001 hematemesis 1 3 0 4 0.463 other symptoms 1 3 1 5 0.507 *p-value significant at level <0.05 jcms | vol-18 | no 4 | oct-dec 2022324 esophageal cancer 5 (45%) cases were ulcerative type and 6 (55%) cases was protruding lesion. among gastric cancer cases, 31 (60%) cases were ulceroproliferative type, 6 (11%) cases were ulcerative type, 4 (8%) cases were gastric outlet obstruction, 7 (13%) cases were polypoid type and other types lesion were seen in 4 (8%) cases, that includes fungating and infiltrative type. all 4 cases of duodenum (100%) were ulceroproliferative type. during this study, total 48 cases of gastric and duodenal cancers were tested for helicobacter pylori rut (rapid urease test), 87% (42 cases) of the study population were positive for h.pylori. 37 (79%) cases out of 43 cases of stomach cancer were positive for h. pylori, while all 4 cases of duodenal cancer were positive. in our study, histologically most cases revealed adenocarcinoma 54 (82%), followed by 7 (10%) cases of squamous cell carcinoma, all of which belongs to esophageal carcinoma, 3 cases of gist,1 case of carcinoid tumor, and 1 case of lymphoma. all 4 (100%) cases of duodenal carcinoma were adenocarcinoma, and 46 (90%) cases of gastric cancers were adenocarcinoma and among remaining 5 (10%) cases, 3 (5.8%) were gastrointestinal stromal tumor along with each carcinoid tumor and lymphoma. gautam et al. clinicopathological study of upper gi malignancy in tertiary care centre of nepal figure 1. bar diagram showing lesion types (endoscopic appearance) of cancer in stomach (n=51). table 4. association between biopsy findings and endoscopic location of different carcinomas. biopsy findings endoscopic location p-value esophagus stomach duodenum adenocarcinoma 4 (6.1%) 46 (69.6%) 4 (6.1%) 0.010* squamous cell carcinoma 7 (10.6%) 0 (0%) 0 (0%) other types 0 (0%) 5 (7.6%) 0 (0%) *p-value significant at <0.05 ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-18 | no 4 | oct-dec 2022 325 only 26 gastric adenocarcinoma cases were sub classified, 10 (38%) were poorly differentiated, 7 (27%) were moderately differentiated, 6 (23%) cases were signet ring cell carcinoma, 2 (7.7%) well differentiated and 1 (3.8%) undifferentiated. among all cases distant metastasis were observed in 7 (12%) cases. intraabdominal lymph nodes were involved in 28 (48%) cases, among gastric cancers 26 (53%) were involved with nodal metastasis, 2(18%) in case of esophageal cancer and 1(25%) in case of duodenal cancer. discussion cancer incidence in general and gi cancer in particular varies widely in different parts of the world in different age groups. studies from nepal showed higher incidence compared to other parts of the world.5,6 in this study of 66 patients of upper gi malignancy, upper gi malignancy were seen more commonly in the male gender compared to the female counter part (1.36:1), the average age of patient was 59 years and peaked between 60 year and above age group (54.5%). gastric carcinoma is extremely rare before the age of 30 years and most patients are above 50 years of age.7,8 there was a spectrum of median age incidence reported in different parts of the world. in the western world, it was 71 years in the usa, which is higher than this study. in asian countries, median ages in different countries were low. similar to this study was seen in japan (61 years).9 in tuth nepal (59.6±12.4 years),17 in western region nepal (age group 51-70 years)10 contrast to this study, in pakistan (48 ± 4.47 years) and saudi arabia (47 years) incidence of cancer in early age population were seen.11,12 compared to this study, male: female ratio was higher in mizoram (2.7: 1)13 in nigeria (2.5:1),14 in kashmir (3.3: 1)15 and in saudi arabia (2.2: 1)12. similar to this study was seen in pakistan (1.5: 1)16, in western region nepal (1.8:1)10 and tuth nepal (2:1)17 presumably, this male preponderance could be attributed to the high incidence of risk factors in male (like; smoking >60%, alcohol >50%), with male to female smoking ratio of 1.7:1 in this study). majority of patients (53%) in this study had a history of smoking, and 50% with history of alcohol intake, consumption of smoked meat were seen in 24% cases, along with spicy meal consumption in 29% cases. similarly, in a study from nigeria ajayi et al.14 identified alcohol, smoking and spices are the three main risk factors for upper gi malignancy. study from north eastern india showed overwhelming majority of patients (77.8%) had a history of consumption of smoked meat, and 67.7% of patients had history of consumption of dried, fermented fish, and smoking history in 67.6% of males and 44% of females.18 another study from nepal also reported smoked meat, alcohol and smoking were associated with gastric cancer in more than 50% of cases (western region nepal).10 current study showed, dysphagia (82%) and weight loss (82%) were most common presentation of esophageal caarcinoma, in keeping up with the many studies as dysphagia (86%) was reported as the most common presenting complaint of esophageal carcinoma by durrani et al.16 and study by ajayi et al.14 also reported similar stats. in nepal, thakur et al reported dysphagia was presenting complain in 98.5 % of cases of esophageal carcinoma.19 most of our patients with gastric cancer presented with abdominal pain (88%), weight loss (57%), vomiting (43%), loss of appetite (%) and melena (57%), which is similar to many studies, barad et al.18, durrani et al.16, ajayi et al.14 in nepali context shah et al.17, revealed pain abdomen (87%), anorexia (81%), and weight loss (77%) gautam et al. clinicopathological study of upper gi malignancy in tertiary care centre of nepal. jcms | vol-18 | no 4 | oct-dec 2022326 which is very similar to our results. 51.9% of the patients in this study presented at the hospital within 3 months of the onset of symptoms while the only less than 15% presented after 6 months. in this study, most common presenting symptom of upper gi malignancy noted was abdominal pain (75%), followed by weight loss (60%), vomiting (39%), loss of appetite (45%) and melena in 19% of cases. similar to our study, abdominal pain was most common presentation in nigeria (ajayi et al.)14 64% of cases with anemia on presenting symptom was higher in our study than only 2.6% of anemia in same study, whereas abdominal lump was present in only 12% of cases in our study, which is lower than 30.8% reported by ajayi et al.14 the prevalence of oesophageal malignancies in this study was low (16%) in keeping with a similar study from nigeria where oesophageal carcinoma were present in 16.6% of upper gastrointestinal tumors. contrast to our study, durrani et al.16 reported higher incidence (43.3%) of esophageal cancer, which also included cases of upper gi cancers. other studies from nepal also reported lower incidence, where incidence ranges from 1.6% to 10.7%.6,20 gastric malignancies are important cause of mortality from cancer and one of the most deadly malignant neoplasm worldwide and in nepal. the prevalence of gastric malignancies in this study was quite high (77%). which is comparable to similar studies, in nigeria by a. ajayi et al.(67.9%),14 in punjab by durrani et al.(57.6%)16 the incidence of stomach cancer is said to be highest in japan, china, south america and the eastern europe. the high prevalence obtained here was in sharp contrast to 13.3% recorded in nigeria by atoba et al.21, 12% recorded in lagos by abdulkareem et al.,2 and 4.6% in maharastra by khatib et al.22 in nepal the incidence of gastric carcinoma recorded ranges from 4% to 15.1%.6,20 the prevalence of duodenal carcinoma in this study was extremely low (6%), which is comparable to low incidence reported in nigeria in similar study population by ajayi et al.14 in this study, most common site for esophageal cancer was middle one third (64%) followed by lower third (36%). our findings are similar to many other studies where middle third was commonest site followed by lower third. mchembe et al.23, kuwano et al.24, ajayi et al.14 and durrani et al.16 contrast to our study, in kashmir by mustafa et al.25 reported distal third (45%) as the most common site followed by middle (34.8%). similar finding of distal esophagus as a commonest site of esophageal cancer was reported in nepal by pun et al.5 among esophageal cancers, in our study most common endoscopic/macroscopic appearance of cancer were protruding lesion (55%) and 50% cases of ulcerative lesions. as only few studies mentioned esophageal gross lesion, in tanzania by mchembe et al.(2013),23 unlike this study, most common macroscopic appearance of esophageal cancer was ulcerative type 132 (40.3%) ,similar finding were seen by mustafa et al.(2016),25 who reported localized ulcerative lesion as the most common appearance (50%) followed by protruding lesion (19%) similary in nepal, pun et al. (2012)5 reported gross findings in squamous cell carcinoma were either exophytic or ulcerative lesion with deep irregular ulcers. unlike western countries,in asia still oesophageal squamous cell carcinoma (osca) is the predominant histologic type of oesophageal malignancy, in iran by pedram et al.26 reported 81.3% cases of squamous cell carcinoma, 16.3% cases of adenocarcinoma, in japan kuwano et al.24 also reported esophageal squamous cell carcinoma as commonest histological type with 91.6 %, in india by cherian et al. also gautam et al. clinicopathological study of upper gi malignancy in tertiary care centre of nepal. ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-18 | no 4 | oct-dec 2022 327 gautam et al. clinicopathological study of upper gi malignancy in tertiary care centre of nepal. reported similar findings as squamous cell carcinoma were seen in 92%. among very few studies done in nepal, pun et al.5a total of 106 cases of esophageal cancer were received in the department of pathology, bp koirala memorial cancer hospital. relevant clinical data were retrieved from computer database of the hospital.results: a total of 106 cases of esophageal carcinomas were diagnosed during a three years period. there were 68 (64.15% also reported similar study as 64 % of squamous cell carcinoma. this study showed 64% cases of esophageal adenocarcinoma, which is contrast to the many asian studies mentioned above, may reflect small study sample or changing trend of cancer pattern in our part of the world due to increase in risk factors that are associated with the occurrence of esophageal adenocarcinoma. as reports from asian countries have also shown a decline in incidence of scc. similar to study by pun et al.5 where the maximum number of scc were seen in middle esophagus and the maximum number of adenocarcinoma was seen in distal esophagus, our study also showed all squamous cell carcinoma in middle third and maximum number of adenocarcinoma in distal esophagus followed by middle esophagus. unlike in the usa where proximal stomach is the commonest site of cancer in stomach, in this study, distal part including body of stomach (51%) and antrum (35%) were common site followed by fundus (17%). similarly, in nigeria by ajayi et al. (2016)14 62.3% were in the antrum while 37.7% were in the corpus. likewise, barad et al.18 in india, the most common site of gastric cancer was antrum (50.6%). in nepal antrum was the commonest site of involvement (70%) by gosh a et al. (2010)10, lower third of stomach was common site for gastric cancer (61.5%) followed by middle third (20%) and upper third (15%) sah et al.(2015).17 in this study, 60% of gastric lesions were ulceroproliferative type, 11% ulcerative type, 8% gastric outlet obstruction. similar to our study qureshi et al. showed 35.5% ulceroproliferative, 26% proliferative, 31% ulcerative, and 7.4% infiltrative lesions in kashmiri patients.15 shaha a et al.11, ulcerative lesion was 57.8% followed by ulceroproliferative lesion 24.9% and polypoidal lesion 17.3%. another study done by kabir et al.27 showed that ulcerative lesion was 56%, ulceroproliferative lesion 10%, and polypoidal lesion 34%.unlike our report, ghosh a et al.10 reported type iv (40%) as most common gastric cancer in nepal, followed by type iii (33%) and type ii (27%) in this study, histologically majority (82%) were found to be adenocarcinoma consistent with other studies, ajayi et al.14 reported 83 % as adenocarcinoma, barad et al.18 95.6% adenocarcinoma, in nepal ghosh a et al.10 reported 100% adenocarcinoma, sah et al.17 also showed 100% adenocarcinoma. majority of the tumours in our study were poorly differentiated and moderately differentiated, similar to other studies (ghosh et al.10, barad et al.18). in this study, 12% had distant metastasis and majority (48%) had locally advanced gastric cancers at the time of presentation. this figure is higher to 9-17% seen in western countries and much higher to the prevalence of japan where mass screening programmes for gastric cancer are in place. these studies suggest that patients with gastric adenocarcinomas usually present with advanced disease unfavorable histopathology. h. pylori positivity in this study for those with gastric cancer was 79% and 100% for duodenal cancer. this was significant statistically. in bangladesh, talukdar et al. showed that the prevalence of h. pylori was 66% out of 50 cases of gastric cancer.27 kabir et al.27 showed prevalence of h. pylori in 71.8% of gastric cancer patients. jcms | vol-18 | no 4 | oct-dec 2022328 references 1. pourhoseingholi ma, vahedi m, baghestani ar. burden of gastrointestinal cancer in asia; an overview. gastroenterol hepatol bed bench. 2015;8(1):19-27. 2. abdulkareem fb, faduyile fa, daramola ao, et al. malignant gastrointestinal tumours in south western nigeria: a histopathologic analysis of 713 cases. west afr j med. 2009;28(3):173–6. 3. ferlay j, soerjomataram i, dikshit r, eser s, mathers c, rebelo m, et al. cancer incidence and mortality worldwide:sources, methods and major patterns in globocan 2012. int j cancer. 2015;136(5):e359-86. 4. siegel rl, miller kd, jemal a. cancer statistics 2019. ca cancer j clin. 2019;69(1):7–34. 5. pun cb, pradhananga kk, siwakoti b, subedi k, moore ma. malignant neoplasm burden in nepal data from the seven major cancer service hospitals for 2012. asian pacific j cancer prev. 2016;16(18):8659–63. 6. poudel kk, huang z, neupane pr, steel r, poudel jk. hospital-based cancer incidence in nepal from 2010 to 2013. nepal j epidemiol. 2017;7(1):659–65. 7. mahadevia ps, tanaka k, fineberg s. diagnostic cytopathology. 9th ed. mosby jr, editor. vol. 34, rosai and ackerman’s surgical pathology. edinburgh: wiley; 2004. 382–383 p. 8. fenoglio-preiser c, carneiro f, correa p, guilford p, lambert r mf et al. gastric carcinoma. in: hamilton sr, aaltonen la, eds. pathology & genetics tumors of digestive system. lyon iarc press. 2000;3(2):39–52. 9. timothy aaj and cw. adenocarcinoma and other tumors of the stomach. 9th ed. m. feldman, l. s. friedman and ljb, editor. vol. 2, sleisenger and fordtrean’s gastrointestinal and liver disease. elsevier saunders, philadelphia; 2010. 1230–7p. 10. ghosh a, sathian b, ghartimagar d, narasimhan r, talwar op. epidemiologic analysis of gastric carcinoma in the western region of nepal. nepal j epidemiol. 2010;1(1):26–32. 11. saha ak, maitra s, hazra sc. epidemiology of gastric cancer in the gangetic areas of west bengal. isrn gastroenterol. 2013;3(2):1–6. 12. satti m, al-quorain a, al-gindan y, al hamdan a, al-idrissi h. gastric malignancy : clinicopathologic spectrum and relationship to helicobacter pylori infection. saudi j gastroenterol. 2005;11(3):149 13. sharma a, radhakrishnan v. gastric cancer in india. indian j med paediatr gautam et al. clinicopathological study of upper gi malignancy in tertiary care centre of nepal. ajayi et al.14 also showed 71.7% were positive for h.pylori in gastric cancer patients. conclusions upper gi malignancy mainly gastric cancers are apparently predominant in our part of the world. in view of the fact that upper gi tumors can rapidly progress to advanced stages even in the absence of serious symptoms, early esophagogastroduodenoscopy is needed in high risk cases to avoid delayed diagnosis and improve the disease outcome. conflict of interest: none. ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-18 | no 4 | oct-dec 2022 329 citation: gautam ak, dewan kr, patawary bs, clinicopathological study of upper gi malignancy in a tertiary care centre of nepal. jcms nepal. 2022; 18(4); 321-29. oncol. 2011;32(1):12–6. 14. ajayi ao, ajayi ea, solomon oa, omonisi ea, dada sa. pattern of upper gastrointestinal malignancies as seen at endoscopy in ekiti state university teaching hospital, ado-ekiti, nigeria. oalib. 2016;03(06):1–7. 15. qurieshi ma, masoodi ma, kadla sa, ahmad sz, gangadharan p. gastric cancer in kashmir. asian pac j cancer prev. 2011;12(1):303–7. 16. durrani a.a., yaqoob n., abbasi s. sm and ms. pattern of upper gastaro intestinal malignancies in northern punjab. pakistan j med sci. 2009;25(2):302–7. 17. sah jk, singh yp, ghimire b. presentation and outcomes of gastric cancer at a university teaching hospital in nepal. asian pac j cancer prev. 2015;16(13):5385– 8. 18. barad ak, mandal sk, harsha hs, sharma bm, singh ts. gastric cancer-a clinicopathological study in a tertiary care centre of north-eastern india. j gastrointest oncol. 2014;5(2):142–7. 19. thakur b, li h, devkota m. results of management of esophageal and ge junction malignancies in nepalese context. j thorac dis. 2013;5(2):123–8. 20. pradhananga kk, baral m, shrestha bm. multi-institution hospital-based cancer incidence data for nepal an initial report. asian pacific j cancer prev. 2009;10(2):259–62. 21. atoba ma, olubuyide io, aghadiuno po. gastrointestinal malignancies in a young tropical african population. trop doct. 1989;19(3):135–7. 22. khatib wm, patel pm, demde rb, aher vc. malignancies of the gastrointestinal tract-an overview. asian pacific j heal sci. 2016;3(4):165–70. 23. mchembe md, rambau pf, chalya pl, et al. endoscopic and clinicopathological patterns of esophageal cancer in tanzania: experiences from two tertiary health institutions. world j surg oncol. 2013;11(1):257. 24. kuwano h, nishimura y, oyama t, et al. guidelines for diagnosis and treatment of carcinoma of the esophagus april 2012 edited by the japan esophageal society. esophagus. 2015;12(1):1–23. 25. mustafa sa, zaffar banday s, bhat ma, et al. clinico-epidemiological profile of esophageal cancer in kashmir. int j sci study. 2016;23(3):11–6. 26. sepehrvand n, mahmodlou r, pedram a, enshayi a. esophageal cancer in northwestern iran. vol. 48, indian journal of cancer. 2011. 165 p. 27. kabir ma, barua r, masud h, et al. clinical presentation, histological findings and prevalence of helicobacter pylori in patients of gastric carcinoma. faridpur med coll journal. 2011;6(2):78– 81. gautam et al. clinicopathological study of upper gi malignancy in tertiary care centre of nepal. ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-18 | no 3 | jul-sep 2022 185 association between superior attachment of uncinate process and frontal sinusitis journal of college of medical sciences-nepal, vol-18, no 4, oct-dec 2022 issn: 2091-0657 (print); 2091-0673 (online) open access doi: 10.3126/jcmsn.v18i3.42487 1department of otorhinolaryngology, 2department of radiology, nepal medical college and teaching hospital, kathmandu university, nepal. original research article abstract introduction methods a cross sectional study was conducted in the otorhinolaryngology out-patient department. patients were diagnosed as chronic rhinosinusitis according to the american academy of otolaryngology– head and neck surgery rhinosinusitis task force criteria. patients then underwent a non-contrast ct scan of paranasal sinuses. superior attachment of the up was noted from the ct, and the association between the superior attachment of the up and chronic frontal sinusitis was recorded. results conclusions among the superior attachments of the uncinate process, attachment into the lamina papyracea was the commonest. it was noted that chronic frontal sinusitis was significantly associated with the superior attachment of the uncinate process. keywords: chronic frontal sinusitis; lamina papyracea; superior attachment; uncinate process. anupama shah rijal, 1abhushan siddhi tuladhar, 2rupesh raj joshi, 1kundan kumar shrestha, 1anup dhungana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a(b&(c1 &'( b#$-,&,#$= d'( "#+& b#""#$ +2@(3,#3 /e/b'"($& #: &'( fg 0/+ ,$&# &'( ;/",$/ @/@13/b(/ c(,$% h<? /$hi=j? #$ &'( 3,%'& /$;(:& +,-(+ 3(+@(b&,k(;1= d'(3( 0/+ / +,%$,lb/$& /++#b,/&,#$ c(&0(($ &'( +2@(3,#3 /e/b'"($& #: &'( 2$b,$/&( @3#b(++ /$b'3#$,b :3#$&/; +,$2+,&,+ 4@m6=66) /$=6659 #$ c#&' +,-(+= correspondence: dr. anupama shah rijal, department of otorhinolaryngology nepal medical college and teaching hospital, kathmandu university, nepal. email: asrijal@gmail.com. phone: +977-9841906215 jcms | vol-18 | no 3 | jul-sep 2022186 introduction the uncinate process (up) is a sickle shaped bone, which attaches inferiorly to the inferior turbinate and palatine bone and anterosuperiorly to the lacrimal bone.1 the superior attachment of uncinate process can be into the lamina papyracea (type i), the skull base (type ii) and the middle turbinate (type iii).2,3 drainage of the frontal sinus depends on the superior attachment of the uncinate process and alteration in the drainage predisposes to frontal sinus diseases. chronic frontal rhinosinusitis (crs) is encountered frequently in otorhinolaryngology. crs can be diagnosed by using the rhinosinusitis task force criteria of american academy of otolaryngology–head and neck surgery (aaohns).4 computed tomography (ct) currently is the gold standard imaging method to show the anatomy and pathology of paranasal sinuses.5,6 this study was conducted with an aim to determine an association between the superior attachment of uncinate process and chronic frontal sinusitis. methods a cross sectional study was conducted at nepal medical college teaching hospital (nmcth), otorhinolaryngology out-patient department (opd). the study duration was from april to september 2022. all consecutive opd patients with nasal obstruction and discharge for more than 12 weeks, above 20 years of age and who consented were included in the study. patients with past history of sinonasal surgery, craniofacial malformations, fractures, malignant neoplasm, fungal sinusitis, mucocele were excluded. other variations of uncinate processes namely, pneumatised, hypertrophied, medially bent, laterally bent and unclear or multiple superior attachments were also excluded. ethical approval was obtained from the research and institutional review committee of nmcth results rijal et al. association between superior attachment of uncinate process and frontal sinusitis !"#$" %$ %&' (%)*+, -'%.#/'* &#(%$"+ 0.( %.1'2 .2* 3/#2#3./ '4.5#2.%#$2 $6 %&' !.%#'2%( 0'"' *$2', 7.%#'2%( 0'"' 3/#2#3.//+ *#.82$('* .( 3&"$2#3 "&#2$(#2)(#%#( .33$"*#28 %$ %&' 95'"#3.2 93.*'5+ $6 :%$/."+28$/$8+;<'.* .2* ='31 >)"8'"+ ?99:<=>@ a&#2$(#2)(#%#( b.(1 c$"3' 3"#%'"#., d&"$2#3 "&#2$(#2)(#%#( 0.( *#.82$('* e+ %&' !"'('23' $6 %0$ $" 5$"' 5.f$" 6.3%$"( $" $2' 5.f$" 0#%& %0$ 5#2$" 6.3%$"(, g.f$" 6.3%$"( ."' 6.3#./ !.#2h!"'(()"'i 2.(./ $e(%")3%#$2he/$31.8'i 2.(./ *#(3&."8'h !)")/'23'h*#(3$/$)"'* !$(%2.(./ *".#2.8'i &+!$(5#.h.2$(5#.i !)")/'23' #2 2.(./ 3.j#%+ $2 '4.5#2.%#$2 .2* 6'j'" ?#2 .3)%' "&#2$(#2)(#%#( $2/+@, g#2$" 6.3%$"( ."' &'.*.3&'i 6'j'" ?.// 2$2k .3)%'@i &./#%$(#(i 6.%#8)'i *'2%./ !.#2i 3$)8&i '." !.#2h!"'(()"'h6)//2'((, c.3#./ !.#2h!"'(()"' ./$2' *$'( 2$% 3$2(%#%)%' . ()88'(%#j' &#(%$"+ 6$" "&#2$(#2)(#%#( #2 %&' .e('23' $6 .2$%&'" 5.f$" 2.(./ (+5!%$5( $" (#82(, l7.%#'2%( .6%'" e'#28 3/#2#3.//+ *#.82$('* 0'"' "'6'""'* %$ %&' *'!."%5'2% $6 a.*#$/$8+ 6$" 2$2k3$2%".(% db (3.2 $6 !.".2.(./ (#2)('(, m5.8'( 0'"' $e%.#2'* )(#28 b$(&#e.i 9n)#/#$2i ol (/#3' 5)/%#*'%'3%$" db >3.22'", g)/%#!/.2." "'6$"5.p'* #5.8'( 0'"' $e%.#2'* #2 q 55 .4#./i 3$"$2./ .2* (.8#p./ !/.2'(, b&' db (3.2( 0'"' (%)*#'* .2* "'!$"%'* e+ %&' (.5' ".*#$/$8#(%, b&' *.%. 0.( "'3$"*'* #2 %&' !"$6$"5.i 3$*'* .2* .2./+('*, >%.%#(%#3./ .2./+(#( 0.( *$2' )(#28 >7>> j'"(#$2 ro, -'(3"#!%#j' (%.%#(%#3( ()3& .( 6"'n)'23+i 5'.2 .2* (%.2*."* *'j#.%#$2 0.( 3./3)/.%'*, d&#k(n)."' %'(% 0.( )('* %$ s2 * %&' .(($3#.%#$2 e'%0''2 %&' j."#.e/'(, !"# $%&'( #)*+&*%#' ,.*%/#0%$ 1/%" 233 4"560/4 7560%*+ $/0&$#$8 9#:*+#$ ;< =>-8<?@ 1#5# :65# *a#4%#' %"*0 :*+#$ ;3 =3,8-?@ 1/%" %"# 5*%/6 282b28 !"# *c# 5*0c#' 756: -d (#*5$ %6 ,e (#*5$ 1/%" %"# :#*0 67 ;<8f> (#*5$ g2;8ff8 !"# :*h/:&: 0&:i#5 67 .*%/#0%$j -=;d8f?@ 1#5# 1/%"/0 -d %6 -e (#*5$ *c# c56&.j 1/%" 2=2f8,?@ ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-18 | no 3 | jul-sep 2022 187 rijal et al. association between superior attachment of uncinate process and frontal sinusitis males and 10 (13.9%) females. in the other two groups of 30 to 39 years and 40 to 49 years there were 18 (25%) patients in each. in the 30 to 39 years age group there were 7 (9.7%) males and 11 (15.3%) females and in the 40 to 49 years age group there were 12 (16.7%) males and 6 (8.3%) females. the 50 to 59 years age group consisted of 8 (11.1%) patients out of which 2 (2.8%) were males and 6 (8.3%) were females. there were 6 (8.3%) patients above sixty years of age with 5 (6.9%) females and 1 male (figure 1). the up was attached into the lamina papyracea in 54 (75.0%) on the right side and 53 (73.6%) on the left side. attachment into the skull base was seen in 13 (18.1%) on the right and 11 (15.3%) on the left side. on the right side 5 (6.9%) and on the left 8 (11.1%) were attached into the middle turbinate.the various attachments of superior part of up in our study are shown in the ct scans below. (figure 2), (table1) overall total chronic frontal sinusitis was seen in 39 (54.2%) frontal sinuses on the right side out of which 23 (31.9%) frontal sinusitis had attachment to the lamina papyracea. twelve (16.7.%) out of 39 showed chronic frontal sinusitis with the attachment to skull base, whereas 4 (5.6%) had sinusitis with attachment to middle turbinate. in our study on the right side there was significant association seen between the superior attachment of the up and chronic frontal sinusitis (p=0.001). figure 1. distribution of age and gender. table 1. distribution of superior attachment of up superior attachment of up right side left side frequency percentage (%) frequency percentage (%) lamina papyracea 54 75.0% 53 73.6% skull base 13 18.1% 11 15.3% middle turbinate 5 6.9% 8 11.1% total 72 100% 72 100% figure 2. ct scan coronal view showing superior attachment of up. a. insertion into the lamina papyracea on the right side and skull base on the left side b. insertion into the middle turbinate bilaterally a b (table 2) jcms | vol-18 | no 3 | jul-sep 2022188 rijal et al. association between superior attachment of uncinate process and frontal sinusitis we also looked at the total number of chronic frontal sinusitis in relation to the total number of sides studied. as documented in the previous tables the total number of chronic frontal sinusitis was 77 out of 144 sides, out of which 52 (67.5%) had the superior attachment of the uncinate process into the lamina papyracea. seventeen (22.2%) had the attachment of the uncinate process into the skull base and 8 (10.3%) had attachment into the middle turbinate. this is documented in table 4. discussion chronic frontal rhinosinusitis is a common condition frequently encountered in the ent outpatient, which can lead to considerable morbidity for the patient. among the various factors leading to this condition, we looked at the association between the superior attachment of the uncinate process and chronic frontal sinusitis. our demographics showed younger age groups were more affected, with 30.6% between 20 to 29 table 2. association of right superior attachment of up and chronic frontal sinusitis superior attachment of up not developed no (%) normal no (%) frontal sinusitis no (%) total sides no (%) lamina papyracea 1 (1.4%) 30 (41.6%) 23 (31.9%) 54 (75%) skull base 0 (0.0%) 1 (1.4%) 12 (16.7%) 13 (18.1%) middle turbinate 1 (1.4%) 0 (0.0%) 4 (5.6%) 5 (6.9%) total 2 (2.8%) 31 (43%) 39 (54.2%) 72 (100%) table 3. association of left superior attachment of up and chronic frontal sinusitis superior attachment of up not developed no (%) normal no (%) frontal sinusitis no (%) total sides no (%) lamina papyracea 0 (0.0%) 24 (33.3%) 29 (40.3%) 53 (73.6%) skull base 0 (0.0%) 6 (8.3%) 5 (6.9%) 11 (15.3%) middle turbinate 2 (2.8%) 2 (2.8%) 4 (5.6%) 8 (11.1%) total 2 (2.8%) 32 (44.4%) 38 (52.8%) 72 (100%) table 4. superior attachment of up and chronic frontal sinusitis superior attachment of up frontal sinusitis present no. (%) total sides no. (%) lamina papyracea 52 (67.5%) 107 (74.3 %) skull base 17 (22.2%) 24 (16.7 %) middle turbinate 8 (10.3 %) 13 (9.0 %) total 77 (100%) 144 (100 %) !"#$%"&$' ()(*+ ,-.)/", 0.)/(*+ &"/1&"("& %*& &$$/ "/ 23 4567389 )/ (-$ +$0( &":$'%"(6; 4<=7289 0.)/(*+ &"/1&"("& -*: *>*,-?$/( "/() (-$ +*?"/* @*@a.*,$*7 b>*,-?$/( () (-$ &#1++ c*&$ .$&1+($: "/ 5 4d27689 ,-.)/", 0.)/(*+ &"/1&"("&7 e"/1&"("& .$&1+("/f 0.)? *>*,-?$/( "/() (-$ ?"::+$ (1.c"/*($ *,,)1/($: 0). < 4d=7589 )0 (-$ ,*&$&7 g.)/(*+ &"/1&$& %$.$ /)( :$h$+)@$: "/ 6738 c"+*($.*++a7 b& %"((-$ ."f-(i&":$ &"f/"j,*/( *&&),"*(")/ %*& &$$/ c$(%$$/ (-$ *>*,-?$/( )0 (-$ kl */: +$0( ,-.)/", 0.)/(*+ &"/1&"("& 4lm=7==697 4n*c+$ 29 ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-18 | no 3 | jul-sep 2022 189 rijal et al. association between superior attachment of uncinate process and frontal sinusitis years followed by 25% in both 30 to 39 and 40 to 49 age groups. this was similar to a study done by singh i., who also showed that in his study two third of the cases were below 35 years with 40% of the cases between18 to 25 years.7 tuli et al. also demonstrated that 30% patients in their study were between the ages of 21-35 years with chronic sinusitis.8 one plausible reason for this is that younger patients are more active and are involved in more outdoor activities. likewise younger patients are also more concerned about their health and tend to seek medical care earlier compared to other age groups. similarly, female patients with chronic rhinosinusitis were seen to be higher in numbers than males, which again is similar to the study done by singh i. this could be because females in our country are more involved in household chores, agriculture and are generally more exposed to various allergens. it is imperative to understand the anatomy of the frontal sinuses along with its drainage to comprehend the factors responsible for the development of sinusitis. in this respect we need to understand the osteomeatal complex, which is the small compartment located in the area between the middle turbinate and the lateral nasal wall in the middle meatus and this represents the region for drainage of anterior ethmoid, maxillary and frontal sinuses. variations in any one of the components of the ostiomeatal complex (omc) can lead to improper drainage of these sinuses causing chronic frontal sinusitis.9 the uncinate process is a key structure of the anterior omc, which is important for drainage and ventilation. the omc consists of the hiatus semilunaris, a two-dimensional crescentshaped region located between the free edge of the up and the anterior surface of the bulla ethmoidalis, extending laterally into the ethmoid infundibulum.10,11 the superior attachment of the uncinate process will determine the direction of frontal sinus outflow that finally drains into the middle meatus and ethmoidal infundibulum, either medial or lateral to up.12 this drainage mechanism is considered as one of the important factors in the development of chronic frontal sinusitis. !" #$%"& %'(% $# %'" )*+'%,-*&" %'" (.(/'0"#% $1 %'" 23 %$ %'" -4566 7(-" 8(-""# *# 9:;9<= 8'")"( $# %'" 6"1% -*&" *% 8(9>;?<; @*0*6()6a= @)*b(-%(b( "% (6 (#& c56* "% (6 1$5#& de;?<= 9f< (#& g*# h "% (6; df;>< *#%$ %'" -4566 7(-"= #"b")%'"6"--= i)j"-4* )"k$)%"& ??;9d< (.(/'0"#% *#%$ %'" -4566 7(-"= 8'*/' 8('*+'") %'(# %'" $%'") -%5&*"-; 9dl.(/'0"#% $1 %'" 23 %$ %'" 0*&&6" %5)7*#(%" 8(1$5#& *# 9f;??< 7a i)j"-4*= d9;>< 7a g*# "% (6;= ?< 7a c56* (#& m;d< 7a @)*b(-%(b(; g*&&6" %5)7*#(%" (.(/'0"#% 8(-""# *# m;n< $# %'" )*+'% -*&" (#& 99;9< $# %'" 6"1% -*&" *# $5) -%5&a; g$-% $1 %'" -%5&*"-'$8"& %'(% %'" 0$-% /$00$# %ak" $1 -5k")*$) (.(/'0"#% $1 %'" 23 8(*#%$ %'" 6(0*#( k(ka)(/"( 1$66$8"& 7a %'" -4566 7(-" (#& 0*&&6" %5)7*#(%"= 8'*/' 8( -*0*6() *# $5) -%5&a; ob")(66= 8" 1$5#& 1)$#%(6 -*#5-"8")" #$% &"b"6$k"& *# d;:< 8'*/' * -*0*6() %$ %'" -%5&a &$#" 7a g$*&""# @3 "% (6;= d;><;9m !" #$% &'$() '*+ ,-./,$, "$,0+% #1 &$2+%/#% -3-4*,+"'& #1 '*+ 56 7-& &++" '# 0+ /"'# '*+ 8-,/"2-2)%-4+#" 0#'* &/(+&9 !' 7-& "#'+( '*-' '*+ %/:*' &/(+ *-( ;<9=> -3-4*,+"' /"'# '*+ 8-,/" 2-2)%-4+7*/8+ #" '*+ 8+1' &/(+ /' 7-& ;?9@>9 a*/& 7-& 4#,2-%-08+ '# &'$(/+& (#"+ 0) b-:-% +' -8c a$8/ +' -89 -"( a$%:$' +' -89 '*-' -8&# &*#7+( %+8-'/d+8) */:*+% 2+%4+"'-:+ #1 -3-4*,+"' #1 '*+ 56 /"'# '*+ 8-,/"2-2)%-4+-c ef>c ;g9e> -"( ;@> %+&2+4'/d+8)9 ech?chij#7+d+%c b%/d-&'-d+' -8 -"( k/" l +' -89 1#$"( &8/:*'8) 8#7+% 2+%4+"'-:+ #1 -3-4*,+"'& /"'# '*+ 8-,/" 2-2)%-4+<;9e> -"( <i>9 gch<!" 4#"'%-&'c m%n+&o/ +' -89 #"8) *-( h;9e> -3-4*,+"' /"'# '*+ 8-,/" 2-2)%-4+-9hf jcms | vol-18 | no 3 | jul-sep 2022190 references 1. dalgorf d m, harvy r j. anatomy of nose and paranasal sinuses. in: watkinson jc, clarke rw, edit ors. scottbrown’s otorhinolaryngology head and neck surgery. 8th ed. vol. i, london: crc press; 2019:961-76. 2. stammberger hr, kennedy dw. anatomic terminology group. paranasal sinuses: anatomic terminology and nomenclature. ann otol rhinol laryngol suppl. 1995 oct;167(6):7-16. pmid: 7574267 3. stammberger h, posawetz w. functional endoscopic sinus surgery. european rijal et al. association between superior attachment of uncinate process and frontal sinusitis considering the attachments of the up and their relation it was seen that there was significant association on both sides with superior attachment of the uncinate process and chronic frontal sinusitis (p=0.001 and p=0.002 respectively). this was similar to studies done by gnanavelraja c et al.17 taking into account both sides, 67.5% of superior attachment of the uncinate process into the lamina papyracea was seen to give rise to chronic frontal sinusitis that was similar to other studies.8,9,13,14 the pathophysiology explaining this phenomenon seems to be unclear, however, it has been speculated the superior attachment of uncinate process changes the pattern of drainage of frontal sinus, which may be one factor determining the development of frontal sinusitis.theoretically, attachment into lamina papyracea is likely to have less frontal sinusitis because the frontal sinus drains directly into the middle meatus. however, in our study, frontal sinusitis was more frequent than in this type. similar findings have been reported in literature as well.8,9,13,14 this finding suggests that several other factors, such as airflow of the nasal cavity and the status of nasal mucosa other than simple anatomic narrowing of the omc may play an important role in functional and anatomic disturbance of omc. the cause of frontal sinusitis in patients with lamina papyracea attachments may be attributed to infundibular disease displacing the uncinate process medially and obstructing the frontal sinus drainage between the uncinate and middle turbinate.15 several other factors have also been previously discussed regarding the pathophysiologic process of chronic frontal sinusitis. kuhn classified a number of cells that can lead to obstruction of the frontal recess and cause frontal sinusitis. these are namely frontal recess cells including agger nasi, supraorbital ethmoid cells, frontal cells, frontal bulla cells, suprabullar cells, and interfrontal sinus septal cells.18 in addition to anatomical obstruction, mucosal obstruction of the frontal recess plays an important role in chronic frontal sinusitis.19 there are also different factors such as hypoxia, dehydration, infection, foreign bodies, environmental irritants, trauma, tumor, and allergens that can affect the frontal sinus physiologic functions by disrupting the mucociliary clearance.20 further studies regarding the superior attachment of the up in larger sample may identify attachment to lamina papyracea as an independent major contributing factor to chronic frontal sinusitis. conclusions chronic frontal rhinosinusitis was more common in the younger age group and among female patients. among the superior attachments of the uncinate process, attachment into the lamina papyracea was the commonest. it was noted that frontal sinusitis was significantly associated with the superior attachment of the uncinate process. ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-18 | no 3 | jul-sep 2022 191 rijal et al. association between superior attachment of uncinate process and frontal sinusitis archives of oto-rhino-laryngology. 1990 mar;247(2):63-76. doi: 10.1007/ bf00183169 4. benninger ms, ferguson bj, hadley ja, hamilos dl, jacobs m, kennedy dw, lanza dc, marple bf, osguthorpe jd, stankiewicz ja, anon j. adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology. otolaryngology-head and neck surgery. 2003 sep 1;129(3):s1-32.doi: 10.1016/ s0194-5998(03)01397-4 5. mancuso aa, hanafee wn: computed tomography and magnetic resonance imaging of the head and neck: malignant sinuses, benign sinuses, facial trauma. (2nd ed) baltimore: williams & wilkins, 1985; 1–42. 6. cashman ec, macmahon pj, smyth d. computed tomography scans of paranasal sinuses before functional endoscopic sinus surgery. world journal of radiology. 2011 aug 8;3(8):199. doi: 10.4329/wjr.v3.i8.199 7. singh i, sherstha a, gautam d. chronic rinosinusitis and nasal polyposis in nepal. an international journal clinical rhinology. 2010 aug 1;3(2):87-91. doi: 10.1016/j.jaip.2016.04.012 8. tuli ip, sengupta s, munjal s, kesari sp, chakraborty s. anatomical variations of uncinate process observed in chronic sinusitis. indian journal of otolaryngology and head & neck surgery. 2013 apr;65(2):157-61. doi: 10.1007/s12070-012-0612-8 9. srivastava m, tyagi s. role of anatomic variations of uncinate process in frontal sinusitis. indian journal of otolaryngology and head & neck surgery. 2016 dec;68(4):441-4. doi: 10.1007/s12070-015-0932-6 10. stammberger h, hawke m. essentials of endoscopic sinus surgery. st. louis: mosby inc. 1 st edition. 1993:01-108. 11. güngör g, okur n, okur e. uncinate process variations and their relationship with ostiomeatal complex: a pictorial essay of multidedector computed tomography (mdct) findings. polish journal of radiology. 2016;81:173. doi: 10.12659/pjr.895885 12. krzeski a, tomaszewska e, jakubczyk i, galewicz–zielińska a. anatomic variations of the lateral nasal wall in the computed tomography scans of patients with chronic rhinosinusitis. american journal of rhinology. 2001 sep;15(6):3715. doi:10.1177/194589240101500603 13. sagar gr, jha bc, meghanadh kr. a study of anatomy of frontal recess in patients suffering from ‘chronic frontal sinus disease’. indian journal of otolaryngology and head & neck surgery. 2013 aug;65(2):435-9. doi: 10.1007/s12070-013-0653-7 14. turgut s, ercan i, sayın i, başak m. the relationship between frontal sinusitis and localization of the frontal sinus outflow tract: a computer-assisted anatomical and clinical study. archives of otolaryngology–head & neck surgery. 2005 jun 1;131(6):518-22. doi: 10.1001/ archotol.131.6.518 15. min yg, koh ty, rhee cs, han mh. clinical implications of the uncinate process in paranasal sinusitis: radiologic evaluation. american journal of jcms | vol-18 | no 3 | jul-sep 2022192 citation: shah rijal a, tuladhar as, joshi rr, shrestha kk, dhungana a. association between superior attachment of uncinate process and frontal sinusitis. jcms nepal. 2022; 18(4); ........ rijal et al. association between superior attachment of uncinate process and frontal sinusitis rhinology. 1995 may;9(3):131-6. doi:10.2500/105065895781873782 16. moideen sp, khizer hussain afroze m, mohan m, regina m, sheriff rm, moideen cp. incidence of frontal sinus aplasia in indian population. int j otorhinolaryngol head neck surg 2017;3:108-11. doi:10.18203/issn.24545929.ijohns20164811 17. gnanavelraja c, senthilnathan v, vijayakumar m. anatomical variations in the superior attachment of uncinated process and its association with frontal sinusitis. mimj. 2014;1(8):399-401. http:// www.medpulse.in 18. kuhn fa. chronic frontal sinusitis: the endoscopic frontal recess approach. operative techniques in otolaryngologyhead and neck surgery. 1996 sep 1;7(3):222-9. doi: https://doi.org/10.1016/s1043-1810(96)80037-6 19. jacobs jb. 100 years of frontal sinus surgery. the laryngoscope. 1997 nov;107(s83):1-36. doi: 10.1097/00005537-199711001-00001 20. mclaughlin rb, rehl rm, lanza dc. clinically relevant frontal sinus anatomy and physiology. otolaryngologic clinics of north america. 2001 feb 1;34(1):1-22. doi: 10.1016/s0030-6665(05)70291-7 jcms | vol-18 | no 4 | oct-dec 2022348 prevalence of exclusive breastfeeding and factors influencing infant feeding practices among mothers of central nepal journal of college of medical sciences-nepal, vol-18, no 4, oct-dec 2022 issn: 2091-0657 (print); 2091-0673 (online) open access doi: 10.3126/jcmsn.v18i4.49737 srijana panthi,1 pallavi koirala,1 prerna bansal,1 meera prasai,1 kamal khadka,1 ranjeeta phuyal,1 ayasha shrestha1 1department of community medicine, college of medical sciences-teaching hospital, chitwan, nepal. original research article correspondence: dr. srijana panthi, department of community medicine, college of medical sciences, bharatpur, chitwan, nepal. email: srijanapanthi7@gmail.com. phone: +977-9843028082. abstract introduction infants should be exclusively breastfeed for the first six months of life to achieve optimal growth, development and health. considered as an ideal food for infants, it also helps to fight disease like diarrhea and pneumonia. in nepal only two third of the mother exclusively breastfeed their child in the past 24 hrs. the aim of this study is to find prevalence of exclusive breastfeeding and factors influencing infant feeding practices among mothers. methods a cross-sectional study was conducted in bharatpur, chitwan among 290 lactating mothers at the immunization center of bharatpur hospital chitwan. mothers were interviewed on details regarding feeding of their child. results the mean age of the study population was 25.6 ± 4.5 years. a majority of the respondents were <30 years of age (234, 82.4%), primipara (175, 61.6%) and living in a joint family (199, 70.1%). exclusive breast feeding (ebf) was practiced by 203 (71.5%) mothers on the current infant. low production of milk was the commonest reason for not practicing ebf (66.6%). over two-thirds (195, 68.7%) had started breastfeeding within 1 hour of delivery. cesarean section was the most frequent cause (71, 88.6%) for late initiation of breastfeeding. conclusions the study revealed that prevalence of exclusive breast feeding is 71.5% and 93.5% of respondents had heard of ebf. low production of milk was the commonest reason for not practicing ebf (66.6%). still 28.5% mothers did not practice ebf, 7.7 %mothers had not heard of ebf, indicating a need for ebf promotion which could be carried out within the existing healthcare system such as the antenatal and vaccination clinics. keywords: exclusive breastfeeding; infants; mother; practiced. ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-18 | no 4 | oct-dec 2022 349 introduction according to who, exclusive breastfeeding means the infant receives only breast milk. no other liquids or solids are givennot even waterwith the exception of oral rehydration solution, or drops/ syrups of vitamins, minerals, or medicines.1 for the first six months of life, a baby should only be breastfed in order to obtain the best possible growth, development, and health.2 considered an ideal food for infants, besides providing nutrients, it also contains antibodies and immunoglobulins that help to fight diseases like diarrhea and pneumonia.1starting breastfeeding early stimulates prolactin secretion and increases milk production.3 mothers should start breastfeeding within an hour of giving birth, continue it exclusively for six months, and then supplement with safe, nutritious foods until the child is at least two years old.4 in addition, breastfeeding decreases the baby's risk of obesity and overweight, even while decreasing the mother's risk of ovarian and breast cancer in the long term.5 however, in nepal, only two third of the mother exclusively breastfeed their child in the past 24 hours (66%).6 poor infant feeding practices have been associated to undernutrition, as seen by stunting and wasting, and mortality in nepal and other countries in south asia.4 according to the nepal demographic health survey (ndhs) of 2011 and 2016, there is a slight reduction from 70% to 66% respectively.7 malnutrition possess a serious threat to millions of children worldwide. it is estimated that if breastfeeding rates worldwide reached 90%, 13% of all infant deaths in lowand middle-income countries would be prevented.8 nepal is one of the thirty-four countries that account for 90% of the world's child malnutrition incidences.9 36% of children are stunted, 10% are wasted, and 27% are underweight, according to ndhs.10 for our country nepal to meet the sustainable development goal we have to overcome hindering factors associated with the high infant mortality rate.this study aims to find the prevalence of breastfeeding among lactating mothers in bharatpur. also to evaluate the associated factors that hinder exclusive breastfeeding and to assess the complementary feeding practices in bharatpur. methods a cross-sectional study was conducted among 290 lactating mothers at the immunization center of bharatpur hospital chitwan. prior to the main study to check the reliability and validity of the questionnaire pilot study were done among 23 (10% of the total sample size). then using spss20 cronbach’s alpha was calculated, and its value was 0.793. also, consulting other research expert questionnaires was finalized. a predesigned questionnaire was used. non-probability, convenient sampling technique was used. prevalence of exclusive breastfeeding (p) = 0.757, q=1 -0.757=0.243, z score value at 95% ci=1.96 error (e) =5%=0.05. the sample size was determined by using the formula (n) = z 2pq/e2 =1.962x0.757x0.243/ (0.05)2=283. the minimum sample size for this study was 283. ethical approval was taken from the institutional review committee of college of medical sciences (comsth-irc/2021-67). mothers of children <1 year of age who are breastfeeding were enrolled and infants suffering from any congenital abnormalities were excluded. data were collected by interview. the interview schedule had socio-demographic information and questions on the practices of mothers regarding exclusive breastfeeding, and factors associated with exclusive breastfeeding. the respondents were informed about the purpose of the study, verbal consent was obtained from each mother before the interview, who was willing to participate in the study. data analysis was done using spss 18 software. descriptive statistics including to panthi et al. prevalence of exclusive breastfeeding and factors influencing infant feeding practices... jcms | vol-18 | no 4 | oct-dec 2022350 panthi et al. prevalence of exclusive breastfeeding and factors influencing infant feeding practices... summarize mother’s socio-demographic and practice related information. univariate analysis was carried out to identify any factors that were associated with exclusive breastfeeding. results out of a total 290 mothers that were initially interviewed, data from only 284 respondents was used for further analysis, because 6 of them had incomplete data. the mean age of the study population was 25.6 ± 4.5 years (range: 17 – 42 years). table 1 shows the sociodemographic characteristics of the study participants. a majority of the respondents were <30 years of age (234, 82.4%), primipara (175, 61.6%), and living in a joint family (199, 70.1%). more than one-third (112, 39.4%) of the mothers were from the janajati ethnicity. a vast majority of the mothers (211. 74.3%) were homemakers, and only 15 (5.3%) were illiterates. the median age of the infant during the interview was 10 months (4 – 14 months). table 1. sociodemographic characteristics of the study population (n = 284). variables summary statistic age category, n (%) <30 years ≥ 30 years 234 (82.4) 50 (17.6) parity, n (%) primi multi 175 (61.6) 109 (38.4) family type, n (%) nuclear joint 85 (29.9) 199 (70.1) ethnicity, n (%) brahmin chhetri janjati others 71 (25.0) 38 (13.4) 112 (39.4) 63 (22.2) religion, n (%) hindu buddhist muslim christian 223 (78.5) 42 (14.8) 9 (3.2) 10 (3.5) occupation, n (%) homemaker service business agriculture 211 (74.3) 35 (12.3) 21 (7.4) 17 (6.0) educational status, n (%) illiterate up to primary education up to higher secondary education up to graduation 15 (5.3) 51 (18.0) 190 (66.9) 28 (9.9) sex of the infant, n (%) male female 167 (58.8) 117 (41.2) age of the infant (months), median (iqr) 10 (4 – 14) table 2. characteristics related to exclusive breast feeding (n = 284). variables summary statistic heard about exclusive breast feeding (ebf), n (%) 262 (92.3) practiced ebf on the current infant, n (%) yes no 203 (71.5) 81 (28.5) reasons for not practicing ebf, n (%) # low production of milk working mother painful breasts difficulty in sucking na 54 (66.6) 9 (11.1) 8 (9.9) 2 (2.5) 8 (9.9) time of starting breast feeding after delivery, n (%) less than 1 hour more than 1 hour na 195 (68.7) 80 (28.2) 9 (3.1) reasons for late initiation of breast feeding, n (%)! cesarean section severe pain baby in nicu na 71 (88.6) 3 (3.8) 3 (3.8) 3 (3.8) # out of 81 mothers that did not practice ebf ! out of 80 mothers that had the time of initiation of breast feeding >1 hour na: information not available exclusive breast feeding (ebf) was practiced by 203 (71.5%) mothers on the current infant. low ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-18 | no 4 | oct-dec 2022 351 production of milk was the commonest reason for not practicing ebf (66.6%). working mothers, painful breasts, and difficulty in sucking were the other reasons. [table 2] over two-thirds (195, 68.7%) had started breast feeding within 1 hour of delivery. among the mothers that had late initiation of breast feeding, having undergone a cesarean section was the most frequent cause (71, 88.6%). furthermore, univariate analysis was carried out to identify any factors that were associated with ebf. none of the maternal factors (age, parity, family type, ethnicity, religion, educational status, occupation, and prior information about ebf) was found to be significantly associated with ebf. [table 3] sex of the child was also not found to be associated with ebf. multivariate regression was carried out as none of the factors were found to be associated with ebf in univariate analysis. panthi et al. prevalence of exclusive breastfeeding and factors influencing infant feeding practices... table 3. factors associated with exclusive breast feeding. variables exclusive breast feeding p-value# yes (n = 203) no (n = 81) age <30 years ≥ 30 years 166 (81.3) 37 (18.2) 68 (84.0) 13 (16.0) 0.73 parity primi multi 122 (60.1) 81 (39.9) 53 (65.4) 28 (34.6) 0.42 family type nuclear joint 63 (31.0) 140 (69.0) 22 (27.2) 59 (72.8) 0.57 ethnicity brahmin chhetri janjati others 45 (22.2) 28 (13.8) 85 (41.8) 45 (22.2) 26 (32.1) 10 (12.3) 27 (33.3) 18 (22.3) 0.34 religion hindu buddhist muslim christian 164 (80.8) 28 (13.8) 5 (2.5) 6 (3.0) 59 (72.8) 14 (17.3) 4 (4.9) 4 (4.9) 0.37 occupation homemaker service business agriculture 155 (76.4) 20 (9.9) 16 (7.9) 12 (5.9) 56 (69.1) 15 (18.5) 5 (6.2) 5 (6.2) 0.25 educational status illiterate up to primary education up to higher secondary education up to graduation 12 (5.9) 35 (17.2) 140 (69.0) 16 (17.9) 3 (3.7) 16 (19.8) 50 (61.7) 12 (14.8) 0.27 sex of the infant male female 116 (57.1) 87 (42.9) 51 (63.0) 30 (37.0) 0.42 heard about ebf 187 (93.5) 75 (93.8) 1.0 # fisher’s exact test jcms | vol-18 | no 4 | oct-dec 2022352 discussion this study aimed to identify the prevalence of exclusive breastfeeding and factors influencing infant feeding practices among nepalese mothers. in this study, the prevalence of exclusive breast feeding (ebf) was 71.5%, which is in alignment with the study by bhandari et al conducted in dhulikhel municipality (75.7%).4 studies from africa such as the ones done in nigeria and ethiopia mentioned ebf prevalence to be 66.7%11 and ethiopia 82.2% 12 respectively. a study done in ghana found that the prevalence of ebf was 66.0%. 13 also similar findings were observed in studies from northwest ethiopia (60.8%) central ethiopia (68.6%), and hossana town (70.5%).14-16 the prevalence of ebf in this study was higher than in other studies conducted in nepal. a study conducted by mukta et al tertiary-level reported a prevalence of (45%)5, whereas dharel and dhugana et al reported 23.2%, in a study done in mid-western and eastern regions of nepal.10 eastern ethiopia (45.8%)17 other study findings bahirdar city (50.3%)18 and (49.1%) and muta town19, east gojjam zone (50.1%).20 these findings show that there are significant cultural, geographical, and socioeconomic differences in exclusive breastfeeding habits both globally and within nepal, as well as differences in the study population and study setting. a high proportion of mothers with a higher educational level would be the reason for the high prevalence of ebf in our study. exclusive breastfeeding is very important for the growth of children.21 the new global ebf target is above 60% by 2030 and only a few countries have met the target.22 colostrum (first milk), which is suitable during this early period for a baby because it contains a high concentration of protein and another nutrient the body needs, is also rich in antiinfective factors that protect the baby against respiratory infections and diarrheal diseases, so early breastfeeding initiation is extremely important.23 the commonest reason for not practicing ebf in our study was less production and secretions of milk (66.6%). a study in bangladesh by joshi pc et al has similar findings with 64% of the mothers having inadequate secretion.8 nutrition of the mother and position of breastfeeding to infant have a crucial role to enhance milk flow. so after the delivery mother has to take in extra calorie which contains lots of protein, vitamin, and minerals. the majority of our research participants (68.7%) practiced early initiation of breastfeeding within 1 hour of delivery. nepal demographic health survey (ndhs) has reported that 55% of children are breastfed within the first hour of life 24which is higher in our study. health education and awareness programs in health institutions are going well, and therefore would have an effect on the higher rates of early initiation of breastfeeding. a similar rate (63.4%) was found in the study by bernard et al13. in a study done in the rupandehi district in nepal, khanal and scott reported a slightly lower rate (42.2%). one reason may be that some mothers had traditional birth attendant assistance during delivery. 18 the delay in early initiation of breastfeeding in this study was a cesarean section, severe pain, baby in nicu. this also affects the duration of exclusive breastfeeding practice could be that some mothers also had delivery assisted by a traditional birth attendant.25 in our study, 81.3% of mothers less than 30 years of age practiced ebf whereas exclusive breastfeeding practice mothers among age >35 (66.7%) than mothers of other age group study done by joshi et.26 as mentioned by bernard exclusive breast feeding were high when the mother’s age is over to 20 years13. asemahagn presented that practice of the exclusive breastfeeding was more panthi et al. prevalence of exclusive breastfeeding and factors influencing infant feeding practices... ;]km8{ sn]h, pdpd6l gjf}+ aofr, lk|g6 ;d"xsf] k|sfzgjcms | vol-18 | no 4 | oct-dec 2022 353 in mothers of age group 30 or more, the reason that mothers get to experience an increase in age.27 but it was not statistically significant. cesarean section was the reason for late initiation of breast milk was found in 88.6% of mothers in our study. different studies also stated that cesarean delivery is one of the main causes to delay initiation of breast feeding. 28 29. the study of chandrashekhar in western nepal stipulated 27.5% of mothers had problems breastfeeding like pain in the nipple.30 in contrast to his study, only 9.9% of mothers had experienced problem feeding in the study. now more women are aware. health education during antenatal visits and advice on breast care help to minimize the problem of feeding, which is being run in maternal and child health care nowadays properly. most of the deliveries are conducted at home with the help of family members. pregnant women rarely attend medical facilities for antenatal treatment and guidance.31 this study does not find differences with caste to practice exclusive breast feeding, whereas khanal v found a delay in initiating breastfed within one hour in the middle caste and dalit caste groups.25there need to have more studies regarding caste and socio-culture difference start breastfeeding within one hour. mothers’ occupation is also found one of the influential factors in the early initiation of exclusive breast feeding. in the study majority of mothers are homemakers 74.3% and practiced exclusive breastfeeding. our studies have shown that a large number of male infants are exclusively breastfed (57.1%) than female infants (42.9%). chakravarty has also reported that there is a gender bias in breastfeeding in egypt.32 whereas it is found by the study of joshi et al, female infants were more likely to be exclusively breastfeeding than male infants. although this finding was found to be statistically not significant.26 in this study, primiparous mother practice exclusive breastfeeding (60.1%) compare to multiparous mothers (39.9%) which is in contrast to the study done by timilsina. 26 in the current study, homemaker mothers were more likely to practice ebf (76.4%) than job-holder mothers which are similar to the study done in ethiopia 79.6%.20 this result is similar to studies from malaysia,33 the netherlands 34 utah state35, cameroon36, ghana 37, and debre markos, ethiopia 38 it is due to homemakers staying with their kids and they have time for breastfeeding. though the finding was similar, it was not statistically significant. in addition to the above factors, mothers who delivered normally were two times more likely to exclusively breastfeed than those who delivered by a cesarean section which was similar to a study done by dachew assefa berihun. though it was not statistically significant in our study. this study aimed to identify the prevalence of exclusive breastfeeding and factors influencing infant feeding practices among nepalese mothers. conclusions the study revealed that the prevalence of exclusive breast feeding is 71.5%. 93.5% of respondents had heard of ebf. low production of milk was the commonest reason for not practicing ebf (66.6%), working mothers, painful breasts, and difficulty in sucking were the other reasons. we have to encourage women to have a healthy diet and initiation of breastfeeding should be supported by hospital staff. acknowledgments we would like to express our sincere gratitude to all the respondents of our study for giving their valuable time, also we want to thank bharatpur hospital for permitting us for data collection. panthi et al. prevalence of exclusive breastfeeding and 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